Hi!!
Anyone interested in discussing Nephro Questions???

#1
A 16-year-old man is evaluated before joining a high school.
His medical history is unremarkable and he takes no medications.
Family history is significant for breast cancer in his maternal grandmother and hypertension in his father.

On physical examination, pulse rate is 55/min and blood pressure is 106/62 mm Hg.

Lab:CBC and serum chemistry studies are normal.
Dipstick urinalysis reveals 2+ proteinuria and no blood, and microscopic analysis shows a bland urine sediment. Urinary protein–creatinine ratio is 1.2 mg/g.

Whats the most appropriate next step in this patient's evaluation?

#2
49 yr female with ESRD is evaluated for painful ulcers involving both legs. 6 months ago, she noted nodular lesions on the right thigh and then the left. These lesions became progressively more painful and developed into ulcerative lesions over several months. She also has DM2, atrial fib. and hypertension. She has been maintained on IHD for the past 6 years.
Medications are warfarin; aspirin, 81 mg/d; enalapril; metoprolol; atorvastatin; calcium carbonate; calcitriol; and erythropoietin.

On physical examination, pulse rate is 86/min and irregular and blood pressure is 140/90 mm Hg. She is obese.
There are necrotic ulcers covering most of the thighs bilaterally. Cardiac examination shows an irregularly irregular rhythm. The lungs are clear to auscultation. Abdominal examination is unremarkable. There is no peripheral edema.

Laboratory Studies
Hemoglobin 11.6 g/dL, Leukocyte count 15,000/µL Platelet count 326,000/µL INR 2.6
Sodium 136 mmol/L, Potassium 5.3 mmol/L, Chloride 105 mmol/L, Bicarbonate 19 mmol/L,
Calcium 2.52 mmol/L Phosphorus 2.84 mmol/L .

Whats the most likely diagnosis?
a) Calcinosis cutis
b) Necrrobiosis lipoidica diabetoricum
c) Calcific uremic arteriolopathy
d) Venous stasis ulcers
e) Warfarin-induced skin necrosis

nnavam wrote:
#2
49 yr female with ESRD is evaluated for painful ulcers involving both legs. 6 months ago, she noted nodular lesions on the right thigh and then the left. These lesions became progressively more painful and developed into ulcerative lesions over several months. She also has DM2, atrial fib. and hypertension. She has been maintained on IHD for the past 6 years.
Medications are warfarin; aspirin, 81 mg/d; enalapril; metoprolol; atorvastatin; calcium carbonate; calcitriol; and erythropoietin.

On physical examination, pulse rate is 86/min and irregular and blood pressure is 140/90 mm Hg. She is obese.
There are necrotic ulcers covering most of the thighs bilaterally. Cardiac examination shows an irregularly irregular rhythm. The lungs are clear to auscultation. Abdominal examination is unremarkable. There is no peripheral edema.

Laboratory Studies
Hemoglobin 11.6 g/dL, Leukocyte count 15,000/µL Platelet count 326,000/µL INR 2.6
Sodium 136 mmol/L, Potassium 5.3 mmol/L, Chloride 105 mmol/L, Bicarbonate 19 mmol/L,
Calcium 2.52 mmol/L Phosphorus 2.84 mmol/L .

Whats the most likely diagnosis?
a) Calcinosis cutis
b) Necrrobiosis lipoidica diabetoricum
c) Calcific uremic arteriolopathy
d) Venous stasis ulcers
e) Warfarin-induced skin necrosis



My answer: Answer C

nnavam wrote:
Hi!!
Anyone interested in discussing Nephro Questions???

#1
A 16-year-old man is evaluated before joining a high school.
His medical history is unremarkable and he takes no medications.
Family history is significant for breast cancer in his maternal grandmother and hypertension in his father.

On physical examination, pulse rate is 55/min and blood pressure is 106/62 mm Hg.

Lab:CBC and serum chemistry studies are normal.
Dipstick urinalysis reveals 2+ proteinuria and no blood, and microscopic analysis shows a bland urine sediment. Urinary protein–creatinine ratio is 1.2 mg/g.

Whats the most appropriate next step in this patient's evaluation?



Next step is to perform a urinalysis with albumin or protein quantification (with a spot ratio) BOTH mid-day and on upon waking in the morning. This likely represents postural proteinuria. If the daytime reading shows protein when the AM one does not, this would consistent with such a diagnosis

#A1

Yes, Its Orthostatic proteinuria.

Common finding in adolescents and young adults, and long-term follow-up reveals no increased risk for the development of kidney disease and no specific therapy is required.

#A2

Yes, Its Calcific uremic arteriolopathy.

It presents as painful violaceous nodules on the trunk, proximal extremities, and buttocks in patients with chronic kidney disease.

Other risk factors are 1) use of warfarin,2) vitamin D analogues,3) calcium-based phosphate binders, 4) an elevated calcium–phosphorus product 5) protein S or C deficiency 6) obesity and female sex.

????Is it treated by avoiding vitamin D analogues and calcium-based phosphate binders, control of the phosphorus level with non–calcium-based phosphate binders, aggressive wound care, and treatment of secondary infection.


Calcinosis cutis-painless calcified subcutaneous nodules that do not ulcerate.

Necrobiosis lipidoca diabeticorum - oval to irregularly shaped plaques on the shins of patients with diabetes,usually asymptomatic.

Venous stasis ulcers-shallow, red-based ulcers typically located medially in the lower leg.

Warfarin-induced skin necrosis - erythematous macules which progress to ulcers within hours, typically occurs early in the course of warfarin therapy.