Case-based learning 2

Renal/Urinary system
Group C
Advisors: ผศ.นพ.จิตวัต รุ่งเจิดฟ้า
ผศ.ดร.วรเชษฐ์ ขอบใจ
อ.ดร.ณัฏฐพล ศุภกมลเสนีย์
 Members
Ausadang Boonporn 6406300010
Pornmongkol Rattanasarun 6406300014
Nabthong Teerakul 6406300017
Tanakrit Srisukmangmee 6406300020
Pattheera Kongrid 6406300026
Pasoot Thaninpitak 6406300027
Pongsapish Treegosol 6406300037
Parkphum Bhongmaliwal 6406300049
Thaksapond Eiamudomsuk 6406300052
Krongjit Sittikityotin 6406300053
Nathawan Amatathaweewat 6506300009
Saminee Meephewhom 6506300037
 Topic
1. Lab Investigation/Interpretation

2. How to diagnosis SLE with

nephrotic syndrome
 Problem List
SYMSTEMIC LUPUS
ERYTHEMATOSUS (SLE)
 Problem list
Periorbital edema
Lower extremity edema and sometimes muscle and joint pains
S Tired and fatigue
Three years ago, she had first diagnosed of systemic lupus
erythematosus (SLE)

Body temperature 37.8°C

O
Blood pressure 150/90 mmHg
Pitting edema 3+ of lower legs
Periorbital edema
Malar rash
 Problem list
A Nephritic syndrome
Nephrotic syndrome (NS)

Diagnostic plan Therapeutic plan

Complete Blood Count Prednisolone

P (CBC)
Urinalysis
Hydroxychloroquine
Azathioprine
Blood chemistry
Lipid profile
 Problem List
Generalized edema
(Anasarca)
 Problem list
Periorbital edema

S
Lower extremity edema and sometimes muscle and joint pains
Tired and fatigue
Taking Ibuprofen , Prednisolone, Hydroxychloroquine,
Azathioprine, Oral contraceptive pills, Multivitamin

Body temperature 37.8°C

Blood pressure 150/90 mm Hg

O
Pitting edema 3+ of lower legs
Periorbital edema
Weight gained 5 kg in 2 weeks
Mild distension abdomen, Active bowel sound
 Problem list
A Nephritic syndrome
Nephrotic syndrome (NS)

Diagnostic plan Therapeutic plan

Complete Blood Count (CBC) Diuretics and albumin

P
Urinalysis Limit salt intake to
Blood chemistry reduce the swelling
Renal function test physical activities
Liver function test Taking good nutritious
Lipid profile food
Lab Investigation
&
Interpretation
CBC
Lab Investigation & Interpretation; CBC

CBC Normal Nephrotic Patient’s lab result

syndrome (SLE with NS)

WBC (10^3 cell/mcL) 4 - 11 N 3.6

RBC (10^6 cell/mcL) 4.0 - 5.0 N 3.5

Hb (g/dL) 12 - 16 N 1.035

Hct (%) 36 - 48 N 29.7

PLT (10^3 cell/mcL) 150 - 400 N 180

PLT Smear Adequate Adequate Adequate

Lab Investigation & Interpretation; CBC (RBC indicy)
CBC (RBC indicy) Normal Nephrotic syndrome Patient’s lab result
(SLE with NS)

MCV 80 - 100 N 84.9

(fL) Normocytic

MCH 27 - 33 N 28.3
(pg)

MCHC 31 - 35 N 30
(g/dL)

RBC Normochromic Normochromic Normochromic

Morphology Normocytic Normocytic Normocytic
Lab Investigation & Interpretation; CBC (WBC differential)
CBC Normal Nephrotic Patient’s lab result
(WBC differential) syndrome (SLE with NS)

Neutrophil (%) 40-75 N 40

Lymphocyte (%) 20-50 N 45

Monocyte (%) 2-10 N 8

Eosinophil (%) 1-6 N 6

Basophil (%) 0-1 N 1

Urinalysis
Lab Investigation & Interpretation : UA (Physical & Chemical)
Normal Nephrotic syndrome Patient’s lab result

Color pale yellow Yellow Yellow

Appearance clear Foamy slightly turbid Foamy slightly turbid

PH 4.5 - 8.0 not specific diagnostic marker PH : 7.5

Sp.Gr 1.003 - 1.030 > 1.030 1.035

Protein Negative 3+ or 4+ 3+

Blood Negative Negative or Trace Trace

Glucose,Ketone, Negative Negative Negative

Bilirubin,
Urobilinogen
Lab Investigation & Interpretation : UA (Microscopic)

Nephrotic
Normal Patient’s lab result
syndrome

WBC 0-3 cell/HPF N WBC : 1-2 cell/HPF

RBC 0-3 cell/HPF N 2-3 cell/HPF

Squamous epithelial No reference 1-2 cell/HPF

cell range N

Hyaline cast 0-3 cell/HPF N 2-3 cell/HPF

Fatty cast, Oval fat

Negative specific finding 2-3 cell/HPF
body
Blood Chemistry
Lab Investigation & Interpretation: Blood chemistry
Blood chemistry Normal Nephrotic syndrome Patient’s lab result

FBG (mg/dL) 70-100 N 88

Renal function test

Blood urea 7-20 N 25

nitrogen (BUN)
(mg/dL)

Creatinine 0.7-1.3 N 0.8

(mg/dL)

eGRF > 100 N 101

(ml/min/1.73m^2)
Lab Investigation & Interpretation: Blood chemistry
Normal Nephrotic syndrome Patient’s lab result

Liver function test

Total protein (g/dL) 6.6-8.7 less than normal 4.9

Albumin (g/dL) 3.5-5.2 less than normal 2.1

Globulin (g/dL) 3.1-3.5 N 2.8

A/G ratio 1.2 - 1.5 < 1.2 0.75

AST (IU/L) <40 N 39

ALT (IU/L) <40 N 35

ALP (IU/L) 35-104 N 90

Lab Investigation & Interpretation: Blood chemistry (cont.)

Normal Nephrotic syndrome Patient’s lab

result

Liver function test

Total bilirubin 0.3-1.5 N 0.8

(mg/dL)

Direct bilirubin 0-0.5 N 0.3

(mg/dL)
Lab Investigation & Interpretation : Blood chemistry

Normal Nephrotic syndrome Pateint’s lab result

Electrolytes: by indirect ion selective electrode (ions) and enzymatic

assay (CO2)

Na+ (mmol/L) 136–145 N* 138

K+(mmol/L) 3.4-4.5 N* 4.0

Cl- (mmol/L) 95-106 N 98

Total CO2 (mmol/L) 22-29 N 23

*There may be higher electrolyte (Na+ or K+) values ​than normal due to due to protein loss in the urine.
Additional Lab
Lab Investigation & Interpretation : Additional lab
Additional LAB Normal Nephrotic syndrome Patient’s lab result

Lipid profile

Totalcholesterol 140-200 mg/dl Hyperlipidemia 350 mg/dl

HDL-C ≥ 40 mg/dl (Excess of 62 mg/dl
LDL-C <130 mg/dl lipoprotein 260 mg/dl
Triglycerides 50-200 mg/dl production) 210 mg/dl

Serology test for SLE

Anti-dsDNA < 15 U/mg N 165 U/mg

C3 level 0.9-1.8 g/l N 0.6 g/l

C4-level 0.1-0.4 g/l N 0.075 g/l

Lab Investigation & Interpretation : Additional lab

Nephrotic Patient’s lab

Additional LAB Normal
syndrome result

24-hr. urine protein < 100 3,794

(mg/24 hr) Specific finding

ESR (mm/hr) < 20 (Female) 60

< 15 (Male) Elevates
Differential diagnosis
between
Nephrotic and
Nephritic syndrome
Differential diagnosis between Nephrotic and Nephritic syndrome
Lab investigation Nephrotic syndrome Nephritic syndrome

Urinalysis

Color Yellow Red or Pink

Appearance Foamy slightly turbid Foamy

Protein Positive Negative or Positive

Blood Negative or Trace Positive (Hematuria)

RBC Normal > 3 cells/HPF (dysmorphic RBC)

RBC cast Not found Found

Fatty cast, oval fat body Found Not found

Differential diagnosis between Nephrotic and Nephritic syndrome

Lab investigation Nephrotic syndrome Nephritic syndrome

Liver function test

Total protein L normal or slightly low

Albumin L normal or slightly low

AST N normal or slightly low

ALT N normal or slightly low

ALP N normal or slightly low

Differential diagnosis between Nephrotic and Nephritic syndrome

Renal biopsy is used for differential diagnosis between

nephrotic and nephritic syndrome. Moreover, it can identify
types of nephrotic and nephritic syndrome
How to Diagnosis SLE
with
Nephrotic syndrome
Intro
Systemic Lupus Erythematosus (SLE)
with Neprotic syndrome
History taking
Physical examination
Urinalysis
Blood chemistry
Additional lab investigation
Renal biopsy
53
History taking

Periorbital edema
Puffy eyelid
Swelling at lower extremities
Frothy urine
Weight gain
Physical examination

Generalized edema
Pitting edema Grade 3+
High blood pressure
 Diagnostic criteria for nephrotic syndrome
Factor Criteria Pateint’s lab result

Spot urine showing a protein-to-creatinine

ratio of > 3 to 3.5 mg protein/mg creatinine
24-hour urine protein 3.794 g/24 hr
(300 to 350 mg/mmol), or 24-hour urine
Heavy proteinuria collection showing > 3 to 3.5 g protein

Urine dipstick positive (2/3/4+) 3+

Hypoalbuminemia Serum albumin <2.5 g per L (25 g per L)* Serum albumin 2.1 g/dl

Edema Clinical evidence of peripheral edema Lower extremity edema

Hyperlipidemia (not Severe hyperlipidemia, total cholesterol is

Total cholesterol 350 mg/dl
required for diagnosis) often > 350 mg per dL (9.06 mmol per L)

*—Some experts use a cutoff of < 3.0 g per dL (30 g per L).
Adapted with permission from Hull RP, Goldsmith DJ. Nephrotic syndrome in adults. BMJ. 2008;336(7654):1185.
https://www.aafp.org/pubs/afp/issues/2016/0315/p479.html
 Lab investigation

Factor Criteria Pateint’s lab result

Appearance Foamy Foamy, slightly turbid

Urine dipstick positive

Blood Trace
(1/2/3+)

https://www.aafp.org/pubs/afp/issues/2016/0315/p479.html
 Laboratory criteria for SLE
Factor Criteria Pateint’s lab result

Leukopenia WBC count <4,000 cells/μl WBC count 3,600 cells/μl

Thrombocytopenia Platelet count <100,000 cells/μl Platelet count 180,000 cells/μl

C3 below the lower limits of normal

C3 (normal 0.8-1.78 g/L)
C3 level 0.6 g/L

C4 below the lower limits of normal

C4 (normal 0.12-0.42 g/L)
C4 level 0.075 g/L

normal 0–19 mm/h for females under

ESR 50 years old
60 mm/hr (high)
 Renal biopsy

In renal biopsies, the pattern and severity of injury are

important in diagnosis and selecting the best therapy. Most
recent clinical studies of lupus nephritis have used the
International Society of Nephrology (ISN) and the Renal
Pathology Society (RPS).

59
Systemic Lupus Erythematosus (SLE)

Definition
Autoimmune disease in which organs and cells undergo
damage initially mediated by tissue-binding autoantibodies and
immune complexes. It can affect the joints, skin, brain, lungs,
kidneys, and blood vessels.

33
 Lupus nephritis
Lupus nephritis occurs when SLE causes your immune
system to attack your kidneys.
Class 1: Minimal mesangial lupus nephritis
Class 2: Mesangial proliferative lupus nephritis
Class 3: Focal lupus nephritis
Class 4: Diffuse lupus nephritis
Class 5: Membranous lupus nephritis.
Class 6: Advanced sclerosis lupus nephritis.
34
Harrison’s Principles of Internal Medicine, 21th edition

35
Harrison’s Principles of Internal Medicine, 21th edition

36
 Harrison’s
Principles of
Internal
Medicine, 21th
edition
37
Harrison’s Principles of Internal Medicine, 21th edition

38
Lupus nephritis Class V
(Membranous lupus nephritis/
membranous glomerulonephritis)

45
Lupus nephritis Class V
(Membranous lupus nephritis/membranous glomerulonephritis)

Etiology

Primary cause

Idiopathic

Associated with Human Leukocyte antigen (HLA) Alleles

e.g. HLA-DQA1

46
Lupus nephritis Class V
(Membranous lupus nephritis/membranous glomerulonephritis)

Etiology

Secondary cause

Infections e.g. HBV, HCV, syphilis

Autoimmune disease e.g. SLE
Medications e.g. NSAIDs
Malignancy

47
Lupus nephritis Class V
(Membranous lupus nephritis/membranous glomerulonephritis)

Pathophysiology

Inflammation of glomerular basement membrane triggered by

immune complex deposits increased permeability,
proteinuria nephrotic syndrome

Glomerular basement membrane damaged , Podocyte injury , by

immune complex deposits (subendothelial deposits)

48
Lupus nephritis Class V
(Membranous lupus nephritis/membranous glomerulonephritis)

Symptoms Signs

Periorbital edema Pitting edema

Generalized edema High blood pressure
Foamy urine
Weigth gain

49
Lupus nephritis Class V
(Membranous lupus nephritis/membranous glomerulonephritis)

Diagnosis
Renal biopsy
Light microscopic seen Diffuse thickening of glomerular
basement membrane
Electron microscopic seen spike and dome appearance due
to glomerula basement membrane on top of
subendothelial immune complex deposits

50
https://www.ajkd.org/article/s0272-6386(17)30747-3/fulltext 51
Lupus nephritis Class V
(Membranous lupus nephritis/membranous glomerulonephritis)

Management

Treat underlying conditions e.g. HBV, HCV, syphilis

Diuretic e.g. Furosemide
ACE inhibitor
Prednisolone
Immune suppressor e.g. cyclophosphamide
In additional to Oral contraceptive pills

52
 Reference
1. Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, et al. 2019 European League against Rheumatism/American
College of Rheumatology classification criteria for systemic lupus erythematosus [Internet]. U.S. National Library of Medicine; 2019
[cited 2023 Nov 6]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827566/
2. Birmingham DJ, Irshaid F, Nagaraja HN, Zou X, Tsao BP, Wu H, et al. The complex nature of serum C3 and C4 as biomarkers of lupus
renal flare [Internet]. U.S. National Library of Medicine; 2010 [cited 2023 Nov 6]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086056/
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4. Fogo AB [Internet]. 2017 [cited 2023 Nov 4]. Available from: https://www.ajkd.org/article/S0272-6386(17)30745-X/fulltext
5. Hull RP, Goldsmith DJA. Nephrotic syndrome in adults [Internet]. U.S. National Library of Medicine; 2008 [cited 2023 Nov 6]. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2394708/
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https://www.aafp.org/pubs/afp/issues/2016/0315/p479.html
7. Lupus nephritis | cimjournal [Internet]. [cited 2023 Nov 4]. Available from: https://cimjournal.com/confer-update/lupus-nephritis/
8. Lynne Eldridge M. What is mean corpuscular hemoglobin concentration (MCHC)? [Internet]. Verywell Health; 2023 [cited 2023 Nov 4].
Available from: https://www.verywellhealth.com/mean-cell-hemoglobin-concentration-4584155
9. Musa R [Internet]. 2023 [cited 2023 Nov 4]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499817/
10. Nephritic syndrome: Pathogenesis and clinical findings: Calgary guide [Internet]. 2016 [cited 2023 Nov 3]. Available from:
https://calgaryguide.ucalgary.ca/nephritic-syndrome-pathogenesis-and-clinical-findings/
 Reference
11. Nephritic syndrome - statpearls - NCBI bookshelf [Internet]. [cited 2023 Nov 3]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK562240/
12. Nephrotic syndrome: Pathogenesis and clinical findings: Calgary guide [Internet]. 2021 [cited 2023 Nov 3]. Available from:
https://calgaryguide.ucalgary.ca/nephrotic-syndrome-pathogenesis-and-clinical-findings/
13. Nephrotic syndrome - statpearls - NCBI bookshelf [Internet]. [cited 2023 Nov 3]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470444/
14. https://study.com/learn/lesson/anasarca-swelling-cause-treatment.html
Question
Time