Kub guide without tos

Table of Contents

1. Introduction

2. Theme 1: Patient with Painful haematuria

3. Theme 2 : Patient with generalised edema

4. Theme 3: Patient with difficulty in passing urine

5. Theme 4: Patient with oliguria / decreased urine output

6. Theme 5: Patient with progressive rise in serum creatinine

7. Theme 6: Patient with renal transplant

8. List of Recommended Books

1

INTRODUCTION

This study guide includes KUB modules for the 2nd spiral. The duration of the module is four
weeks. The module will be delivered around six themes. Clinical cases have been developed
for each theme. These cases will be used as triggers to deliver the respective objectives, using
different learning strategies. Relevant research articles will be discussed in Journal club.
Learning Strategies:
Large group interactive sessions
These sessions are used to introduce the clinical theme and to discuss concepts in an
interactive manner utilizing audiovisual aids.
Small group discussions
Some of the objectives included in the curriculum, are discussed in small groups of 8-10
students. These sessions involve a facilitator who mainly controls the process. These
discussions are structured as reading the case scenario by students, brainstorming within the
group about the application of the learnt knowledge, and clarification of concepts by
facilitator.
Integrated practical sessions
Students are divided into groups which perform relevant practical in basic sciences and
clinical skill laboratories.
Self directed learning
Sufficient time is allocated for self directed learning.

2

The module asks you to plan your time right at the very beginning. So look at the following
tips which should help you to plan your time, to protect it from other distractions and to keep
up at the rate of two hours a day for just three weeks:

• Decide to give yourself the gift of 2 hours a day – you deserve it!

• Think about the times of day when you study best and when you know that you can close
the door, switch off your phone and just study – is this the morning, the evening or after
dinner?

• Talk with your friends, your room mate or your parents about how they could help you to
protect those hours of the day.

• Make sure that you have organized somewhere to study, to keep your books and to have
access to a computer . A desk with good lighting and a comfortable chair will help.

It’s as easy as that!

We hope that this study guide will help you organize the learning process during this
module.

Good Luck!

3

THEMES IN KUB Y3

1. Theme 1: Patient with Painful haematuria

2. Theme 2 : Patient with generalised edema

3. Theme 3: Patient with difficulty in passing urine & incontinence

4. Theme 4: Patient with oliguria / decreased urine output

5. Theme 5: Patient with progressive rise in serum creatinine

6. Theme 6: Patient with renal transplant

THEME 1
PATIENT WITH PAINFUL HEMATURIA

Case of Loin pain (addresses painful hematuria and UTI)

Presenting complaints:
A 40 year male presents to the ER with history of severe pain in his right loin for 2 day. He
also noticed that his urine had frank blood in it on two occasions. The pain radiated to the
groin and right testicle. He had fever on day of admission. There is history of slight nausea
and he vomited once before coming to the hospital.
Past History:
No previous history of such pain. No history of Diabetes Mellitus, Hypertension, or any other
significant illness.
His uric acid had been checked in the past and was found to be high.
Family History:
2 of his brothers have been treated for kidney stones in the past.
Social History:
He is a traffic warden. Non-smoker. Married and has 1child.
Drugs History:
None

ON EXAMINATION:
GPE: He is rolling in bed with pain. His BP is 160/100 mm Hg, pulse 110/ min. regular and
temp is 1000 F. He appears pale and sweaty.
Systemic examination:
Abdominal examination shows slight tenderness in the right lumbar region. Bowel sounds
reduced. There is no supra pubic mass or tenderness. Testicular examination is normal. Renal
punch is positive on the right side.
CVS: No abnormal finding.
Respiratory System and CNS: Unremarkable
Investigations:
CBC: Hb 14 gm/dl, WBC count 12,500 /cmm with 85% Polymorphs.
S Creatinine: 0.7 mg/dl (0.5-1.0 mg/dl)
Urine RE: Blood ++++, protein+, RBCs numerous/HPF, WBCs >25, Leukocyte esterase
positive, bacteria +
Further investigations: Next day
X-ray KUB, USG KUB, IVP.

4

Critical Questions:

1. What is the significance of high uric acid levels in this case?
2. Do we require urine C/S in this patient? Why?
3. How is the patient`s occupation related to his disease?
4. What is the significance of occupation on pathogenesis of this disease?
5. Is there any role of urine cytology in this case?
6. How is smoking related to the clinical presentation of a case of hematuria?

OBJECTIVES

KUB Y3 (3rd year)

Knowledge:
1. Describe the role of renal stones in UTI
2. Describe the microorganisms involved in UTI (Gm—rods incl.
Enterobacteriaciae) Enterococci, Staph. Saprophyticus and shistosomes.
3. Identify different types of UTI’s in adults, children, pregnant females and
compare complicated and uncomplicated UTI
4. Describe the role of different types of analgesia in managing renal colic.
5. List the common antibiotics used in the treatment of UTI’s.

Skills:

1. Take a detailed history of a patient with dysuria
2. Palpate kidneys
3. Instruct procedures for proper specimen collection of urine for UTI
4. Examine urine sediment under the microscope.
5. Perform urine dipstick test.
6. Interpret urine RE report
7. Identify microbial colonies on CLED Agar medium.

Attitudes:
1. Take consent for various procedures.
2. Recognize the need for pain assessment and relief.
2. Show respect to the patients
3. Demonstrate the principles of good communication skills.

THEME 2
PATIENT WITH GENERALIZED EDEMA

Case:

A 16 year old boy presented to the clinic with complaint of progressive generalized body
swelling for the past one year. Initially the swelling was limited to his face particularly
around the eyes but for the past few weeks it has involved the entire body.
Past History: Not significant
Social History: Student of 10th grade.
Family history: Not significant for any chronic disease.

5

GPE: Patient is appropriate for his age, height 168cm weight 84kg. Pulse 79/min,
BP135/80mmHg, RR 20/min. Pedal edema+++.

SYSTEMIC EXAMINATION:
Abdomen : Significant ascites
CVS: Unremarkable
Respiratory System: Chest exam is suggestive of pleural effusion

INVESTIGATIONS: Urine analysis with sp gravity of 1010, pH 6, protein ++++, blood nil,
WBC 0-1, RBC 0-1,
Serum creatinine 0.8mg/dl,
serumNa:132 mEq/l, serum K: normal, albumin was 2g/dl, total protein 6.1g/dl. LDL
cholesterol 200mg/dl.

Critical Questions(083)?

1. What are the possible reasons for elevated lipid levels in this case?
2. What is the importance of early diagnosis and morphological typing of the
disease?
3. What is the importance of dietary modifications in such a case?
4. What is the role of immunoflorescent studies in this type of clinical
presentation?

OBJECTIVES

KUB Y3 (3rd year)

Knowledge

1. Enlist renal causes of edema.
2. Describe the pathophysiology of edema formation.
3. List different types of diuretics and describe their mechanism of action and side effects.
4. Enlist drugs that can affect potassium levels and their mechanism of action

Skills:

1. Prescribe appropriate diuretics with
2. Examination of a patient for pitting and nonpitting edema.

THEME 3
PATIENT WITH DIFFICULTY IN PASSING URINE AND INCONTINENCE

Case

A 53y old male, comes to urology clinic with severe burning, increased frequency of
urination and urgency for last 6 days. For the last 1year he had to strain to begin urination.
The stream has gradually become weaker and he has a sense of incomplete emptying of

6

bladder. For last 3 months he also has to wake up many times at night to void. Sometimes he
dribbles and passes urine before reaching the toilet. This has been causing day time fatigue.
Past history:
well controlled diabetes mellitus - 10years.
Family history: Diabetes Mellitus
Social history: Businessman
Drugs history: Glibenclamide Tablet ,5mg, One daily

GPE: Temperature: normal; Pulse: 70/min; BP is 130/90 mm Hg, Respiratory rate: 16/min

SYSTEMIC EXAMINATION
CVS: Unremarkable.
Resp: Unremarkable.
CNS: Unremarkable
Abdomen:
Mild supra pubic tenderness; no urethral discharge; normal external urethral meatus ,testicles
normal size, non tender
Rectal Examination: Rectal tone and perianal sensations are normal Enlarged prostate with
rubbery feel, rectal mucosa is mobile, median groove palpable, upper limit cannot be reached,
no nodule or indurated area.

INVESTIGATIONS:
Urine RE: WBC: 1-2 /HPF, RBC: few, Bacteria : nil, Leukocyte Estrase :negative, Nitrite:
negative
Ultrasound: weight of prostate is about 50g; urinary volume: pre void 405 ml, post void
100ml; kidneys: normal size.
Serum Creatinine is normal.

1. Differentiate between prostatism and symptoms due to BPH?
2. What is the role of Serum PSA level in this patient?
3. What is the significance of tissue biopsy prior to TURP?

OBJECTIVES

KUB Y3 (3rd year)

Knowledge:

1. Differentiate between symptoms of UTI and urethritis.
2. Workup a differential diagnosis of urethritis.
3. Discuss the lab diagnosis of urethritis.
4. Correlate the clinical features of enlarged prostate gland with its patho-physiology.
5. Describe the various drugs used in treatment of Benign prostatic hyperplasia (BPH)
their mode of action and side effects.
6. List various causes of impaired Detrusor function and the effect of various drugs on
it.

Skills:

1. Identify Gonococci in urethral smear.

7

2. Take a good history to reach a diagnosis of the cause of incontinence.
3. Request appropriate investigations to identify cause of incontinence
4. Perform catheterization on a mannequin

THEME 4
PATIENT WITH OLIGURIA/ DECREASED URINE OUTPUT

Case ARF:

A 40 year old man is admitted with a 5 day history of passing less urine, following an acute
episode of diarrhoea. The GI symptoms have now settled. He has now noticed a decrease in
urine output for the last 4 days.

Past History: He is a known smoker (20 per day). He had an episode of fever with diarrhoea
and vomiting 10 days ago. He had a routine medical checkup 4 months ago and all his lab
investigations were normal.

Drug History: He is taking NSAIDs and antibiotics for fever.

GPE: Drowsy but arousable.
Vitals: BP is 80/50 mm Hg, temperature: 37.6 0C, pulse: 110/min, respiratory rate: 24/min.
Oral mucosa is dry, decreased skin turgor.
CVS: Unremarkable.
Resp: Unremarkable.
Abdomen: Unremarkable.
CNS: Drowsy, no focal deficits on motor examination.

INVESTIGATIONS:
Na 125 mmol/lit, K 3.5 mmol/lit, Bicarb 13 mmol/L, BUN 85mg/dl, Cr 7.0 mg/dl.
Urine examination shows: Protein trace, Blood negative, WBC: 8-10/HPF, RBC: nil.

1. What is the importance of recognition of the cause and early diagnosis?
2. What is the importance of maintaining of intake/output charts in this patient?
3. Is this disease treatable?

OBJECTIVES

KUB Y3 (3rd year)

Knowledge

1. Relate the history, clinical presentation and epidemiology of oliguria to various
causes leading to acute renal failure.
2. Describe drug induced Acute renal failure, and pathological mechanisms involved in
drug induced ARF
3. Develop a differential diagnosis of causes leading to ARF
4. Describe the role of dopamine, mannitol and diuretics in ARF
5. Enumerate basic principles of management of patients with ARF

8

Skills:

1. Perform Urinalysis with special reference to sediment
2. Take a detailed history and perform a detailed physical examination
3. List the principles of supportive therapy in an acutely ill patient
4. Visit dialysis unit to understand the principles of haemodialysis
5. Counsel the family of a critically ill patient.

THEME 5
PATIENT WITH PROGRESSIVE RISE IN SERUM CREATININE

Case:

A 55 year old woman, known diabetic and hypertensive, is referred to the renal outpatient
clinic. She complains of progressively increasing anorexia, nausea, shortness of breath on
exertion and has recently noticed ankle swelling.
Past History:
She has a history of ischemic heart disease, diabetic retinopathy and long standing
hypertension which is also poorly controlled. She had a serum creatinine done 1 year ago
which was 2.6 mg/dl.
Family History:
Her mother was also diabetic.
Social History:
She is a widow dependent on her son who is a cobbler.

GPE: Clinically she looks pale; Pulse:110/min;BP is 160/100 mm Hg, Respiratory rate :
26/min;JVP is raised, ankle edema is positive.

CVS: S1 +S2+A systolic murmur in apical region (flow murmur)
Resp: Examination of chest reveals basal crackles.
Abdomen: Unremarkable.
CNS: Unremarkable.

INVESTIGATIONS: Hemoglobin 8 gm/dl, Creatinine 8.0 mg/dl, BUN 60, K 5.8 mEq/l, Na
130 mEq/l, and Bicarb 14 mEq/l. Her Cholesterol is 300 mg/dl, Triglyceride 300mg/dl, HDL
30mg/dl, and LDL 135 mg/dl.

She was started on hemodialysis shortly afterwards.


1. What is the cause of her presenting complaints?
2. What is the importance of celebrating Kidney Day Internationally?
3. What other options are available for dialysis other than hemodialysis?
4. What advice would you give regarding protection of renal function in a patient
of DM & HTN?

9

OBJECTIVES

KUB Y3 (3rd year)

1. Enumerate causes of chronic kidney disease
2. Diagnose CKD on the basis of history, physical examination and lab findings.
3. State the principles of drug dosing in Kidney disease
4. List various radiological investigations useful in management of CKD , effect of contrast
on kidneys and strategies to prevent any harm.

Skills:

1. Take a good history of a patient with chronic kidney disease

THEME 6
Patient with Renal Graft Rejection

CASE
A Forty six year old female underwent renal transplant in November 1999 for end stage renal
disease secondary to hypertension. The donor was her healthy daughter.
The Human Leucocyte Antigen (HLA) profile of the patient and the donor was as follows:
HLA- Patient A11 A33 (19) B7 - B52 (5) BW4 - BW6
CW7 DR16 (2) - DR9, DR51
DQ5 (1) - DQ2
HLA- Donor A26 (10) - A33 (19). B7 - B38 (16), BW4 -BW6
CW4 - CW7, DR16 (2) - DR14 (6)
DR51 - DR52, DQ5 (1)

The pre-transplant investigations included:
T cell B cell cross match,
Autocrossmatch and T cell cross match by flowcytometery: Negative.
The patient was screened for ANA, ADNA, CMV antibody, HbsAg, Anti-HCV, Anti-HIV:
Negative.
G6PD deficiency or hemoglobinopathy was not found.
The immunosuppressant regimen was one dose of Interleukin (IL) -2 receptor antibody during
surgery, followed by cyclosporine, azathioprine and methyl prednisolone.
Postoperatively, the patient had a spike of fever with lowering of urine output which
improved with intravenous fluids.
Later, the hemoglobin and platelet count dropped below 9 gm/dl
and 178 x 109 / litre respectively.
The following day, the hematological and biochemical parameters showed further
deterioration, Hb dropped to 7.7 gm/dl, Platelet count dropped to 40x 109 /litre, WBC 14.7 x
109 /litre (Polymorphs 87%; Lymphocytes 9%; Monocytes 1%; Band cells 2%; myelocyte
1%; reticulocyte count 1%).
The peripheral blood smear showed fragmented red cells, burr cells and polychromatophilic
red cells.
There was no improvement in serum creatinine as it remained at 280micro mol /litre.
Coomb's test was negative.
Urine analysis revealed massive proteinuria and 7-8 red blood cells/HPF

10

The patient received platelet transfusion followed by plasmapheresis on 3-12-1999. Inspite of
this, serum creatinine increased to 300 micro mol/l An open renal biopsy of the allograft was
taken and at the operation the graft was congested, oedematous and swollen.
Histopathology revealed over 30 glomeruli in the biopsy specimen and all were distended
with platelet thrombi. The tubular lumina showed red cell and protein casts. The stroma was
oedematous. There was no tubulitis or vasculitis.
Based on the morphology, a diagnosis of Accelerated acute antibody rejection was made.
At this stage, a repeat TB cell cross match was done which proved to be negative again.
Cyclosporine, azathioprine and co-trimoxazole were withdrawn gradually. Mycophenolate
mofetil and methyl prednisolone were included in the treatment.
Plasmapheresis continued, but renal dysfunction persisted. The patient was maintained in
non-oliguric phase with frusemide.

On the 5th post-operative day, the patient needed haemodialysis and ultra filtration for fluid
overload and azotemia.
The platelet count rose to 100x109/litre, the hemoglobin level remained below 5gm/dl with
fragmented red cells in the peripheral blood.
A second dose of IL-2 receptor antibody was administered as scheduled. Pulse doses of
methyl prednisolon were also given.

A second biopsy was taken on 12-12-1999 since there was no improvement in the renal
function and uncontrolled hypertension. The renal biopsy at this stage showed similar
glomerular pathology as in the previous biopsy, but less in severity. There was tubulitis in
more than 25% of the tubular compartment involving more than 10% of the parenchyma.
Endotheleitis was present in one artery. The morphological diagnosis was Acute rejection.
The graft function improved temporarily, but deteriorated gradually in the next four months
with persistent renal dysfunction and uncontrolled hypertension. The patient succumbed to
the illness in May 2000.


1. What is the importance of doing the HLA crossmatch?
2. What are the social issues related to cadaver organ transplant?
3. What advice would you give regarding life style modifications to this patient?

OBJECTIVES

KUB Y3 (3rd year)

Knowledge:

1. State the basics of renal transplantation
2. Describe the mechanisms involved in rejection of grafts with reference to kidney.
3. Correlate the pathologic mechanisms of hyperacute, acute and chronic rejection to its
mode of clinical presentation .
4. Describe the use of immunosuppressant drugs for prevention of graft rejection,
complications of the therapy and their management.
5. Identify the ethical and legal issues related to tissue donation/sale of human organs.

11

RESOURCE MATERIAL

KUB Y3 (3rd year)

1. Basic & Clinical Pharmacology by Katzung (latest edition)

2. Davidson’s Principles and practice of Medicine (latest edition)

3. Bailey & Love’s Short Practice of Surgery (latest edition)

4. Warren Levinson`s Review of Medical Microbiology and Immunology (latest

edition)

5. Robbins and Cotran- Pathological Basis of Diseases 7th Ed.

(Chapters 6,7,20)

6. Current Medical Diagnosis & Treatment (latest edition)

Original articles:

1. Luis Alberto Batista,Peres1,Rubia Biela,Michelle Herrmann,Tiemi Matsuo2,Hi Kyung Ann,
Maurício T. A. Camargo,Noris R.S.Rohde, Vanessa S. M.Uscocovich. Epidemiological study of
end-stage renal disease in western Paraná. An experience of 878 cases in 25years. J Bras Nefrol
2010;32(1):49-54

1. Murai et al .Current Usage of Diuretics among Hypertensive Patients in Japan; The Japan Home
versus Office Blood Pressure Measurement Evaluation (J-HOME) Study;. Hypertens Res Vol. 29,
No. 11 (2006)

http://www.gamewood.net/rnet/renalpath/htm
http://library.med.utah.edu/WebPath/webpath.html#MENU

NOTE: Please do not restrict yourself to textbooks, make sure to look for the latest Best
Available Evidence and also consult other reference books.

12

PLEASE DON’T HESITATE TO CONTACT

Prof. Talat Ahmad
Professor, Pharmacology
Ext: 3403
e-mail: talatnishat@hotmail.com

Dr. Sameena Ghayur
Associate Professor, Pathology
Ext: 3761
e-mail:sameena.ghayur@yahoo.com

Dr Rifat Nadeem Ahmed
Assitant Professor, Pathology
Ext: 3761
e-mail:rifatnahmad @yahoo.com

Dr Abida Shaheen
Assitant Professor, Pharmacology
Ext: 3403
e-mail:abidashaheen97@yahoo.com

13

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