Case study- Renal and urinary tract Disease

Question 1

A 60-year-old man with a 17-year history of type 2 diabetes mellitus visits a clinic because of increasing swelling in his lower
extremities. The swelling began approxi mately 7 months previously and has worsened over the past 6 to 8 weeks. The patient reports no recent ill nesses and specifically denies any fever, chills, arthralgias,
joint swelling, or skin rash. In addition, he reports no visual changes, epistaxis, hemoptysis, or cough. The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and an a ppendectomy.
His medications include g lyburide 10 mg daily10 mg daily, and ibuprofen occasional ly. He does not abuse alcohol, tobacco, or illicit drugs. No family history of kidney d isease is present, although several of his family members have diabetes mellitus
and heart d isease. His physical exami nation reveals a healthy-appearing man in no acute distress. He has 3+ pitting edema up to
the midcalf. His glomerular biopsy shows the lesion below (Fig. 2-5).

Blood tests : Hemoglobin A1 c, 8 . 1% ↑
Urinalysis fi ndi ngs:
Protein 4+
RBCs, 1 0-1 5/hpf
Renal tubular epithelial cells, few ova l fat bodies, few Hyaline
casts, few
G FR, 31 m Umin J. m i croalbumin 310 mg/24 hrs ↑

1. What is the most likely cause of the patient’s renal disease?
   a. Diabetic nephropathy
   b. Focal and segmental glomerulonephritis
   c. Acute glomerulonephritis
   d. Membranous glomerulonephritis
   e. Minimal change disease

Answer 1

a. Diabetic nephropathy

Question 2

A 60-year-old man with a 17-year history of type 2 diabetes mellitus visits a clinic because of increasing swelling in his lower
extremities. The swelling began approxi mately 7 months previously and has worsened over the past 6 to 8 weeks. The patient reports no recent ill nesses and specifically denies any fever, chills, arthralgias,
joint swelling, or skin rash. In addition, he reports no visual changes, epistaxis, hemoptysis, or cough. The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and an a ppendectomy.
His medications include g lyburide 10 mg daily10 mg daily, and ibuprofen occasional ly. He does not abuse alcohol, tobacco, or illicit drugs. No family history of kidney d isease is present, although several of his family members have diabetes mellitus
and heart d isease. His physical exami nation reveals a healthy-appearing man in no acute distress. He has 3+ pitting edema up to
the midcalf. His glomerular biopsy shows the lesion below (Fig. 2-5).

2. What is the most appropriate treatment?
   a. Administer more amlodipine for better control of blood
   pressure
   b. Begin insulin therapy for better glycemic control
   c. Initiate therapy with an angiotensin-converting enzyme
   inhibitor
   d. Restrict dietary protein to 0.6 g/kg body weight per day

Answer 2

b. Begin insulin therapy for better glycemic control

Question 3

A 60-year-old man with a 17-year history of type 2 diabetes mellitus visits a clinic because of increasing swelling in his lower
extremities. The swelling began approxi mately 7 months previously and has worsened over the past 6 to 8 weeks. The patient reports no recent ill nesses and specifically denies any fever, chills, arthralgias,
joint swelling, or skin rash. In addition, he reports no visual changes, epistaxis, hemoptysis, or cough. The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and an a ppendectomy.
His medications include g lyburide 10 mg daily10 mg daily, and ibuprofen occasional ly. He does not abuse alcohol, tobacco, or illicit drugs. No family history of kidney d isease is present, although several of his family members have diabetes mellitus
and heart d isease. His physical exami nation reveals a healthy-appearing man in no acute distress. He has 3+ pitting edema up to
the midcalf. His glomerular biopsy shows the lesion below (Fig. 2-5).

3. In what stage of chronic kidney disease is this patient?
   a. 2
   b. 3AI
   c. 3B
   d. 4
   e. 5

Answer 3

3. C

Question 4

A 39-yea r-old female suddenly noti ces her urine is a
dark smoke calor and she feels general malaise. Her urine output is
decreased and she has edema with puffy eyelids. Her blood pressu re
has become elevated. She has a history of systemic lupus erythematosis, but her urinary symptoms, edema, and hypertension are new; so
she goes to see her physician. The physician orders a BUN, creatinine,
creatinine cleara nce test, and a urinalysis. Her resu lts are below:

1. Is this condition acute or chronic?
2. What do you suspect is her condition?
3. What are other conditions in this group?
4. What further tests could you do to confirm this?

Answer 4

1. Is this condition acute or chronic?
   - Acute
2. What do you suspect is her condition?
   - Rapidly progressive (crescentic) glomerulonephritis
3. What are other conditions in this group?
   - Acute poststreptococcal glomerulonephritis,
   Goodpasture syndrome
4. What further tests could you do to confirm this?
   - Look at the appearance of glomeruli in biopsy

Question 5

65-yea r-old female has a long history of m i croscopic hematuria and has had oliguria for a few yea rs. She has
been feeling fatigued and run down this past year and feels like
she has been getting worse for a few yea rs. She visits her physician
and he orders a BUN, creatinine, creatinine clearance test, serum
phosphorus, seru m lgA, and a urinalysis. Her resu lts a re below:

1. Is this condition acute or chronic?
2. What do you suspect is her condition?
3. What are the other conditions in this group?
4. Is the specific gravity significant in this case?
5. What additional problems does this urinalysis suggest?
6. What is the significance of broad and waxy casts?
7. Why might this patient have glucose in her urinalysis
   findings?

Answer 5

1. Is this condition acute or chronic?
   - Chronic.
2. What do you suspect is her condition?
   - Immunoglobulin A nephropathy (Berger Disease).
3. What are the other conditions in this group?
   - Any of the chronic glomerulonephritis diseases with an immunological component.
4. Is the specific gravity significant in this case?
   - It is not changed from that of the ultrafiltrate, suggesting loss of the ability to concentrate or dilute urine.
5. What additional problems does this urinalysis suggest?
   - Tubular disease is also present.
6. What is the significance of broad and waxy casts?
   - Broad casts indicate severe disease with the
   involvement of many nephrons as they are formed in the collecting duct and many nephrons are fed into each collecting duct. Waxy casts are an indication of chronic disease.
7. Why might this patient have glucose in her urinalysis findings?
   -From her chronic kidney disease, she has developed tubular dysfunction as well, and cannot reabsorb the glucose

Question 6

A 67-year-old female has a history of kidney and
circulatory problems and now has oliguria and ma rked edema.
She visits her physician and he orders a BUN, creati n i ne, creati nine
clearance test, blood lipid and albumin l evels, a urinalysis, and a
urine culture and sensitivity. Her resu lts a re below:

1. Is this condition acute or chronic?
2. What do you suspect is her condition?
3. Is the specific gravity significant in this case?
4. What additional problems does this urinalysis suggest?
5. What is the significance of waxy casts?
6. Are renal tubular epithelial cells seen in this condition?
   Why?
7. What are oval fat bodies?
8. What type of microscopy helps visualize fatty casts?
9. Why might this patient have glucose in the urinalysis
   findings?

Answer 6

1. Is this condition acute or chronic?
   - Chronic.
2. What do you suspect is her condition?
   - Nephrotic syndrome.
3. Is the specific gravity significant in this case?
   - It is not changed from that of the ultrafiltrate,
   which if it stays that way despite varying hydration conditions, suggests loss of the ability to concentrate or dilute urine.
4. What additional problems does this urinalysis suggest?
   - Tubular disease is also present.
5. What is the significance of waxy casts?
   -Chronic, severe kidney disease.
6. Are renal tubular epithelial cells seen in this condition? Why?
   - Yes, in nephrotic syndrome the renal tubular
   epithelial cells fill with lipids and slough off
7. What are oval fat bodies?
   - Oval fat bodies are cells (thought to be either renal tubular epithelial cells or foam cell macrophages), with birefringent fat droplets inside their cytoplasm. True oval fat bodies show a characteristic “maltese
   cross” formation when viewed under polarized light. Under low-power magnification, oval fat bodies
   are typically seen as dark spots depending upon the intensity of the microscopic illumination. This coloration is due to the yellowish brown pigmented fat making droplets. These fat laden cells are usually seen along with lipiduria and heavy proteinuria
8. What type of microscopy helps visualize fatty casts?

• Polarized microscopy.

9. Why might this patient have glucose in the urinalysis findings?
   - Tubular damage prevents reabsorption of glucose.

Question 7

A 5-yea r-old female has a history of previous lower
UTis. She suddenly becomes very ill and develops rust-colored uri ne,
burning, back pain, and fever. The physician orders a BUN, creati ni ne,
u rinalysis, and a urine culture and sensitivity. Her resu lts are below:

1. What is this patient’s condition?
2. What dipstick findings and what microscopic findings
   support this decision?
3. Is the patient’s history significant?
4. If the child were taking vitamins and extra vitamin C, could this interfere with the test results?

Answer 7

1. What is this patient’s condition?
   - Acute pyelonephritis.
2. What dipstick findings and what microscopic findings support this decision?

• Dipstick: 2+ protein, 1 + blood, 4+ leukocyte esterase, 4+ nitrate (of these, the leukocyte esterase and the nitrate especially correlate with a bacterial UTI). Blood and protein commonly accompany these findings as well

3. Is the patient’s history significant?
   - The past history of urinary tract infections goes along with pyelonephritis.
4. If the child were taking vitamins and extra vitamin C, could this interfere with the test results?

• Yes, vitamin C, a powerful reducing substance, can interfere with many urinalysis dipstick pad results, causing either false-negative or false-positive results.
  For this reason, the physician may ask that the
  patient temporarily refrain from taking vitamin C supplements while testing is needed.