Section 5: Nephrotic Syndrome, Other Primary Renal Disorders, Proteinuria, ESRD, ETC

Question 1

Features of nephrotic syndrome

Answer 1

• Hyperproteinuria
• Hypoproteinemia (Hypoalbuminemia)
• Hyperlipidemia
• Edema

Question 2

Explain the pathophysiology of hyperproteinuria and hypoalbuminemia

Answer 2

When the damage becomes severe enough, the condition leads to the loss of more than 3.5 g per day of protein in the urine. When this happens, albumin levels in the blood fall, and there is also edema

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7798-7803). . Kindle Edition.

Question 3

Expalin the pathophysiology of hyperlipidemia in Nephrotic syndrome

Answer 3

Hyperlipidemia is a part of nephrotic syndrome. LDL and VLDL are removed from serum by lipoprotein signals. If the lipoprotein is lost in the urine with nephrotic syndrome, then the lipid levels in the blood rise

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7798-7803). . Kindle Edition.

Question 4

Explain the pathophysiology of thrombosis in Nephrotic syndrome?

Answer 4

Thrombosis can occur because of the loss of antithrombin, protein C, and protein S in the urine.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7798-7803). . Kindle Edition.

Question 5

Nephrotic syndrome

1. Best initial test
2. Next best best
3. Most accurate test

Answer 5

1. Urinalysis showing a markedly elevated protein level
2. Spot urine for a protein-to-creatinine ratio > 3.5: 1. The spot urine protein creatinine level is equal in accuracy to a 24-hour urine collection; 24-hour urine protein collection showing > 3.5 g of protein
3. Renal biopsy

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7808-7814). . Kindle Edition.

Question 6

State the type of Nephrotic syndrome on kidney biopsy in the following group of patients

1. Children
2. Adults, Cancers such as lymphoma
3. Hepatitis C
4. HIV, Heroin use
5. Unclear

Answer 6

1. Minimal change disease
2. Membranous
3. Membranoproliferative
4. Focal segmental
5. Mesangial

Question 7

Rx of Nephrotic syndrome

Answer 7

Steroids

Cyclphosphamide (if no response - decrease in urine protein after 12 weeks)

Question 8

List the steps for proteinuria evaluation

Answer 8

• Repeat the UA
• Evaluate for orthostatic proteinuria
• Get a protein/ creatinine ratio
• Perform a renal biopsy.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7851-7862). . Kindle Edition.

Question 9

How to confirm orthostatic proteinuria?

Answer 9

The first step to confirm orthostatic proteinuria is to split the urine. Do a morning urine for protein and then one in the afternoon. If protein is present in the afternoon and not in the morning, then the patient likely has orthostatic proteinuria

Orthostatic proteinuria does not need to be treated

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7851-7862). . Kindle Edition.

Question 10

List the indications for dialysis in end stage renal disease

Answer 10

• Hyperkalemia
• Metabolic acidosis
• Uremia with encephalopathy
• Fluid overload
• Uremia with pericarditis
• No renal failure, but patient has toxicity with dialyzable drug, such as lithium, ethylene glycol, or aspirin.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7867-7876). . Kindle Edition.

Question 11

List the other manifestations of uremia and their treatment

Answer 11

Hyperphosphatemia - Calcium acetate, calcium carbonate phosphate binders

Hypermagnesemia - Dietary magnesium restriction

Anemia - Erythropoietin replacement

Hypocalcemia - Vitamin D replacement

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 7879-7887). . Kindle Edition.

Question 12

CF of polycystic kidney disease (PKD)

Most common site of extrarenal cysts

Most common cause of death in PKD

Rx

Answer 12

• Recurrent hematuria
• Stones
• Infections

There are cysts throughout the body, such as in the liver, ovaries, and circle of Willis; mitral valve prolapse; and diverticulosis.

The most common site of extrarenal cysts is the liver.

The most common cause of death is end-stage renal disease

No specific Rx

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 8181-8185). . Kindle Edition.

Question 13

Presentation, diagnostic test and treatment of urge incontinence

Answer 13

Pain followed by urge to urinate

No relationship to coughing, laughing, or straining

Urodynamic pressure monitoring

Behavior modification

Anticholinergic medications

• Tolterodine
• Trospium
• Darifenacin
• Solifenacin
• Oxybutynin

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 8196-8216). . Kindle Edition.

Question 14

Presentation, diagnostic test and treatment of stress incontinence

Answer 14

No pain

Brought on by coughing and laughing

Observe leakage with coughing

• Kegel exercises
• Estrogen cream

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 8196-8216). . Kindle Edition