{"id":37038,"date":"2026-06-12T07:14:50","date_gmt":"2026-06-12T01:44:50","guid":{"rendered":"https:\/\/atsixty.com\/?p=37038"},"modified":"2026-06-19T08:36:29","modified_gmt":"2026-06-19T03:06:29","slug":"nephrology-summative-revision-notes","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/morning-rounds\/nephrology-summative-revision-notes\/","title":{"rendered":"Nephrology: Summative Revision Notes"},"content":{"rendered":"\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n\/* Namespaced to #nrev01 *\/\n#nrev01 *,#nrev01 *::before,#nrev01 *::after{box-sizing:border-box;margin:0;padding:0}\n#nrev01{\n  --nep:#2A5470;--nep-dark:#1C3D52;--nep-pale:#EBF3F8;--nep-mid:#3A7499;\n  --acc:#8B3D20;--acc-pale:#FDF0EB;\n  --ink:#1A2C38;--ink-mid:#3D5A6A;--ink-soft:#7A9BAD;\n  --line:#D8E6EE;--cream:#F4F8FB;--warm:#FAFCFE;\n  --correct:#2D6B47;--correct-bg:#EAF6EF;\n  font-family:'Source Serif 4',Georgia,serif;\n  font-size:16px;color:var(--ink);background:var(--cream);\n  line-height:1.78;padding:0 0 72px;\n}\n#nrev01 .rv-header{background:var(--nep);color:#F0F7FC;padding:36px 24px 30px;text-align:center}\n#nrev01 .rv-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#nrev01 .rv-title{font-family:'Playfair Display',serif;font-size:1.9rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#nrev01 .rv-title em{font-style:italic;font-weight:400;opacity:0.88}\n#nrev01 .rv-subtitle{font-size:0.84rem;opacity:0.72;font-style:italic;margin-top:8px}\n#nrev01 .rv-chips{display:flex;justify-content:center;gap:10px;margin-top:16px;flex-wrap:wrap}\n#nrev01 .rv-chip{background:rgba(255,255,255,0.13);border:1px solid rgba(255,255,255,0.22);border-radius:20px;padding:4px 13px;font-size:0.72rem}\n#nrev01 .rv-body{max-width:740px;margin:0 auto;padding:0 18px}\n#nrev01 .rv-section{background:var(--warm);border:1px solid var(--line);border-left:4px solid var(--nep);border-radius:10px;margin:28px 0;overflow:hidden;box-shadow:0 1px 6px rgba(26,44,56,0.05)}\n#nrev01 .rv-sec-head{background:var(--nep-pale);padding:14px 20px 12px;border-bottom:1px solid #C0D8E8}\n#nrev01 .rv-sec-num{font-size:0.61rem;font-weight:700;letter-spacing:0.14em;text-transform:uppercase;color:var(--nep);margin-bottom:3px}\n#nrev01 .rv-sec-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--nep-dark)}\n#nrev01 .rv-sec-body{padding:16px 20px 18px}\n#nrev01 .rv-sec-body p{font-size:0.92rem;color:var(--ink-mid);line-height:1.75;margin-bottom:0.9em}\n#nrev01 .rv-sec-body p:last-child{margin-bottom:0}\n#nrev01 .rv-sec-body strong{font-weight:600;color:var(--ink)}\n#nrev01 .rv-sec-body em{font-style:italic}\n#nrev01 .rv-sub{font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;color:var(--acc);margin:16px 0 6px;letter-spacing:0.02em}\n#nrev01 .rv-pill{display:inline-block;background:var(--acc-pale);border:1px solid #E8C8B8;border-radius:16px;padding:3px 11px;font-size:0.78rem;font-weight:600;color:var(--acc);margin:2px 3px 2px 0}\n#nrev01 .rv-pill-blue{background:var(--nep-pale);border:1px solid #B8D0E0;color:var(--nep-dark)}\n#nrev01 .rv-pill-green{background:var(--correct-bg);border:1px solid #A8D8B8;color:var(--correct)}\n#nrev01 .rv-table-wrap{overflow-x:auto;margin:12px 0 4px}\n#nrev01 table{width:100%;border-collapse:collapse;font-size:0.83rem}\n#nrev01 th{background:var(--nep);color:#F0F7FC;padding:8px 12px;text-align:left;font-weight:600;font-family:'Source Serif 4',serif}\n#nrev01 td{padding:7px 12px;border-bottom:1px solid var(--line);color:var(--ink-mid);vertical-align:top}\n#nrev01 tr:last-child td{border-bottom:none}\n#nrev01 tr:nth-child(even) td{background:#EFF5F9}\n#nrev01 td strong{color:var(--ink)}\n#nrev01 .rv-figure{margin:18px 0 8px;background:var(--warm);border:1px solid var(--line);border-radius:8px;padding:16px;text-align:center}\n#nrev01 .rv-fig-cap{font-size:0.76rem;color:var(--ink-soft);font-style:italic;margin-top:10px;line-height:1.45}\n#nrev01 .rv-rule{height:1px;background:var(--line);margin:6px 0 12px}\n#nrev01 .rv-intro{margin:28px 0 8px;font-size:0.93rem;color:var(--ink-mid);line-height:1.8;padding:0 2px}\n#nrev01 .rv-intro p{margin-bottom:0.9em}\n@media print{\n  #nrev01 .rv-header{background:#2A5470 !important;-webkit-print-color-adjust:exact}\n  #nrev01{padding-bottom:20px}\n  #nrev01 .rv-section{break-inside:avoid;box-shadow:none}\n}\n@media(max-width:480px){\n  #nrev01 .rv-title{font-size:1.45rem}\n  #nrev01 .rv-sec-title{font-size:1rem}\n  #nrev01 table{font-size:0.76rem}\n  #nrev01 td,#nrev01 th{padding:6px 8px}\n}\n<\/style>\n\n<div id=\"nrev01\">\n\n  <div class=\"rv-header\">\n    <div class=\"rv-eyebrow\">Morning Rounds &middot; Nephrology Series<\/div>\n    <div class=\"rv-title\">Nephrology<br><em>Summative Revision Notes<\/em><\/div>\n    <div class=\"rv-subtitle\">Seven topics &middot; NEET-PG and UPSC CMS &middot; Key facts, tables, and diagrams<\/div>\n    <div class=\"rv-chips\">\n      <span class=\"rv-chip\">AKI<\/span>\n      <span class=\"rv-chip\">CKD<\/span>\n      <span class=\"rv-chip\">Glomerular<\/span>\n      <span class=\"rv-chip\">Tubular<\/span>\n      <span class=\"rv-chip\">Electrolytes<\/span>\n      <span class=\"rv-chip\">Dialysis &amp; Transplant<\/span>\n      <span class=\"rv-chip\">Hereditary &amp; Vascular<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"rv-body\">\n\n    <div class=\"rv-intro\">\n      <p>These notes summarise the seven Morning Rounds in the Nephrology series. They are written for rapid pre-exam revision, not first-time learning. Each section is self-contained. Read the debrief panels in the quizzes for the full clinical reasoning \u2014 use these notes to consolidate, not to meet the topic for the first time.<\/p>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 1 \u2014 ACUTE KIDNEY INJURY\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 01 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Acute Kidney Injury<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">RIFLE vs KDIGO \u2014 staging<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Stage<\/th><th>Creatinine (both systems)<\/th><th>Urine Output<\/th><th>RIFLE equivalent<\/th><\/tr>\n            <tr><td><strong>KDIGO Stage 1<\/strong><\/td><td>&#x2265;1.5&times; baseline <em>or<\/em> &#x2265;0.3 mg\/dL rise within 48 h<\/td><td>&lt;0.5 mL\/kg\/h &gt;6 h<\/td><td>Risk<\/td><\/tr>\n            <tr><td><strong>KDIGO Stage 2<\/strong><\/td><td>&#x2265;2.0&times; baseline<\/td><td>&lt;0.5 mL\/kg\/h &gt;12 h<\/td><td>Injury<\/td><\/tr>\n            <tr><td><strong>KDIGO Stage 3<\/strong><\/td><td>&#x2265;3.0&times; baseline <em>or<\/em> Cr &#x2265;4.0 mg\/dL <em>or<\/em> RRT initiated<\/td><td>&lt;0.3 mL\/kg\/h &#x2265;24 h or anuria &#x2265;12 h<\/td><td>Failure<\/td><\/tr>\n            <tr><td><strong>RIFLE only<\/strong><\/td><td>Loss (&gt;4 weeks); ESRD (&gt;3 months)<\/td><td>\u2014<\/td><td>Outcome stages<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>Key KDIGO addition over RIFLE: the <strong>0.3 mg\/dL rise within 48 hours<\/strong> criterion for Stage 1. KDIGO dropped RIFLE's outcome stages (Loss, ESRD).<\/p>\n\n        <div class=\"rv-sub\">Pre-renal vs ATN \u2014 rapid differentiation<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Parameter<\/th><th>Pre-renal<\/th><th>ATN (Intrinsic)<\/th><\/tr>\n            <tr><td>FENa<\/td><td><strong>&lt;1%<\/strong><\/td><td><strong>&gt;2%<\/strong><\/td><\/tr>\n            <tr><td>Urine Na<\/td><td>&lt;20 mEq\/L<\/td><td>&gt;40 mEq\/L<\/td><\/tr>\n            <tr><td>Urine SG<\/td><td>&gt;1.020<\/td><td>~1.010 (isosthenuria)<\/td><\/tr>\n            <tr><td>BUN:Cr ratio<\/td><td>&gt;20:1<\/td><td>~10:1<\/td><\/tr>\n            <tr><td>Urine microscopy<\/td><td>Normal \/ hyaline casts<\/td><td>Muddy brown granular casts<\/td><\/tr>\n            <tr><td>Response to fluids<\/td><td>Creatinine falls<\/td><td>Does not respond<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p><strong>FENa caveat:<\/strong> falsely elevated (&gt;1%) in pre-renal AKI if patient is on diuretics. Use <strong>FE-Urea (&lt;35% = pre-renal)<\/strong> in patients on diuretics. FENa is also &lt;1% in contrast nephropathy and myoglobinuria despite ATN.<\/p>\n\n        <div class=\"rv-sub\">RRT indications \u2014 AEIOU<\/div>\n        <p><strong>A<\/strong>cidosis (pH &lt;7.2 unresponsive to treatment) &middot; <strong>E<\/strong>lectrolytes (K&#x207A; &gt;6.5 with ECG changes) &middot; <strong>I<\/strong>ntoxication (dialysable toxins) &middot; <strong>O<\/strong>verload (pulmonary oedema refractory to diuretics) &middot; <strong>U<\/strong>raemia (encephalopathy, pericarditis, bleeding). Creatinine alone is <em>never<\/em> an absolute threshold.<\/p>\n\n        <div class=\"rv-sub\">Contrast-induced AKI<\/div>\n        <p>Prevention: <strong>IV isotonic saline<\/strong> (1 mL\/kg\/h before and after) is the only evidence-based intervention. NAC: large RCTs (PRESERVE, ACT) showed no benefit over hydration \u2014 no longer routinely recommended. Iso-osmolar contrast reduces osmotic load but does not replace hydration.<\/p>\n\n        <p><span class=\"rv-pill\">FENa &lt;1% = pre-renal<\/span> <span class=\"rv-pill\">Muddy brown casts = ATN<\/span> <span class=\"rv-pill blue\">KDIGO adds 0.3 mg\/dL\/48h<\/span> <span class=\"rv-pill-green\">NAC = no benefit (PRESERVE)<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 2 \u2014 CHRONIC KIDNEY DISEASE\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 02 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Chronic Kidney Disease<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">KDIGO staging \u2014 eGFR \u00d7 albuminuria grid<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Stage<\/th><th>eGFR (mL\/min\/1.73 m&#x00B2;)<\/th><th>Label<\/th><th>Albuminuria<\/th><\/tr>\n            <tr><td><strong>G1<\/strong><\/td><td>&#x2265;90<\/td><td>Normal\/High<\/td><td rowspan=\"2\">A1 &lt;30 mg\/g (normal\u2013mild)<\/td><\/tr>\n            <tr><td><strong>G2<\/strong><\/td><td>60\u201389<\/td><td>Mildly decreased<\/td><\/tr>\n            <tr><td><strong>G3a<\/strong><\/td><td>45\u201359<\/td><td>Mild\u2013moderately decreased<\/td><td>A2 30\u2013300 mg\/g (moderate)<\/td><\/tr>\n            <tr><td><strong>G3b<\/strong><\/td><td>30\u201344<\/td><td>Moderately\u2013severely decreased<\/td><td>A3 &gt;300 mg\/g (severe)<\/td><\/tr>\n            <tr><td><strong>G4<\/strong><\/td><td>15\u201329<\/td><td>Severely decreased<\/td><td><\/td><\/tr>\n            <tr><td><strong>G5<\/strong><\/td><td>&lt;15<\/td><td>Kidney failure (ESRD)<\/td><td><\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>CKD requires abnormality persisting <strong>&gt;3 months<\/strong>. G1A1 or G2A1 without structural abnormality does <em>not<\/em> constitute CKD.<\/p>\n\n        <div class=\"rv-sub\">CKD-MBD \u2014 the cascade<\/div>\n        <p>Failing kidney &#x2192; &#x2193;1-alpha-hydroxylase &#x2192; &#x2193;1,25-OH Vitamin D &#x2192; hypocalcaemia + phosphate retention &#x2192; secondary HPT (&#x2191;PTH). First-line: dietary phosphate restriction + phosphate binders (sevelamer, calcium carbonate, lanthanum). Active Vitamin D analogues (calcitriol, alfacalcidol) for the 1,25-OH deficiency. <strong>Tertiary HPT<\/strong> = autonomous PTH secretion after prolonged secondary HPT; PTH stays high even after calcium corrected.<\/p>\n\n        <div class=\"rv-sub\">Slowing progression \u2014 evidence hierarchy<\/div>\n        <p><strong>RAS blockade (ACEi or ARB)<\/strong>: reduces intraglomerular pressure via efferent arteriolar dilation; first-line in diabetic nephropathy with proteinuria. <strong>SGLT2 inhibitors<\/strong>: renal protection independent of glycaemic effect \u2014 CREDENCE, DAPA-CKD, EMPA-KIDNEY trials. BP target in CKD with proteinuria: <strong>&lt;130\/80 mmHg<\/strong>. <strong>Dual RAS blockade (ACEi + ARB)<\/strong>: contraindicated \u2014 ONTARGET trial showed increased AKI and hyperkalaemia, no additional benefit.<\/p>\n\n        <div class=\"rv-sub\">Anaemia of CKD \u2014 management sequence<\/div>\n        <p>Before starting ESA: confirm iron stores adequate \u2014 <strong>TSAT &gt;20% and ferritin &gt;200 ng\/mL<\/strong> (dialysis patients); &gt;100 ng\/mL (non-dialysis). IV iron preferred in dialysis (hepcidin blocks oral absorption). ESA targets: Hb <strong>10\u201312 g\/dL<\/strong>. Targeting &gt;13 g\/dL increases stroke and thrombosis (CHOIR, CREATE trials). ESA hyporesponsiveness: exclude iron deficiency, infection, aluminium toxicity, haemolysis, myeloma.<\/p>\n\n        <div class=\"rv-sub\">RRT timing \u2014 IDEAL trial<\/div>\n        <p>Early initiation (eGFR 10\u201314) vs late (eGFR 5\u20137): <strong>no survival advantage<\/strong> to early start. Initiate when uraemic symptoms, refractory fluid overload, or metabolic complications develop \u2014 not at a fixed eGFR threshold.<\/p>\n\n        <p><span class=\"rv-pill\">CKD &gt;3 months + two measurements<\/span> <span class=\"rv-pill\">SGLT2i: CREDENCE, DAPA-CKD<\/span> <span class=\"rv-pill blue\">Dual RAS = contraindicated<\/span> <span class=\"rv-pill-green\">Hb ceiling 12 g\/dL on ESA<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 3 \u2014 GLOMERULAR DISEASES\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 03 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Glomerular Diseases<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Nephrotic vs Nephritic \u2014 framework<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Feature<\/th><th>Nephrotic<\/th><th>Nephritic<\/th><\/tr>\n            <tr><td>Proteinuria<\/td><td>&gt;3.5 g\/day<\/td><td>&lt;3.5 g\/day<\/td><\/tr>\n            <tr><td>Haematuria<\/td><td>Absent\/minimal<\/td><td><strong>Prominent (RBC casts)<\/strong><\/td><\/tr>\n            <tr><td>Hypertension<\/td><td>Usually absent initially<\/td><td>Present<\/td><\/tr>\n            <tr><td>Oedema mechanism<\/td><td>Hypoalbuminaemia<\/td><td>Sodium retention<\/td><\/tr>\n            <tr><td>Renal function<\/td><td>Normal early<\/td><td>&#x2191; Creatinine<\/td><\/tr>\n          <\/table>\n        <\/div>\n\n        <!-- Glomerular disease at-a-glance SVG -->\n        <div class=\"rv-figure\">\n          <svg viewBox=\"0 0 680 210\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:680px;display:block;margin:0 auto\">\n            <rect width=\"680\" height=\"210\" fill=\"#FAFCFE\" rx=\"6\"\/>\n            <text x=\"340\" y=\"17\" text-anchor=\"middle\" fill=\"#1A2C38\" font-size=\"11\" font-weight=\"700\" font-family=\"Georgia,serif\">Glomerular Diseases \u2014 At a Glance<\/text>\n            <!-- Headers -->\n            <rect x=\"8\"   y=\"23\" width=\"90\"  height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n            <rect x=\"102\" y=\"23\" width=\"95\"  height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n            <rect x=\"201\" y=\"23\" width=\"110\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n            <rect x=\"315\" y=\"23\" width=\"100\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n            <rect x=\"419\" y=\"23\" width=\"120\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n            <rect x=\"543\" y=\"23\" width=\"129\" height=\"18\" rx=\"2\" fill=\"#2A5470\"\/>\n            <text x=\"53\"  y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Disease<\/text>\n            <text x=\"149\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Syndrome<\/text>\n            <text x=\"256\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Key feature<\/text>\n            <text x=\"365\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">IF pattern<\/text>\n            <text x=\"479\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Marker<\/text>\n            <text x=\"607\" y=\"35\" text-anchor=\"middle\" fill=\"#F0F7FC\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Treatment<\/text>\n            <!-- MCD -->\n            <rect x=\"8\"   y=\"43\" width=\"90\"  height=\"22\" rx=\"2\" fill=\"#eaf6ef\"\/>\n            <rect x=\"102\" y=\"43\" width=\"95\"  height=\"22\" rx=\"2\" fill=\"#f4fbf7\"\/>\n            <rect x=\"201\" y=\"43\" width=\"110\" height=\"22\" rx=\"2\" fill=\"#f4fbf7\"\/>\n            <rect x=\"315\" y=\"43\" width=\"100\" height=\"22\" rx=\"2\" fill=\"#f4fbf7\"\/>\n            <rect x=\"419\" y=\"43\" width=\"120\" height=\"22\" rx=\"2\" fill=\"#f4fbf7\"\/>\n            <rect x=\"543\" y=\"43\" width=\"129\" height=\"22\" rx=\"2\" fill=\"#f4fbf7\"\/>\n            <text x=\"53\"  y=\"57\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">MCD<\/text>\n            <text x=\"149\" y=\"57\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Nephrotic (child)<\/text>\n            <text x=\"256\" y=\"57\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Foot process effacement (EM)<\/text>\n            <text x=\"365\" y=\"57\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Negative<\/text>\n            <text x=\"479\" y=\"57\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">None<\/text>\n            <text x=\"607\" y=\"57\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Steroids (90% respond)<\/text>\n            <!-- FSGS -->\n            <rect x=\"8\"   y=\"67\" width=\"90\"  height=\"22\" rx=\"2\" fill=\"#eaf6ef\"\/>\n            <rect x=\"102\" y=\"67\" width=\"95\"  height=\"22\" rx=\"2\" fill=\"#edf8f4\"\/>\n            <rect x=\"201\" y=\"67\" width=\"110\" height=\"22\" rx=\"2\" fill=\"#edf8f4\"\/>\n            <rect x=\"315\" y=\"67\" width=\"100\" height=\"22\" rx=\"2\" fill=\"#edf8f4\"\/>\n            <rect x=\"419\" y=\"67\" width=\"120\" height=\"22\" rx=\"2\" fill=\"#edf8f4\"\/>\n            <rect x=\"543\" y=\"67\" width=\"129\" height=\"22\" rx=\"2\" fill=\"#edf8f4\"\/>\n            <text x=\"53\"  y=\"81\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">FSGS<\/text>\n            <text x=\"149\" y=\"81\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Nephrotic (adult)<\/text>\n            <text x=\"256\" y=\"81\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Segmental sclerosis on biopsy<\/text>\n            <text x=\"365\" y=\"81\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">IgM, C3 (non-specific)<\/text>\n            <text x=\"479\" y=\"81\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">None specific<\/text>\n            <text x=\"607\" y=\"81\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Steroids; often resistant<\/text>\n            <!-- MGN -->\n            <rect x=\"8\"   y=\"91\" width=\"90\"  height=\"22\" rx=\"2\" fill=\"#fff5e0\"\/>\n            <rect x=\"102\" y=\"91\" width=\"95\"  height=\"22\" rx=\"2\" fill=\"#fffaf2\"\/>\n            <rect x=\"201\" y=\"91\" width=\"110\" height=\"22\" rx=\"2\" fill=\"#fffaf2\"\/>\n            <rect x=\"315\" y=\"91\" width=\"100\" height=\"22\" rx=\"2\" fill=\"#fffaf2\"\/>\n            <rect x=\"419\" y=\"91\" width=\"120\" height=\"22\" rx=\"2\" fill=\"#fffaf2\"\/>\n            <rect x=\"543\" y=\"91\" width=\"129\" height=\"22\" rx=\"2\" fill=\"#fffaf2\"\/>\n            <text x=\"53\"  y=\"105\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">MGN<\/text>\n            <text x=\"149\" y=\"105\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Nephrotic (adult)<\/text>\n            <text x=\"256\" y=\"105\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Subepithelial deposits; spike &amp; dome<\/text>\n            <text x=\"365\" y=\"105\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Granular IgG + C3<\/text>\n            <text x=\"479\" y=\"105\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Anti-PLA2R (70\u201380%)<\/text>\n            <text x=\"607\" y=\"105\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Rituximab; cyclophosphamide<\/text>\n            <!-- IgA -->\n            <rect x=\"8\"   y=\"115\" width=\"90\"  height=\"22\" rx=\"2\" fill=\"#f4eef8\"\/>\n            <rect x=\"102\" y=\"115\" width=\"95\"  height=\"22\" rx=\"2\" fill=\"#f8f2fc\"\/>\n            <rect x=\"201\" y=\"115\" width=\"110\" height=\"22\" rx=\"2\" fill=\"#f8f2fc\"\/>\n            <rect x=\"315\" y=\"115\" width=\"100\" height=\"22\" rx=\"2\" fill=\"#f8f2fc\"\/>\n            <rect x=\"419\" y=\"115\" width=\"120\" height=\"22\" rx=\"2\" fill=\"#f8f2fc\"\/>\n            <rect x=\"543\" y=\"115\" width=\"129\" height=\"22\" rx=\"2\" fill=\"#f8f2fc\"\/>\n            <text x=\"53\"  y=\"129\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">IgA Nephropathy<\/text>\n            <text x=\"149\" y=\"129\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Nephritic<\/text>\n            <text x=\"256\" y=\"129\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Synpharyngitic haematuria<\/text>\n            <text x=\"365\" y=\"129\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Mesangial IgA<\/text>\n            <text x=\"479\" y=\"129\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Normal complement<\/text>\n            <text x=\"607\" y=\"129\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">ACEi\/ARB; SGLT2i<\/text>\n            <!-- Anti-GBM -->\n            <rect x=\"8\"   y=\"139\" width=\"90\"  height=\"22\" rx=\"2\" fill=\"#fdf0f0\"\/>\n            <rect x=\"102\" y=\"139\" width=\"95\"  height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"201\" y=\"139\" width=\"110\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"315\" y=\"139\" width=\"100\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"419\" y=\"139\" width=\"120\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"543\" y=\"139\" width=\"129\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <text x=\"53\"  y=\"153\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Anti-GBM (Goodpasture)<\/text>\n            <text x=\"149\" y=\"153\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">RPGN + haemoptysis<\/text>\n            <text x=\"256\" y=\"153\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Crescents &gt;50%; lung haem<\/text>\n            <text x=\"365\" y=\"153\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Linear IgG<\/text>\n            <text x=\"479\" y=\"153\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Anti-GBM Ab<\/text>\n            <text x=\"607\" y=\"153\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Plasma exchange + steroids + CYC<\/text>\n            <!-- Lupus IV -->\n            <rect x=\"8\"   y=\"163\" width=\"90\"  height=\"22\" rx=\"2\" fill=\"#fdf0f0\"\/>\n            <rect x=\"102\" y=\"163\" width=\"95\"  height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"201\" y=\"163\" width=\"110\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"315\" y=\"163\" width=\"100\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"419\" y=\"163\" width=\"120\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <rect x=\"543\" y=\"163\" width=\"129\" height=\"22\" rx=\"2\" fill=\"#fdf5f5\"\/>\n            <text x=\"53\"  y=\"177\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Lupus Nephritis IV<\/text>\n            <text x=\"149\" y=\"177\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Mixed (nephritic++)<\/text>\n            <text x=\"256\" y=\"177\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Wire-loop lesions; diffuse prolif<\/text>\n            <text x=\"365\" y=\"177\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">Full house<\/text>\n            <text x=\"479\" y=\"177\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">&#x2193;C3, &#x2191;anti-dsDNA<\/text>\n            <text x=\"607\" y=\"177\" text-anchor=\"middle\" fill=\"#143a4e\" font-size=\"7\" font-family=\"Georgia,serif\">MMF + prednisolone (induction)<\/text>\n            <!-- PSGN note -->\n            <text x=\"340\" y=\"200\" text-anchor=\"middle\" fill=\"#7A9BAD\" font-size=\"7\" font-family=\"Georgia,serif\" font-style=\"italic\">IgA vs PSGN: IgA haematuria concurrent with URTI (synpharyngitic); PSGN haematuria 1\u20133 weeks after (latent period). PSGN: low C3. IgA: normal C3.<\/text>\n          <\/svg>\n          <div class=\"rv-fig-cap\">The IF pattern is the single most exam-tested histological feature in glomerular disease. Linear IgG = anti-GBM. Granular IgG+C3 = immune-complex (MGN, PSGN, lupus). Negative IF = MCD. \"Full house\" (IgG, IgA, IgM, C3, C1q) = lupus nephritis.<\/div>\n        <\/div>\n\n        <p><span class=\"rv-pill\">Linear IgG = anti-GBM<\/span> <span class=\"rv-pill\">Wire-loop = Lupus IV<\/span> <span class=\"rv-pill blue\">Anti-PLA2R = primary MGN<\/span> <span class=\"rv-pill-green\">Synpharyngitic = IgA nephropathy<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 4 \u2014 RENAL TUBULAR DISORDERS\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 04 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Renal Tubular Disorders<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">RTA \u2014 the three-line summary<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Type<\/th><th>Defect<\/th><th>Serum K&#x207A;<\/th><th>Urine pH<\/th><th>Stones\/NCC<\/th><th>Classic causes<\/th><\/tr>\n            <tr><td><strong>Type I (Distal)<\/strong><\/td><td>&#x2193;H&#x207A; secretion, collecting duct<\/td><td><strong>&#x2193; Low<\/strong><\/td><td><strong>&gt;5.5 always<\/strong><\/td><td>Yes (Ca-PO&#x2084;)<\/td><td>Sj&ouml;gren, SLE, amphotericin B, lithium<\/td><\/tr>\n            <tr><td><strong>Type II (Proximal)<\/strong><\/td><td>&#x2193;HCO&#x2083;&#x207B; reabsorption<\/td><td>&#x2193; Low<\/td><td>Variable; can be &lt;5.5<\/td><td>Rare<\/td><td>Fanconi (Wilson, cystinosis, tenofovir, myeloma)<\/td><\/tr>\n            <tr><td><strong>Type IV<\/strong><\/td><td>&#x2193;Aldosterone \/ resistance<\/td><td><strong>&#x2191; High<\/strong><\/td><td>&#x2264;5.5<\/td><td>No<\/td><td>DM (hyporeninism), ACEi\/ARB, heparin, CKD<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>All three RTAs: <strong>normal anion gap metabolic acidosis (NAGMA)<\/strong>. Type I is the only one where urine pH <em>cannot<\/em> fall below 5.5 regardless of systemic acidosis. Type IV is the commonest RTA in adults.<\/p>\n\n        <div class=\"rv-sub\">Fanconi syndrome \u2014 generalised proximal wasting<\/div>\n        <p>All proximal tubular reabsorptates lost: glucose (normoglycaemic glycosuria), phosphate, uric acid, amino acids, potassium, bicarbonate. Mnemonic: <strong>GARBAGE<\/strong>. Causes: cystinosis (children), Wilson disease, tenofovir (TDF), ifosfamide, lead, multiple myeloma. Tenofovir mechanism: mitochondrial DNA polymerase gamma inhibition in proximal tubular cells. Switch to TAF (tenofovir alafenamide \u2014 less nephrotoxic).<\/p>\n\n        <div class=\"rv-sub\">Bartter vs Gitelman \u2014 the calcium pivot<\/div>\n        <p>Both: hypokalaemic metabolic alkalosis, normal BP, high renin\/aldosterone, mimic diuretics. <strong>Bartter<\/strong> (thick ascending limb defect = furosemide-like): presents in infancy\/childhood, <strong>hypercalciuria<\/strong>, nephrocalcinosis, polyuria. <strong>Gitelman<\/strong> (DCT defect = thiazide-like): presents in adults incidentally, <strong>hypomagnesaemia + hypocalciuria<\/strong>. Exam pivot: <em>Bartter = Ca up; Gitelman = Ca down<\/em>.<\/p>\n\n        <div class=\"rv-sub\">Nephrogenic DI \u2014 lithium mechanism<\/div>\n        <p>Lithium enters collecting duct principal cells via ENaC &#x2192; inhibits adenylyl cyclase &#x2192; &#x2193;cAMP &#x2192; AQP2 channels not inserted &#x2192; tubule impermeable to water despite normal\/high ADH. DDAVP test: no response (vs central DI where urine osmolality rises &gt;50%). Paradoxical treatment: thiazides (mild volume depletion &#x2192; &#x2191; proximal reabsorption &#x2192; &#x2193; urine volume) + amiloride (blocks ENaC, &#x2193; lithium entry).<\/p>\n\n        <p><span class=\"rv-pill\">Type I RTA: urine pH &gt;5.5 always<\/span> <span class=\"rv-pill\">Type IV: K&#x207A; high<\/span> <span class=\"rv-pill blue\">Bartter = hypercalciuria<\/span> <span class=\"rv-pill-green\">Gitelman = hypoMg + hypocalciuria<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 5 \u2014 ELECTROLYTES\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 05 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Electrolytes \u2014 The Renal Lens<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">Hyponatraemia \u2014 diagnostic axis<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Volume status<\/th><th>Urine Na<\/th><th>Diagnoses<\/th><\/tr>\n            <tr><td>Hypovolaemic<\/td><td>&lt;20 mEq\/L<\/td><td>GI\/skin losses (vomiting, diarrhoea, burns)<\/td><\/tr>\n            <tr><td>Hypovolaemic<\/td><td>&gt;20 mEq\/L<\/td><td>Diuretics, adrenal insufficiency, RTA<\/td><\/tr>\n            <tr><td>Euvolaemic<\/td><td>&gt;40 mEq\/L<\/td><td><strong>SIADH<\/strong>, hypothyroidism, polydipsia<\/td><\/tr>\n            <tr><td>Hypervolaemic<\/td><td>&lt;20 mEq\/L<\/td><td>CCF, cirrhosis, nephrotic syndrome<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p><strong>SIADH criteria:<\/strong> true hypoosmolar hyponatraemia + urine osmolality &gt;100 mOsm\/kg + urine Na &gt;40 + euvolaemic + normal thyroid\/adrenal. Causes: SSRIs, carbamazepine, malignancy (SCLC), pulmonary\/CNS disease. Treatment: fluid restriction first; hypertonic saline for symptomatic severe cases. <strong>Correction ceiling: 8 mEq\/L in 24 h.<\/strong> Overcorrection &#x2192; <strong>ODS (osmotic demyelination syndrome)<\/strong>.<\/p>\n\n        <div class=\"rv-sub\">Hypernatraemia correction<\/div>\n        <p>Always a free-water deficit. Formula: <strong>Water deficit = 0.6 &times; weight &times; [(Na\/140) &minus; 1]<\/strong>. Replace with 0.45% saline or 5% dextrose. Correction rate: <strong>no faster than 0.5 mEq\/L\/hour or 10\u201312 mEq\/L\/day<\/strong>. Rapid correction &#x2192; cerebral oedema (brain has made idiogenic osmoles).<\/p>\n\n        <div class=\"rv-sub\">Hyperkalaemia \u2014 C-B-D-E-R sequence<\/div>\n        <p><strong>C<\/strong>alcium gluconate (membrane stabilisation, onset 1\u20133 min \u2014 first when ECG changes present) &#x2192; <strong>B<\/strong>icarbonate (if acidotic) &#x2192; <strong>D<\/strong>extrose-insulin (10 u actrapid + 50 mL 50% dextrose, lowers K by 0.5\u20131.5 mEq\/L, onset 15\u201330 min) &#x2192; <strong>E<\/strong>xcretion (resonium, patiromer, SZC, loop diuretic) &#x2192; <strong>R<\/strong>RT. Calcium does not lower K \u2014 it antagonises membrane depolarisation.<\/p>\n\n        <div class=\"rv-sub\">Hypokalaemia with hypertension \u2014 Conn syndrome<\/div>\n        <p>Hypokalaemia + hypertension + metabolic alkalosis + renal K wasting (UK:UCr elevated) + <strong>suppressed renin + elevated aldosterone<\/strong> = Primary Hyperaldosteronism. Workup: ARR (&gt;30 with aldosterone &gt;15 ng\/dL) &#x2192; confirmatory test &#x2192; adrenal CT &#x2192; adrenal vein sampling. Unilateral adenoma: adrenalectomy. Bilateral hyperplasia: spironolactone\/eplerenone.<\/p>\n\n        <div class=\"rv-sub\">Metabolic alkalosis \u2014 urine chloride classification<\/div>\n        <p><strong>Urine Cl &lt;20 mEq\/L = chloride-responsive (saline-responsive)<\/strong>: vomiting, nasogastric drainage, antacid excess, post-diuretic state. Treat with IV normal saline. <strong>Urine Cl &gt;20 = chloride-resistant<\/strong>: primary hyperaldosteronism, Cushing \u2014 saline will not correct; treat the cause. Alkalosis &#x2192; tetany from reduced ionised calcium (alkalosis increases protein binding).<\/p>\n\n        <p><span class=\"rv-pill\">ODS: &gt;8 mEq\/L\/day overcorrection<\/span> <span class=\"rv-pill\">Ca gluconate first in hyperkalaemia<\/span> <span class=\"rv-pill blue\">Conn: suppressed renin + &#x2191; aldosterone<\/span> <span class=\"rv-pill-green\">Urine Cl classifies metabolic alkalosis<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 6 \u2014 DIALYSIS & TRANSPLANT\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 06 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Dialysis &amp; Transplantation<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">HD vs PD \u2014 key comparison<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Feature<\/th><th>Haemodialysis<\/th><th>Peritoneal Dialysis<\/th><\/tr>\n            <tr><td>Setting<\/td><td>Hospital\/centre, 3&times;\/week<\/td><td>Home (CAPD or APD)<\/td><\/tr>\n            <tr><td>Residual renal function<\/td><td>Lost faster (haemodynamic stress)<\/td><td><strong>Better preserved<\/strong><\/td><\/tr>\n            <tr><td>Solute clearance<\/td><td>More efficient per session (KT\/V &#x2265;1.2)<\/td><td>Continuous but lower per-session<\/td><\/tr>\n            <tr><td>Contraindications<\/td><td>Vascular access failure<\/td><td>Prior abdominal surgery\/adhesions, herniae<\/td><\/tr>\n            <tr><td>Access<\/td><td>AV fistula (preferred), graft, CVC<\/td><td>Tenckhoff catheter<\/td><\/tr>\n          <\/table>\n        <\/div>\n\n        <div class=\"rv-sub\">Intra-dialytic hypotension (IDH)<\/div>\n        <p>Commonest HD complication (~20\u201330% sessions). Mechanism: UF rate exceeds plasma refilling. Management: stop UF, Trendelenburg, IV saline\/hypertonic saline. Prevention: sodium profiling, cooled dialysate (35\u00b0C), UF rate limit &lt;13 mL\/kg\/h, hold antihypertensives on dialysis day.<\/p>\n\n        <div class=\"rv-sub\">PD peritonitis<\/div>\n        <p>Diagnosis: effluent WBC &gt;100\/mm&#x00B3; with &gt;50% neutrophils. Commonest organism: coagulase-negative <em>Staphylococcus<\/em>. Treatment: <strong>intraperitoneal<\/strong> vancomycin + ceftazidime (empirical). Catheter removal: fungal peritonitis, refractory\/relapsing peritonitis, faecal peritonitis, tunnel infection with peritonitis.<\/p>\n\n        <div class=\"rv-sub\">Transplant rejection \u2014 summary<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Type<\/th><th>Timing<\/th><th>Mechanism<\/th><th>IF pattern<\/th><th>Treatment<\/th><\/tr>\n            <tr><td><strong>Hyperacute<\/strong><\/td><td>Minutes on table<\/td><td>Pre-formed anti-HLA Ab<\/td><td>Thrombosis, fibrin<\/td><td>Irreversible; nephrectomy<\/td><\/tr>\n            <tr><td><strong>Acute Cellular<\/strong><\/td><td>Wk 1\u20133 (peak)<\/td><td>CD8+ T-cell mediated<\/td><td>Tubulitis + interstitial infiltrate<\/td><td>Pulse IV methylprednisolone &times;3d<\/td><\/tr>\n            <tr><td><strong>Chronic<\/strong><\/td><td>Months\u2013years<\/td><td>T-cell + antibody<\/td><td>Fibrosis, intimal hyperplasia<\/td><td>Optimise IS; no reversal<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>Hyperacute prevented by pre-transplant <strong>crossmatch<\/strong>. Standard triple IS: tacrolimus + MMF + prednisolone. Steroid-resistant acute rejection: ATG (anti-thymocyte globulin).<\/p>\n\n        <div class=\"rv-sub\">PTLD \u2014 post-transplant lymphoproliferative disorder<\/div>\n        <p>EBV-driven B-cell proliferation from immunosuppression-induced T-cell suppression. Presents months\u2013years post-transplant. First step: <strong>reduction of immunosuppression (RIS)<\/strong> \u2014 stop MMF first. CD20+ disease not responding: rituximab. Aggressive disease: R-CHOP.<\/p>\n\n        <p><span class=\"rv-pill\">PD peritonitis: WBC &gt;100<\/span> <span class=\"rv-pill\">Hyperacute = pre-formed Ab<\/span> <span class=\"rv-pill blue\">ACR: pulse steroids<\/span> <span class=\"rv-pill-green\">PTLD: reduce IS first<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\n         SECTION 7 \u2014 HEREDITARY, VASCULAR & STRUCTURAL\n    \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"rv-section\">\n      <div class=\"rv-sec-head\">\n        <div class=\"rv-sec-num\">Topic 07 &middot; Nephrology<\/div>\n        <div class=\"rv-sec-title\">Hereditary, Vascular &amp; Structural Nephrology<\/div>\n      <\/div>\n      <div class=\"rv-sec-body\">\n\n        <div class=\"rv-sub\">ADPKD \u2014 key facts<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Feature<\/th><th>PKD1 (chromosome 16p)<\/th><th>PKD2 (chromosome 4q)<\/th><\/tr>\n            <tr><td>Frequency<\/td><td>~85%<\/td><td>~15%<\/td><\/tr>\n            <tr><td>Protein<\/td><td>Polycystin-1<\/td><td>Polycystin-2<\/td><\/tr>\n            <tr><td>ESRD median age<\/td><td><strong>~54 years<\/strong><\/td><td>~74 years<\/td><\/tr>\n            <tr><td>Severity<\/td><td>More severe<\/td><td>Milder<\/td><\/tr>\n            <tr><td>Inheritance<\/td><td colspan=\"2\">Autosomal dominant (1 in 400\u20131000)<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>Earliest manifestation: <strong>hypertension<\/strong> (&#x2191;intrarenal RAAS). Progression marker: <strong>total kidney volume (TKV)<\/strong> on MRI. Treatment: tolvaptan (V2-receptor antagonist slows TKV growth \u2014 TEMPO trial). Diagnosis by ultrasound: Ravine criteria (age-dependent cyst counts).<\/p>\n        <p><strong>Extrarenal manifestations:<\/strong> intracranial berry aneurysms (5\u201310%, most feared \u2014 SAH), hepatic cysts (commonest, ~80% by age 60, usually benign), mitral valve prolapse (~25%), aortic root dilatation, pancreatic and seminal vesicle cysts. MRA brain screening: indicated if family history of SAH, high-risk occupation, prior aneurysm \u2014 not routine for all.<\/p>\n\n        <div class=\"rv-sub\">Renal artery stenosis \u2014 FMD vs atherosclerotic<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Feature<\/th><th>Fibromuscular Dysplasia<\/th><th>Atherosclerotic RAS<\/th><\/tr>\n            <tr><td>Patient<\/td><td>Young women<\/td><td>Older, cardiovascular risk factors<\/td><\/tr>\n            <tr><td>Location<\/td><td>Mid\/distal renal artery<\/td><td>Ostial\/proximal<\/td><\/tr>\n            <tr><td>Angiography<\/td><td><strong>String of beads<\/strong><\/td><td>Smooth stenosis<\/td><\/tr>\n            <tr><td>Treatment<\/td><td><strong>PTA alone<\/strong> (no stent)<\/td><td>Medical therapy (ASTRAL, CORAL trials \u2014 stenting no benefit)<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p><strong>ACEi\/ARB in RAS:<\/strong> contraindicated in bilateral RAS or RAS in a solitary kidney \u2014 loss of efferent arteriolar tone &#x2192; acute GFR fall.<\/p>\n\n        <div class=\"rv-sub\">Malignant hypertension<\/div>\n        <p>Severe BP + papilloedema (Grade IV retinopathy) + AKI + MAHA (schistocytes). Fibrinoid necrosis of arterioles &#x2192; RAAS activation &#x2192; vicious cycle. Treatment: IV antihypertensives (labetalol, nicardipine). <strong>Critical rule: reduce MAP by no more than 20\u201325% in the first hour.<\/strong> Rapid normalisation &#x2192; cerebral\/renal hypoperfusion (autoregulation reset). Renal function may transiently worsen before improving.<\/p>\n\n        <div class=\"rv-sub\">HUS vs TTP<\/div>\n        <div class=\"rv-table-wrap\">\n          <table>\n            <tr><th>Feature<\/th><th>STEC-HUS<\/th><th>TTP<\/th><\/tr>\n            <tr><td>Mechanism<\/td><td>Shiga toxin &#x2192; endothelial injury<\/td><td>ADAMTS13 deficiency &#x2192; ultra-large vWF<\/td><\/tr>\n            <tr><td>Trigger<\/td><td>E. coli O157:H7 (bloody diarrhoea)<\/td><td>Autoantibody to ADAMTS13<\/td><\/tr>\n            <tr><td>Dominant organ<\/td><td><strong>Kidney<\/strong> (AKI)<\/td><td><strong>Brain<\/strong> (neuro symptoms)<\/td><\/tr>\n            <tr><td>Treatment<\/td><td>Supportive; <strong>avoid antibiotics<\/strong><\/td><td><strong>Plasma exchange (urgent)<\/strong><\/td><\/tr>\n            <tr><td>Age\/context<\/td><td>Children, food outbreak<\/td><td>Young women, idiopathic\/drug<\/td><\/tr>\n          <\/table>\n        <\/div>\n        <p>Both: MAHA (schistocytes) + thrombocytopenia + negative Coombs. In STEC-HUS: antibiotics lyse bacteria &#x2192; massive Shiga toxin release &#x2192; worsens clinical course. Plasma exchange is <em>not<\/em> indicated in STEC-HUS; it is essential in TTP (ADAMTS13 &lt;10%).<\/p>\n\n        <p><span class=\"rv-pill\">ADPKD berry aneurysm: screen if FHx SAH<\/span> <span class=\"rv-pill\">FMD: PTA no stent<\/span> <span class=\"rv-pill blue\">MAP: max 25% drop in 1st hour<\/span> <span class=\"rv-pill-green\">HUS: no antibiotics<\/span><\/p>\n\n      <\/div>\n    <\/div>\n\n    <!-- Footer -->\n    <div style=\"margin-top:32px;text-align:center;font-size:0.80rem;color:#7A9BAD;font-style:italic;line-height:1.6\">\n      Nephrology Summative Revision &middot; atsixty.com &middot; Morning Rounds Series<br>\n      For clinical reasoning practice, return to the seven Morning Rounds quizzes linked in the series index.\n    <\/div>\n\n  <\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Morning Rounds &middot; Nephrology Series NephrologySummative Revision Notes Seven topics &middot; NEET-PG and UPSC CMS &middot; Key facts, tables, and diagrams AKI CKD Glomerular Tubular Electrolytes Dialysis &amp; Transplant Hereditary &amp; Vascular These notes summarise the seven Morning Rounds in the Nephrology series. They are written for rapid pre-exam revision, not first-time learning. Each section&hellip;&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[84,74],"tags":[82,83,89],"class_list":["post-37038","post","type-post","status-publish","format-standard","hentry","category-medicine","category-morning-rounds","tag-cms","tag-neet-pg","tag-nephrology"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Nephrology: Summative Revision Notes - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/morning-rounds\/nephrology-summative-revision-notes\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Nephrology: Summative Revision Notes - atsixty\" \/>\n<meta property=\"og:description\" content=\"Morning Rounds &middot; Nephrology Series NephrologySummative Revision Notes Seven topics &middot; NEET-PG and UPSC CMS &middot; Key facts, tables, and diagrams AKI CKD Glomerular Tubular Electrolytes Dialysis &amp; Transplant Hereditary &amp; Vascular These notes summarise the seven Morning Rounds in the Nephrology series. 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Nephrology Series NephrologySummative Revision Notes Seven topics &middot; NEET-PG and UPSC CMS &middot; Key facts, tables, and diagrams AKI CKD Glomerular Tubular Electrolytes Dialysis &amp; Transplant Hereditary &amp; Vascular These notes summarise the seven Morning Rounds in the Nephrology series. They are written for rapid pre-exam revision, not first-time learning. 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