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Nephrology
CLINICAL CASES UNCOVERED
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Nephrology
CLINICAL CASES UNCOVERED
Menna Clatworthy
BSc, MBBCh, PhD, MRCP
University Lecturer in Renal Medicine and
Honorary Consultant Nephrologist
University of Cambridge
Addenbrooke’s Hospital
Cambridge, UK
A John Wiley & Sons, Ltd., Publication
This edition fi rst published 2010, © 2010 by Menna Clatworthy
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Library of Congress Cataloging-in-Publication Data
Clatworthy, Menna.
Nephrology / Menna Clatworthy.
p. ; cm. – (Clinical cases uncovered)
Includes indexes.
ISBN 978-1-4051-8990-3
1. Kidneys–Diseases–Case studies. 2. Kidneys–Diseases–Examinations, questions,
etc. I. Title. II. Series: Clinical cases uncovered.
[DNLM: 1. Kidney Diseases–Case Reports. 2. Kidney Diseases–Problems and Exercises.
WJ 18.2 C614n 2010]
RC903.C5525 2010
616.6′10076–dc22
2009018584
ISBN: 9781405189903
A catalogue record for this book is available from the British Library
Set in 9 on 12 pt Minion by Toppan Best-set Premedia Limited
Printed in Malaysia
1 2010
Contents
Preface, vii
Acknowledgements, ix
How to use this book, x
List of abbreviations, xi
Normal range for investigations, xiv
Part 1 Basics, 1
Basic science, 1
Approach to the patient, 8
Clinical overview, 13
Part 2 Cases, 30
Patients with acute renal failure
Case 1 An 84-year-old man with reduced urine output, 30
Case 2 A 74-year-old man with acute renal failure, 37
Case 3 A 64-year-old man with back pain and polydipsia, 45
Case 4 A 20-year-old woman with facial swelling and coke-coloured urine, 51
Case 5 A 68-year-old man with hearing loss, fatigue and arthralgia, 56
Case 6 A 19-year-old man with macroscopic haematuria, 62
Case 7 A 27-year-old woman with a rash and renal impairment, 68
Case 8 A 26-year-old man with haemoptysis and oliguria, 72
Case 9 A 25-year-old woman presents with rash and joint pain, 78
Case 10 An 18-year-old girl with lethargy and headache, 86
Patients with nephrotic syndrome
Case 11 A 56-year-old man with ankle swelling, 93
Case 12 An 80-year-old man with abdominal discomfort and ankle swelling, 98
v
vi Contents
Case 13 A 23-year-old obese woman with ankle swelling, 106
Case 14 A 15-year-old girl with facial swelling and frothy urine, 113
Patients with hypertension
Case 15 A 50-year-old woman with hypertension, 117
Case 16 A 60-year-old male smoker with hypertension and renal impairment, 123
Patients with urine dipstick abnormalities
Case 17 A 25-year-old woman with dysuria and urine dipstick abnormalities, 128
Case 18 A 40-year-old ex-intravenous drug user with protein and blood on
urine dipstick, 133
Case 19 A 35-year-old man with macroscopic haematuria, 138
Case 20 An 82-year-old woman with dark urine, 143
Acid–base and electrolyte problems
Case 21 A 28-year-old type I diabetic man with abdominal pain and vomiting, 148
Case 22 A 22-year-old man with weakness and lethargy, 154
Case 23 A 58-year-old type II diabetic with confusion and hyponatraemia, 159
Patients with chronic kidney disease/end-stage renal failure
Case 24 A 49-year-old man with headache and malaise, 163
Case 25 A 23-year-old man with shortness of breath, 169
Case 26 A 34-year-old man on haemodialysis, 176
Case 27 A 54-year-old man with end-stage renal failure, 181
Case 28 A 50-year-old man on peritoneal dialysis with abdominal pain, 187
Renal transplantation
Case 29 A 49-year-old man with chronic kidney disease, 193
Case 30 A 38-year-old man with a rise in creatinine 2 weeks post renal transplant, 201
Case 31 A 45-year-old man with a renal transplant and fever, 210
Part 3 Self-assessment, 215
MCQs, 215
EMQs, 220
SAQs, 227
Answers, 229
Index of cases by diagnosis, 246
Index, 247
Preface
Renal medicine is often viewed as a complex, ‘ hard - core ’ knowledge, and is perhaps one of the few remaining gen-
medical specialty, mastered by a small minority of eralists. This is deliberately refl ected in some of the cases,
intellectual physicians. The lasting impression of many whose presentation begins with a symptom or sign which
medical students (and indeed non- r enal specialists) is of appears unrelated to the kidneys. As a result, this book
a list of glomerulonephritides (GNs), which have random will also help you polish up on some basic general
and diffi cult names and blur into one incomprehensible medical facts.
mass. In reality, nephrology is actually relatively simple Another concept which I have tried to convey in this
and logical. text is that the kidneys are ‘ sensitive ’ organs, and can
I n the fi rst section of the book, I have provided a broad frequently become acutely dysfunctional in the context
introduction to nephrology. Where possible, I have tied of a variety of pathologies. Thus, all doctors, regardless
together a clinical presentation with underlying pathol- of their specialty or career choice, will encounter patients
ogy and immunology, using diagrams to distil the impor- with acute renal failure (acute kidney injury). On the
tant points. I have also provided an ‘ A BC of GN’ , which average ‘ medical take ’ or surgical/orthopaedic ward,
offers a simple framework in which to place the GNs so there will always be a handful of patients with acute renal
that they can be understood. failure. These patients can be very unwell but if managed
T he main part of this book consists of 31 cases, which promptly and appropriately, may regain their renal func-
have been chosen because they refl ect the bread and tion. These are typifi ed by the 10 cases of acute renal
butter of day - to - day life as a nephrologist. Nephrology is failure, starting with common causes and moving to
a fantastic specialty which allows the physician to deal rarer, to illustrate the principles of investigation, man-
with a wide variety of clinical problems, ranging from the agement and diagnosis of this important problem.
critically unwell patient with acute renal failure to those C hronic kidney disease (CKD) is now widely diag-
with multisystem immune - mediated disease or tubular nosed, due to the increased availability of measurements
dysfunction, and those with chronic disease who we of renal function, in particular eGFR. General practitio-
sometimes look after for decades on dialysis or following ners need to be aware of the complications associated
transplantation. For the junior doctor on a 4- m onth with CKD and the appropriate time for referral to
renal attachment (or even the junior renal trainee), the nephrology services. I have therefore presented a number
cases I have presented will be surprisingly similar to those of cases of patients with CKD, which touch upon the
which you see (and the questions that follow will refl ect practicalities of managing associated complications and
those which your consultant will ask). For the purposes of providing renal replacement therapy for the increasing
of clarity, the cases are divided into seven sections accord- number of patients diagnosed with CKD. For those with
ing to clinical presentation: those presenting with acute CKD reaching end - stage renal failure, dialysis and renal
renal failure, nephrotic syndrome, hypertension, urine transplantation are no longer limited to the lucky, ‘ fi t ’
dipstick abnormalities, acid – base disturbances, chronic few but are available to all. Very few textbooks provide
kidney disease/dialysis - associated problems and renal practical advice on the management of these patients and
transplant - related problems. I hope that students (and junior doctors) asked to deal
T he kidneys are often involved in diseases which are with these chronic nephrology patients will fi nd the cases
primarily the remit of other specialties, for example, in this book of genuine practical use. On a more prag-
infectious diseases, oncology or haematology. Thus, the matic note, patients with CKD are often well with stable
renal physician needs to maintain a breadth of medical clinical signs and are therefore frequent attendees at
vii
viii Preface
student clinical examinations (with an arteriovenous many students clinical medicine at the bedside. There is
fi stula, palpable kidneys or a transplanted kidney). This no substitute for this but in this text, I have tried to recre-
text should allow you to really fl y through those stations ate some of these cases in an attempt to convey some of
of the exam. The MCQs, EMQs and SAQs also provide the important concepts and, I hope, to make renal medi-
practical help to test your nephrology knowledge prior cine accessible to all.
to examinations.
I n summary, nephrology need not be feared and can Menna Clatworthy
be understood. Over the last 10 or so years, I have taught Cambridge
