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HY RENAL
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HY Renal – by Dr Mike Mehlman

Basic HY Renal lab values you must know for USMLE

- Should be <20 mg/dL.
- High urea nitrogen in the blood is called azotemia.
Blood urea nitrogen
- “Uremia” technically means “urea in the blood,” but is used to refer to patients
(BUN)
who have symptomatic renal failure with poor lab values. This has absolutely zero
to do with hyperuricemia (gout) and is sometimes confused by students.
- 0.7-1.2 mg/dL
Creatinine (Cr)
- Once you’ve hit a creatinine of 2, you’ve lost ~90% of your renal function.
- 3.5-5.0 mEq/L.
- Will always be elevated in renal failure on USMLE.
Potassium (K+) - This is because the kidney normally secretes (i.e., excretes through tubular walls
into the urine) K+ in the cortical collecting duct under the action of aldosterone. So
if the kidney is fucked up, we can’t do that, so serum K+ rises.
- 135-145 mEq/L.
- Can be variable in renal failure as per my observation on NBMEs.
- Aldosterone normally reabsorbs sodium in the cortical collecting duct in exchange
Sodium (Na+)
for potassium being secreted, so one might think it should automatically be low if
the kidney can’t reabsorb it. But the kidney has a multitude of sodium regulation
mechanisms (i.e., vasopressin), so Na+ can be normal.
- 8.4-10.2 mg/dL.
- Always ¯ in renal failure. This is due to 2 reasons:
1) Ca2+ is normally reabsorbed in the late-distal convoluted tubule (DCT),
so if we can’t do that, serum Ca2+ falls.
2) Proximal convoluted tubule (PCT) of the kidney is normally where 1a-
hydroxylase, under the action of PTH, activates inactive 25-OH-D3 into
Calcium (Ca2+)
active 1,25(OH)2-D3. The latter then goes to the small bowel, where it ­
absorption of Ca2+. So if we can’t do that, serum Ca2+ falls.
- Low serum Ca2+ means ¯ negative feedback at the Ca2+-sensing receptors at the
parathyroid glands à PTH goes up. We call this secondary hyperparathyroidism,
which means PTH is high due to a cause external to the parathyroid glands
themselves. You need to know secondary hyperthyroidism is due to renal failure.
- 3.0-4.5 mEq/L.
- Always ­ in renal failure.
- This is for 2 reasons:
1) The kidney cannot filter it out sufficiently. Lots of phosphate is normally
filtered by healthy kidneys.
Phosphate (PO43-)
2) PTH normally acts to ¯ phosphate reabsorption in the PCT via
downregulation of 3 different types of phosphate pumps. Since the
function of PTH is impaired, the kidney reabsorbs too much phosphate, so
serum levels rise.
- Combo of ¯ Ca2+ and ­ PO43- in renal failure = secondary hyperparathyroidism.
- 22-28 mEq/L.
- Always ¯ in renal failure.
- This is for 2 reasons:
1) The kidney cannot reabsorb bicarb in the PCT as well, so ­ bicarb in the
Bicarbonate (HCO3-) urine à ¯ bicarb in serum à metabolic acidosis.
2) The kidney cannot secrete protons (H+) in the cortical collecting duct as
readily à retention of H+ mops up HCO3- à ¯ serum bicarb.
- Renal failure = Uremia = the U in MUDPILES for high anion-gap metabolic
acidoses. (If you need help on the acid-base stuff, do my HY Arrows PDF).

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Afferent vs efferent regulation

- Go to the kidney.
- Patency maintained by vasodilating prostaglandins.
- NSAIDs inhibit prostaglandin synthesis à ¯ dilation of afferent arterioles à ¯ renal
Afferent arterioles
blood flow.
- NSAIDs don’t actively constrict the afferent arterioles. This is incorrect wording.
They just merely ¯ vasodilation / ¯ diameter of the afferent arterioles.
- Efferent (Exit) leave the kidney.
- Angiotensin II normally constricts these.
- ACEi/ARBs therefore ­ diameter of the efferent arterioles. They are not dilating
them; they are merely ¯ constriction of them. As mentioned above, prostaglandins
Efferent arterioles
will actively dilate the afferent arterioles.
- Some students might say, “Well doesn’t AT II act on the afferent arterioles as well?”
In theory, a very minor amount, but on USMLE, this will get you questions wrong. You
want to think:
AT II = constricts efferent;
ACEi/ARBs = ¯ constriction of efferent (­ diameter).
Summary
Prostaglandins = dilate afferent;
NSAIDs = ¯ dilation of afferent (¯ diameter).

Pre-, intra-, and post-renal azotemias

- BUN/Cr = Blood urea nitrogen to creatinine ratio.
- FENa = fractional excretion of sodium (i.e., amount of sodium in the urine).
- There’s no “normal” range you should be looking for here for either of these.
- What matters is that when there is an actual kidney problem, we look at the values to help
us figure out what the diagnosis is. But we never actually say, “Oh the BUN/Cr or FENa is out
of the normal range.”
BUN/Cr,
- BUN/Cr >20 and FENa <1% mean pre-renal azotemia.
FENa
- BUN/Cr <20 and FENa >1% just simply mean “not pre-renal.”

- The notion of intra- vs post-renal having slightly different ranges is nonsense for USMLE.
- Also, what I’ve come to learn from NBME Qs is that only ~9/10 times the BUN/Cr will be
what we expect. There are a couple 2CK NBME Qs that give BUN/Cr <20 for pre-renal
azotemia and >20 for acute tubular necrosis. If the NBME ever “breaks the rules” this way,
the vignette will be overwhelmingly obvious what the diagnosis is anyway.
- Pre-renal azotemia means there is renal pathology because of reduced renal blood flow
over the sub-acute to chronic time frame. The kidney will do everything it can to ­ retention
of fluid (because it thinks blood volume is low). The way it accomplishes this is by ­
reabsorption of urea and sodium, since water will follow. This is why blood urea nitrogen is
high (i.e., BUN/Cr >20) and sodium in the urine is low (FENa <1%).
- Notice above I stress sub-acute to chronic time frame (i.e., days-months), since one of the
highest yield points you need to know for USMLE is that acute ¯ perfusion (i.e., seconds to
minutes) to the kidney from blood loss, acute heart failure exacerbation, or arrhythmia (i.e.,
VFib for 30 seconds before resusc) causes acute tubular necrosis, not pre-renal.
Pre-renal
- This is all over the NBME exams. For example, if they say a guy loses lots of blood during
surgery and receives 20 packs of RBCs, then two days later while recovering in hospital he
gets oliguria + deterioration of renal function, the answer is acute tubular necrosis, not pre-
renal. Student says, “Wait, but there was ¯ renal perfusion though, so how does that make
any sense. Isn’t pre-renal caused by ¯ perfusion?” à The PCT of the kidney is the most
susceptible to anoxic/hypoxic injury due to the ­ concentration of ATPase transporters. So
acute drop in blood flow à acute hypoxia à PCT sheds.
- There is a 2CK NBME Q where they mention a guy post-op who had not lost any blood
during surgery + had not experienced any episodes of low BP + was started on ketorolac (an

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NSAID) for pain post-op + now has oliguria and ­ creatinine à answer = “hypoperfusion” as
cause; this is example of where NSAIDs, not ATN, can cause post-op oliguria from pre-renal.
- HY causes of pre-renal for USMLE are NSAID or diuretic use, chronic left heart failure, or
dehydration from days of vomiting/diarrhea.
- USMLE will give patient who’s been on an NSAID (e.g., naproxen) for several weeks, or who
was commenced on furosemide (loop diuretic) a few days ago.
- Vignette can give patient who is on an NSAID + now has peripheral edema + they ask why
there’s edema à answer = “¯ renal excretion of sodium.” This is because the PCT ­
reabsorption of sodium in pre-renal (FENa <1%). They will also sometimes give NSAID +
edema + ask what you do, and the answer is just “discontinuation of ibuprofen.”
- Essentially synonymous with acute tubular necrosis on USMLE.
- The kidney can’t reabsorb urea and sodium as easily, so BUN is lower (i.e., BUN/Cr is <20)
and sodium is higher in the urine (i.e., FENa is >1%).
Intra-renal - I discuss acute tubular necrosis in more detail in its own table below, but as I mentioned
above in red font, the most important point for USMLE is that you remember acute drop in
perfusion to the kidney causes acute tubular necrosis, not pre-renal. I need to be an asshole
and inculcate that.
- Almost always due to BPH on USMLE, but can also be due to ovarian or cervical cancer
impingement on the ureter(s).
- What you need to know is: old dude + high creatinine = BPH till proven otherwise.
- The answer on USMLE can often just be “increased Bowman capsule hydrostatic pressure.”
- Next best step is “insertion of catheter” to relieve the urinary retention, even if the patient
has bacteriuria (i.e., choose catheter insertion over antibiotics).
- Another 2CK Q has “check post-void volume” as answer in elderly male with high Cr.
USMLE won’t force you to choose between catheter insertion of checking post-void volume.
- Normal post-void volume is <50ish mL. If the USMLE wants overflow incontinence, they’ll
give post-void volume ~300-400+ mL.
- Diabetic neurogenic bladder (i.e., hypotonic bladder from neuropathy to the detrusor
muscle) can also lead to overflow incontinence and post-renal azotemia, but as I said, most
Qs on USMLE will focus on the old dude with BPH.
- Hydronephrosis can be seen as large, dilated kidneys in patients with obstruction, but this
is rare diagnosis.

Post-renal

- Step 1 wants you to know above gross specimen post-nephrectomy in patient with Hx of
hydronephrosis. They can give, e.g., kid with chronic ureteral obstruction + show above pic.

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Nephritic vs Nephrotic syndromes

- Nephritic conditions have blood in the urine; nephrotic syndromes don’t.
- You need to memorize for USMLE which HY conditions are nephritic vs nephrotic. Don’t worry, I keep
things real clean and concise in the tables below without the bullshit nonsense of other resources.
- There are four main points you should memorize as being part of each syndrome type.

Nephritic syndromes:
1) Hematuria (blood in the urine).
2) Oliguria (¯ urinary output; the definition is <400 mL/day, but USMLE won’t assess that number).
3) Azotemia (­ blood urea nitrogen; this is because urinary output is ¯).
4) Hypertension (­ RAAS due to inflammation of renal microvasculature).

Nephrotic syndromes:
1) Proteinuria (nephrotic level by definition is >3.5g/day, but USMLE won’t assess that number).
2) Hypoalbuminemia (due to the proteinuria; will be <3.5 g/dL, but USMLE doesn’t care about the #).
3) Peripheral edema (due to the hypoalbuminemia à ¯ serum oncotic pressure à transudation of
fluid into interstitial spaces; if severe can present with ascites; if the stem says “pre-sacral edema,”
this is nephrotic syndrome till proven otherwise on USMLE).
4) Hyperlipidemia (liver pumps out apolipoproteins in an attempt to preserve serum osmolality /
oncotic pressure).

- Should be noted that nephritic syndromes often have proteinuria, just usually not at nephrotic levels.
Students sometimes erroneously think nephritic syndromes don’t have proteinuria because it’s not part of
the 4-point categorization above.
- You don’t have to worry about the notion of which conditions are “both nephritic and nephrotic.” What is
most important is: simply know which conditions have hematuria and which ones don’t (via tables below).
- Nephrotic syndromes can ­ risk of DVT, renal vein thrombosis, and varicocele due to loss of antithrombin
III in the urine à hypercoagulable state. This is because nephrotic syndrome usually entails non-specific
massive protein loss due to loss of size and charge barrier, and antithrombin is a protein. The NBME wants
you to know left renal vein thrombus accretion from hypercoagulable state can cause varicocele.

HY Nephritic syndromes
- Post-streptococcal glomerulonephritis; aka “proliferative glomerulonephritis”; the
latter is asked on NBME, where they give vignette of PSGN, and answer is just
“proliferative glomerulonephritis.” Student is like what the hell?
- Answer can sometimes be written by NBME as just “acute glomerulonephritis.”
- The answer on USMLE for red urine 1-3 weeks following a sore throat caused by
Group A Strep (Strep pyogenes). This is in contrast to IgA nephropathy (which I discuss
in detail below), which is red urine 1-3 days following a sore throat (viral infection).
- PSGN can be caused by skin infections. This can be impetigo (school sores), cellulitis,
or erysipelas (I discuss these in detail in my HY Derm PDF). For example, the Q might
say a 10-year-old has yellow crusties on his arm for the past 7 days (impetigo) + now
has red urine à answer = “acute glomerulonephritis.”
PSGN - Type III hypersensitivity (antigen-antibody complexes that form in blood and deposit
in the kidney). Don’t confuse with rheumatic heart disease, which is a type II HS.
- Serum complement protein C3 can be ¯ (can also be ¯ in SLE, but unrelated).
- Streptolysin O or A titers will be ­.
- PANDAS is tested on Psych forms for 2CK à Pediatric Autoimmune Neuropsychiatric
Disorder Associated with Streptococci à presents as new-onset tic/Tourette, OCD, or
ADHD within weeks of Group A Strep infection.
- Descriptors such as subepithelial deposits or “lumpy bumpy” appearance on electron
microscopy (EM), etc., have been parroted across resources over the years but are
essentially garbage for USMLE.
- PSGN usually self-resolves in kids without sequela. But USMLE wants you to know
that ­ age means worse prognosis, where chance of renal failure is ­ it if occurs in

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adults. This is probably related to the more robust immune response resulting in more
advanced renal damage.
- Aka Berger disease; IgA deposition in renal mesangium.
- Red urine 1-3 days after a sore throat. This is in contrast to PSGN, which is red urine
1-3 weeks after a sore throat. I just mentioned it above obviously. But students fuck
this up despite the inculcation so I’m reiterating it like an asshole.
- Caused by viral infection, not Group A Strep.
- Can sometimes be caused by GI infections, but USMLE usually avoids this etiology
unless including it in the Henoch-Schönlein purpura constellation.
IgA nephropathy
- Henoch-Schönlein purpura is LY for Step 1 but HY for 2CK Peds. It’s a tetrad:
1) Palpable purpura (usually on buttocks/thighs).
2) IgA nephropathy (red urine).
3) Arthralgias.
4) Abdominal pain.
- All 4 need not be present for HSP, but the abdo pain component here is presumably
viral gastroenteritis leading to IgA nephropathy.
- The answer on USMLE for a male 20s-40s with hematuria and hemoptysis. Similar to
Wegener and microscopic polyangiitis, can cause RPGN.
- Caused by anti-glomerular basement membrane antibodies (anti-GBM), which are
antibodies against collagen IV.
- Mnemonic: "2,3,4. 2,3,4. The goodpasture is marching through the field. 2,3,4." à
Type 2 hypersensitivity against the alpha-3 chains of type 4 collagen.
- Renal biopsy will show linear immunofluorescence. USMLE likes showing the bright
green image for this.

Goodpasture
syndrome

- Do not confuse this with Alport syndrome, which is an XR condition caused by

mutations in collagen IV.
- X-linked disease; mutation in collagen IV gene.
- Do not confuse with Goodpasture syndrome, which is antibodies against type IV
collagen.
- The answer on USMLE for a male who has red urine + an eye or ear problem (collagen
IV is present in basement membranes in the kidney, ear, and eyes).
Alport syndrome
- The “eye problem” can be blurry vision/cataracts; the “ear problem” will be
neurosensory hearing loss (due to organ of Corti dysfunction).
- Some students have asked if it’s XR or XD. Literature appears to be varied, but USMLE
doesn’t care. On offline NBME 18, however, it’s mentioned in a Q as XR.
- You can memorize “splitting of the lamina densa” as associated with Alport.
- Membranoproliferative glomerulonephritis.
MPGN - The answer on USMLE for red urine in a patient with hepatitis C, heroin use, or
malignancy.

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- Descriptors such as “dense deposits,” “C3 nephritic factor” and “duplication of

basement membranes” are all basically nonsense for USMLE.
- Answer is “renal biopsy” as the next best step. This guides our management.
- A 2CK IM form has “heroin” as the answer (heroin-induced nephropathy) for patient
with protein and blood in the urine. In contrast, if heroin causes a renal issue without
blood, the answer they want is FSGS.
- Diffuse proliferative glomerulonephritis.
- The answer on USMLE for red urine in a patient with SLE.
DPGN - Can sometimes be associated with “wire-looping of capillary walls.”
- Same as with MPGN, USMLE wants “renal biopsy” as the next best step, since this
guides our management.
- Rapidly progressive glomerulonephritis.
- Acute deterioration in renal function in the setting of a vasculitis (i.e., Wegener,
microscopic polyangiitis) or Goodpasture syndrome. I discuss these conditions in detail
later in this PDF, don’t worry.
- Characterized by fibrin crescents on biopsy.

RPGN

HY Nephrotic syndromes
- The answer on USMLE for otherwise unexplained edema in a kid who doesn’t have
blood in the urine.
- Presents as peripheral edema, periorbital edema, and/or ascites.
- Almost always this is pediatric. Very rarely it can be due to Hodgkin in adult.
- Classically post-viral (i.e., URTI), but ~50% of vignettes won’t mention that.
- In other words, textbook vignette is an 8-year-old who has the sniffles for 4 days,
followed by peripheral and periorbital edema a week later, without blood in the
Minimal change urine. Once again though, the stem need not mention the viral infection.
disease - Called minimal change disease because light microscopy (LM) shows no
abnormalities. EM, however, shows effacement of the podocytes.
- MCD is aka lipoid nephrosis (lipid droplets can be seen in urine on LM).
- Mechanism for nephrotic syndrome is “loss of size and charge barrier.”
- Corticosteroids are the treatment and are highly effective.
- A 2CK Peds Q gives minimal change disease as etiology for spontaneous bacterial
peritonitis (i.e., any cause of ascites can cause SBP; I discuss this stuff in the GIT PDF
in extensive detail).
- The answer on USMLE for nephrotic syndrome in patient who has:
Membranous
- Exposure to drugs: dapsone, gold salts, sulfonamides.
glomerulonephritis
- Infection: hepatitis B (Hep C can cause it too, but rare).
/ nephropathy
- Visceral cancers, e.g., breast, pancreatic.

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- Autoimmune (primary): antibodies against phospholipase A2 receptor.

- The LM image is important and shows highly eosinophilic (pink) and inflamed /
thickened capillary walls.

- Can cause “spike and dome” appearance of subepithelial deposits on EM.

- The answer on USMLE for nephrotic syndrome in multiple myeloma.
- Amyloidosis means protein depositing where it shouldn’t be depositing.
- Multiple myeloma = cancer of plasma cells that produce too many immunoglobulins
à high serum IgG kappa/lambda light chains. Immunoglobulins are proteins à these
fly through the kidney and cause Bence-Jones proteinuria; they also deposit in the
renal parenchyma, causing renal amyloidosis.
- Biopsy shows classic apple-green birefringence with Congo red stain.

Renal amyloidosis

- For some magical reason, USMLE cares you know that the amyloid appears this way
because it is b-pleated sheets (i.e., answer on NBME; a-helices is wrong); makes
sense since the former are “flat” and can reflect light at different angles.
- An NBME Q has “renal parenchymal disease” as answer for kidney issue due to
multiple myeloma.
- Diabetes is the most common cause of chronic renal failure.
- Renal failure simply means ¯ glomerular filtration rate (GFR).
Diabetic - USMLE wants the first two changes that occur in the kidney due to diabetes as
glomerulosclerosis follows:
1) Hyperfiltration (­ glucose crossing the glomerular basement pulls water
with it à polyuria). Sometimes the Q can just simply give you diabetes +

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they ask what’s most likely to be seen initially à answer = “­ glomerular

filtration.” Over time, the kidney will fail and GFR will ¯.
2) Thickening of the glomerular basement membrane (non-enzymatic
glycosylation of the membrane à loss of size and charge barrier).
- Kimmelstiel-Wilson nodules are composed of hyaline and look like pink circles on
light microscopy. This image is very HY.

- Hyaline arteriolosclerosis is deposition of hyaline (protein) in the walls of the renal

vasculature. Although this can be due to many things, on USMLE, they want you to
know this is caused by diabetes.
- ACEi (e.g., lisinopril) or ARBs (e.g., valsartan) are the first drugs used in diabetes if
there is HTN (>130/80 in diabetes, not 140/90), proteinuria, or ­ creatinine or renin.
- AT-II normally constricts efferent arterioles leaving the kidney, causing a backup of
pressure at the glomerulus. This serves the purpose of maintaining GFR (i.e., filtration
through Bowman capsule) when renal blood flow has ¯.
- In other words, when renal perfusion ¯, RAAS goes ­, AT-II goes ­, and we get
constriction of efferent flow leaving the kidney à ­ filtration fraction (GFR/renal
plasma flow), where we have GFR staying the same despite ¯ perfusion.
- ACEi/ARBs ¯ constriction of efferent arterioles (they don’t “dilate”; this refers to the
action of prostaglandin on the afferent arterioles going to the kidney), thereby ¯
filtration fraction and reducing GFR. This might sound like a bad thing – i.e., “Why
would we want to ¯ GFR in diabetes if it’s the most common cause of chronic renal
failure?” à The answer is because the slightly reduced GFR and filtration fraction
early on ¯ the rate at which excess glucose is filtered across the glomerulus. Over
time, it is inevitable that the glomerular basement membrane will non-enzymatically
glycosylate and thicken, so ACEi/ARBs slow this process (i.e., slightly reduce GFR early
in order to prevent a massive decrease later).
- The answer on USMLE for nephrotic syndrome in sickle cell, heroin, or HIV.
- Not as responsive to steroids as MCD.
Focal segmental - FSGS literally means “some parts of some nephrons are affected.”
glomerulosclerosis - Focal = some glomeruli.
(FSGS) - Diffuse = all glomeruli.
- Segmental = part of nephron.
- Global = all of nephron.

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Acute tubular necrosis

- Sloughing of PCT tubular epithelial cells due to chemical or ischemic insult.
- Only ~50% of Qs will mention “muddy brown granular casts,” or “dirty brown granular casts,” or “brown,
pigmented casts.”
- The other ~50% of Qs will just mention oliguria or acutely worsening renal function in patient with classic
ATN etiologies.
Next best step in diagnosis is “measurement of urine sodium and creatinine concentrations.” We expect
FENa >1% and BUN/Cr <20 almost always for ATN.
Cause HY points
- Can be caused by drugs: aminoglycosides (gentamicin, tobramycin, amikacin);
cisplatin (a chemo agent), or IV contrast.
- Any of the above drugs + new-onset oliguria or ­ creatinine (there need not be
mention of casts) = ATN.
- For instance, NBME simply tells you patient was given many drugs and now has
creatinine of 2 (NR 0.1-1.2) + no mention of casts + they ask for what was given à
answer = gentamicin. Not hard.
Drugs
- Patient who’s recently been treated for endocarditis + now has new-onset oliguria =
ATN due to gentamicin (empiric Tx for endocarditis = gentamicin + vancomycin [new
literature suggests vancomycin is not reliably nephrotoxic]).
- Contrast nephropathy is exceedingly HY on 2CK, where they want you to know that
adequate hydration prior to IV contrast is the number-one way to prevent it. For
instance, they’ll say patient got a CT + now has ­ creatinine + they’ll ask how it could
have been prevented à answer = “0.9% saline,” or just “IV hydration therapy.”
- Myoglobin is nephrotoxic. Big risk factors are alcoholism, falls, intense training
(e.g., marathon), McCardle syndrome, statins/fibrates.
- Rhabdo causes a false (+) blood on urine dipstick. They will say urinalysis shows 2+
blood but only 1-2 RBCs/hpf. This is because the dipstick can’t differentiate between
free myoglobin and hemoglobin on RBCs.
- One NBME Q gives 3-4 RBCs/hpf as negative. I’ve seen this fool some students who
were already aware of the false (+) blood point about rhabdo. If the Q wants (+)
RBCs, they’ll say like 10-20+/hpf.
- The other half of rhabdo vignettes won’t mention the false (+) urinalysis and will
Rhabdomyolysis instead just say oliguria. You need to know that refers to ATN.
- For example, an NBME-favorite vignette is patient being found at bottom of stairs in
his/her house + has false (+) blood on urine dipstick and/or oliguria à answer =
rhabdomyolysis.
- They also like ­ K+ as part of rhabdo vignettes (makes sense if we have renal failure
from ATN) and ­ serum creatine kinase (CK).
- Q can say 44-year-old guy found on bench in park has ­ K+, ­ CK, and oliguria à
diagnosis = rhabdo. Or they’ll say just ­ CK + oliguria, and they ask what is most likely
to be seen in this guy à answer = ­ K+.
- It’s to my observation acute ischemia is the highest yield cause of ATN on NBME
exams.
- Even though the medulla of the kidney technically receives less blood flow
compared to the cortex, as I mentioned earlier, the USMLE is obsessed with the PCT
of the kidney as most susceptible to anoxic / hypoxic injury. This is due to the ­
concentration of PCT ATPase transporters, so acute drop in blood flow à acute
hypoxia à PCT sheds.
Acute ischemia - Step 1 Qs love cellular swelling as part of this mechanism – i.e., acute ischemia à ¯
activity of PCT ATPases à buildup of intracellular Na+ à water stays with sodium à
tubular cell swelling. Answer on NBME for why there’s swelling simply = ¯ ATPase
activity (this is similar mechanism for why we get swelling + hemolysis in pyruvate
kinase deficiency).
- Acute ischemia to the kidney can be due to loss of blood from trauma/surgery,
acute arrhythmia (e.g., 30 seconds of Vfib), MI, or acute exacerbation of heart failure
(on 2CK Free 120). These conditions cause ATN, not pre-renal. Once again, ¯ flow to

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the kidney causing pre-renal azotemia will be more subacute/chronic, such as due to
NSAID use, recent initiation of diuretic, or dehydration. There are rare Qs that are
exceptions, but that is the general principle.
- As mentioned earlier, USMLE will give a one-liner where they say, “Dude had
surgery where he lost a lot of blood + received many packs of RBCs. 2 days later, he’s
now recovering in hospital + gets oliguria” (they don’t say anything about brown
casts) à answer = ATN, not pre-renal.
- Likewise, they’ll say woman had surgery + had 30-second episode intra-operatively
where BP fell to 80/40 à answer = ATN, not pre-renal.
- Guy has an MI (cardiogenic shock) + new-onset oliguria à ATN, not pre-renal.
- Guy has burns covering 50% of his body + develops oliguria à ATN due to excessive
fluid loss à acute ¯ perfusion to kidney.
- Acute exacerbation of heart failure causing ATN is a difficult one since heart failure
is classically associated with pre-renal from chronic ¯ blood flow to the kidney. But in
acute exacerbation of heart failure, we have acute ¯¯ blood flow, leading to ATN (as
I said, it’s on Free 120).

Other renal conditions associated with ischemia

- Diffuse cortical necrosis is a term thrown around sometimes and causes
confusion for students. I don’t think I’ve ever seen USMLE assess this. I’ve only
seen it show up rarely as an incorrect answer choice.
Diffuse cortical necrosis
- DCN is simply considered an extension of ischemic ATN, where DCN can occur
in severe cases of ischemia (e.g., obstetric hemorrhages).
- You can be aware it exists, but don’t worry about it for USMLE.
- Renal papillae = parts of kidney where the collecting ducts meet the ureters.
- The answer on USMLE for red/dark urine in a patient with sickle cell.
- In contrast, if a sickle cell patient has a renal condition + no blood in the urine,
the answer = FSGS, as mentioned earlier.
- RPN is loss of the renal medulla from ischemia, but unlike ATN, the etiology is
usually more subacute or chronic. NSAIDs are a notable cause in this regard,
Renal papillary necrosis where ¯ afferent blood flow due to ¯ vasodilating prostaglandins over weeks-
(RPN) months causes the medullar blood flow to be slowly choked off.
- RPN can occur more acutely in sickle crises, where sickling within
microvasculature feeding the medulla results in focal pockets of ischemia.
- Pyelonephritis (discussed later) can also cause RPN due to inflammatory
compression of the medullar microvasculature. There’s one NBME Q I can recall
where renal papillary necrosis is the answer due to infection. But I’d say, overall,
the highest yield point is just remembering red/dark urine in sickle cell = RPN.

Interstitial nephritis
- Exceedingly HY renal condition often confused with ATN.
- Aka interstitial nephropathy, or tubulointerstitial nephritis/-nephropathy.
- Think of this as “an allergic reaction of the kidney.”
- 4/5 Qs will be an NSAID, b-lactam, cephalosporin, or allopurinol followed by getting a maculopapular rash
and WBCs (eosinophils) in the urine. This presentation is textbook/pass-level.
- Only ~50% of vignettes will mention the maculopapular rash.
- The stem need not say “eosinophils” either. They can just say patient is on b-lactam + now has WBCs in
the urine + no mention of rash à answer = interstitial nephritis. If they say the rash, it’s even easier.
- 1/5 Qs will just say a patient was on an NSAID, b-lactam, or cephalosporin and now has mild proteinuria
and hematuria. They don’t mention a rash or WBCs in the urine.
- There is also a singular NBME Q where they just say a patient has simple peripheral edema due to an
NSAID, with no mention of anything else, and the answer is interstitial nephropathy. This is more unusual,

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since “NSAIDs + edema” classically = pre-renal, but I’ve seen the NBME assess interstitial nephropathy for
this as well.
- NBME also can give you simple vignette of interstitial nephritis, and then ask for the location in the kidney
that’s affected (e.g., efferent arterioles, etc.) à answer = “renal tubule.”
- For example, 40M + treated with nafcillin for 6 weeks for MSSA endocarditis + now has maculopapular
rash and eosinophils in the urine; diagnosis? à interstitial nephritis.
- 60F + using naproxen (an NSAID) for 6 weeks for her osteoarthritis + has peripheral edema à answer =
interstitial nephropathy.
- 35F + just recently finished 10-day course of cephalexin + has mild proteinuria and hematuria à answer =
interstitial nephropathy.
- 35F + taking ibuprofen + has maculopapular rash and eosinophils in the urine; Q asks where in the kidney
is fucked up à answer = “renal tubule.” Student says, “But don’t NSAIDs affect the afferent arteriole?” à
Yes, but this particular presentation is clearly tubulointerstitial nephropathy. I haven’t seen them be
ambiguous here with “NSAID + peripheral edema alone,” where you have to debate whether it’s interstitial
nephropathy or pre-renal. They’ll either ask one or the other.

Renal tubular acidosis

Quick notes before discussing RTA:

MUDPILES = mnemonic for high anion-gap metabolic acidoses = Methanol, Uremia (renal failure), DKA,
Phenformin (a drug you don’t have to worry about), Iron/Isoniazid, Lactic acidosis, Ethylene glycol,
Salicylates (aspirin).

Anion-gap is calculated as Na+ - (Cl- + HCO3-). Normal range is 8-12. High anion-gap = 13 or greater.
- USMLE really doesn’t give a fuck that you know the specifics of types I, II, and IV.
- The way they assess this is by you knowing this is a type of normal anion-gap metabolic acidosis (i.e., it is
not part of MUDPILES).
- For example, you’ll get a 15-line massive paragraph + tons of lab values + have no idea what’s going on,
but then you calculate the anion gap as 12 (NR 8-12), so you can eliminate all of the MUDPILES answer
choices, such as lactic acidosis, DKA, and ethylene glycol poisoning, and you’re left with, e.g., Crohn disease
or renal tubular acidosis. Then you just say, “Well this clearly ain’t Crohn, so it must be RTA.” That is how I
would say 4/5 RTA Qs show up.

- RTA type I = ¯ ability to secrete H+ in the cortical collecting duct.

- RTA type II = ¯ ability to reabsorb HCO3- in the PCT.
- RTA type IV = renal resistance to aldosterone, or hyporeninemic hypoaldosteronism.

- Type IV presents with hyperkalemia. The others do not. Type III apparently is hyper-rare.
- Type IV will be a patient who has Addisonian-like picture (i.e., ¯ Na+, ­ K+, ¯ HCO3-), but the vignette will
present in a patient who has chronic renal failure.
- Type II can be caused by Fanconi syndrome (discussed more in table below).
- Type I can apparently have renal parenchymal stones (i.e., stones in the actual tissue of the kidney, rather
than within the tubular lumina as with traditional nephrolithiasis).
- As I said, the key point is you just know RTA is normal anion-gap / not part of MUDPILES. That’ll cover you
like 4/5 times.

Other renal conditions

- Lysis of tumor cells (especially leukemic) by chemoradiotherapy leads to release
of uric acid and phosphate that can overwhelm the kidneys and cause crystals,
namely from uric acid.
Tumor lysis syndrome - USMLE loves asking what can be given to prevent renal failure in patient
undergoing chemo à answer = “allopurinol.”
- Or they’ll ask for MOA of drug that can prevent renal failure à answer =
“xanthine oxidase.”

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- The arrows USMLE wants for what will be seen in the blood in tumor lysis
syndrome is same as renal failure except we also have ­ uric acid.
- Inability of the PCT to reabsorb “lots of stuff.”
- Shows up on NBME as an arrow Q, where they ask about the reabsorption of
amino acids, glucose, bicarbonate, and phosphate, and the answer is a ¯ for all of
them.
- Since bicarb reabsorption is impaired, this can lead to RTA type II, but USMLE
doesn’t really give a fuck. The key point is the ¯ for the reabsorption of the above
Fanconi syndrome
substrates.
- For whatever magical reason, an important cause of Fanconi syndrome is
consumption of expired tetracyclines.
- Don’t confuse Fanconi syndrome with Fanconi anemia. The latter is an
autosomal recessive aplastic anemia with hypoplastic thumbs/radii (I’ve made
YouTube clips discussing this).
- Inability of the PCT to reabsorb tryptophan.
- Can cause niacin (B3) deficiency in theory, since tryptophan is a precursor in
niacin synthesis.
Hartnup disease
- This is more just textbook masturbation to be honest that’s been parroted over
the years. Can’t say I’ve seen this ever assessed once. Just mentioning it here
otherwise I’ll get some umbrageous student popping into my DMs about it.
- Cystine stones (hexagonal) can occur in young adult due to an inability to
reabsorb the COLA (dibasic) amino acids à Cysteine, Ornithine, Lysine, Arginine.
Cystinuria
- Cystine is two cysteines put together.
- Cystinuria can be diagnosed with cyanide-nitroprusside test.
- Nonsense diagnosis on USMLE that will sometimes show up as an incorrect /
distractor answer choice.
Hepatorenal syndrome - Apparently liver failure can sometimes cause renal failure via obscure
mechanisms.
- Renal biopsy will be normal almost always.
Thin glomerular - Benign familial condition where patient can have mild hematuria.
basement membrane - Thin basement membranes allow for passage of small amounts of RBCs.
disease - No treatment necessary.

Renovascular hypertension
- Narrowing of one or both renal arteries due to atherosclerosis that causes ­
renin-angiotensin-aldosterone system (RAAS) and ­ BP.
- Q will be patient over the age of 50 with cardiovascular disease risk factors,
such as diabetes, HTN, and/or smoking.
- Patients who have pre-existing HTN causing atherosclerosis leading to RAS will
often have 10-20 years of background HTN that then becomes accelerated over
a few-month to 2-year period. What this means is: the slowly developing
atherosclerosis in the renal arteries finally reaches a point at which the kidney is
unable to maintain autoregulation, and the RAS is now clinical (i.e., accelerated
HTN of ­­ BP within, e.g., 3 months).
Renal artery stenosis
- Another way USMLE will give RAS is by giving ­ BP in patient with significant
(RAS)
evidence of atherosclerotic disease (i.e., Hx of coronary artery bypass grafting,
intermittent claudication), and then ask for the most likely cause à RAS. You
have to say, “Well he clearly has atherosclerosis in his coronaries and aortoiliac
vessels, so that means he’ll have it in the renal arteries too.”
- Q can say older patient with carotid bruit has recent ­­ in BP and then ask for
diagnosis à answer = RAS. Similar to above, if the patient has atherosclerosis in
one location (i.e., the carotids), then he/she will have it elsewhere too.
- HY factoid about RAS is that ACEi or ARBs will cause renin and/or creatinine
to go up. This is a HY point that is often overlooked and is asked on NBMEs. I
have not seen NBME care whether it’s uni- or bilateral in this case. à Kidney

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can autoregulate across flux in perfusion. Patients with already-compromised

renal blood flow are more sensitive to the subtle ¯ in filtration fraction that
occurs secondary to ACEi/ARB use, so renin/creatinine ­.
- If USMLE gives you unilateral RAS, renin is only ­ from that kidney. The other
kidney will not produce ­ renin.
- After renin and aldosterone levels are obtained, MR angiography of the renal
vessels is what USMLE wants for the next best step in diagnosis.
- The answer on USMLE for narrowing of the renal arteries in a woman 20s-40s.
- Not the same as renal artery stenosis, and not caused by atherosclerosis.
- If you broadly say “renal artery stenosis,” that specifically refers to
atherosclerosis of the renal arteries in patient >50 with CVD.
- FMD is tunica media hyperplasia (not dysplasia, despite the name) that results
in a “string of beads” appearance on renal angiogram.

Fibromuscular dysplasia
(FMD)

- MR angiography is answer on NBME for diagnostic modality.

- Can affect the carotid vessels. A 2CK Surg Q gives FMD vignette and also says
there is 25% occlusion of one of the carotids.
- As discussed in the cardio PDF, this is a medium-vessel vasculitis that causes a
“string of pearls” appearance of the renal vessels. This can be confused with
FMD, but note the difference in the imaging. FMD shows more beading along
the larger/proximal arterial sections, whereas PAN shows pearls more at the
vascular termini, with the more proximal parts more likely to be spared.

Polyarteritis nodosa
(PAN)

Angiogram of PAN shows pearls that are more distal in the renal vasculature;
FMD, in contrast, shows more proximal beading, with the termini not as
conspicuously involved.

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- There is an NBME Q where they list both PAN and FMD as answer choices and
it relies on you knowing the angiogram to get it right. They don’t mention
hepatitis B, but answer is PAN. That’s why I’m harping on this here.
- Causes fibrinoid necrosis. I’ve also seen this on NBME as “segmental, ischemic
necrosis.”
- Can be caused by hepatitis B.
- Spares the pulmonary vasculature.
- The answer on USMLE for hypertension in a neonate following umbilical artery
catheterization. USMLE simply wants “­ renin, ­ aldosterone” as the answer.
- Sounds weird, but you need to know umbilical artery catheterization is a major
risk factor for renal artery thrombosis in neonates.
Renal artery thrombosis - 2CK NBME Q gives brief umbilical artery catheter insertion in kid born 26
weeks’ gestation in order to monitor blood pressure for a pneumonia. 3 weeks
later, he has ­ BP (128/86) à answer = “­ renin, ­ aldosterone” as answer.
- BP in term neonates should be ~60/40. In a preemie 29 weeks’ gestation, it
should be ~50/30 according to Google.

HY Vasculitides affecting the kidney

- Vasculitides is a fancy word that is pleural for vasculitis.
- Formerly known as Wegener granulomatosis.
- Answer on USMLE for adult with triad of 1) hematuria, 2) hemoptysis, and 3)
“head-itis” – i.e., any problem with the head, such as nasal septal perforation,
Granulomatosis with mastoiditis, sinusitis, otitis.
polyangiitis - Associated with cANCA and anti-proteinase 3 (anti-PR3) antibodies.
- Causes “necrotizing glomerulonephritis” that can lead to rapidly progressive
glomerulonephritis (RPGN).
- USMLE can give a vignette of Wegener and then the answer is just “vasculitis.”
- Will just present as hematuria in a patient who is pANCA / anti-MPO (+).
Microscopic polyangiitis
- Similar to Wegener, can cause RPGN.
- The above conditions can be associated with a weird neuropathy called mononeuritis multiplex, which
means neuropathy of “one large nerve in many locations” – e.g., wrist drop + foot drop in same patient.
- You don’t need to worry about the fancy term “mononeuritis multiplex,” but what I do want you to be
aware of is that neuropathy will sometimes show up in these vasculitis vignettes, so don’t be confused
about it.
- Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss) less commonly has renal
involvement compared to Wegener and MP. I discuss many vasculitides in more detail in the HY Cardio PDF.

HY Uremia points
- As mentioned earlier, “uremia” means “urea in the blood,” but is used to refer to patients who have
symptomatic renal failure with poor lab values.
- On USMLE, uremic patients will have: ­ K+, ¯ HCO3-, ¯ Ca2+, ­ PO43-. Na+ is variable.
- Friction rub in patient with ­ BUN and Cr.
Uremic pericarditis
- Answer = hemodialysis.
- Mental status change in patient with ­ BUN and Cr.
Uremic encephalopathy
- Answer = hemodialysis.
- Nosebleeds and/or petechiae in patient with renal failure.
- Qualitative, not quantitative, platelet problem. In other words, bleeding
time is ­, but platelet count is normal.
Uremic platelet dysfunction
- Mechanism is ­ BUN causing impairment of platelet function.
- Answer on USMLE can be written as “acquired platelet dysfunction.”
- Treatment = hemodialysis.

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- On 2CK NBME 10, Surg Q wants “initiation of dialysis” as answer in uremic

patient pre-op. Improving RFTs will ¯ peri-op morbidity/mortality + ¯ risk of
intra-op bleeding due to uremic platelet dysfunction.
- Yellow skin sometimes seen in severe renal failure due to ¯ ability to
excrete urea. Excess is excreted in sweat, precipitating out as white
Uremic frost
crystalline deposits (frost).
- Can be associated with itchy skin (uremic pruritis).

Urolithiasis
- Urolithiasis is broad, umbrella term that refers to both nephrolithiasis and ureterolithiasis.
- Diagnosed with non-contrast CT of abdomen and pelvis.
- KUB (X-ray of kidney, ureters, bladder) can be done but isn’t as sensitive (although below I show an X-ray).
Stone type HY points
- Most common type of stone. Can be calcium oxalate or calcium phosphate, although I’ve
never seen USMLE once assess or give a fuck about phosphate stones.
- Most young adults with idiopathic kidney stones will have “normocalcemia and
hypercalciuria” – i.e., normal serum calcium but elevated urinary calcium.
- USMLE will give you healthy male in his 20s with sharp pain in the flank or groin + RBCs in
the urine à answer = urolithiasis.
- Crohn disease and disorders causing fat malabsorption increase the risk for calcium
oxalate stones (­ fat retained in GI tract à ­ chelation with calcium in GI tract à ¯
calcium available to bind oxalate à ­ oxalate absorption by GI tract à ­ urinary oxalate).
Calcium - Primary hyperparathyroidism and malignancy causing hypercalcemia are HY etiologies.
- Milk-alkali syndrome: ­ calcium + ­ bicarb + calcium stones. Textbook scenario is a
patient taking too many antacids, but vignette will usually not mention this and it will
simply be a diagnosis of exclusion (i.e., you eliminate to get there).
- Ethylene glycol (Anti-Freeze) and hypervitaminosis-C can cause oxalate stones.
- First step in prevention and treatment of stones is “adequate hydration.”
- Thiazides can be used to prevent recurrent stones by ¯ urinary calcium. NBME has a Q
that asks why à answer = ­ reabsorption of calcium.
- In theory, alkalinization of the urine can help treat oxalate stones, and acidification of the
urine can help treat phosphate stones.
- Composed of ammonium magnesium phosphate.
- Formed in ­ pH in the presence of urease (+) bacteria.
- Klebsiella, Serratia, and Proteus are HY causes.
- These stones are large, ram-horn like. The image is HY.

Struvite

- Apart from adequate hydration, Tx is acidification of urine with NH4Cl + surgery.

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- Seen in patients who have gout. Not complicated.

- First-line Tx for chronic gout is xanthine oxidase inhibitors (i.e., allopurinol or febuxostat).
They are preferred over uricosurics (meaning ­ urinary excretion of uric acid) like
probenecid and sulfinpyrazone because the latter agents ­ risk of uric acid stones.
- Probenecid and sulfinpyrazone inhibit organic anion transporter (OAT), which normally
Uric acid functions to ­ absorption of uric acid.
- Weird factoid about probenecid is that it can help maintain serum b-lactam levels, since
the latter are excreted by OAT. There’s an NBME Q around somewhere that asks about
this. Sometimes old-school docs will put a patient on a b-lactam and probenecid. Don’t be
confused by this. The patient doesn’t have gout. It’s just a way of ¯ renal excretion of the
b-lactam.
- As mentioned earlier, cystine is two cysteines put together.
- Cystine stones (hexagonal) can occur in young adult due to an inability to reabsorb the
Cystine
COLA (dibasic) amino acids à Cysteine, Ornithine, Lysine, Arginine.
- Cystinuria can be diagnosed with cyanide-nitroprusside test.
- Acyclovir (for HSV and shingles) and indinavir (for HIV) can cause crystal nephropathy.
Miscellaneous
Not particularly HY, but worthy of 1-2 lines here.

Cystic kidneys
- Autosomal dominant polycystic kidney disease; chromosome 16.
- The answer on USMLE if disease starts as an adult (i.e., 30s-40s).
- Cysts are technically present early in life, but only become clinical as adult (i.e., ­ BP and
­ RFTs).

ADPKD

- These patients have ­ BP due to ­ RAAS (compression of microvasculature of kidney due

to enlarging cysts).
- Can cause saccular (berry) aneurysms of the circle of Willis à risk for subarachnoid
hemorrhage.
- Highest yield point is that serial blood pressure checks are correct over circle of Willis
MR angiogram screening. Latter is wrong answer on USMLE. MR angiogram screening of
circle of Willis is only done when there is (+) family Hx of SAH or saccular aneurysms.
- Step 1 NBME gives easy vignette of ADPKD, and then the answer is just “polycystin” as
the protein that’s fucked up. Sounds obvious, but it’s asked so I’m mentioning it.
- Cystic kidneys are part of “ciliopathies,” which is obscure term that refers to conditions
where cilia are abnormal. Polycystin is a protein required for cilia function on renal
epithelium.
- Most common extra-renal location for cysts is the liver (85% by age 30).
ARPKD - Autosomal recessive polycystic kidney disease; chromosome 6.

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- The answer on USMLE for cystic kidneys in pediatrics.

- Can be associated with hepatic fibrosis.
- Just be aware renal cysts can occasionally develop in other conditions, such as chronic
Miscellaneous dialysis patients.
- Conditions such as medullary sponge kidney are garbage for USMLE. Waste of time.

HY anatomic abnormalities
- Exceedingly HY for Peds for 2CK; also shows up on Step 1 NBME.
- Most common genitourinary abnormality in neonatal males.
- Urethra has abnormal presence of valves at the posterior (prostatic) urethra,
preventing the outflow of urine.
- USMLE will give Qs of varying severity.
- Most severe is in utero oligohydramnios.
- Can present as 12-hour-old neonate who hasn’t yet urinated + has
Posterior urethral valves
suprapubic mass (i.e., full bladder).
(PUV)
- Can also present as 6-week-old boy who has full bladder (i.e., possibly slower
accumulation due to only partially obstructed outflow).
- Obstructed outflow ­ risk for UTIs, cystitis, and pyelonephritis.
- Apart from knowing this diagnosis, highest yield point is that we do
ultrasound followed by voiding cystourethrogram to diagnose.
- NBME Qs might already mention negative ultrasound in the vignette, or
might omit it altogether, where you just select “voiding cystourethrogram.”
- Congenital abnormality in which urine from the bladder can go back up into
the ureter toward the kidney.
- This ­­ risk for recurrent acute pyelonephritis à chronic pyelonephritis (as I
discuss below).
Vesicoureteral reflux - Can also occur in pregnancy due to 2 reasons: 1) larger uterus in 3rd trimester
can compress the ureters; 2) progesterone ¯ ureteral peristalsis.
- This is why pregnant women can get pyelonephritis, and also why we always
treat asymptomatic bacteriuria in pregnancy, whereas we don’t treat it if
woman is not pregnant.
- Bit of a weird one, but not me being fancy. It’s on NBME.
- “Failure of canalization of proximal ureter” will be the answer if they tell you
the renal collecting duct system is dilated, but the ureters are not dilated.
- Sounds obvious, but I see students get this wrong a lot.
Ureteral atresia - You need to simply know: kidneys à ureters à bladder à urethra, and if we
have a congenital obstruction at any point, that could be referred to as
“failure of canalization.”
- “Congenital ureteral obstruction” is an answer on one of the NBMEs for
chronic pyelonephritis causing tubular atrophy (once again, discussed below).

Genitourinary infection-related stuff

- For all of the STD/STI-related stuff, I cover that in the Repro/Obyn PDF. I’m keeping this small table more
limited to kidney/bladder stuff.
- Infection of the kidney. “Pyelo” means kidney.
- 9/10 questions will mention fever + costovertebral angle (CVA) tenderness,
which is pain with percussion of the flank.
- “Granular casts” can be seen. Do not confuse this with acute tubular necrosis.
Acute pyelonephritis “General granular casts” can sometimes be seen in pyelonephritis and
dehydration. It’s on one of the 2CK IM forms, where students say, “Wait, but they
say granular casts; how is this not ATN?”
- Major risk factors are vesicoureteral reflux (especially in pregnancy) and
posterior urethral valves.

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- Most common organism is E. coli. Other organisms, i.e., Klebsiella, Serratia, and
Proteus cause struvite stones.
- Neutrophilic infiltration will show up as lots of blue/purple (basophilic) cells on
histo. USMLE likes this image.

- For above image, you say, “Mike I feel weird. Idk what I’m looking at.” The blue
cells are neutrophils infiltrating the kidney in acute pyelo. The USMLE will show
images basically identical to this for a variety of infections, e.g., prostatitis, where
the bigger picture concept is, “Oh that’s acute inflammation. Those purple cells
are neutrophils.” That’s what USMLE wants you to know. For instance, a nearly
identical image of prostate histo in old dude with prostate pain and fever à
you’d know immediately it’s prostatitis.
- It’s to my observation bacteria can be few in the urine in acute pyelo. This
confuses some students. But it’s typically what I see on NBME forms. If the
infection is further down, i.e., UTI in the urethra, then bacteria are more copious.
- Treatment for pyelo is ciprofloxacin or ceftriaxone. USMLE is known to ask
these.
- Persistent fever despite Abx Tx à do CT to look for perinephric abscess.
- For example, old dude + high Cr (caused by post-renal from BPH) + treated for
pyelo à now gets sore ankle à was treated with cipro (causes tendonopathy).
- 2CK form has ceftriaxone as an answer in pyelo Q where cipro isn’t listed. But
cipro is classic Tx. It’s to my observation that ceftriaxone is HY drug on 2CK for
community-acquired “general sepsis” or “general complicated/severe infections”
– i.e., it is hard-hitting and covers wide array of community organisms.
- There is one 2CK Q where they mention pyelo is treated with amp + gent in the
stem, but I’ve never seen this assessed as an answer you need to choose. I’ve only
ever seen ciprofloxacin or ceftriaxone as actual NBME answers for pyelo.
- Due to recurrent acute pyelonephritis.
- Almost always pediatric, where they give a 4-year-old who has a small, shrunken
Chronic pyelonephritis
kidney with tubular atrophy and blunting and scarring of the renal calyces.

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Kidney appears to show loss of architecture + scarring.

- USMLE will show you kidney that looks similar to the above in a child with
recurrent UTIs, and then the answer is just “tubular atrophy” for what is most
likely to be seen on microscopic examination.
- Another Q shows the same image and the answer is “congenital ureteral
obstruction” as the cause.
- “Thyroidization of the kidney” is a buzzy phrase that has been applied to chronic
pyelo over the years, but USMLE doesn’t so much care about this. What they
really like is the tubular atrophy and scarring / loss of architecture of the calyces.
- Chronic pyelo doesn’t present with cellular infiltration the way acute pyelo does.
It refers to the kidney being destroyed/shrunken from repeated prior infections.
- Suprapubic tenderness in female. Patient need not have fever.
- E. coli most common cause. HY for USMLE you know fimbriae and pilus proteins
facilitate E. coli’s attachment to urothelium.
- Will have bacteria and WBCs in the urine (i.e., bacteriuria + pyuria).
Cystitis - Urinary nitrites and leukocyte esterase can be positive. These just reflect
bacterial infections. Some students get pedantic about which organisms result in
which combo of (+) or (-) findings here, but that’s low-yield for USMLE.
- Can be caused by suprapubic catheters (on 2CK IM and Surg).
- Nitrofurantoin is HY drug to treat cystitis on USMLE.
- Not an infection.
- This is >6 weeks of suprapubic tenderness + dysuria (pain with urination) that is
unexplained, where laboratory and urinary findings are negative.
Chronic interstitial
- They can mention anterior vaginal wall pain (bladder is anterior to vagina).
cystitis
- USMLE wants you to know you don’t treat. Steroids are wrong answer.
“Treatment” is standard placating placebo nonsense such as “education,” “self-
care,” and “physiotherapy.”
- Classically E. coli infection of the urethra.
- Common in women due to shorter urethras.
- As mentioned above for cystitis, fimbriae and pilus proteins facilitate E. coli’s
attachment to urothelium.
- Inoculation of the urethra following sexual activity is most common mechanism.
General UTI - Can be caused by catheters. You need to know dysuria + Hx of catheter = UTI.
- Tangentially, this is also HY for general sepsis, where if they mention Hx of IV
line/catheter, USMLE wants you to be able to say, “Got it. That’s the cause.”
- Trimethoprim, trimethoprim/sulfamethoxazole (TMP/SMX), or nitrofurantoin
are standard treatments for UTI.
- For prevention, post-coital voiding confers ¯ risk of recurrence.

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- If post-coital voiding doesn’t work, “post-coital nitrofurantoin therapy” is

answer on 2CK NBME form.
- If post-coital nitrofurantoin therapy doesn’t work, “daily TMP/SMX prophylaxis”
is the answer. Sounds absurdly wrong / like a bad idea, but it’s an answer a
couple times on Obgyn assessments.
- There’s also a Q where they say a girl was treated successfully in the past with
TMP/SMX for a UTI + ask how to prevent recurrent UTIs now, and they just jump
straight to “daily TMP/SMX prophylaxis.”
- If patient is treated for a UTI and dysuria persists, the next best step is testing
for Chlamydia and Gonorrhea.

HY Bladder incontinences
- The answer for loss of urine with ­ intra-abdominal pressure from laughing, sneezing,
coughing.
- Stereotypical risk factor is grand multiparity (i.e., Hx of many childbirths) leading to
weakened pelvic floor muscles.
- I’d say only ~50% of Qs will mention Hx of pregnancy. The other ~50% are idiopathic.
- Buzzy vignette descriptors and answer choices are: “downward mobility of the
vesicourethral junction,” “urethral hypermobility,” and “urethral atrophy with loss of
urethrovesical angle.”
- Treatment is pelvic floor (Kegel) exercises. These notably strengthen levator ani,
pubococcygeus, and the external urethral sphincter.
Stress
- USMLE is known to ask which muscle is not strengthened by Kegel exercises, which
sounds obscure, since any muscle could theoretically be the answer (“Well the deltoid
isn’t strengthened.”). But a favorite answer here is internal urethral sphincter. The
way you know this is the answer is because internal sphincters are under sympathetic
(i.e., involuntary; autonomic) control, which means it’s impossible to strengthen it via a
voluntary (i.e., somatic) exercise. USMLE doesn’t expect you to be an obstetrician. The
bigger picture concept is simply knowing internal sphincter control is involuntary. It is
external sphincter control that is voluntary (somatic).
- Do not give medications for stress incontinence on USMLE.
- If Kegel exercises fail, patients can get a mid-urethral sling (LY; asked once).
- The answer on USMLE for patient who has an “urge” (NBME will literally say that
word and I’ve seen students get the Q wrong) to void 6-12+ times daily unrelated to
sneezing, coughing, laughing, etc. (otherwise stress incontinence).
- Ultra-HY for multiple sclerosis. I’ve had students ask whether MS is urge or overflow.
It shows up repeatedly on the NBMEs as urge; I’ve never seen it associated with
overflow. I’d say ~1/3 of urge incontinence vignettes on NBME forms are MS.
- Other vignettes will be peri-menopausal women, or idiopathic in old women.
- Mechanism is “detrusor hyperactivity,” or “detrusor instability.”
- Vignette can mention woman has urge to void when stepping out of her car, or when
sticking her key in the car/front door of her house. Sounds weird, but these are
Urge important Qs to ask when attempting to diagnose urge incontinence.
- UTIs can present similarly to urge incontinence. Some students have asked, “Well
isn’t that because UTIs are a cause of urge incontinence?” Not really. It just happens to
be that UTIs can sometimes cause transient urinary urgency. For example, if they give a
Q where they say patient had Hx of urinary catheter + now has dysuria and urinary
urgency, answer = “urinary tract infection” on NBME; “detrusor hyperactivity” is wrong
answer.
- Treatment is oxybutynin (muscarinic receptor antagonist); this ¯ activity of the
detrusor muscle of the bladder.
- Some students get hysterical about mirabegron (b3-agonist), but I’ve never seen
NBME forms assess this.
Overflow - Will be due to either BPH or diabetes on USMLE.

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- Will have ­ post-void volume. Normal is < ~50 mL. On USMLE for overflow, they’ll
give you 300-400 mL as post-void volume.
- As I talked about earlier for BPH, they will give old dude + high creatinine (post-renal
azotemia). Next best step is “insertion of catheter” to relieve the obstruction. If they
don’t have this listed, “measurement of post-void volume” can be an answer. We then
treat the BPH with finasteride (5a-reductase inhibitor) or an a1-blocker (tamsulosin,
terazosin).
- For diabetes, the mechanism is neuropathy to the bladder causing “neurogenic
bladder,” or “hypotonic bladder,” or “hypocontractile bladder/detrusor muscle.”
- For neurogenic bladder causing overflow incontinence +­ post-void volume,
remember that USMLE is first obsessed with “measure post-void volume” and
“insertion of catheter” if they are listed. They will not force you to choose between the
two. But they like these answers prior to giving medications.
- Give bethanechol (muscarinic receptor agonist); this stimulates the detrusor muscle.
- Making sure you don’t confuse oxybutynin and bethanechol is pass-level for USMLE.
- Patient who has “wet, wobbly, wacky” presentation (i.e., urinary incontinence, ataxia,
cognitive changes) +/- Parkinsonism (e.g., short-steppage gait).
Normal pressure
- Caused by failure of reabsorption of CSF by the arachnoid granulations, resulting in
hydrocephalus
impingement on the zona radiata and “failure to inhibit the voiding reflex” (answer on
(NPH)
NBME).
- Enlargement of the lateral ventricles on head CT.
AIDS complex - Presents similar to NPH – i.e., “wet, wobbly, wacky” in AIDS patient.
dementia

Urinary retention diagnoses

- Lack of coordination between bladder sphincters and detrusor muscle.
- HY cause is spinal cord injury, which can cause either inability to void or
urinary incontinence.
Bladder neck dyssynergia
- MS is another theoretical cause, which is where “overflow incontinence”
as a result of MS has been asked by students, but once again, I’ve only
ever seen urge incontinence for MS on NBME exams. Qbank ¹ NBMEs.
- Acute urethral obstruction due to catheter removal is HY on Surg forms.
- They’ll say patient has anuria (i.e., no urinary output at all) following
removal of a catheter.
Bladder outflow obstruction
- “Acute urethral obstruction” or “bladder outflow obstruction” is the
answer.
- Treatment on NBME is “re-insertion of urinary catheter.”
- Will present as leg pain + urinary retention on USMLE.
- Can be idiopathic, from disc herniation, or other trauma.
- Metastases is HY cause (i.e., random guy over 50; or female with Hx of
mastectomy 5 years ago).
Cauda equina syndrome - “Saddle anesthesia” is an overrated detail and doesn’t show up in the
vast majority of NBME Qs, as per my observation.
- Cauda equina is the collection of nerves at the end of the spinal cord.
Impingement on these nerves is what causes the syndrome. I cover this
stuff in more detail in my HY Neuroanatomy PDF.

HY Genitourinary injuries
- Always presents with blood at the urethral meatus.
- 3 ways this presents on USMLE:
Urethral injury 1) Blood at urethral meatus + saddle injury (dude falls on balance beam).
2) Blood at urethral meatus + pelvic fracture/instability.
3) Blood at urethral meatus + “prostate not palpable.”

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- Next best step is retrograde urethrogram.

- Answer on USMLE for blunt force trauma to abdomen + exquisite suprapubic
tenderness + catheter insertion yields 10-30 mL of dark bloody fluid.
Bladder injury
- Next best step is retrograde cystourethrogram. Do not confuse with voiding
cystourethrogram, which is for posterior urethral valves.
- Just be aware this is USMLE-favorite injury in Obgyn for any surgery done in the
gynecologic area.
Ureteral injury - Diagnosis is with retrograde pyelogram or CT urogram, although I haven’t seen the
USMLE give a fuck. Any ureter injury Q I’ve seen just has “ureter” as answer in the
setting of a random gyn surgery.
- Exceedingly HY on both IM and Surg forms on 2CK.
- Will present as bruising or pain over a flank following accident.
- Blood in the urine is highly sensitive, meaning if it’s not there, we can rule-out.
- First step in diagnosis: “Is there gross blood in the urine?” If yes à do CT of the
abdomen with contrast to diagnose (sounds wrong, since we’re worried about kidney
Renal injury
injury, so student says, “Why would we use contrast?” But it’s what USMLE wants.
Ultrasound is wrong answer).
- If patient does not have gross blood in the urine, next best step is urinalysis looking
for microscopic blood. If present à answer = CT of the abdomen with contrast. If
negative à “no further diagnostic studies indicated.”

Urothelial malignancies
- Aka “clear cell carcinoma”; this is most common variant of RCC.
- Classic Q is a smoker over 50 with red urine and a painful flank mass.
- Q need not mention smoking, but it is biggest risk factor.
- USMLE likes the histo for this, which will show you large clear cells.

Renal cell carcinoma

(RCC)

- Can cause polycythemia due to ­ EPO and hypercalcemia due to PTHrp

secretion (correct, same as squamous cell carcinoma of the lung).
- For example, they say 55-year-old male + red urine + polycythemia +
hypercalcemia + show you above image; they ask for the source of the
malignancy à answer = “kidney,” not lung. Squamous cell carcinoma of the
lung won’t cause hematuria, nor does it metastasize to the kidney.
- The answer for painless flank mass in a kid age 2-4 years.
Wilms tumor
- Does not present in newborns. If they give you a 12-hour-old male, for
(Nephroblastoma)
instance, with a midline mass, that is posterior urethral valves causing a full

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bladder (let alone the fact they say “midline,” not flank). I’ve seen tons of
students select Wilms for this, and I’m like, is the kidney in your midline?
- If they give you a kid 2-4 years with a midline mass, that is neuroblastoma.
- For whatever magical reason, you need to know Wilms tumor is sometimes
caused by mutations on chromosome 11. They ask this factoid on 2CK as well.
There are various Wilms tumor syndromes you need to be aware of:
- Beckwith-Wiedemann syndrome
- Wilms tumor + macrosomia (big baby >4,000g) + hemi-hypertrophy
(half of the body is bigger than the other) + macroglossia +
omphalocele + hypoglycemia.
- Hard 2CK Peds Q gives newborn with macrosomia + hemi-
hypertrophy + macroglossia + omphalocele; they don’t mention a
Wilms tumor (makes sense, since we said we won’t see it in
newborns); they ask for what else could be seen in this patient à
answer = “hypoglycemia.” I say hard Q because Wilms plays no role.
- WAGR syndrome
- Wilms tumor, Aniridia (iris abnormalities), Genitourinary anomalies,
Retardation.
- Usually an easy Q, where they mention “aniridia” straight up in the
vignette and then the answer is just “Wilms tumor” for what the kid
can go on to develop.
- Denys-Drash syndrome
- Ambiguous genitalia + Wilms tumor.
- Rare as fuck. 0-3% of renal malignancies. But count on NBME asking it
anyway.

Collecting duct carcinoma

- Offline NBME Q shows some pic of a kidney split open like this and then the
answer is just “naphthylamine” (moth balls) as the causative agent.
- Most common bladder cancer.
- Classic vignette is hematuria in smoker without a painful flank mass or
polycythemia/hypercalcemia (otherwise RCC).
- USMLE wants you to know smoking is most common risk factor, but aniline
dyes (industrial clothing dyes) and naphthylamine are important causes.
Transitional cell carcinoma
- 2CK Surg Q gives Stage 0 bladder cancer vignette; answer is just “endoscopic
of the bladder
resection.”
- I’ve never seen BCG vaccine as correct answer on NBME. I’ve only seen it as a
distractor. For whatever reason, some studies in the past have suggested
intra-cystic instillation of the TB vaccine can help with bladder cancer. But this
is wrong on USMLE.

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Can have papillary structure on histo.

- Can be caused by Schistosoma hematobium (a trematode or fluke, which is a

type of helminth).
- S. hematobium lays its eggs in the bladder wall and cystic veins draining the
Squamous cell carcinoma
bladder.
of the bladder
- Vignette will be young guy who has red urine months after returning from
Africa where he went swimming in a lake à answer is just Schistosomiasis. Or
they ask what he’s at ­ risk of à answer = squamous cell carcinoma.

SIADH vs DI vs PP
- Syndrome of Inappropriate Anti-Diuretic Hormone secretion à means too much ADH
(vasopressin secretion).
- ADH is produced by supraoptic nucleus of hypothalamus à stored in posterior pituitary.
- ADH ­ free water reabsorption by the medullary collecting duct (MCD) of the kidney by
causing aquaporin insertion.
- Central SIADH à follows head trauma, meningitis, brain cancer, and pain (latter on 2CK Surg).
- Ectopic SIADH à small cell lung cancer secreting ADH.
- Drug-induced ADH à ultra-rare on USMLE, but carbamazepine can do it.

- Patient will have dilute serum and concentrated urine:

- ¯ serum sodium, ¯ serum osmolality, ¯ serum specific gravity.
- ­ urinary osmolality, ­ urinary specific gravity.
- You must know serum sodium is normally 135-145 mEq/L. So in SIADH, it’s <135.
- Serum vs urinary osmolalities will be all over the place and you do not need to
SIADH
memorize values. They might say serum osmolality is 250 and urinary is 750, and then
you say, “Well I can tell serum is dilute compared to urine, which sounds like SIADH.”
- Specific gravity will be 1.000-1.030 on USMLE. Sounds obscure, but it shows up quite
a bit, particularly on 2CK Qs. It’s to my observation that values 1.000-1.006ish are
“dilute”; 1.024-1.030 are “concentrated.” For 9/10 Qs, values will be what you expect.

- As I talk about in detail in my HY Arrows PDF, only the medullary collecting duct osmolality will
change in response to ADH. The USMLE will ask you for the osmolality of the urine at different
nephron locations in comparison to serum, and the combo is: PCT isotonic; juxtaglomerular
apparatus (JGA) hypotonic; MCD hypertonic. à The PCT is always isotonic no matter what; the
JGA (at top of thick ascending limb of loop of Henle) is always hypotonic no matter what; the
MCD is clearly hypertonic in SIADH since we’re pulling free water out of the urine.
- “Fluid restriction” is first answer in diagnosis on 2CK. We want to see how serum/urinary
values change in response.

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- Demeclocycline is answer on 2CK offline NBME 8 for treatment of SIADH. Demeclocycine is

technically a tetracycline antibiotic but isn’t used because it can cause insensitivity to ADH at
the kidney (i.e., nephrogenic diabetes insipidus). So we essentially cause a 2nd problem that
cancels out the 1st problem.
- Conivaptan and tolvaptan are ADH receptor antagonists that can be used for SIADH.
- Central diabetes insipidus à means not enough ADH secretion by hypothalamus, or the
posterior pituitary is unable to release it properly.
- Nephrogenic DI à insensitivity to ADH at the kidney (serum ADH is ­).
- Similar to central SIADH, central DI can be caused by head trauma, meningitis, and cancer.
- Nephrogenic DI is caused by lithium, demeclocycline, hypercalcemia, and NSAIDs.
- There is an NBME Q that asks about a patient’s response to ADH who is on chronic NSAIDs,
and the answer is “« Response to ADH” and “« urinary osmolality” (meaning no change).
- 2CK Q gives patient with primary hyperparathyroidism and ­­ serum calcium + nephrogenic
DI; Q asks cause of the DI à answer = hypercalcemia. High calcium can cause renal insensitivity
to vasopressin.

- Serum vs urinary values are the opposite of SIADH:

- ­ serum sodium (>145 mEq/L), ­ serum osmolality, ­ serum specific gravity.
- ¯ urinary osmolality, ¯ urinary specific gravity.

- PCT isotonic; JGA hypotonic; MCD hypotonic. à The PCT is always isotonic no matter what;
the JGA is always hypotonic no matter what; the MCD is clearly hypotonic in DI since we’re not
pulling free water out of the urine.
DI - When we are trying to first diagnose DI, the first thing we do is fluid restriction, same as with
SIADH. We want to see how serum/urinary values change first.
- After we determine that the urine is staying dilute + the serum is staying concentrated, the
next best step is desmopressin (analogue of vasopressin). If the urine gets more concentrated,
(i.e., if the drug works), we know central DI is the diagnosis and we’re merely deficient in ADH.
- If desmopressin doesn’t work, we know we have nephrogenic DI. I should point out that even
in nephrogenic DI, desmopressin might work but only very little, whereas with central DI,
administration will ­­ urinary osmolality robustly. It will be obvious on USMLE. But my point is,
don’t say, “Oh well desmopressin worked like 5% so we can’t have nephrogenic DI here.”
- Treatment for central DI is therefore desmopressin.
- Treatment for nephrogenic DI is NSAID + a thiazide. Sounds weird, but ¯ Na+ reabsorption
induced by thiazides in the early-DCT promote compensatory ­ Na+ reabsorption in the PCT,
where water follows Na+ and our net loss of fluid is less than without the thiazide. In healthy
individuals, however, they will lose more net fluid with the thiazide. The NSAID presumably ¯
renal blood flow, which will ¯ GFR and ¯ net fluid loss.
- There is difficult 2CK NBME Q where they say patient is on lithium + has ­ urinary output, and
fluid restriction is wrong answer to this question (I say hard because 9/10 times, fluid restriction
is correct when it’s listed); answer = NSAID + thiazide diuretic. The implication is, if it’s obvious
what the patient’s diagnosis is already nephrogenic DI, going straight to Tx is acceptable.
- Psychogenic polydipsia means the patient is simply drinking too much.
- Both the urine and serum will be dilute.
- Serum vs urinary values are the opposite of SIADH:
- ¯ serum sodium (<135 mEq/L), ¯ serum osmolality, ¯ serum specific gravity.
- ¯ urinary osmolality, ¯ urinary specific gravity.
PP
- I’d say 3/4 Qs on USMLE are obvious and will say some psych patient is drinking lots to “clear
himself from evil spirits,” etc.
- Probably 1/4 Qs won’t be an obvious psych vignette, but will just show you the lab values
where you have to say, “The urine and serum are both dilute, so this is psychogenic polydipsia.”
- First step in diagnosis is fluid restriction in order to see how urinary/serum values change.

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Obscure miscellaneous conditions

- Disease that presents as though patient is on loop diuretic.
Bartter syndrome
- For whatever magical reason, is associated with juxtaglomerular cell hyperplasia.
Gitelman syndrome - Disease that presents as though patient is on thiazide diuretic.

Hyper-terse summary of drugs causing HY renal conditions

- Discussed all this stuff earlier. But students confuse this stuff a lot. So the summary is warranted.
- Aminoglycosides (gentamicin, tobramycin, amikacin).
Acute tubular necrosis
- Cisplatin.
Interstitial nephritis - NSAIDs, b-lactams, cephalosporins, allopurinol.
Membranous glomerulonephropathy - Dapsone, gold salts, sulfonamides.

Diuretics / Renal-related drugs

- Osmotic diuretic that ­ osmolality of urine, thereby retaining free water within
the PCT and descending limb of loop of Henle.
- Can be used as Tx for ­ intracranial pressure after patient has been intubated +
hyperventilated (¯ CO2 à ¯ cerebral perfusion).
- Avoid in heart failure (transient ­ in serum osmolality prior to renal excretion à ­
retention of free water within vascular space à transient ­ preload on heart).
- USMLE asks about mannitol’s effect on serum osmolality and ADH. This is a Q
repeated twice on the NBMEs. They will show a graph same as below and ask what
change will be expected with mannitol administration:

Mannitol

Answer = C; serum osmolality goes ­, which then causes ADH to go ­ (this is

because ADH normally ­ free water reabsorption in setting of ­ serum osmolality).

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- Carbonic anhydrase inhibitor (enzyme that enables H2CO3 « HCO3- + H+) that acts
within the tubular cells of the PCT.
- Classic use is altitude sickness à causes ¯ reabsorption of HCO3- in the PCT à
Acetazolamide results in ­ urinary pH and volume + ¯ serum pH and volume. In altitude sickness,
patients hyperventilate (¯ CO2 à ­ pH) to take in more O2, but it takes a minimum
of 12-24 hours for the kidney to ¯ HCO3- reabsorption, so acetazolamide forces the
¯ reabsorption by causing metabolic acidosis.
- Can cause Fanconi syndrome (¯ ability of PCT to reabsorb amino acids, glucose,
Expired tetracyclines
bicarb, and phosphate).
- Classic loop diuretic that inhibits the apical Na+/K+/2Cl- ATPase symporter on the
thick ascending limb. Apical means side of urine. Basolateral means side of blood.
- Most efficacious diuretic at enabling fluid unloading for pulmonary and peripheral
edema. Do not decrease mortality in cardiac patients.
- Answer on USMLE for patient with heart failure who has ¯ O2 sats who “refuses
to lie supine/back on the gurney” because he/she can’t breathe. Q might say CXR or
exam shows fluid 2/3 up the lung fields.
- Application of loops can be confused by students with ACEi/ARB. For instance, the
latter are used first-line to ­ EF in heart failure even if O2 sats are low (¯ AT-II
constrictive effect on arterioles à ¯ afterload à heart pumps easier), but loops
Furosemide are first-line if the vignette specifically emphasizes the dyspnea and low O2 sats of
the patient as the focus.
- HY point is that they can cause hypokalemia. What USMLE loves to do is tell you a
patient is initiated on furosemide but it is insufficient + now needs a second
diuretic à answer = anything that is potassium-sparing (i.e., ENaC inhibitor such as
amiloride or triamterene; or aldosterone receptor antagonist such as
spironolactone or eplerenone).
- Can also cause ototoxicity (tinnitus, vertigo).
- Loops ­ urinary calcium. This is in contrast to thiazides, which ¯ it.
- Ethacrynic acid is another loop you can be aware of. It is used in patients with
sulfa allergies, since furosemide is a sulfa drug. It is also ototoxic.
- Hydrochlorothiazide (HCTZ) is HY example; chlorthalidone is “thiazide-like.”
- Inhibit the Na+/Cl- symporter on the apical membrane of the early-DCT.
- ­ calcium reabsorption in the DCT of the kidney. Used to ¯ recurrence of calcium
stones by promoting ­ reabsorption of urinary calcium. In turn, they can
sometimes cause hypercalcemia. There is an NBME Q where they ask for MOA of
HCTZ, where Na+/Cl- symporter inhibition isn’t listed; answer is just “­ calcium
reabsorption.”
- Thiazides and dihydropyridine calcium channel blockers are used first-line for HTN
in patients without any renal or cardiovascular issues. If patient has proteinuria, ­
Thiazides
in creatinine or renin, or pre-diabetes or diabetes, ACEi or ARBs are used first.
- Can be used in heart failure in patients with diabetic nephropathy who are already
on ACEi and b-blocker. Sounds specific, but there’s a new 2CK Q that has thiazide as
correct over spironolactone in a diabetic. Spironolactone can cause hyperkalemia in
patients who have worrisome kidney function.
- Thiazides can cause gout (i.e., contraindicated in gout).
- Offline NBME 20 wants you to know thiazides can cause galactorrhea (milky
discharge from the nipples) via some obscure mechanism. Literature search shows
it accounts for ~0.2% of adverse effects of thiazides, but count on NBME to ask it.
- ENaC inhibitors à block apical sodium channel in cortical collecting duct à ¯ Na+
reabsorption à ¯ water reabsorption.
- These are potassium-sparing, which means they do not ¯ serum K+. This is
Amiloride, because by inhibiting the apical ENaC channel, they indirectly inhibit the basolateral
Triamterene Na+/K+ ATPase à ¯ Na+ reabsorption + ¯ K+ secretion.
- The answer on USMLE for a second diuretic given in a patient already on
furosemide who needs additional fluid unloading. Be careful however. I’ve seen
one Q where the patient is on furosemide, but the point of the Q is he/she needs

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HTN control, and the answer is a thiazide, not the ENaC inhibitor. You want to
select an ENaC inhibitor specifically if the Q says, “We have a patient who has
peripheral/pulmonary edema due to X cause + is already on furosemide; what do
we do now?” à answer = amiloride or triamterene.
- Aldosterone receptor antagonists.
- By blocking aldosterone receptor, they ¯ activity of the basolateral Na+/K+ ATPase
à leads to indirect ¯ activity of apical ENaC à ¯ Na+ reabsorption à ¯ water
reabsorption.
- Potassium-sparing. Same as with ENaC inhibitors, used for fluid unloading in
patients who are already on furosemide in whom we worry about dropping their K+
too much.
Spironolactone,
- Used in heart failure up the hierarchy of meds – i.e., ACEi/ARB first-line, followed
Eplerenone
by adding b-blocker, followed by spironolactone (but if patient is diabetic with poor
renal function, don’t add spironolactone here; give thiazide instead as per new 2CK
NBME).
- Can be for aldosteronoma (Conn syndrome) prior to surgery.
- Spironolactone can cause gynecomastia (anti-androgenic effect by blocking
androgen receptors).
- Eplerenone has ¯ risk of gynecomastia compared to spironolactone.
- USMLE-favorite ACE inhibitor.
- Prevents conversion of AT-I into AT-II in the lungs.
- Used for HTN in patients with pre-diabetes, diabetes, atherosclerotic disease, or
renal disease (I talk about this in HY Risk Factors PDF in more detail).
Lisinopril - Can cause dry cough (ACE is aka bradykininase, so ACEi cause ¯ breakdown of
bradykinin in lungs à cough).
- Can ­ serum K+, since ¯ aldosterone synthesis. Aldosterone normally secretes K+
in the distal kidney).
- Avoid in hereditary angioedema.
- Angiotensin II receptor blocker (ARB).
- Use-cases are identical on USMLE to ACEi (i.e., if you see both as answer choices
Valsartan
to a question, they’re usually both wrong because they’re the “same”).
- Doesn’t cause dry cough the way ACEi do.
- ADH receptor antagonists at V2 receptor in the medullary collecting duct.
Tolvaptan,
- Can be used for SIADH.
Conivaptan
- Remember, however, that demeclocycline is also answer on 2CK NBME for SIADH.

- 27M + dilated renal pelvis and collecting system + ureters not dilated; Dx? à USMLE wants

“incomplete recanalization of proximal ureter.”

- Four classic findings you see in nephrotic syndrome?

o Proteinuria (usually high, i.e., >3g/24 hours)

o Hypoalbuminemia (because of the proteinuria)

o Peripheral edema (due to decreased intravascular oncotic pressure because of the

hypoalbuminemia)

o Hyperlipidemia (liver exports more apolipoproteins in an attempt to compensate for the low

serum albumin)

- Four classic findings you see in nephritic syndrome?

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o Hematuria (due to glomerular inflammation allowing RBCs to escape into the urine)

o Oliguria (<400mL/24 hours in adults; due to defective glomerular filtration with diminished

GFR)

o Azotemia (means high nitrogen compounds in the blood à blood urea nitrogen [BUN])

o Hypertension (renal inflammation leads to microvascular disruption + upregulation of RAAS

à high angiotensin-II probably more responsible for HTN than aldosterone, as AT-II is potent

systemic vasoconstrictor, and patient need not have full-blown hyper-aldosteronism to have

HTN in nephritic syndrome, in addition to HTN being able to occur in acute renal failure).

- Is there proteinuria in nephritic syndrome? à almost always yes, but just typically not as much as in

nephrotic syndrome. The key differentiator between nephritic and nephrotic is the former has blood

in the urine.

- Important nephrotic syndromes for USMLE? à membranous glomerulonephritis/nephropathy;

minimal change disease (lipoid nephrosis); focal segmental glomerulosclerosis (FSGS); renal

amyloidosis; diabetic glomerulonephropathy.

- Important nephritic syndromes for USMLE? à IgA nephropathy (Berger disease); post-streptococcal

glomerulonephritis (PSGN);

- 12M + sore throat + blood in the urine 1-3 days later; Dx? à answer = IgA nephropathy, not post-

streptococcal glomerulonephritis (PSGN).

- 12M + sore throat + blood in the urine 1-2 weeks later; Dx? à PSGN. This distinction between IgA

nephropathy and PSGN is mega-HY.

- 12M + viral infection + red urine 2 days later; renal biopsy finding? à IgA deposition in the

mesangium (IgA nephropathy).

- 12M + GI infection (diarrhea) + red urine 2 days later; Dx? à IgA nephropathy.

- 3F + violaceous lesions on her buttocks/thighs + arthralgias + abdominal pain + red urine; renal Dx? à

IgA nephropathy. The tetrad of findings here is classic for Henoch-Schonlein purpura (HSP). The renal

component is IgA nephropathy.

- “Wait I’m confused. How does HSP relate to IgA nephropathy?” à don’t think of IgA nephropathy and

HSP as distinct / unrelated conditions; they’re on the same disease spectrum. While some patients

might just get IgA nephropathy from a viral or GI infection, others might get the immune complex

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deposits in the skin (purpura), immune complex deposits in joints (reactive arthritis; type III

hypersensitivity), and mesenteric adenitis (abdo pain), leading to presentation of HSP. HSP is seen in

pediatrics, whereas IgA nephropathy can easily occur in adults.

- 12F + crusty yellow lesions around the mouth for past week + today has red urine; Dx? à PSGN

secondary to impetigo à give topical mupirocin to Tx the impetigo.

- Can you get PSGN from skin infections? à as per above, clearly à impetigo, cellulitis, and erysipelas,

if caused by Group A Strep, can cause PSGN, yes. This is HY for the USMLEs. However it should be

noted that rheumatic heart disease does not occur from cutaneous Strep infections; it occurs from

Strep pharyngitis only.

- 28M + blurry vision and/or hearing issue + red urine; Dx? à Alport syndrome.

- Inheritance pattern of Alport? à X-linked recessive (according to retired NBME 19 for Step 1; I point

this out because some sources say X-linked dominant, but the NBME says XR; the NBME always wins).

- Mechanism of Alport? à mutation in type IV collagen (in contrast to Goodpasture, which is

antibodies against type IV collagen) à important in the lens of the eye + stereocilia within the

cochlea + basement membranes within the kidney à classically “ear and/or eye problem + red urine”

in a male. Question on retired NBME 19 for Step 1 gave the above 28M presentation, and the answer

to the Q was “X-linked recessive.”

- 13M + upper URTI + red urine after one week + decreased complement C3; Dx? à “acute

glomerulonephritis” à yes, PSGN – same thing – but on one of the 2CK NBME’s, they list the answer

as just simply “acute glomerulonephritis,” which for some reason throws people off.

- 13M + PSGN; renal biopsy shows what? à subepithelial deposits or “lumpy bumpy appearance.”

- When is membranoproliferative glomerulonephritis (MPGN) the answer? à red urine in patient with

hepatitis C or malignancy.

- “Splitting of glomerular basement membrane”; Dx? à MPGN. “Tram-track appearance.”

- When is diffuse proliferative glomerulonephritis (DPGN) the answer? à red urine in patient with SLE.

- When is rapidly progressive glomerulonephritis (RPGN) the answer? à acute deterioration in renal

function (high Cr, high BUN, oliguria) in someone who has a vasculitis (granulomatosis with

polyangiitis [formerly Wegener], eosinophilic granulomatosis with polyangiitis [formerly Churg-

Stauss], or microscopic polyangiitis) or Goodpasture syndrome.

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- Biopsy shows what in RPGN? à fibrin crescents; parietal cell hyperplasia; leukocytic infiltrate à

should be noted that the crescents on biopsy are extremely HY on Steps 1+2CK; on Step 1, knowing

their composed of fibrin is high-yield.

- If the question is about Wegener, what will the renal biopsy often show? à “necrotizing”

glomerulonephritis.

- Antibodies in Wegener vs CS vs MP? à Wegener = c-ANCA; CS + MP = p-ANCA. It should be noted

that in real life, there is often overlap between the ANCAs, as well as times when patients may be

ANCA-negative, but on the USMLE, the classic associations stand correct.

- Which antibodies are present in the ANCAs? à c-ANCA = anti-proteinase 3 (anti-PR3); p-ANCA = anti-

myeloperoxidase (anti-MPO).

- Mechanism for Goodpasture? à antibodies against the alpha-3 chains of type IV collagen (anti-

glomerular basement membrane antibodies; anti-GBM) à an NBME Q asks for mechanism, and

answer is à “autoantibodies against host cell basement membranes.”

- Diagnosis of Goodpasture? à biopsy shows linear immunofluorescence.

- How does Goodpasture present? à 40s male with hemoptysis + hematuria.

- How does Wegener present? à hematuria + hemoptysis + “head”-itis (i.e., any type of head finding,

e.g., nasal septal perforation, mastoiditis, otitis, sinusitis).

- How does Churg-Strauss present? à asthma + eosinophilia; head findings rare.

- How does microscopic polyangiitis present? à basically just isolated hematuria in patient who’s p-

ANCA positive.

- Wrist- or foot-drop in someone with W, C-S, or MP; Dx? à Mononeuritis multiplex, which is palsy of

one large nerve in multiple locations, such as the radial or peroneal, causing wrist or foot drop. Seen

sometimes in vasculitides where you say, "Why is there neuropathy in this Wegener patient?” Etc.

- 38F + hematuria + hemoptysis + anti-PR3; Dx? à Wegener.

- 38F + hematuria + nasal septal perforation + c-ANCA; Dx? à Wegener.

- 38F + hematuria + p-ANCA; Dx? à MP.

- 38F + hematuria + anti-MPO; Dx? à MP.

- 38F + asthma + eosinophilia + nasal septal perforation; Dx? à Churg-Strauss (yes, “head”-itis is more

rare, but the asthma + eosinophilia are overwhelmingly CS over Wegener; saw one question like this).

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- 44M + hematuria + hemoptysis + no other findings; Dx? à Goodpasture most likely. If Wegener, they

usually give you a "head-itis" finding, such as nasal septal perforation. If microscopic polyangiitis,

usually just hematuria alone.

- 44M + hematuria + hemoptysis + renal biopsy shows necrotizing glomerulonephritis; Dx? à Wegener.

- 44M + hematuria + hemoptysis + linear immunofluorescence on renal biopsy; Dx? à Goodpasture.

- Alport syndrome vs Goodpasture key difference? à Alport = mutation in type IV collagen gene

(COL4A3/4/5); Goodpasture = antibodies against type IV collagen.

- 12M + periorbital edema + red urine + low C3; Dx? à PSGN.

- 12M + periorbital edema + no blood in the urine + no other information; Dx? à minimal change

disease (MCD; lipoid nephrosis).

- 12M + recent viral infection + periorbital/pedal edema + ascites; Dx? à MCD.

- 40M + Hodgkin lymphoma + renal condition (no blood in urine); Dx? à MCD à student says wtf? à

MCD is almost always children following viral infection, but it’s also seen in adults with Hodgkin. First

time you hear this it’s super-weird, but it’s not a big deal.

- Tx for MCD? à steroids (highly effective)

- Sickle-cell + nephrotic syndrome; Dx? à FSGS.

- HIV / IV drug use + nephrotic syndrome; Dx? à FSGS.

- Interferon use + nephrotic syndrome; Dx? à FSGS.

- What does FSGS mean? à focal vs global; segmental vs diffuse; focal means a part of the kidney;

diffuse means the whole kidney; segmental means part of a single nephron; global means an entire

single nephron. So in FSGS, parts of some nephrons are involved. This makes sense for sickle-cell, for

instance, where sickling will cause irregular microvascular pathology leading to non-uniform renal

involvement.

- Tx for FSGS? à steroids (not as effective as compared to MCD).

- Sulfa drug + kidney issue + no blood in urine; Dx? à membranous glomerulonephropathy (MG).

- Biopsy finding in MG? à subepithelial deposits; “spike and dome” appearance.

- HepB or C + nephrotic syndrome; Dx? à MG à usually due to HepB.

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- Autoantibodies in membranous glomerulonephropathy? à Sometimes patients are positive for anti-

phospholipase A2 receptor antibodies.

- HepC + nephritic syndrome; Dx? à MPGN.

- Multiple myeloma + renal diagnosis? à renal amyloidosis à immunoglobulin light chains at high

levels moving through the kidney (Bence Jones proteinuria) leads to deposition in the renal

parenchyma. You should memorize the sentence: “Multiple myeloma is the most common cause of

renal amyloidosis.”

- First change in the kidney with diabetes? à hyperfiltration à increased filtered glucose pulls water

with it. USMLE Q mentions guy with diabetes + polyuria; asks why he has increased urinary output à

answer = “increased glomerular filtration rate.”

- First histologic change in the kidney with diabetes? à thickening of the glomerular basement

membrane à due to non-enzymatic glycosylation of basement membrane. If the question asks you

for the first renal change seen overall in diabetes, select hyperfiltration.

- Amount of glucose reabsorbed in PCT? à 100% physiologically; glycosuria not seen until serum levels

exceed around 180 mg/dL.

- Late finding seen histologically in diabetic nephropathy? à Kimmelstiel-Wilson nodules.

- What are KW nodules composed of? à hyaline à HY on Step 1 for some reason; don’t confuse this

fibrin, which is the answer for the crescents in RPGN.

- Example of type II diabetes drug that acts in the kidney? à Dapagliflozin (SGLT2 inhibitor in PCT;

prevents reabsorption of glucose).

- What is hyaline arteriolosclerosis? à hyaline deposition in the arterioles of the kidney usually seen in

diabetes à non-enzymatic glycosylation of vascular endothelium leads to leakage of plasma proteins

into vessel walls.

- First drug given to diabetics with HTN or proteinuria? à ACEi (e.g., enalapril) or ARB (e.g., valsartan).

- Most common cause of chronic renal failure? à diabetes mellitus.

- Comment on which endogenous mediators affect diameter of the renal afferent vs efferent arterioles

à prostaglandins dilate the afferent; angiotensin-II constricts the efferent.

- What do NSAIDs do to renal vasculature? à decrease dilation of the afferent arterioles (decreased

prostaglandin synthesis doesn’t cause constriction; we simply see attenuated degree of dilation).

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- What do ACEi/ARBs do to renal vasculature? à decrease constriction of the efferent arterioles

(decreased AT-II synthesis/binding doesn’t cause dilation; we simply see attenuated degree of

constriction). USMLE will show you pic of glomerulus + ask where NSAID or ACEi acts, so just simply

be able to identify that.

- Student asks, “Why does AT-II act on the efferent arteriole? What’s the physiologic reason for that?”

à physiologically, AT-II increases in the setting of low blood volume à constriction of efferent

arteriole à increased filtration fraction (GFR/RBF) à GFR can be maintained in the setting of reduced

renal blood flow

- What do ACEi/ARB do to filtration fraction? à decrease it.

- Student asks, “If diabetes is most common cause of chronic renal failure, and renal failure is defined

as low GFR, why would we give them ACEi or ARB then first-line if those drugs decrease filtration

fraction?” à It’s paradoxical, yes. Although you’d be decreasing filtration fraction with one of these

drugs, you’d also be decreasing the rate at which glucose is being filtered across the basement

membrane, thereby slowing the non-enzymatic glycosylation of the BM + progression of disease.

Patients with end-stage renal disease are generally taken off ACEi/ARB, however early on these drugs

are a mainstay of treatment.

- BUN/Cr ratio in pre-, intra-, vs post-renal failure? à >20 in pre-; <20 if not pre- à FA for Step 1 had

stratified this out as <15 for intra- and 15-20 for post-, but I’ve seen at least three 2CK NBME/CMS Qs

where the diagnosis was acute tubular necrosis and the BUN/Cr was in the 16s or 17s. So I’ve learned

to just tell students: >20 = pre-; if <20, you simply know it’s not pre-.

- Fractional excretion of sodium (FeNa) in pre-/intra-/post-renal failure? à need to know it’s <1% in

pre-renal; >1% in intra-/post-renal à the low FeNa in pre-renal is due to the PCT’s attempt to

reabsorb Na (water follows sodium) in low-volume state (or in FMD, RAS).

- Urine osmolality in pre-/intra-/post-renal failure? à concentrated (high; >500 mOsm) in pre-; dilute

(low; <350 mOsm) in intra-/-post.

- When is pre-renal failure the answer? à Chronic heart failure, NSAID or diuretic use, dehydration

from vomiting/diarrhea. Reduced perfusion over sub-acute to chronic time frame.

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- Guy has MI + has low BP; NBME Q asks what is most likely to be seen (ask a bunch of reabsorption /

secretion answers); answer = “increased potassium secretion” à low-volume status leads to RAAS

upregulation and distal renal K wasting.

- When is intra-renal failure the answer? à ATN due to drugs (aminoglycosides, cisplatin), acute

ischemia from acute blood loss (surgery, trauma), contrast nephropathy, rhabdomyolysis.

- Why does acute hypoxia cause acute tubular necrosis? à PCT is most susceptible to anoxic injury.

Proximal convoluted tubules have high concentrations of Na-K-ATPase transporters with high oxygen

demand.

- Lab animal is given 100% nitrogen in dumb experiment; most likely part of the kidney to experience

anoxic injury (they list everything) à answer = “proximal tubule.”

- Classic finding in urine with ATN? à muddy brown granular casts; it should be noted that general

“granular casts” are not specific to ATN. There’s an IM CMS Q with an elderly woman who has CVA

tenderness + granular casts on U/A; answer is pyelo not ATN.

- USMLE Q gives guy who has MI requiring resuscitation + subsequent oliguria; then they ask what you

see on microscopic examination of the kidney; answer = “degenerating epithelial cells and dirty

brown granular casts” or “necrosis of epithelial cells in proximal convoluted tubules.”

- Electrolyte disturbance in ATN? à first week is oliguric phase (hyperkalemia due to decreased

filtration); weeks 2-3 are polyuric phase (hypokalemia due to increased kaliuresis from PCT cells not

being able to reabsorb K yet) à btw, kaliuresis means urination of K (great word if you want to feel

sophisticated).

- When is post-renal the answer? à classically BPH or distal obstruction secondary to strictures or

malignancy.

- How does USMLE like to assess post-renal? à classically will give you BPH + show you a pic of

hydronephrosis (massively dilated kidney), then they’ll ask the most likely cause of this patient’s

condition; answer = “increased Bowman capsule hydrostatic pressure,” or “increased tubular

hydrostatic pressure.” This answer is on several NBMEs.

- BPH Tx? à alpha-1 blocker (e.g., tamsulosin, terazosin) and/or 5-alpha-reductase inhibitor (i.e.,

finasteride); patients may receive mono- or dual therapy.

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- Tx for prostatic adenocarcinoma? à flutamide + leuprolide administered together (if the USMLE

forces you to choose a sequence, pick flutamide then leuprolide, but in practice they’re administered

together) à flutamide blocks androgen receptors; leuprolide is a GnRH receptor agonist (given

continuously it shuts off LH + FSH secretion).

- When are hyaline casts the answer? à classically dehydration on USMLE.

- When are waxy casts the answer? à end-stage renal disease (not HY, but student occasionally asks).

- When are RBC casts the answer? à glomerulonephritis.

- When are WBC casts the answer? à pyelonephritis classically.

- Wtf is Tamm-Horsfall protein? à most common protein found in urine; not found in plasma;

produced by tubular cells (classically thick ascending limb); no other real significance; more just the

name pops up in Qbank rarely and student will ask about it.

- What is interstitial nephropathy? à aka interstitial nephritis, or tubulointerstitial nephritis, where

there are WBCs (eosinophils) in the urine; patient may or may not present with a fine maculopapular

rash à almost always due to beta-lactams, cephalosporins, NSAIDs, or allopurinol.

- 62M + 6 weeks nafcillin for MSSA endocarditis + WBCs on U/A; Dx? à interstitial nephropathy.

- 35F + uses ibuprofen daily for headaches + rash + eosinophils in urine; what do you see on biopsy? à

NBME answer = “inflammatory infiltrates in the interstitium” = interstitial nephropathy.

- What is analgesic nephropathy? à renal damage due to NSAIDs à can be renal papillary necrosis,

interstitial nephritis, or generalized edema from reduced renal blood flow. If renal papillary necrosis,

will present with dark urine from ischemia. If interstitial nephritis, will present with eosinophils in

urine as described previously (patient may not necessarily have a rash). Analgesic nephropathy is not

a specific/different renal diagnosis. It is just an umbrella term that refers to any situation in which the

kidney is fucked up due to NSAIDs.

- 80F + taking high doses of naproxen for 6 weeks for osteoarthritis + peripheral edema; mechanism of

the edema? à Mechanism for edema in setting of NSAID use à USMLE answer = “increased renal

retention of sodium,” or “decreased renal excretion of sodium.”

- Why would analgesic nephropathy cause increased renal retention of sodium? à NSAID knocks out

COX à decreased prostaglandin synthesis à decreased diameter of afferent arterioles à decreased

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renal blood flow à PCT attempts to increase water reabsorption to compensate for perceived low

volume status à PCT accomplishes this by increasing Na reabsorption à water follows sodium à

fluid retention + edema.

- Patient with analgesic nephropathy; USMLE Q asks mechanism in terms of NSAID’s ability to inhibit

constriction/dilation at afferent vs efferent arterioles; answer = “vasodilating prostaglandins at

afferent arteriole,” causing reduced renal blood flow.

- When is renal papillary necrosis the answer? à classically in sickle cell; can also from drugs like

NSAIDs; urine will be dark à renal papillae in the medulla receive less blood flow, so small changes in

the microvascular supply can lead to sloughing + necrosis of the medulla. You’ll be able to contrast

this disorder from diffuse cortical necrosis and acute tubular necrosis because the latter two

conditions, in the context of ischemia, are associated with massive, acute events.

- First answer for Tx of all kidney stones on USMLE à hydration / fluids.

- Tx for calcium oxalate stones? à fluids, then alkalinize urine (citrate); prevent recurrence with

thiazide (decrease urinary Ca).

- Tx for calcium phosphate stones? à fluids; prevent recurrence with thiazide (decrease urinary Ca).

Calcium phosphate stones form at higher pH, so do not alkalinize; CaOxalate stones form at lower pH,

which is why citrate helps.

- Tx for struvite (ammonium magnesium phosphate) stones? à fluids; acidify urine with ammonium

chloride; surgery (because they’re often huge).

- Tx for uric acid stones? à fluids + alkalinize urine with citrate; treat the underlying gout; avoid

uricosurics such as probenecid indefinitely; avoid low-dose aspirin.

- Tx for cystine stones? à fluids; alkalinize urine with citrate.

- Who gets calcium oxalate stones? à classically those with intestinal malabsorptive disorders such as

Crohn, Celiac, CF à malabsorption of fats means increased intraintestinal binding of fat to calcium à

less calcium available to bind oxalate intraluminally à more oxalate is absorbed through intestinal

wall. CaOxalate stones can also be seen in ethylene glycol (AntiFreeze) poisoning and

hypervitaminosis C.

- Who gets struvite stones? à UTIs caused by urease (+) organisms. Proteus spp. is classic. Stones are

coffin lid-shaped.

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- Who gets uric acid stones? à generally uric acid over-producers such as in Lesch-Nyhan syndrome or

tumor lysis syndrome; alcoholics (USMLE wants under-excretion as mechanism via which EtOH causes

gout, but EtOH also can increase production); stones are radiolucent on non-contrast CT.

- Who get cystine stones? à patients with cystinuria caused by inability to absorb COLA (cysteine,

ornithine, lysine, arginine) à two cysteines (-SH) joined via disulfide bond make one cystine (-S—S-).

- Any factoid to know about cystine stones? à AR disorder; generally young adults in USMLE vignette;

nitroprusside urine test yields a magenta color; hexagon-shaped stones.

- What do I need to know about renal tubular acidosis type I (RTA I)? à decreased ability of the DCT to

secrete protons (urine pH is >5.5) à leads to metabolic acidosis; patient does not have hyperkalemia.

Can be associated with bilateral renal parenchymal stones (i.e., not within the lumina but instead in

the actual meat of the kidney); can be seen in Sjogren syndrome.

- What do I need to know about renal tubular acidosis type II (RTA II)? à decreased ability of the PCT

to reabsorb bicarb (urine pH is >5.5) à associated with carbonic anhydrase inhibitors and Fanconi

syndrome (expired tetracyclines). Patient does not have hyperkalemia.

- What do I need to know about renal tubular acidosis type IV (RTA IV)? à either hyporeninemic

hypoaldosteronism or aldosterone insensitivity at the kidney (urine pH <5.5) à patient will present

with lab values resembling Addison disease, but the etiology will be chronic renal failure, not adrenal.

For instance, 68F diabetic with biochemistry resembling Addison = RTA IV, not Addison à patient will

have low serum sodium, high potassium, low bicarb (metabolic acidosis). Patient is hyperkalemic, in

contrast to RTA I and II.

- USMLE Q asks “decreased absorption” vs “no change” for Fanconi syndrome with respect to glucose,

amino acids, phosphate, bicarb à answer = decreased absorption for all four.

- Explain RAAS system. à reduced renal perfusion (low blood volume, renal artery stenosis,

fibromuscular dysplasia) à juxtaglomerular cells secrete renin à renin cleaves angiotensinogen

(produced by liver) in the plasma into angiotensin I à AT I goes to lung where it’s cleaved by ACE into

AT II à AT II causes vasoconstriction in systemic arterioles (HTN) + at the efferent arterioles of the

kidney (increases FF); it also goes to the zona glomerulosa in the adrenal cortex, where it upregulates

aldosterone synthase, thereby converting 11-deoxycorticosterone into aldosterone.

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- Where does aldosterone act in the kidney? à cortical collecting duct; binds to intracytosolic receptor,

causing upregulation of basolateral Na/K-ATPase pumps (1, 2, 3 à for every 1 ATP utilized, 2 K

secreted into tubular cell from blood; 3 Na reabsorbed from tubular cell into blood) à this causes

decreased intra-tubular cell Na à creates a favorable high-low gradient from urine into the tubular

cell à ENaC is upregulated secondarily on apical membrane to allow Na to move from urine into

tubular cell.

- Another important point about renin secretion? à USMLE wants you to know that beta-1 activity

causes renin release. Sometimes you’ll get a Q where a patient has low blood volume and they’ll ask

which is true, and the answer is “increased renal sympathetic activity.”

- Where does vasopressin (ADH) act in the kidney? à medullary collecting duct à inserts aquaporins

on apical membrane à increased free water reabsorption.

- Urine + serum findings in SIADH à concentrated urine (high osmolality) + low serum sodium (<135

mEq/dL).

- Urine + serum findings in diabetes insipidus à dilute urine (low osmolality) + high serum sodium

(>145 mEq/dL).

- Four causes of nephrogenic DI or USMLE? à lithium + demeclocycline are the two highest yield.

NSAIDs and hypercalcemia can also cause it.

- Urine + serum findings in psychogenic polydipsia (patient drinks too much) à dilute urine (low

osmolality) + low serum sodium (<135 mEq/dL).

- In DI, comment on the urine osmolality relative to plasma (i.e., hypotonic, isotonic, or hypertonic) for

PCT, JGA, medullary collecting duct à PCT is always isotonic regardless of renal condition; JGA is

always hypotonic regardless of renal condition (joins the early-DCT with the afferent arteriole);

medullary collecting duct hypotonic. In SIADH, the latter would merely be hypertonic.

- What is the JGA? à juxtaglomerular apparatus contains JGC that secrete renin.

- What is the macula densa? à modified smooth muscle cells of the DCT that sense changes in serum

sodium, thereby triggering the JGC to secrete renin; if volume status is low, PCT is attempting to

reabsorb more water to compensate; in order to do so, it reabsorbs more Na, where water follows

Na. This means that less sodium will still be left in the urine in the DCT. The macula densa will sense

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that as a signal that the PCT is reabsorbing it because the patient is fluid deficient à triggers JGA to

secrete renin.

- What do I need to know about mannitol? à osmotic diuretic that acts by retaining water within the

nephron lumina; USMLE likes proximal straight tubule (short segment after the PCT) as the answer if

it shows you a drawing and is very specific; if proximal straight tubule isn’t shown or labeled, choose

thin descending limb over PCT. Avoid in heart failure because administration transiently increases

intravascular volume à increased preload going to RA à increased myocardial oxygen demand.

Mannitol is used to treat increased intracranial pressure (pseudotumor cerebri) in some patients after

intubation + hyperventilation have been instituted (decreased CO2 à decreased cerebral perfusion).

- What do I need to know about acetazolamide and the kidney? à carbonic anhydrase inhibitor that

acts to prevent bicarb reabsorption à causes a transient metabolic acidosis that can be used to

counteract the respiratory alkalosis secondary to altitude sickness (kidney cannot physiologically

compensate fast enough so the drug forces the metabolic acidosis).

- What do I need to know about Loops? à Furosemide is standard first-line agent à does not decrease

mortality in heart failure à used to fluid-unload in patients with generalized edema or symptomatic

pulmonary edema à inhibits the Na/K/2Cl symporter on the apical membrane of the thick-ascending

limb à causes hypokalemia notably, but is also associated with contraction alkalosis (RAAS kicks up

and secretes protons distally when volume status is low because of the Loop); also causes increased

urinary calcium and magnesium; classically ototoxic, especially when combined with aminoglycosides

like gentamicin; furosemide is a sulfa drug, so patients with sulfa allergy can go on ethacrynic acid

instead (not a low-yield drug; memorize that). Bumetanide is an alternative to furosemide in some

patients. In general, be aware that loop diuretics are the most effective fluid-unloaders of all of the

diuretics.

- How are calcium + magnesium reabsorbed in the thick ascending limb? à paracellular (between the

cells).

- What is Bartter syndrome? à disease that presents as though the patient is indefinitely on loop

diuretic (associated with JGC hyperplasia).

- What do I need to know about thiazides? à hydrochlorothiazide (HCTZ) is standard drug à inhibits

the Na/Cl symporter on the apical membrane of the early-DCT à associated with decreased urinary

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calcium and magnesium (in contrast to loops) à known to cause hyperGLUC (hyperglycemia, -

lipidemia, -uricemia, -calcemia) à avoid in diabetics + patients with Hx of gout; can be used to

prevent recurrent calcium nephro-/ureterolithiasis. Thiazides may be used to Tx HTN in patients who

do not have cardiovascular disease or diabetes (in these patient groups, use ACEi or ARB initially

instead). Chlorthalidone is an alternative to HCTZ.

- What is Gitelman syndrome? à disease that presents as though the patient is indefinitely on thiazide

diuretic.

- What do I need to know about amiloride and triamterene? à simply that they’re ENaC inhibitors and

are potassium-sparing (meaning they don’t cause kaliuresis).

- What do I need to know about spironolactone? à aldosterone receptor antagonist used in heart

failure after the patient is already on ACEi (or ARB) and a beta-blocker. Can also be used in patients

with Conn syndrome / primary hyperaldosteronism. USMLE loves asking spironolactone as the answer

in patients who are already on furosemide who need another diuretic (furosemide fluid-unloads the

best but causes potassium wasting, whereas spironolactone is potassium-sparing, so adding the latter

on top of furosemide can limit potassium losses). Also very HY to know that spironolactone causes

gynecomastia due to its anti-androgenic effects. Eplerenone is an alternative to spironolactone that

carries much lower risk of gynecomastia. These drugs decrease mortality in heart failure (HY; in

contrast to furosemide, which does not decrease mortality and is used for symptoms only).

- What do I need to know about tolvaptan/conivaptan? à vasopressin (ADH) receptor antagonists that

can be used in SIADH (e.g., due to small cell lung cancer).

- What are the three main effects of parathyroid hormone (PTH) at the kidney?

o Upregulates apical Ca2+ reabsorption in the late-DCT (increases Ca reabsorption).

o Decreases phosphate reabsorption in the PCT.

o Upregulates 1-alpha-hydroxylase in the PCT à increases conversion of inactive 25-OH-D3 to

active 1,25-(OH)2-D3 à active vitamin D3 then goes to small bowel to increase both Ca +

PO4 absorption; active D3 also goes to bone to increase mineralization of osteoid into

hydroxyapatite.

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- What kind of PTH-related pathology is seen in renal disease? à secondary hyperparathyroidism is

caused by chronic renal failure à kidney cannot reabsorb Ca in the DCT or synthesis 1,25-D3 in PCT

(decreased intestinal absorption), leading to hypocalcemia. PCT goes up to compensate.

- Comment on vitamin D in relation to renal disease. à patient will have decreased 1,25-(OH)2-D3 and

increased 24,25-(OH)2-D3 (the latter is an inactive storage form that is created by the shunting of 25-

OH-D3; USMLE asks about 24,25 sometimes). Student then asks, “I don’t get it though. If vitamin D

deficiency is associated with decreased Ca + decreased PO4, and there’s vitamin D deficiency in

chronic renal failure, why are the electrolytes in CRF decreased Ca + increased PO4?” à answer is:

the renal disease always wins; yes, there’s decreased PO4 absorption in the small bowel, but there’s

also decreased filtration at the kidney, and the latter wins in terms of the arrows. That is:

o Vitamin D deficiency due to renal failure: low Ca + high PO4.

o Vitamin D deficiency not due to renal failure: low Ca + low PO4.

- What is renal osteodystrophy? à any bone problem caused by renal disease, but is usually

synonymous with “renal-induced osteomalacia” due to renal effects on reducing active Vit D3.

- Patient with chronic renal disease has a pseudofracture of the hip; Dx? à osteomalacia à

“pseudofracture” is pathognomonic for vitamin D deficiency; in this case, the pseudofracture is just a

type of renal osteodystrophy that may be seen.

- Patient has renal failure + friction rub heard on auscultation of the chest; Dx + Tx? à uremic

pericarditis (a type of fibrinous pericarditis) à USMLE Tx is immediate hemodialysis.

- What is the biochemical / acid-base disturbance seen in renal disease? à sodium is variable;

potassium high; calcium low; phosphate high; bicarb low; pH low; CO2 low (compensation).

- What do I need to know about EPO and the kidney? à Kidney secretes it in response to anemia / low

oxygen states (e.g., COPD). EPO deficiency occurs in renal failure, leading to anemia of chronic

disease. EPO excess secretion can occur in renal cell carcinoma.

- Smoker + hypercalcemia + polycythemia + hematuria; Dx? à RCC (paraneoplastic EPO + PTHrp).

- Smoker + flank pain + red urine; Dx? à RCC.

- Most common type of RCC? à clear cell carcinoma (histo shows large clear cells on Step 1).

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- Notable disease associated with RCC? à Von-Hippel Lindau (VHL) à RCC can be bilateral. VHL is AD,

chromosome 3, and also associated with retinal + cerebellar hemangioblastomas; caused by

constitutive activation of hypoxia-inducible factor.

- Renal cancer in children? à Wilms tumor.

- 3M + painless flank mass + no other info; Dx? à Wilms tumor.

- 6M + painless flank mass + seizure + MRI of brain shows periventricular nodules; Dx? à Tuberous

sclerosis with renal angiomyolipoma.

- Anything else about Wilms tumor? à increased incidence in horseshoe kidney in Turner syndrome.

- Horseshoe kidney key point? à not only increased risk of Wilms tumor, but the kidney gets caught

under the IMA.

- What is WAGR complex? à Wilms tumor, Aniridia, Genitourinary malformation, Retardation; caused

by WT1 gene mutation.

- What is Denys-Drash syndrome? à Wilms tumor + male pseudohermaphroditism (secondary sex

characteristics are female; primary sex characteristics are male); caused by WT1 gene mutation.

- What is Beckwith-Wiedemann syndrome? à Wilms tumor + neonatal hypoglycemia + macrosomia /

macroglossia + hemihypertrophy +/- omphalocele; caused by WT2 gene mutation.

- Comment on AR vs AD polycystic kidney disease. à ARPKD is chromosome 6 and a pediatric

condition; it’s associated with hepatic fibrosis. ADPKD is chromosome 16 and presents in 30s or 40s;

associated with HTN and circle of Willis saccular (berry) aneurysms.

- Most common extra-renal location for cysts in ADPKD? à liver.

- What’s more important in management of ADPKD, serial BP checks or MRI angiogram circle of Willis?

à answer = serial BP checks à renal cysts compress microvasculature, causing surges in RAAS.

- Comment on systemic sclerosis and the kidney? à systemic sclerosis (diffuse type) can cause renal

crises with malignant HTN.

- 68M + diabetic + Hx of intermittent claudication + CABG + gradually increasing BP past two years; Dx?

à renal artery stenosis.

- Cause of renal artery stenosis? à atherosclerosis. They will always give RAS in a patient who has

cardiovascular disease.

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- 23F + high aldosterone + high renin + high BP; Dx? à fibromuscular dysplasia à this is not renal

artery stenosis; if you say RAS, that means atherosclerosis. FMD is a tunica media proliferative

pathology resulting in RAS-like presentation; it’s seen classically in young women, whereas RAS will be

patients with CVD.

- How to Dx FMD? à MR angiography (HY on the USMLE) à NBME has actually said the buzz /

colloquial phrase “string of beads” appearance seen on MR angiography.

- Patient with high BP is given an ACEi or ARB and gets a spike in either renin or creatinine; Dx? à FMD

if young patient; RAS if patient with CVD. USMLE loves this point and it shows up on Steps 1 and 2CK.

If you have FMD or RAS, renal blood flow is already reduced, so the kidney has a reduced capacity to

remain within physiologic range for GFR à giving an ACEi or ARB will reduce filtration fraction and

lead to a clinically significant reduction in GFR à renin + Cr go up.

- Hx of many pregnancies + downward movement of vesicourethral junction à stress incontinence.

- Tx of stress incontinence à pelvic floor exercises (Kegel); if insufficient à mid-urethral sling.

- Hyperactive detrusor or detrusor instability à urge incontinence.

- Need to run to bathroom when sticking key in a door à urge incontinence.

- Incontinence in multiple sclerosis patient or perimenopausal à urge incontinence.

- Tx of urge incontinence à oxybutynin (muscarinic cholinergic antagonist) or mirabegron (beta-3

agonist).

- Incontinence + high post-void volume (usually 3-400 in question; normal is <50 mL) à overflow

incontinence.

- Incontinence in diabetes à overflow incontinence due to neurogenic bladder.

- Tx for overflow incontinence in diabetes à bethanechol (muscarinic cholinergic agonist).

- Incontinence in BPH à overflow incontinence due to outlet obstruction à eventual neurogenic

bladder.

- Tx for overflow incontinence in BPH à insert catheter first; then give alpha-1 blocker of 5-alpha-

reductase inhibitor; then TURP if necessary.

- Innervation of external urethral sphincter à pudendal nerve (somatic; voluntary).

- Innervation of internal urethral sphincter à hypogastric nerves (sympathetic).

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- Innervation of detrusor muscle à pelvic splanchnic nerves (parasympathetic; S2-4).

- What is Brenner tumor? à ovarian tumor with bladder (transitional cell) epithelium.

- Exquisitely tender prostate on digital rectal exam à prostatitis.

- Prostatitis Tx à ciprofloxacin (fluoroquinolone à DNA gyrase / topoisomerase II inhibitor).

- Costovertebral angle tenderness + fever à pyelonephritis.

- Costovertebral angle tenderness + granular casts à pyelonephritis (correct, super-weird; NOT acute

tubular necrosis; this is on 2CK NBME).

- Tx for pyelonephritis à ciprofloxacin, OR ampicillin + gentamicin.

- Is chronic pyelonephritis ever an answer? à usually young patient, i.e., 3-4-year-old, who has

recurrent bouts of acute pyelo à need to know recurrent acute pyelo is what causes chronic pyelo.

For Step 1 level, they will show an image of a small, scarred kidney and give you the above

description, then the answer is simply “vesicoureteral reflux” as the mechanism. They might also ask

what you see on biopsy; answer = “tubular atrophy.” Ultrasound shows “broad scars with blunted

calyces.” The phrase “thyroidization of the kidney” is buzzy and more Qbank, not NBME. You need to

walk away knowing that chronic pyelo will produce scarred renal calyces in someone who’s had

recurrent acute pyelo.

- Tx for simple UTI à nitrofurantoin is classic answer (need not be cystitis in pregnant women; this is

listed as the correct answer in many 2CK-level NBME/CMS Qs); TMP/SMX is also classic combo.

- Q asks best initial Mx to prevent UTIs à answer = postcoital voiding. If unsuccessful, NBME wants

“postcoital nitrofurantoin prophylaxis” next; if not listed, choose “daily TMP/SMX prophylaxis.” The

latter sounds incredibly wrong, and I agree, sounds outrageous, but it’s correct on one of the obgyn

CMS forms and everyone gets it wrong.

- 22F + Sx of dysuria for 6 months + anterior vaginal wall pain + U/A completely normal + afebrile; Dx?

à chronic interstitial cystitis à answer on one of the obgyn forms. Must have at least 6 weeks of UTI-

like Sx without any identifiable pathology.

- Tx for asymptomatic bacteriuria à if pregnant, must Tx. If not pregnant, do not Tx. Exceedingly HY for

2CK.

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- Why must Tx asymptomatic bacteriuria in pregnancy? à progesterone slows ureteric peristalsis,

increasing the risk of pyelo.

- 82F falls down stairs; urine dipstick shows 2+ blood and 3-4 RBCs/hpf on LM; Dx? à rhabdomyolysis

à need to know that false (+) blood on urine dipstick is rhabdomyolysis (dipstick cannot differentiate

myoglobinuria from actual RBCs).

- 22F has Sx of UTI + U/A completely normal; next best step? à test for chlamydia/gonorrhea (answer

on one of the newer obgyn forms).

- 25M + mucopurulent urethral discharge + culture grows nothing; Dx? à chlamydia (obligate

intracellular).

- Tx for chlamydia and gonorrhea on the Step à If chlamydia, give azithromycin or doxycycline. If

gonorrhea, give ceftriaxone PLUS either azithro or doxy (must co-treat for chlamydia). If you don’t see

the gram (-) diplococci on light microscopy, you know gonorrhea likely isn’t there, so you only need to

treat for chlamydia. But if you see gonorrhea there, you don’t know whether chlamydia is also there

or not, so must treat for both.

- Most common type of bladder cancer? à transitional cell carcinoma.

- Most specific cause of bladder cancer? à industrial (aniline) dyes.

- Most common cause of bladder cancer? à smoking.

- Type of bladder cancer seen with Schistosoma haematobium infection à squamous cell carcinoma.

- What is Potter sequence? à renal agenesis leading to oligohydramnios à causes pulmonary

hypoplasia in fetus.

- Most common genitourinary (GU) abnormality in neonatal males? à posterior urethral valves (PUV)

à thin membrane(s) in the urethra preventing the outflow of urine.

- Male neonate + suprapubic mass + no passage of urine; Dx? à PUV.

- Neonatal male with PUV; next best step in Dx? à ultrasound then voiding cystourethrogram.

- 34M falls on balance beam + saddle injury + blood at urethral meatus; Dx + next best step in Mx? à

urethral injury; do retrograde urethrogram.

- 16M + skiing accident + bruising and/or pain over a flank + red urine; Dx + next best step in Mx? à

kidney injury; must do CT with contrast, not ultrasound. This is exceedingly HY on surgery forms and

sounds wrong (i.e., “why would you do CT with contrast in someone with suspected renal injury if

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contrast can cause nephrotoxicity?”) à great question, but CMS/NBME/USMLE still want CT with

contrast, so don’t pick ultrasound.

- 16M + skiing accident + bruising and/or pain over a flank + no gross blood of urine (i.e, urine not red);

next best step in Mx? à urinalysis to look for blood (super HY) à if urinalysis shows blood, do CT

scan to check for renal injury. If U/A negative, renal injury unlikely, so choose “no further

investigations indicated,” not CT.

- 16M + skiing accident + bruising and/or pain over a flank + urinalysis is normal; next best step? à no

further investigations indicated.

- USMLE Q gives you creatinine of 1.0 mg/dL in 65M, then tells you 10 years later his Cr is 1.2 mg/dL;

Dx? à normal aging à creatinine clearance naturally decreases with age. There is no definitive cutoff

for USMLE Qs, but the student should be aware that Cr of 1.5 or greater is always pathologic, and at

Cr of 2.0, >90% of nephron function has already been lost. Normal range is 0.7-1.2, but with age can

occasionally creep upwards of 1.4.

- USMLE Q says oophorectomy is being performed + ureter is damaged; during ligation of which vessel

did the damage to the ureter occur? à answer = ovarian artery.

- What is water under the bridge? à ureter travels under the uterine artery in women and vas

deferens in men.

- Kid + bloody diarrhea + petechiae + red urine; Dx? à hemolytic uremic syndrome (HUS) caused by

EHEC O157:H7 or Shigella à HUS = triad of thrombocytopenia + schistocytosis (microangiopathic

hemolytic anemia) + renal insufficiency.

- How does HUS contrast with TTP? à TTP is caused by a mutation that results in defective ADAMTS13,

or antibodies against ADAMTS13, resulting in the inability to cleave vWF multimers à platelet

clumping à similar progression as HUS. One of the points of contrast is that TTP is not toxin-induced,

and TTP also tends to be a pentad of the HUS findings + fever + neurologic signs.

- What is hepatorenal syndrome? à liver failure causing renal failure; rare Dx but the correct answer

USMLE wants is “normal renal biopsy.”

- Endocarditis following a genitourinary procedure (e.g., TURP) or catheterization; organism? à USMLE

wants enterococcus.

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