PANCE Blueprint Renal System (5%)

PANCE Blueprint Renal System (5%)

PANCE Blueprint Renal System (5%)

Follow along with the NCCPA™ PANCE Renal System Content Blueprint

  • 21 PANCE Renal System Content Blueprint Lessons
  • GU and Renal Exam
  • Renal System Pearls Flashcards
  • Picmonic™ Integrated Blueprint lessons
  • Content Blueprint high-yield summary tables
  • ReelDx integrated video lessons
  • PANCE NCCPA board review video lessons with Joe Gilboy covering acid/base and electrolyte disorder


  1. Renal Diseases (PEARLS)

  2. Acute Disorders (PEARLS)

    1. Glomerulonephritis (Lecture)

      Immune-mediated glomerular inflammation results in glomerular damage which results in urinary protein and RBC loss
      • Proteinuria, HTN, azotemia, oliguria (<400 ml urine/day), hematuria (RBC casts) hallmark, edema is not as much as nephrotic syndrome
      • Urinalysis: proteinuria < 3.5 grams per day, hematuria, RBC casts
      • Biopsy: hypercellular, immune complex deposition
      Etiologies of acute glomerulonephritis:
      • IgA Nephropathy (Berger disease): most common cause of acute glomerulonephritis worldwide - often affects young males within days  (24-48 hours) after URI or GI infection.
      • Postinfectious - Group A strep: 10-14 days after infection - diagnosed with ASO titers and low serum complement.
      • Membranoproliferative glomerulonephritis: due to SLE, viral hepatitis.
      • Rapidly progressive glomerulonephritis - crescent formation on biopsy due to fibrin and plasma protein deposition.
        • Goodpasture's syndrome: (+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide.
        • Vasculitis: lack of immune deposits (+) ANCA antibodies.
    2. Glomerular damage results in increased urinary protein loss
      • Proteinuria, hypoalbuminemia, edema, hyperlipidemia, edema is predominant feature, transudative pleural effusion
      • Urinalysis: proteinuria > 3.5 grams on 24-hour urinefatty casts, oval fat bodies
      • Biopsy: hypo-cellular minimal change disease loss of podocytes on microscopy
      The most common primary causes are:
      • Membranous nephropathy: most common in non-diabetic adults associated with malignancies.
      • Minimal change disease: 80% of nephrotic syndrome in kids. Responds to corticosteroids.
      • Focal segmental glomerulosclerosis:  obese patients, heroin, and HIV black males.
      The most common secondary causes are:
      • Lupus: both nephritic and nephrotic.
      • Diabetes: common cause of nephrotic syndrome and subsequent renal failure.
      • Preeclampsia
    3. Irritative voiding + Fever + flank Pain + nausea and vomiting + CVA tenderness
      • Organism: E. coli
      • Urinalysis: Bacteria and WBC casts
      • Outpatient: ciprofloxacin/levofloxacin +/- ceftriaxone IM
      • Inpatient: Ciprofloxacin/levofloxacin or imipenem for more severe disease
  3. Acute renal failure (ReelDx + Lecture)

    Acute tubular necrosis (ATN)
    • Etiology: Kidney ischemia or toxins
    • Urinalysis: Muddy brown casts. Renal tubular epithelial cells + High Urine Osmolality
    • FENa > 2%
    Interstitial nephritis
    • Etiology: Immune-mediated response
      • Drugs: PCN, sulfa, NSAIDs, phenytoin etc.
      • Immunologic and infectious disease: strep, SLE, CMV, Sjogren's, Sarcoidosis
    • Urinalysis: WBC casts and eosinophils
    • Etiology: IGA Nephropathy (Berger disease), postinfectious, membranoproliferative
    • Urinalysis: Oliguria, hematuria and RBC casts
  4. Chronic kidney disease

    CKD is a progression of ongoing loss of kidney function (GFR) defined as < 60 mL/min/1.73 m² or presence of kidney damage (proteinuria, glomerulonephritis or structural damage from polycystic kidney disease) for > 3 months.
    • Measurement of GFR is the gold standard - The Cockcroft - Gault formula (requires age, body weight, and serum creatinine) or Modification of Diet in Renal Disease equation
    • Etiology: Diabetes, hypertension, glomerulonephritis
    • Findings: Fatigue, pruritus, Kussmaul respirations, asterixis (flapping tremor), muscle wasting, broad waxy casts
  5. Congenital or structural renal disorders (PEARLS)

    1. Hydronephrosis

      Urine outflow obstruction causes renal distention
      • Treat underlying cause
    2. Narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia.
      • Renal Arteriography is Gold Standard for diagnosis
      • May hear a renal artery bruit on auscultation
      • Percutaneous transluminal angioplasty (PTA) plus stent placement or with surgical bypass of the stenotic segment
    1. Acid/Base Disorders (PEARLS)

      Average values "24/7 40/40"
      • 24 (HCO3, base) / 7.40 (pH) / 40 (CO2, acid)
      Respiratory Acidosis:
      • pH < 7.35, pCO2 > 45, HCO3 > 26
      • Lungs fail to excrete CO2 (Breathing too slow (holding onto CO2), pulmonary disease, neuromuscular disease, drug-induced hypoventilation - opiates, barbiturates)
      Respiratory Alkalosis:
      • pH > 7.45, pCO2 < 35, HCO3 < 22
      • Excessive elimination of CO2 (Breathing too fast (blowing of CO2), pulmonary embolism, fever, hyperthyroid, anxiety, salicylate intoxication, septicemia )
      Metabolic Acidosis
      • pH <7.35, pCO2 < 35, HCO3 < 22
      • Need to calculate anion gap: Anion Gap = Na – (Cl + HCO3-) = 10-16
      • Increased ion gap (>16): Addition of hydrogen ions (lactic acidosis (think metformin), diabetic ketoacidosis, aspirin overdose)
        •  MUDPILES:
          • Methanol
          • Uremia
          • Diabetic Ketoacidosis
          • Paraldehyde
          • Infection
          • Lactic Acidosis
          • Ethylene Glycol
          • Salicylates
      • Low anion gap (<16): Loss of bicarbonate (diarrhea, pancreatic or biliary drainage, renal tubular acidosis)
      Metabolic Alkalosis:
      • pH > 7.45, pCO2 > 45, HCO3 > 26
      • Loss of hydrogen (vomiting), bulimia, overdose of antacids, addition of bicarbonate (hyperalimentation therapy)
    2. Dehydration

    3. Hyperkalemia/hypokalemia

    4. Hyponatremia

      Hyponatremia / Hypervolemia: serum sodium of < 135 mmol/L
      • Presentation: Muscle cramps and seizures
        • Hypervolemic hyponatremia – CHF, nephrotic syndrome, renal failure, cirrhosis
        • Euvolemic hyponatremia – SIADH (Picmonic), steroids, hypothyroid
        • Hypovolemic hyponatremia – sodium loss (renal, non-renal)
      • Serum Na should be corrected slowly—by ≤ 10 mEq/L over 24 h to avoid osmotic demyelination syndrome
  6. Neoplastic Diseases of the Renal System (PEARLS)

    1. Renal cell carcinoma (Lecture)

      Classic triad of flank pain + hematuria + painless abdominal/renal mass
      • Renal clear cell carcinoma is the most common type (80%)
      • Transitional cell is the second most common type (20%)
      • Smoking is the most significant risk factor
    2. Wilms tumor (ReelDx + Lecture)

      Child with painless, unilateral abdominal mass with no other signs of symptoms, also known as nephroblastoma.

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