9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

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4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

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11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

Key Takeaways Explain This Topic AI

Tubulointerstitial disease, other kidney disorders and hematuria are separately enumerated blueprint subsections under Nephrology and Urology.

Renal vein thrombosis, obstructive uropathy, diabetic nephropathy and cystic kidney disease are the enumerated topics under other kidney disorders.

Dysmorphic red cells, red cell casts and proteinuria indicate glomerular hematuria requiring nephrology evaluation rather than cystoscopy.

Autosomal dominant polycystic kidney disease is associated with intracranial aneurysms, hepatic cysts, mitral valve prolapse and colonic diverticula.

Tolvaptan slows the decline in kidney function in rapidly progressive autosomal dominant polycystic kidney disease.

Last updated: August 2026

1. Hematuria: The First Fork in the Road

Microscopic hematuria is defined as three or more red blood cells per high-power field on a properly collected specimen. A positive dipstick without red cells on microscopy indicates myoglobin or hemoglobin , not hematuria, and points toward rhabdomyolysis or intravascular hemolysis.

The single determination that organizes everything is glomerular versus non-glomerular.

• Feature Glomerular Non-glomerular
• Red cell morphology Dysmorphic , acanthocytes Isomorphic
• Red cell casts Present Absent
• Proteinuria Often significant Absent or minimal
• Color Cola or tea-colored Bright red, clots
• Clots Never May be present
• Next step Nephrology evaluation, consider biopsy Cystoscopy plus CT urography

Clots are never glomerular. Blood arising within the nephron is exposed to urokinase and does not clot; visible clots localize bleeding to the collecting system, ureter or bladder.

Common causes:

Glomerular: IgA nephropathy (the most common glomerular cause worldwide), thin basement membrane nephropathy, Alport syndrome, postinfectious glomerulonephritis, lupus nephritis, vasculitis.

Non-glomerular: urologic malignancy , nephrolithiasis, urinary tract infection, benign prostatic hyperplasia, trauma, exercise, and papillary necrosis.

Risk-stratified evaluation of non-glomerular hematuria weights age, sex, smoking history, degree of hematuria and irritative symptoms. Anticoagulation does not explain hematuria and does not excuse a patient from evaluation — hematuria on an anticoagulant frequently unmasks an underlying lesion.

Papillary necrosis — sloughed papillae causing hematuria, flank pain and occasionally obstruction — occurs in sickle cell disease or trait, analgesic nephropathy, diabetes, pyelonephritis and urinary obstruction .

2. Tubulointerstitial Disease

A separately named blueprint subsection covering disease of the tubules and interstitium rather than of glomeruli or vessels.

Acute interstitial nephritis is most often drug-induced. Culprits include proton pump inhibitors (an increasingly common and easily missed cause), NSAIDs, beta-lactams, sulfonamides, fluoroquinolones, rifampin, allopurinol and checkpoint inhibitors . The classic triad of fever, rash and eosinophilia is present in only a minority , so its absence does not exclude the diagnosis. Urinalysis shows white cells, white cell casts and sterile pyuria ; urine eosinophils are neither sensitive nor specific. Withdrawal of the offending drug is the primary treatment , with corticosteroids considered if creatinine does not improve.

Chronic tubulointerstitial disease presents insidiously with a bland urine sediment, modest proteinuria, and tubular dysfunction disproportionate to the reduction in filtration — concentrating defects with polyuria and nocturia, renal tubular acidosis, and salt wasting. Causes include chronic obstruction, reflux nephropathy, analgesic nephropathy, lithium , calcineurin inhibitors, heavy metals (lead, cadmium), sarcoidosis, Sjogren syndrome, myeloma cast nephropathy and hyperuricemia or hypercalcemia .

Lithium deserves particular mention: it causes nephrogenic diabetes insipidus and chronic tubulointerstitial disease, and amiloride is the agent used to counteract the concentrating defect.

• 3. Cystic Kidney Disease
• Autosomal dominant polycystic kidney disease

The most common inherited kidney disease, from PKD1 (earlier failure) or PKD2 mutation.

Renal features: progressive bilateral cyst growth with kidney enlargement, flank pain , hematuria from cyst hemorrhage , cyst infection, nephrolithiasis (uric acid and calcium oxalate), hypertension (early and nearly universal), and progression to kidney failure typically in middle age.

Extrarenal manifestations are what exam items target:

Site Manifestation

Brain Intracranial berry aneurysms — screen with MR angiography if there is a family history of aneurysm or subarachnoid hemorrhage, or a high-risk occupation

• Liver Hepatic cysts — very common; rarely impair function
• Heart Mitral valve prolapse , aortic root dilation
• Colon Diverticula
• Abdominal wall Hernias

Management: rigorous blood pressure control with renin-angiotensin blockade, high fluid intake, avoidance of nephrotoxins, and tolvaptan for rapidly progressive disease, which slows the decline in glomerular filtration rate at the cost of aquaresis and hepatotoxicity risk requiring liver enzyme monitoring.

Other cystic diseases: medullary sponge kidney (benign, associated with stones and hematuria), autosomal dominant tubulointerstitial kidney disease (formerly medullary cystic disease, with bland sediment and slow progression), and acquired cystic disease of dialysis , which carries an increased risk of renal cell carcinoma.

4. Obstructive Uropathy

An enumerated blueprint topic and one of the few fully reversible causes of kidney failure — but only if identified early, because prolonged obstruction produces permanent injury.

When to suspect it:

Anuria, or fluctuating urine output alternating between anuria and polyuria — highly suggestive of intermittent complete obstruction

• Acute kidney injury with no other explanation
• Known malignancy, retroperitoneal disease, prior pelvic radiation, or stone disease
• Bilateral hydronephrosis on imaging

Remember that bilateral obstruction, or obstruction of a solitary kidney, is required to raise the creatinine. A unilateral obstructed kidney with a normal contralateral kidney produces a normal creatinine, which is why unilateral obstruction can be silent until the kidney is lost.

Causes:

Level Causes

Bladder outlet Benign prostatic hyperplasia , prostate cancer, neurogenic bladder, urethral stricture, anticholinergic drugs

Ureteral (extrinsic) Pelvic or retroperitoneal malignancy, retroperitoneal fibrosis , lymphadenopathy, aortic aneurysm, pregnancy

Ureteral (intrinsic) Stones, blood clot, sloughed papilla, stricture, urothelial tumor

Ultrasonography is the initial test , though hydronephrosis may be absent very early or when the ureters are encased by tumor or fibrosis. CT identifies the level and cause.

Treatment is decompression — bladder catheter for outlet obstruction, ureteral stent or percutaneous nephrostomy for ureteral obstruction. Two post-relief phenomena to anticipate:

Post-obstructive diuresis — a large solute and water diuresis after relief of prolonged bilateral obstruction. Monitor volume status and electrolytes and replace judiciously; over-replacement perpetuates the diuresis.

Hematuria and hypotension after rapid bladder decompression, which is why gradual drainage of a very distended bladder is often advised.

Retroperitoneal fibrosis presents with medial ureteral deviation and obstruction, and may be idiopathic, IgG4-related , drug-associated (methysergide, ergot derivatives) or secondary to malignancy or aortic disease.

5. Diabetic Nephropathy

Enumerated under other kidney disorders and the leading cause of end-stage kidney disease in the United States.

Natural history: glomerular hyperfiltration, then moderately increased albuminuria (formerly microalbuminuria) , then severely increased albuminuria with declining filtration rate, then kidney failure. Screening is by urine albumin-to-creatinine ratio annually, confirmed on repeat because exercise, fever, infection, heart failure and marked hyperglycemia transiently raise albumin excretion.

Diabetic retinopathy usually accompanies diabetic nephropathy in type 1 diabetes. Its absence , or the presence of an active urinary sediment, rapidly declining function, or nephrotic syndrome of abrupt onset , should prompt consideration of a non-diabetic cause and possible biopsy.

Treatment combines glycemic control, blood pressure control, renin-angiotensin blockade for albuminuria, SGLT2 inhibition , and a non-steroidal mineralocorticoid receptor antagonist such as finerenone for residual albuminuria — a combination that now defines cardiorenal protection in type 2 diabetes.

6. Renal Vein Thrombosis

An enumerated topic presenting with flank pain, gross hematuria, a sudden increase in proteinuria and worsening kidney function . It is strongly associated with membranous nephropathy and other nephrotic states, in which urinary loss of antithrombin and other regulatory proteins produces a hypercoagulable state. Other causes include malignancy (particularly renal cell carcinoma with tumor thrombus), trauma and hypercoagulable disorders. Diagnosis is by CT or MR venography, and treatment is anticoagulation.