STUDENT WORKBOOK

IN NEPHROLOGY

Department of Medicine
Faculty of Medicine
Sabaragamuwa University of Sri Lanka
First Edition 2021

2021 Department of Medicine

Faculty of Medicine
Sabaragamuwa University of Sri Lanka

ISBN 978-624-97640-2-6
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CLINICAL APPOINTMENT IN NEPHROLOGY

1. Name of the student

……………………………………………………………………………………………………………

2. Year passed GCE Advanced level Examination.

………………………………………………………………………………………………………….

3. Duration of the appointment

From………/………/…………. To ……../………/………….

4. Name of the consultant

…………………………………………………………………………………………………………
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CONTENTS

CHAPTER Page

Preface 4

Authors 5

1. Introduction 6

2. Core Clinical Knowledge and Skills 9

3. Taking History from a Patient with a Renal Disease 11

4. Examination of a Patient with Renal Disease

16

5. Common Investigations 18

6. Exercises 23

7. Case Based Scenarios 31

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PREFACE

Students of the Faculty of Medicine, Sabaragamuwa University of Sri Lanka, study

nephrology as a separate appointment of one week at Teaching Hospital Ratnapura. During
this period, they will be attached to the nephrology unit under the consultant Nephrologist
appointed by the Ministry of Health.

This workbook in nephrology is compiled to help students achieve essential knowledge and
skills in nephrology expected from an undergraduate when they qualify to work in medical
wards as intern house officers. Thus, the workbook will guide the student during their
nephrology short appointment.

This Workbook is a joint effort between academic staff of the Department of Medicine, SUSL
and the current Consultant Nephrologist of the Teaching Hospital Ratnapura. Students are
expected to organize their classes and do self-studies in order to complete the tasks set out
in the Workbook.

We value your feedback to improve the Workbook.

Dr Udayangani Ramadasa
Dr Champika Gamakaranage
Professor Saroj Jayasinghe
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AUTHORS

Dr. Champika Gamakaranage (CG). MBBS, MD (Col), MRCP (Lond), FRCP (Lond)
Consultant Physician
Senior Lecturer (Grade I), Department of Medicine, Sabaragamuwa University of Sri Lanka

Dr. G. Udayangani Ramadasa (UR). MBBS, MD, FCCP, Dip Pall Med ( Clinical) RACP
Consultant Physician
Head and Senior Lecturer (Grade I), Department of Medicine, Sabaragamuwa University of
Sri Lanka

Dr. Jalitha Thinnarachchi (JT). MBBS, MD (Col)

Consultant Nephrologist
Teaching Hospital Ratnapura

Emeritus Prof. Saroj Jayasinghe (SJ). MBBS, MD, MD (Bristol), FRCP (Lond), FCCP, PhD (Col)
Consultant Physician
Consultant to the Department of Medicine, Sabaragamuwa University of Sri Lanka
Former Chair Professor, Department of Clinical Medicine, University of Colombo

Contribution
UR – Wrote the initial draft, compiled the history taking and examination sections and
updated all the sections
CG – Compiled the investigations and exercises sections and updated all the sections
JT – Assessed and updated all the sections
SJ – Conceptualized the production of this book, compiled mind map section and updated all
the sections

OTHER CONTRIBUTORS
Dr. K. S.N. Prasangani (KP) – Contributed with language editing
BA (Hons) in Languages (SUSL), MA in Linguistics (Kelaniya), PhD in Applied Linguistics
(UNIMAS, Malaysia)
Dr. U.U.K. Udumulla (UUK) – Contributed with designing mind maps and document editing
(MBBS), Demonstrator at Department of Medicine, Sabaragamuwa University of Sri Lanka.
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CHAPTER 1

INTRODUCTION

Dear Students,

We have prepared a series of workbooks to guide you during your medical appointments.
These include 3rd year workbook, 4th year workbook and workbook for each short
appointment and a workbook for the professorial appointment.

The appointments in finer specialties are organized based on the University Grants
Commission guidelines and according to the needs of the Ministry of Health.

The short appointment in Nephrology will give you the opportunity to

study Nephrology with exposure to specific case scenarios in more detail. This workbook is
prepared to provide guidance to the students during the Nephrology appointment to cover
the essential areas expected from an undergraduate. You are expected to learn the
management plans in further detail. This includes the investigation, treatment of common
medical conditions, management of common emergencies, which are essential clinical topics
for an intern medical officer. This knowledge, skills and experience you gather during the
short appointments will help you to understand patient problems in greater depth.

Your continuous assessments will be based on these workbooks.

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Learning Outcomes in Nephrology

At the end of the appointment students should be able to

1. Describe the anatomy and physiology of the nephron-urological system,

pathogenesis of its disorders and scientific basis of their management.

2. Obtain histories, elicit physical signs and interpret physical signs, describe
pathophysiology, principles of management and prognosis of patients having the
following conditions.
a. Acute kidney injury,
b. Chronic Kidney disease including
c. Diabetic nephropathy
d. CKD of unknown origin
e. Glomerulonephritis
f. Nephritic and nephrotic syndrome
g. Infections of urinary tract
h. Systemic diseases with renal manifestation
i. Malignancies of Genito-urinary system (Part of this will be covered
during Urology and oncology appointments)
j. Disorders of fluid, electrolyte and acid base disorders.

3. Arrive at a clinical diagnosis of disorders of the nephro-urological system.

4. Describe the indications, limitations and be able to interpret findings of

investigations that are relevant.
a. urinalysis
b. urine culture
c. blood urea and serum creatinine estimation
d. creatinine clearance
e. X-ray Kidney-Ureter-Bladder (KUB)
f. Ultrasound scanning of the abdomen
g. Intravenous urogram
h. CT of the renal system
i. Renal biopsy
The following investigations will be covered in Radiology and Urology appointment
j. Micturating cysto-urethrogram (MCUG)
k. DTPA/DMSA scan
l. basic cystoscopy findings
m. Renal arteriogram

5. Describe the indications, preparations, basic procedure of renal biopsy and

competent in managing post renal biopsy complications.
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6. Communicate with patient on renal diseases, especially in relation to obtaining

consent for investigations and treatment, prognosis of common renal disorders, and
those related to renal replacement therapy and renal transplant.

7. Identify the indications, describe the necessary preparations and perform under
supervision the following procedures.
a. collection of urine for microscopy and culture ABST.
b. maintenance of a fluid balance chart
c. analysis of urine for reducing substances, protein.
d. collection of urine from a catheterized patient.

The following procedures will be learnt in Urology appointment.

e. digital examination of the rectum to evaluate the prostate gland.
f. urethral catheterization in a model
g. suprapubic puncture in a model

8. Write case notes, daily status, referrals, discharge summaries, clinic notes and
prescriptions.

9. Demonstrate empathy and maintain high ethical standards especially with regards
to the ethics of renal replacement therapy and kidney donations.

10. Be an effective member of the healthcare team and know the health facilities and
social support available to care for renal disorders in Sri Lanka.
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CHAPTER 2

CORE CLINICAL KNOWLEDGE AND SKILLS

At the end of the nephrology appointment, you should be competent in the technique of
history taking, physical examination (general examination and examination of abdomen) and
clinical reasoning at a level of a student about to enter the Final Year.
In addition to the cases you are allocated during the apppointment, you are adviced to see
the following presentations given in the next section on “Topics to cover during Nephrology
Appointment”

2.1 Clinical Presentations: Nephrology appointment

These are some of the key presentations that ought to be ‘covered’ during the Nephrology
Appointment.
• Oliguria, anuria and polyuria
• Dysuria
• Microscopic haematuria
• Active urinary sediment
• Bland urinary sediment

2.2 EMERGENCIES

Following is a list of common nephrological emergencies.

1. Acute Kidney Injury (AKI)
2. Acute glomerulonephritis (Mainly RPGN)
3. End-stage chronic kidney disease with volume overload
4. Hyperkalemia with Kidney disease
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2.3 Topics in Nephrology

These topics are often termed as the theoretical aspects of nephrology and require didactic
teaching (e.g., lectures) or self-study using standard textbooks.

1. Common clinical presentations

2. Acute renal failure (Acute kidney Injury)
3. Chronic renal failure (chronic kidney disease)
4. Urinary tract infections
5. Glomerular diseases 1 (AGN, CGN)
6. Glomerular disease 2 (Nephrotic syndrome)
7. Diabetic nephropathy
8. AKI and glomerular diseases: an overview (repeat)
9. Chronic Kidney Disease (CKD): an overview (repeat)
10. Renal replacement therapy (Dialysis and transplantation)
11. Ethical issues related to renal transplantation (Donor selection, Consent etc.)
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CHAPTER 3

HISTORY TAKING

MEDICAL HISTORY OF A PATIENT WITH A RENAL DISEASE

PRESENTING COMPLAINT

Patient with a renal disease could present with a variety of urinary complains such as
polyuria, oliguria, anuria, increased frequency, difficulty in passing urine or dysuria. Some of
them might come with haematuria, dark urine, incontinence, urgency, hesitancy, or
dribbling.
There may be patients with loin pain, loin to groin pain, lower abdominal pain. There could
be associated fever, nausea or vomiting. Patient with chronic renal disorders could present
with more generalized complains such as fatigue, anorexia, weight loss, pruritus or restless
legs.

HISTORY OF PRESENTING COMPLAINT

If the patient presented with loin pain ask about the exact site, radiation of the pain, the
character of the pain such as dull, aching or colicky pain, unliteral or bilateral, whether it was
acute onset or sub-acute onset or a chronic pain and the duration. Ask whether there are
any aggravating or relieving factors.
Question patients about associated features such as hematuria, increased frequency,
dysuria, fever, chills or rigors.
Ask questions to find out etiology such as history of poorly controlled diabetes, renal stones
or any procedures such as cystoscopy, urinary catheterization or insertion of ureteric stents.
By now you would have come to a clinical diagnosis or differential diagnosis.

SYSTEMIC INQUIRY

Systemic inquiry is to identify symptoms you forgotten to ask in the history of presenting
complain.

• Cardiovascular: Chest pain, shortness of breath, palpitations

• Respiratory: difficulty in breathing, cough or sputum production
• Gastrointestinal: abdominal pain, loose stools, constipation
• Neurological: altered level of consciousness, drowsiness, poor sleep, convulsions,
peripheral neuropathy
• Musculoskeletal: muscle wasting, muscle cramps, muscle weakness, mono or oligo
arthritis
• Dermatological: uraemic frost, scratch marks, dry skin, skin infections or healed scars
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PAST MEDICAL HISTORY

Ask about any medical condition which could be an etiology or chronic long-standing disease
not relevant to the presenting problem, such as diabetes, hypertension, any renal disease or
Genito urinary surgeries or procedures.
Ask about more details of systemic diseases such as the control of the disease, duration,
complications and any hospital admissions.
Ask about connective tissue disorders such as SLE, history of snake bite, any other disease
which has affected renal function (e.g., Stroke/Migraine, snake bite, past history of calculi).

ALLERGIES

Find out allergies to food or medications and if present what type of reaction such as mild
itchy rash or Angio oedema or anaphylaxis.

DRUG HISTORY

Ask about drugs that use long-term for chronic systemic diseases or any drug which could be
nephrotoxic such as NSAIDS or drugs which could not prescribe in patients with advanced
renal disease such as ACE inhibitors, Metformin. Ask about prior use of antibiotics if
suspected to have urinary tract infections.
Ask about drugs which cause hyperkalaemia and cough with ACEI. Also, history of native
treatments.

FAMILY HISTORY

Find out about diseases which has genetic predisposition such as polycystic kidney disease,
malignancies and early deaths due to strokes.

PERSONAL AND SOCIAL HISTORY

Find out the financial and social status of the patient, carers at home and the wellbeing of
the carers and their ability in coping with a patient with a chronic renal disease who might
need renal replacement therapy.
Depending on the patient’s ability to get done activities of daily living independently, assess
the house hold environment, support of carers.
Smoking
Record the history of smoking and pack years of tobacco use.
Alcohol
Type, volume, duration and the frequency of alcohol use and the dependency.
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Diet and fluid intake

Need to be assessed relevant to the renal disease and the stage of the disease, level of
serum potassium, calcium and phosphate. Ask about toilet type and access to road, distance
to hospital and transport facilities, pets at home and water source (running tap water, wells,
tube wells, streams and type of filter if any.
Occupational history
Occupation is important to find out risk for further renal damage, whether patient is capable
in continuing his job further. Financial status of the family, the ability to access the renal
replacement therapy, transport and possibility of renal transplant in case of end stage renal
disease.
Ask about the occupation whether gem mining, farming in paddy fields, sewage workers as
there is risk of exposure to Leptospirosis or Hantavirus infection.
Possibility of snake bite and whether has spend in high CKDu areas if so the period.
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SYMPTOM ANALYSIS

Presentation Causes Describe presentations which help you to

differentiate the causes

Oliguria or anuria 1

2.

3.

Polyuria 1.

2.

3.

Haematuria 1.

2.

3.

Proteinuria 1.

2.

3.

Dysuria 1.

2.

3.
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Following is a mand map developed to depict the key symptoms in nephrology and main causes of each symptom

UTI -Urinary Tract Infection, BOO – Bladder Out flow Obstruction, BPH – Benign Prostatic Hyperplasia, AKI – Acute Kidney Injury, ATN-Acute Tubular Necrosis, AGN – Acute Glomerular Nephritis, CLCD- Chronic
Liver Cell Disease
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CHAPTER 4

EXAMINATION OF A PATIENT WITH RENAL DISEASE

Look for following signs in the examination of a patient with renal disease other than your
routine examination.

General examination
Observe the patient whether dyspneic, wasted, any bedside catheters, if present, check the
volume and the colour of the urine.
See whether there is peritoneal dialysis catheter, nephrostomy tube.
Inspect the pallor, uremic smell, scratch marks, vasculitis rashes, bruises, or arteriovenous
fistulae.
Observe whether patient is fluid overloaded such as periorbital swelling and oedema of legs or
whether patient looks dehydrated.
Examination of hands may reveal, pallor, skin turgor, flapping tremors.
Examination of cardiovascular system- check blood pressure, jugular venous pressure, evidence
of cardiac failure such as gallop rhythm and evidence of pericardial rub.
Respiratory system – fine bi-basal crepitations or evidence of pleural effusion.

Examination of the abdomen

Inspection- Look for sacral edema, nephrectomy scars, peritoneal dialysis scars, any visible
masses in the renal angle and the suprapubic area

Palpation- Tender areas in all 9 quadrants, but specially in the loin area.
Distended bladder, ballotable kidneys

Percussion- Check for ascites

Auscultation- Listen for renal bruits

For the completion of your examination, perform digital examination of the rectum,
ophthalmoscopic examination of retina for hypertensive or diabetic retinopathy, Urine dipstick
for sediments.
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Presentation of a short case of a patient with a renal disease (given as examination of

abdomen)

History presentation is different from history taking. You may ask various questions and system
review when taking history. In contrast, you should state the important positive and negative
findings when presenting the history. In the same way examination should also be carried out in
details however you may select important positive and negative findings to present.

You will be given time to examine the patient and at the end of the allocated time you will be
prompted (e.g. ringing a bell) to conclude examination and present your findings to the
examiner. Always remember before leaving the patient after examining them, cover the clothes
that you exposed and thank the patient. Then you turn towards the examiner and make eye
contact with them. It is not appropriate to look at the patient again, time to time while you
present your findings to the examiner.

You may start presenting the findings on general examination, “I examined this middle-aged
man, who looks overweight and lying comfortably in the bed. He is pale, has a dry skin with
uraemic frost and has bilateral pitting ankle oedema up to his knees. There are half-half nails in
hands and feet but no demonstrable flapping tremors. There is an AV fistula over left arm and
cubital fossa, which is functional with a bruit and in his neck, there are few scar marks
suggestive of previous central venous line insertion. His jugular venous pulse is not elevated.”

You may proceed to present the findings of abdominal examination. “on inspection of the
abdomen, it looks distended with fullness in the flanks. Abdomen moves with respiration and is
symmetrical and has no scars. On palpation I could not feel the liver or spleen. There are
ballotable masses on both lumbar areas suggestive of enlarged kidneys. They are not tender.
There is flank dullness compatible with ballotable kidneys and no evidence of shifting dullness
to suggest the presence of ascites.”

You may present if additional relevant findings you gathered. “I extended my examination to
check the lung bases and listened to heart sounds. The lungs are clear and there is no murmur
heard at the precordium”

You may now conclude your findings and present the diagnosis or differential diagnosis you
have. “in conclusion, this patient has polycystic kidney disease with chronic kidney disease and
had been on haemodialysis and now has created a functioning AV fistula for long term
haemodialysis. He has evidence of ankle oedema without evidence of ascites and pulmonary
oedema and is not dyspnoeic at rest.”

Your examiner will ask questions based on this patient on the discussion part given after the
presentation.
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CHAPTER 5

COMMON INVESTIGATIONS

1) Urinalysis
a) Collect and paste or copywrite sample urinalysis results of following conditions and
highlight the characteristic features of each condition.
i) Culture positive UTI
ii) Nephrotic syndrome
iii) Acute glomerulonephritis
iv) Acute ureteric colic
v) Hypertensive emergency with nephrosclesrosis
vi) Acute tubular necrosis

b) How do you identify the significance of pyuria when you suspect UTI in men and
women?

c) What are the common causes of culture negative pyuria? (aseptic pyuria)

d) What are the common causes of painless and gross haematuria?

e) How do you quantify the proteinuria?

f) What are dysmorphic RBCs? How do you interpret the presence of them in urine?
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g) Draw or paste pictures of different types of casts seen in urinalysis and mention
possible causes for them.
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h) What are the different types of crystals you might see in urinalysis?

2) Serum Creatinine
a) Explain the pathophysiological basis of use of creatinine as a measure of kidney
function.

b) How do you calculate the GFR using serum creatinine value?

c) Explain how AKI is developed in rhabdomyolysis?

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3) Blood urea
a) Briefly explain clinical situations where blood urea is useful in diagnostic evaluation.

4) Serum electrolytes
a) What are the common causes of hyponatraemia?

b) What are the ways of replacement of sodium in a patient with hyponatraemia?

c) Mention common causes of SIADH

d) What are the principles of management of SIADH?

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e) Mention common causes of hyperkalaemia

f) How do you treat hyperkalaemia?

g) Paste a copy of an ECG with hyperkalaemic changes and demonstrate them.

5) Imaging of kidney, ureter and bladder (KUB)

a) Draw and explain the sizes, positions and anatomical relationships of kidneys, ureters
and bladder.
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b) How do you utilize the ultrasonographic findings to help diagnose following conditions?
Give the pathophysiological explanations.
i) AKI

ii) CKD

iii) Diabetic nephropathy

iv) Obstructive uropathy

v) Acute pyelonephritis

c) How do you prepare a patient for X-ray KUB?

d) What are the types of radiolucent renal/ ureteric stones?

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CHAPTER 6

EXERCISES

1) Meet a patient and obtain a history from a patient who had AKI and complete the
followings based on your patient.
a) Write the summary of a patient presented with AKI that you encountered.

b) List the common causes of AKI classifying them in to pre-renal, renal and post renal
causes.

c) Revise the pathogenesis of AKI and draw a diagram to summarize it

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d) What is the cause for AKI in your patient? Clinically reason out your answer.

e) Write down the immediate management plan implemented for the patient at
presentation.

f) Mention 5 drugs that are commonly used, and best be avoided or need dose reductions
in patients having AKI.

2) Meet a patient and obtain a history from a patient who had Acute Glomerular Nephritis
(AGN) and complete the following based on the patient.
a) Write a summary of the patients’ presentation (history and examination findings)
 P a g e | 26

b) What are the cardinal clinical features that your patient had, pointing towards the
diagnosis of AGN?

c) Revise the pathology associated with AGN and draw a picture of a glomerulus in AGN

d) What are the investigations done at the beginning, when the AGN is suspected?

e) Explain the significance of presence of dysmorphic red cells in AGN.

f) Mention common causes for AGN that were considered in your patient.
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g) State the management implemented on admission for your patient

3) Meet a patient and obtain a history from a patient who was diagnosed to have nephrotic
syndrome (NS)
a) Write the summary of the presentation.

b) State the diagnostic criteria of NS.

c) What are the likely complications of NS?

 P a g e | 28

d) Outline the initial management of your patient.

e) Explain the likely pathophysiological basis of development of NS in your patient

4) Study a patient presented acutely with worsening CKD, needing urgent haemodialysis (HD)
and answer the following questions based on your patient.
a) State the indication(s) to offer urgent HD for your patient.

b) What are the key clinical parameters that were recorded in your patient at the
presentation to ensure safety of the patient?

c) What are the important pre-HD preparations and checking carried out on your patient?
 P a g e | 29

d) What are the likely complications of HD?

e) How do you investigate further to find the cause for worsening of renal function?

5) Take a history from a patient being treated for pyelonephritis (PN) and complete the work
below.
a) What are the clinical features that supports a diagnosis of PN in your patient?

b) Write the investigations you would order for further care of your patient. Give reason(s)
for each investigation that you requested.

c) What are the conditions that could predispose to recurrent UTI?

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d) Mention the suitable antibiotics for the treatment of PN according to the current
national guidelines. State the pharmacological principles to choose those drugs.

6) Take a history from a patient with mild to moderate (non-end stage) diabetic nephropathy.
a) How do you conclude diabetic nephropathy on your patient?

b) What are the changes in the management that you should implement when you
diagnose the development of diabetic nephropathy in a diabetic patient?

c) Draw or paste the pictures of different stages of diabetic nephropathy and appreciate
the changes.

d) Briefly outline the management of diabetic nephropathy.

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7) Complete the following on renal replacement therapy (RRT)

a) What are the types of RRTs you know of?

b) What are the indications for hemodialysis?

c) How do you take consent from a patient undergoing HD for the first time?

8) Write Brief descriptions on following topics.

a) Hepato-renal syndrome

b) Contrast nephropathy

c) Post-streptococcal glomerular nephritis.

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CHAPTER 7

CASE BASED SCENARIOS

In this section we expect you to write case histories (5 cases as complete documentations) of
patients that you encountered during your nephrology appointment.
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This book is reviewed and recommended as a teaching and learning material for the
Department of Medicine, Faculty of Medicine Sabaragamuwa University of Sri Lanka, by the
following experts,
1. Dr. Niroshan Lokunarangoda

MBBS (Col). MD Medicine (Col), MRCP(UK), PGCME(Col),

MRCP (Acute Medicine), MSc (Med Toxicology). MRCP (London), FRCP(Edin)
Head and Senior Lecturer and consultant Cardiologist
Department of Medicine
Rajarata University of Sri Lanka

2. Dr. Dumitha Govindapala

MBBS. MD (Col). MRCP (UK). FRCP (Lon). FACP (USA)
Head and Senior Lecturer and consultant Physician
Department of Medicine
Faculty of Medicine
General Sir John Kotelawala Defence University, Sri Lanka
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ISBN 978-624-97640-2-6