Clinical Cases Uncovered Nephrology PDF
16.08 MB PDF
Renal medicine is often viewed as a complex, ‘ hard- core ’ medical specialty, mastered by a small minority of intellectual physicians. The lasting impression of many medical students (and indeed non – renal specialists) is of a list of glomerulonephritides (GNs), which have random and difficult names and blur into one incomprehensible mass. In reality, nephrology is actually relatively simple and logical.
In the first section of the book, I have provided a broad introduction to nephrology. Where possible, I have tied together a clinical presentation with underlying pathology and immunology, using diagrams to distil the important points. I have also provided an ‘ ABC of GN ’ , which offers a simple framework in which to place the GNs so that they can be understood.
The main part of this book consists of 31 cases, which have been chosen because they reflect the bread and butter of day – to – day life as a nephrologist. Nephrology is a fantastic specialty which allows the physician to deal with a wide variety of clinical problems, ranging from the critically unwell patient with acute renal failure to those with multisystem immune – mediated disease or tubular dysfunction, and those with chronic disease who we sometimes look after for decades on dialysis or following transplantation. For the junior doctor on a 4 – month renal attachment (or even the junior renal trainee), the cases I have presented will be surprisingly similar to those which you see (and the questions that follow will reflect those which your consultant will ask). For the purposes of clarity, the cases are divided into seven sections according to clinical presentation: those presenting with acute renal failure, nephrotic syndrome, hypertension, urine dipstick abnormalities, acid – base disturbances, chronic kidney disease/dialysis – associated problems and renal transplant- related problems.
The kidneys are often involved in diseases which are primarily the remit of other specialties, for example, infectious diseases, oncology or haematology. Thus, the renal physician needs to maintain a breadth of medical knowledge, and is perhaps one of the few remaining generalists. This is deliberately reflected in some of the cases, whose presentation begins with a symptom or sign which appears unrelated to the kidneys. As a result, this book will also help you polish up on some basic general medical facts.
Another concept which I have tried to convey in this text is that the kidneys are ‘ sensitive ’ organs, and can frequently become acutely dysfunctional in the context of a variety of pathologies. Thus, all doctors, regardless of their specialty or career choice, will encounter patients with acute renal failure (acute kidney injury). On the average ‘ medical take ’ or surgical/orthopaedic ward, there will always be a handful of patients with acute renal failure. These patients can be very unwell but if managed promptly and appropriately, may regain their renal function. These are typified by the 10 cases of acute renal failure, starting with common causes and moving to rarer, to illustrate the principles of investigation, management and diagnosis of this important problem.
Chronic kidney disease (CKD) is now widely diagnosed, due to the increased availability of measurements of renal function, in particular eGFR. General practitioners need to be aware of the complications associated with CKD and the appropriate time for referral to nephrology services. I have therefore presented a number of cases of patients with CKD, which touch upon the practicalities of managing associated complications and of providing renal replacement therapy for the increasing number of patients diagnosed with CKD. For those with CKD reaching end – stage renal failure, dialysis and renal transplantation are no longer limited to the lucky, ‘ fit’ few but are available to all. Very few textbooks provide practical advice on the management of these patients and I hope that students (and junior doctors) asked to deal with these chronic nephrology patients will find the cases in this book of genuine practical use. On a more pragmatic note, patients with CKD are often well with stable clinical signs and are therefore frequent attendees at student clinical examinations (with an arteriovenous fistula, palpable kidneys or a transplanted kidney). This text should allow you to really fl y through those stations of the exam. The MCQs, EMQs and SAQs also provide practical help to test your nephrology knowledge prior to examinations.
In summary, nephrology need not be feared and can be understood. Over the last 10 or so years, I have taught many students clinical medicine at the bedside. There is no substitute for this but in this text, I have tried to recreate some of these cases in an attempt to convey some of the important concepts and, I hope, to make renal medicine accessible to all.
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