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09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
09.26.08: Course Introduction
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09.26.08: Course Introduction

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Slideshow is from the University of Michigan Medical School's M2 Renal sequence …

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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  • 1. Attribution: University of Michigan Medical School, Department of Internal MedicineLicense: Unless otherwise noted, this material is made available under the terms ofthe Creative Commons Attribution–Noncommercial–Share Alike 3.0 License:http://creativecommons.org/licenses/by-nc-sa/3.0/We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use,share, and adapt it. The citation key on the following slide provides information about how you may share and adapt thismaterial.Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions,corrections, or clarification regarding the use of content.For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or areplacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to yourphysician if you have questions about your medical condition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  • 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. RENAL SEQUENCE 9/26 - 10/13 2008Fall 2008
  • 4. Case 1: Tragic Misdiagnosis25 y.o. female presents complaining of fatigue and mild jointpain. Routine urinalysis with a dipstick shows proteinuria andmicroscopic 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 Misdiagnosis25 y.o. female presents complaining of fatigue and mild jointpain. Routine urinalysis with a dipstick showed proteinuria andmicroscopic 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 Study75 yo female (45 kg) complaining of intermittent chest pains isadmitted to the hospital for cardiac catheterization. Creatinine is1.7 mg/dl. Following the study, patient is noted to havedecreased urine output, and over the next three days hercreatinine progressively increases to 5.5.
  • 7. Case 2: Problems After a Diagnostic Study75 yo female (45 kg) complaining of intermittent chest pains isadmitted to the hospital for catheterization. Creatinine is 1.7mg/dl. Following the study, patient is noted to have decreasedurine output, and over the next three days her creatinineprogressively increases to 5.5.Dx: Contrast-induced acute renal failure in a patient atincreased risk because of reduced renal function. Renalfunction declines with age and at 45 kg she has relatively smallmuscle mass, lowering creatinine production. The creatinine of1.7, therefore, represents not a minimally elevated value, but,rather one indicative of substantially decreased baselineglomerular filtration.
  • 8. Case 3: Life Threatening HyperkalemiaA 35 y.o. female with 20 year history of Type I diabetes andhypertension is hospitalized for treatment of a cellulitis.Creatinine - 2.5 mg/dl, K+ 4.8 mEq/L, BP 150/100. The internstarts enalapril (angiotensin converting enzyme inhibitor) andatenolol (beta-blocker).Three days later, BP is well-controlled at 115/70, but morningchemistries return with a K+ is 6.8 and EKG shows peaked Twaves and widening of the QRS complex. Urgent treatment forhyperkalemia is started.
  • 9. Case 3: Life Threatening HyperkalemiaA 35 y.o. female with 20 year history of Type I diabetes andhypertension is hospitalized for treatment of a cellulitis.Creatinine - 2.5 mg/dl, K+ 4.8 mEq/L, BP 150/100. The internstarts enalapril (angiotensin converting enzyme inhibitor) andatenolol (beta-blocker).Three days later, BP is well-controlled at 115/70, but morningchemistries return with a K+ is 6.8 and EKG shows peaked Twaves and widening of the QRS complex. Urgent treatment forhyperkalemia is started.Dx: Hyperkalemia secondary to inhibition of aldosteroneproduction by angiotensin converting enzyme inhibitor and shiftof potassium out of cells by beta-blocker in the setting ofpreexisting decrease of kidney clearance function and lack ofinsulin.
  • 10. Case 4: A missed treatment opportunityA 77 y.o. man has a renal scan for assessment of hypertensionand a small area of increased tracer uptake is seen in the leftupper pole, so he is referred for a CT scan, which shows a smallundulation 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 possiblediverticulitis shows a 1.7 cm heterogenously enhancing mass inthe posterior left upper kidney and a noncalcified subpleuralnodule in the right middle lobe. What is going on?
  • 11. Case 4: A missed treatment opportunityA 77 y.o. man has a renal scan for assessment of hypertensionand a small area of increased tracer uptake is seen in the leftupper pole, so he is referred for a CT scan, which shows a smallundulation 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 possiblediverticulitis shows a 1.7 cm heterogenously enhancing mass inthe posterior left upper kidney and a noncalcified subpleuralnodule 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 thesubsequent three years, changing a completely curable lesioninto one with a much poorer prognosis.
  • 12. DIALYSIS UNIT VISIT SIGNUP: DATE: ________________12:00 - 1:00 p.m. 1. ____________________Mon. 10/6 2. ____________________Tues. 10/7Wed. 10/8 3. ____________________Thurs. 10/9 4. ____________________This is a patientcontact activity, so 5. ____________________please dressappropriately and 6. ____________________bring a white coat. 7._____________________ 8. ____________________
  • 13. •  Syllabus - Power Point format used throughout.•  Web site - CTools M2 page has all Power Point materialfrom the syllabus as Acrobat PDF files and will have updatesand additions.
  • 14. •  Syllabus - Power Point format used throughout.•  Web site - CTools M2 page has all Power Point materialfrom the syllabus as Acrobat PDF files and will have updatesand additions.•  Introduction to Pathology, Urinalysis labs, and Electrolyteproblems are web-based teaching exercises available viaCTools.
  • 15. •  Syllabus - Power Point format used throughout.•  Web site - CTools M2 page has all Power Point materialfrom the syllabus as Acrobat PDF files and will have updatesand additions.•  Introduction to Pathology, Urinalysis labs, and Electrolyteproblems are web-based teaching exercises available viaCTools.•  Grading Quiz – 10/3-10/5 - Fluid and electrolytes only - 30% Attending and submission of answers to small groupproblem sets on 10/10 - 5% Laboratory practical - 10/10–10/13 - 10% Written final - 10/10–10/13 - 55%
  • 16. Course Texts (not required)!Renal Physiology, 3rd edition by Bruce M. Koeppen andBruce A. Stanton, Mosby, 2007
  • 17. Course Texts (not required)!Renal Physiology, 3rd edition by Bruce M. Koeppen andBruce A. Stanton, Mosby, 2001Renal Pathophysiology, The Essentials, 2nd Edition Rennkeand Denker, J.B. Lippincott and Co. 2006
  • 18. Image of the recommended book for the course: Renal Pathophysiology, The Essentials, 2nd Edition Rennke and Denker, J.B. Lippincott and Co. 2006 removed
  • 19. Course Texts (not required)!Renal Physiology, 3rd edition by Bruce M. Koeppen andBruce A. Stanton, Mosby, 2001Renal Pathophysiology, The Essentials, 2nd Edition Rennkeand Denker, J.B. Lippincott and Co. 2006Robbins 7th editionPrimer on Kidney Diseases, 4rd Edition, National KidneyFoundation, 2005
  • 20. 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
  • 21. Source UndeterminedSource Undetermined
  • 22. Source Undetermined
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  • 24. Source Undetermined
  • 25. 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 columnPiotr Michael Jaworski (Wikipedia)
  • 26. Gray s Anatomy
  • 27. Source Undetermined
  • 28. Source Undetermined
  • 29. Faber, Kupin, Krishna, and Narins
  • 30. Image illustrating the changes of epithelium along the nephron removedFig 2-3
  • 31. Regents of University of Michigan
  • 32. Source Undetermined Source Undetermined
  • 33. Source Undetermined
  • 34. Image illustrating similarities between the epithelial cells of the distal tubuleand collecting duct removed Source Undetermined Figure above showing an epithelial cell of Distal Tubule (similar to collecting tubule epithelial cell)
  • 35. Image illustrating the difference between principal cells andintercalated cells in the collecting duct removed Source Undetermined Collecting Duct
  • 36. Source Undetermined
  • 37. Source Undetermined Source Undetermined
  • 38. Source UndeterminedSource Undetermined Source Undetermined
  • 39. Source Undetermined Source Undetermined
  • 40. Yassiin Mrabet (Wikipedia) Patrick Glanz (Wikipedia)
  • 41. Newslighter (Flickr)
  • 42. Image illustrating a kidney surgical procedure removed
  • 43. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicySlide 31: Source Undetermined; Source UndeterminedSlide 32: Source UndeterminedSlide 33: Source UndeterminedSlide 34: Source UndeterminedSlide 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.htmlSlide 36: Gray s AnatomySlide 37: Source UndeterminedSlide 38: Source UndeterminedSlide 39: Faber, Kupin, Krishna, and NarinsSlide 41: Regents of University of Michigan, CC: BY-SA-3.0 http://creativecommons.org/licenses/by-sa/3.0/Slide 42: Source Undetermined; Source UndeterminedSlide 43: Source UndeterminedSlide 44: Source UndeterminedSlide 45: Source UndeterminedSlide 46: Source UndeterminedSlide 47: Source Undetermined; Source UndeterminedSlide 48: Source Undetermined; Source Undetermined; Source UndeterminedSlide 49: Source Undetermined; Source UndeterminedSlide 50:Yassiin Mrabet (Wikipedia) http://en.wikipedia.org/wiki/File:Hemodialysis-en.svgCC: 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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