Slideshow is from the University of Michigan Medical School's M2 Renal sequence View additional course materials on Open.Michigan: openmi.ch/med-M2Renal

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3. RENAL SEQUENCE
9/26 - 10/13
2008
Fall 2008

4. Case 1: Tragic Misdiagnosis
25 y.o. female presents complaining of fatigue and mild joint
pain. Routine urinalysis with a dipstick shows proteinuria and
microscopic hematuria.
Diagnosed as cystitis and treated with an antibiotic.
6 months later patient returns with hypertension and edema.
Blood tests: Creatinine 10 mg/dl (normal 0.8 - 1.3),
BUN 130 mg/dl (normal 10-20), and, on urinalysis, RBC casts.
Admitted to hospital and started on dialysis.

5. Case 1: Tragic Misdiagnosis
25 y.o. female presents complaining of fatigue and mild joint
pain. Routine urinalysis with a dipstick showed proteinuria and
microscopic hematuria.
Diagnosed as cystitis and treated with an antibiotic.
6 months later patient returns with hypertension and edema.
Blood tests: Creatinine 10 mg/dl (normal 0.8 - 1.3),
BUN 130 mg/dl (normal 10-20), and, on urinalysis, RBC casts.
Admitted to hospital and started on dialysis.
Dx: SLE with diffuse proliferative glomerulonephritis

6. Case 2: Problems After a Diagnostic Study
75 yo female (45 kg) complaining of intermittent chest pains is
admitted to the hospital for cardiac catheterization. Creatinine is
1.7 mg/dl. Following the study, patient is noted to have
decreased urine output, and over the next three days her
creatinine progressively increases to 5.5.

7. Case 2: Problems After a Diagnostic Study
75 yo female (45 kg) complaining of intermittent chest pains is
admitted to the hospital for catheterization. Creatinine is 1.7
mg/dl. Following the study, patient is noted to have decreased
urine output, and over the next three days her creatinine
progressively increases to 5.5.
Dx: Contrast-induced acute renal failure in a patient at
increased risk because of reduced renal function. Renal
function declines with age and at 45 kg she has relatively small
muscle mass, lowering creatinine production. The creatinine of
1.7, therefore, represents not a minimally elevated value, but,
rather one indicative of substantially decreased baseline
glomerular filtration.

8. Case 3: Life Threatening Hyperkalemia
A 35 y.o. female with 20 year history of Type I diabetes and
hypertension is hospitalized for treatment of a cellulitis.
Creatinine - 2.5 mg/dl, K+ 4.8 mEq/L, BP 150/100. The intern
starts enalapril (angiotensin converting enzyme inhibitor) and
atenolol (beta-blocker).
Three days later, BP is well-controlled at 115/70, but morning
chemistries return with a K+ is 6.8 and EKG shows peaked T
waves and widening of the QRS complex. Urgent treatment for
hyperkalemia is started.

9. Case 3: Life Threatening Hyperkalemia
A 35 y.o. female with 20 year history of Type I diabetes and
hypertension is hospitalized for treatment of a cellulitis.
Creatinine - 2.5 mg/dl, K+ 4.8 mEq/L, BP 150/100. The intern
starts enalapril (angiotensin converting enzyme inhibitor) and
atenolol (beta-blocker).
Three days later, BP is well-controlled at 115/70, but morning
chemistries return with a K+ is 6.8 and EKG shows peaked T
waves and widening of the QRS complex. Urgent treatment for
hyperkalemia is started.
Dx: Hyperkalemia secondary to inhibition of aldosterone
production by angiotensin converting enzyme inhibitor and shift
of potassium out of cells by beta-blocker in the setting of
preexisting decrease of kidney clearance function and lack of
insulin.

10. Case 4: A missed treatment opportunity
A 77 y.o. man has a renal scan for assessment of hypertension
and a small area of increased tracer uptake is seen in the left
upper pole, so he is referred for a CT scan, which shows a small
undulation less than 1 cm. in size in the upper left kidney.
Repeat CT scan in 6-12 months is recommended but not done.
Three years later a repeat CT done to evaluate possible
diverticulitis shows a 1.7 cm heterogenously enhancing mass in
the posterior left upper kidney and a noncalcified subpleural
nodule in the right middle lobe. What is going on?

11. Case 4: A missed treatment opportunity
A 77 y.o. man has a renal scan for assessment of hypertension
and a small area of increased tracer uptake is seen in the left
upper pole, so he is referred for a CT scan, which shows a small
undulation less than 1 cm. in size in the upper left kidney.
Repeat CT scan in 6-12 months is recommended but not done.
Three years later a repeat CT done to evaluate possible
diverticulitis shows a 1.7 cm heterogenously enhancing mass in
the posterior left upper kidney and a noncalcified subpleural
nodule in the right middle lobe. What is going on?
Dx: The initial lesion was a renal cell carcinoma
(hypernephroma), which grew and metastasized to lung in the
subsequent three years, changing a completely curable lesion
into one with a much poorer prognosis.

17. DIALYSIS UNIT VISIT SIGNUP:
DATE: ________________
12:00 - 1:00 p.m.
1. ____________________
Mon. 10/6
2. ____________________
Tues. 10/7
Wed. 10/8 3. ____________________
Thurs. 10/9
4. ____________________
This is a patient
contact activity, so 5. ____________________
please dress
appropriately and 6. ____________________
bring a white coat.
7._____________________
8. ____________________

21. • Syllabus - Power Point format used throughout.
• Web site - CTools M2 page has all Power Point material
from the syllabus as Acrobat PDF files and will have updates
and additions.

22. • Syllabus - Power Point format used throughout.
• Web site - CTools M2 page has all Power Point material
from the syllabus as Acrobat PDF files and will have updates
and additions.
• Introduction to Pathology, Urinalysis labs, and Electrolyte
problems are web-based teaching exercises available via
CTools.

25. • Syllabus - Power Point format used throughout.
• Web site - CTools M2 page has all Power Point material
from the syllabus as Acrobat PDF files and will have updates
and additions.
• Introduction to Pathology, Urinalysis labs, and Electrolyte
problems are web-based teaching exercises available via
CTools.
• Grading
Quiz – 10/3-10/5 - Fluid and electrolytes only - 30%
Attending and submission of answers to small group
problem sets on 10/10 - 5%
Laboratory practical - 10/10–10/13 - 10%
Written final - 10/10–10/13 - 55%

26. Course Texts (not required)
!
Renal Physiology, 3rd edition by Bruce M. Koeppen and
Bruce A. Stanton, Mosby, 2007

27. Course Texts (not required)
!
Renal Physiology, 3rd edition by Bruce M. Koeppen and
Bruce A. Stanton, Mosby, 2001
Renal Pathophysiology, The Essentials, 2nd Edition Rennke
and Denker, J.B. Lippincott and Co. 2006

28. Image of the recommended
book for the course: Renal
Pathophysiology, The
Essentials, 2nd Edition
Rennke and Denker, J.B.
Lippincott and Co. 2006
removed

29. Course Texts (not required)
!
Renal Physiology, 3rd edition by Bruce M. Koeppen and
Bruce A. Stanton, Mosby, 2001
Renal Pathophysiology, The Essentials, 2nd Edition Rennke
and Denker, J.B. Lippincott and Co. 2006
Robbins 7th edition
Primer on Kidney Diseases, 4rd Edition, National Kidney
Foundation, 2005

30. Kidney Functions
!
1. Maintenance of body composition - Volume, osmolarity,
electrolyte content, and acidity of all body fluids.
2. Excretion and degradation of metabolic end products (e.g.
urea), foreign substances (drugs), and hormones (insulin).
3. Production and secretion of enzymes and hormones.
- Renin
- Erythropoietin
- 1,25-Dihydoxyvitamin D3
- Prostanoids

31. Source Undetermined
Source Undetermined

32. Source Undetermined

33. Source Undetermined

34. Source Undetermined

35. 1. Renal pyramid 10. Inferior renal
2. Interlobar artery capsule
3. Renal artery 11. Superior renal
4. Renal vein capsule
5. Renal hylum 12. Interlobar vein
6. Renal pelvis 13. Nephron
7. Ureter 14. Minor calyx
8. Minor calyx 15. Major calyx
9. Renal capsule 16. Renal papilla
17. Renal column
Piotr Michael Jaworski (Wikipedia)

36. Gray s Anatomy

37. Source Undetermined

38. Source Undetermined

39. Faber, Kupin, Krishna, and Narins

40. Image illustrating the
changes of
epithelium along the
nephron removed
Fig 2-3

41. Regents of University of Michigan

42. Source Undetermined
Source Undetermined

43. Source Undetermined

44. Image illustrating
similarities
between the
epithelial cells of
the distal tubule
and collecting duct
removed
Source Undetermined
Figure above showing an epithelial cell of
Distal Tubule (similar to collecting tubule
epithelial cell)

45. Image illustrating the
difference between
principal cells and
intercalated cells in the
collecting duct
removed
Source Undetermined
Collecting Duct

46. Source Undetermined

47. Source Undetermined Source Undetermined

48. Source Undetermined
Source Undetermined
Source Undetermined

49. Source Undetermined
Source Undetermined

50. Yassiin Mrabet (Wikipedia)
Patrick Glanz (Wikipedia)

51. Newslighter (Flickr)

52. Image illustrating a
kidney surgical
procedure
removed

53. Additional Source Information
for more information see: http://open.umich.edu/wiki/CitationPolicy
Slide 31: Source Undetermined; Source Undetermined
Slide 32: Source Undetermined
Slide 33: Source Undetermined
Slide 34: Source Undetermined
Slide 35: Piotr Michael Jaworski (Wikipedia) http://en.wikipedia.org/wiki/File:KidneyStructures_PioM.svg (Wikipedia), GNU FDL 1.2
http://www.gnu.org/copyleft/fdl.html
Slide 36: Gray s Anatomy
Slide 37: Source Undetermined
Slide 38: Source Undetermined
Slide 39: Faber, Kupin, Krishna, and Narins
Slide 41: Regents of University of Michigan, CC: BY-SA-3.0 http://creativecommons.org/licenses/by-sa/3.0/
Slide 42: Source Undetermined; Source Undetermined
Slide 43: Source Undetermined
Slide 44: Source Undetermined
Slide 45: Source Undetermined
Slide 46: Source Undetermined
Slide 47: Source Undetermined; Source Undetermined
Slide 48: Source Undetermined; Source Undetermined; Source Undetermined
Slide 49: Source Undetermined; Source Undetermined
Slide 50:Yassiin Mrabet (Wikipedia) http://en.wikipedia.org/wiki/File:Hemodialysis-en.svg
CC: BY http://creativecommons.org/licenses/by/3.0/ ; Patrick Glanz (Wikipedia) http://en.wikipedia.org/wiki/File:Hemodialysismachine.jpg CC: BY-SA-3.0
http://creativecommons.org/licenses/by-sa/3.0/
Slide 51: Newslighter (Flickr) http://www.flickr.com/photos/newslighter/523392/, CC: BY 2.0 http://creativecommons.org/licenses/by/2.0/deed.en
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