PM2020 I+Nephrology
PM2020 I+Nephrology
PM2020 I+Nephrology
You review a 42-year -old woman six weeks following a renal transplant
for focal segmental glomerulosclerosis. Following the procedure she
was discharged on a combination of tacrolimus, mycophenolate, and
prednisolone. She has now presented with a five day history of feeling
generally unwell with anorexia, fatigue and arthralgia. On examination
her sclera are jaundiced and she has widespread lymphadenopathy with
hepatomegaly. What is the most likely diagnosis?
Hepatitis C
Epstein-Barr virus
HIV
Hepatitis B
Cytomegalovirus
Submit answer
Reference ranges v
Score: 0%
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fid) '?' ® £ JI I C> IAJ ISLa
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You review a 42-year-old woman six weeks following a renal transplant
for focal segmental glomerulosclerosis. Following the procedure she
was discharged on a combination of tacrolimus, mycophenolate, and
prednisolone. She has now presented with a five day history of feeling
generally unwell with anorexia, fatigue and arthralgia. On examination
her sclera are jaundiced and she has widespread lymphadenopathy with
hepatomegaly. What is the most likely diagnosis?
Hepatitis C
Epstein-Barr virus
HIV
Hepatitis B
Cytomegalovirus
The human leucocyte antigen (HLA) system is the name given to the
major histocompatibility complex (MHC) in humans. It is coded for on
chromosome 6.
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major histocompatibility complex (MHC) in humans. It is coded for on
chromosome 6.
Graft survival
• 1 year = 90%, 10 years = 60% for cadaveric transplants
• 1 year = 95%, 10 years = 70% for living-donor transplants
Post-op problems
• ATN of graft
• vascular thrombosis
• urine leakage
• UTI
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Q Q4 P
Investigations:
Plasma renin activity (after 30 minutes supine) 6.8 pmol/ mL/ hr (1.1-2.7)
Bartter syndrome
Phaeochromocytoma
Pregnancy
Primary hyperaldosteronism
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Reference ranges
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Bilateral renal artery stenosis
Phaeochromocytoma
Pregnancy
Primary hyperaldosteronism
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DISCUSS { 4 ) improve
Investigation
• MR angiography is now the investigation of choice
• CT angiography
• conventional renal angiography is less commonly performed used
nowadays, but may still have a role when planning surgery
B I B A mM
= " xr H" H ea
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£>3
G Q6 P ©
A young male on peritoneal dialysis (PD) presents with abdominal pain
and inflammation around the extension site of his catheter. As well as
this, he is experiencing general malaise and has vomited on two
occasions. Regarding dialysis, he confesses that his standards of
cleanliness 'could be better '.
Analysis of peritoneal fluid shows a white cell count of 430 per mmA 3
with the majority being polymorphonuclear leukocytes.
Culture of the effluent would most likely isolate which of the following
organisms?
Escherichia coli
Pseudomonas
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
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A 34-year-old woman presents to your GP clinic for ongoing
investigation of her hypertension.
She is normally fit and well apart from a history of childhood asthma.
She is teetotal but smokes 5 cigarettes a day. Her father passed away
last year at the age of 62 from a stroke.
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Assymmetric kidneys are often first noted on ultrasound; imaging of the
vessel is done by duplex and most accurately by contrast catheter
angiography of the renal artery.
A f # Discuss Improve
Fibromuscular dysplasia
Epidemiology
• 90% of patients are female
Features
• hypertension
• chronic kidney disease or more acute renal failure e . g . secondary
to ACE-inhibitor initiation
• 'flash' pulmonary oedema
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Q3
Pituitary surgery
Lithium
Histiocytosis X
Craniopharyngioma
Post head-injury
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Reference ranges v
Score: 100%
1 V
2 >/
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Pituitary surgery
Lithium
Histiocytosis X
Craniopharyngioma
Post head-injury
«
* f # Discuss Improve
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
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Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/ kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
B / a A •M
•mmm EL - Tr E c-o
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Q Q5 P ©
A 62-year -old man is diagnosed with renal cell cancer. Which one of the
following hormones is least likely to be present in excessive levels?
Erythropoietin
Parathyroid hormone
Growth hormone
ACTH
Renin
Submit answer
Score: 75%
1
2 >/
3 X
4 >/
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Q5
A 62-year-old man is diagnosed with renal cell cancer. Which one of the
following hormones is least likely to be present in excessive levels?
Erythropoietin
Parathyroid hormone
Growth hormone
ACTH
Renin
# Discuss (3)
* Improve
Associations*
• more common in middle-aged men
• smoking
• von Hippel-Lindau syndrome
• tuberous sclerosis
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Features
• classical triad: haematuria, loin pain, abdominal mass
• pyrexia of unknown origin
• left varicocele (due to occlusion of left testicular vein)
• endocrine effects: may secrete erythropoietin (polycythaemia),
parathyroid hormone (hypercalcaemia), renin, ACTH
• 25% have metastases at presentation
• paraneoplastic hepatic dysfunction syndrome. Also known as
Stauffer syndrome. Typically presents as
cholestasis / hepatosplenomegaly. It is thought to be secondary to
increased levels of IL- 6
Management
• for confined disease a partial or total nephrectomy depending on
the tumour size
• alpha-interferon and interleukin-2 have been used to reduce
tumour size and also treat patients with metatases
• receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have
been shown to have superior efficacy compared to interferon-
alpha
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i passmedicine.com / question / qu a
EM
mage sourced from Wikipedi « i Image used on li ise from PathoPic
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o Q8 p o
A 38-year-old woman is referred by the general practitioner as her
recent blood test showed elevated creatinine and urea levels. Other
blood test results are normal. She is oliguric but could produce enough
sample for urine dip. Her urine is negative for red cells, nitrites and
leucocytes. She was recently started on Ramipril for hypertension 3
weeks ago.
She is otherwise well. Her observations are within normal limits. The
renal ultrasound shows two normal-sized kidneys with an unobstructed
urinary system. Duplex ultrasound showed stenotic renal arteries.
Subsequent MR angiography confirmed the diagnosis with the finding
of ’string of beads' appearance of the renal arteries.
Glomerulonephritis
Pyelonephritis
Fibromuscular dysplasia
Nephrotic syndrome
Nephrolithiasis
Submit answer
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Fibromuscular dysplasia
Nephrotic syndrome
Nephrolithiasis
The normal urine dip results ruled out glomerulonephritis and nephrotic
syndrome as the cause of kidney failure. Glomerulonephritis typically
presents with haematuria with the presence of red cell casts. Nephrotic
syndrome presents with heavy proteinuria, oedema and
hypoalbuminaemia.
i
* "t # Discuss (1) Improve
Splenic infarction
Haemolytic crisis
Ureteric stone
Submit answer
Reference ranges v
Score: 87.5%
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Haemorrhage into renal cyst
Splenic infarction
Haemolytic crisis
Ureteric stone
Haemorrhage into a renal cyst may present with flank pain and
haematuria but this history is not suggestive of renal cystic disease.
Triors .
* i rs r t i
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Complications
• increased risk of infection due to urinary immunoglobulin loss
• increased risk of thromboembolism related to loss of
antithrombin III and plasminogen in the urine. This may result in a
renal vein thrombosis, resulting in a sudden deterioration in renal
function
• hyperlipidaemia
• hypocalcaemia (vitamin D and binding protein lost in urine)
• acute renal failure
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G Q1
K+ 4.5 mmol/ l
At the time she was started on lisinopril to treat both the hypertension
and act as a renoprotective agent. Lisinopril had been titrated up to
treatment dose. Her current bloods are as follows:
K+ 4.9 mmol/l
eGFR 44 ml / min
No action
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Switch to a different ACE inhibitor
No action
The small change in both the creatinine and eGFR are acceptable and
below the threshold where ACE inhibitors should be stopped
The majority of patients with chronic kidney disease (CKD) will require
more than two drugs to treat hypertension. ACE inhibitors are first line
and are particularly helpful in proteinuric renal disease (e.g. diabetic
nephropathy). As these drugs tend to reduce filtration pressure a small
fall in glomerular filtration pressure (GFR) and rise in creatinine can be
expected. NICE suggest that a decrease in eGFR of up to 25% or a rise
in creatinine of up to 30% is acceptable, although any rise should
prompt careful monitoring and exclusion of other causes (e. g. NSAIDs).
A rise greater than this may indicate underlying renovascular disease.
IgA nephropathy
Renal lithiasis
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although both have since been discharged. On examination his blood
pressure is 124/ 74 mmHg and his creatinine is in the normal range. A
renal USS performed by his GP at the time of referral is normal. What is
the most likely diagnosis?
IgA nephropathy
Renal lithiasis
B / B A m
1“
=' T \w SS "” E c-o
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Q1 pj
Ferrous sulphate
Thiazide diuretics
Lithium
Pyridoxine
Allopurinol
Submit answer
Reference ranges v
Score: 0%
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Lithium
Pyridoxine
Allopurinol
Medication
• the BAUS recommend an NSAID as the analgesia of choice for
renal colic
• whilst diclofenac has been traditionally used the increased risk of
cardiovascular events with certain NSAIDs (e. g. diclofenac,
ibuprofen) should be considered when prescribing
• the CKS guidelines suggest for patients who require admission:
' Administer a parenteral analgesic (such as intramuscular
diclofenac ) for rapid relief of severe pain'
• BAUS no longer endorse the use of alpha- adrenergic blockers to
aid ureteric stone passage routinely. They do however
acknowledge a recently published meta-analysis advocates the
use of a-blockers for patients amenable to conservative
management, with greatest benefit amongst those with larger
stones
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Initial investigations
• urine dipstick and culture
• serum creatinine and electrolytes: check renal function
• FBC / CRP: look for associated infection
• calcium / urate: look for underlying causes
• also: clotting if percutaneous intervention planned and blood
cultures if pyrexial or other signs of sepsis
Imaging
• BAUS now recommend that non-contrast CT KUB should be
performed on all patients, within 14 hours of admission
• if a patient has a fever, a solitary kidney or when the diagnosis is
uncertain an immediate CT KUB should be performed. In the case
of an uncertain diagnosis, this is to exclude other diagnoses such
as ruptured abdominal aortic aneurysm
• CT KUB has a sensitivity of 97% for ureteric stones and a
specificity of 95%
• ultrasound still has a role but given the wider availability of CT
now and greater accurary it is no longer recommend first -line. The
sensitivity of ultrasound for stones is around 45% and specificity
is around 90%
Most renal stones measuring less than 5mm in maximum diameter will
typically pass within 4 weeks of symptom onset. More intensive and
urgent treatment is indicated in the presence of ureteric obstruction,
renal developmental abnormality such as horseshoe kidney and
previous renal transplant. Ureteric obstruction due to stones together
with infection is a surgical emergency and the system must be
decompressed. Options include nephrostomy tube placement, insertion
of ureteric catheters and ureteric stent placement.
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• CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95%
• ultrasound still has a role but given the wider availability of CT now and
greater accurary it is no longer recommend first-line. The sensitivity of
ultrasound for stones is around 45% and specificity is around 90%
Most renal stones measuring less than 5mm in maximum diameter will typically
pass within 4 weeks of symptom onset . More intensive and urgent treatment is
indicated in the presence of ureteric obstruction, renal developmental
abnormality such as horseshoe kidney and previous renal transplant. Ureteric
obstruction due to stones together with infection is a surgical emergency and
the system must be decompressed. Options include nephrostomy tube
placement, insertion of ureteric catheters and ureteric stent placement.
Shockwave lithotripsy
• A shock wave is generated external to the patient, internally cavitation
bubbles and mechanical stress lead to stone fragmentation. The passage
of shock waves can result in the development of solid organ injury.
Fragmentation of larger stones may result in the development of ureteric
obstruction. The procedure is uncomfortable for patients and analgesia is
required during the procedure and afterwards.
Ureteroscopy
• A ureteroscope is passed retrograde through the ureter and into the renal
pelvis. It is indicated in individuals (e.g. pregnant females) where
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• CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95%
• ultrasound still has a role but given the wider availability of CT now and
greater accurary it is no longer recommend first-line. The sensitivity of
ultrasound for stones is around 45% and specificity is around 90%
Most renal stones measuring less than 5mm in maximum diameter will typically
pass within 4 weeks of symptom onset. More intensive and urgent treatment is
indicated in the presence of ureteric obstruction, renal developmental
abnormality such as horseshoe kidney and previous renal transplant. Ureteric
obstruction due to stones together with infection is a surgical emergency and
the system must be decompressed. Options include nephrostomy tube
placement, insertion of ureteric catheters and ureteric stent placement .
Shockwave lithotripsy
• A shock wave is generated external to the patient, internally cavitation
bubbles and mechanical stress lead to stone fragmentation. The passage
of shock waves can result in the development of solid organ injury.
Fragmentation of larger stones may result in the development of ureteric
obstruction. The procedure is uncomfortable for patients and analgesia is
required during the procedure and afterwards.
Ureteroscopy
• A ureteroscope is passed retrograde through the ureter and into the renal
pelvis. It is indicated in individuals (e. g. pregnant females) where
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Ureteroscopy
• A ureteroscope is passed retrograde through the ureter and into the renal
pelvis. It is indicated in individuals (e.g. pregnant females) where
lithotripsy is contraindicated and in complex stone disease. In most cases
a stent is left in situ for 4 weeks after the procedure.
Percutaneous nephrolithotomy
• In this procedure, access is gained to the renal collecting system. Once
access is achieved, intra corporeal lithotripsy or stone fragmentation is
performed and stone fragments removed.
Therapeutic selection
Disease Option
Oxalate stones
• cholestyramine reduces urinary oxalate secretion
• pyridoxine reduces urinary oxalate secretion
B / a A
m
H^ S c-o X
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Q2 pj
Hypercalcaemia
Demeclocycline
Histiocytosis X
Lithium
Hypokalaemia
Submit answer
Reference ranges v
Score: 100%
1 V
2
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except:
Hypercalcaemia
Demeclocycline
Histiocytosis X
Lithium
Hypokalaemia
a
* -* # Discuss (2) Improve
Diabetes insipidus
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
^-
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• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
B m Tr
Save my notes
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Q2 pj
Which of the following types of renal stones are said to have a semi-
opaque appearance on x -ray?
Calcium oxalate
Cystine stones
Urate stones
Xanthine stones
Submit answer
Reference ranges v
Score: 100%
1 V
2
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Q2 p
Which of the following types of renal stones are said to have a semi-
opaque appearance on x-ray?
Calcium oxalate
Cystine stones
Urate stones
Xanthine stones
BA “f # Discuss Improve
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The table below summarises the appearance of different types of renal
stone on x-ray
Radiograph
Type Frequency appearance
*stag-horn calculi involve the renal pelvis and extend into at least 2
calyces. They develop in alkaline urine and are composed of struvite
(ammonium magnesium phosphate, triple phosphate). Ureaplasma
urealyticum and Proteus infections predispose to their formation
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© Q3
Hb 94 g/ L Male: (135-180)
Mesothelioma
- ^ ..
CamScanner l4$ b £> ,^11
HIS ouservauoris were as mnows :
Blood pressure - 180 /109 mmHg, heart rate - 95 beats per minute,
temperature - 37.1 °C, oxygen saturation - 95% on air, respiratory rate -
22 breaths per min.
Hb 94 g/ L Male: (135-180)
Mesothelioma
Prostatic cancer
Phaeochromocytoma
Submit answer
Reference ranges v
Score: 100%
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Renal cell carcinoma
Phaeochromocytoma
Renal cell carcinoma presents with the classic triad only 10% of the
time, and so requires recognition of the other features that are specific
to the pathophysiology of the disease. Other paraneoplastic syndromes
of renal cell carcinoma include polycythaemia and amyloidosis.
This patient 's epigastric pain is likely due to peptic ulcer disease
secondary to hypercalcaemia, his suprapubic dullness likely due to
chronic urinary retention secondary to his benign prostatic hyperplasia.
Associations*
• more common in middle- aged men
• smoking
• von Hippel-Lindau syndrome
• tuberous sclerosis
Features
• classical triad: haematuria, loin pain, abdominal mass
• pyrexia of unknown origin
• left varicocele (due to occlusion of left testicular vein)
• endocrine effects: may secrete erythropoietin (polycythaemia),
parathyroid hormone (hypercalcaemia), renin, ACTH
• 25% have metastases at presentation
• paraneoplastic hepatic dysfunction syndrome. Also known as
Stauffer syndrome. Typically presents as
cholestasis/ hepatosplenomegaly. It is thought to be secondary to
increased levels of IL-6
Management
• for confined disease a partial or total nephrectomy depending on
the tumour size
• alpha-interferon and interleukin-2 have been used to reduce
tumour size and also treat patients with metatases
• receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have
been shown to have superior efficacy compared to interferon-
alpha
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A 60-year- old woman presents to her general practice with signs of
thirst and tiredness. On further questioning, she also complains of
polyuria and nocturia. As a result a 24-hour urine is collected, which
returns showing a urine osmolality of 189 mOsm/ kg ( 500-800
mOsm/ kg).
Hyperkalaemia
Hypercalcaemia
Histiocytosis X
Hypermagnesemia
Hypernatraemia
Submit answer
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© Q8 PJ ©
A 60-year -old woman presents to her general practice with signs of
thirst and tiredness. On further questioning, she also complains of
polyuria and nocturia. As a result a 24-hour urine is collected, which
returns showing a urine osmolality of 189 mOsm/ kg ( 500-800
mOsm/kg).
Hyperkalaemia
Hypercalcaemia
Histiocytosis X
Hypermagnesemia
Hypernatraemia
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© Q9 p ©
A 70-year-old man has been admitted with abdominal pain. The
surgeons wish to perform a contrast -enhanced CT but are concerned
because he has chronic kidney disease stage 3. His latest renal
function is shown below:
Na + 142 mmol/l
K+ 4.6 mmol /l
Which one of the following is the most important step in reducing the
risk of contrast-induced nephropathy?
Submit answer
Reference ranges v
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i4r f # Discuss (1) Improve
Prevention
• the evidence base currently supports the use of intravenous 0.9%
sodium chloride at a rate of 1 mL/ kg / hour for 12 hours pre- and
post - procedure. There is also evidence to support the use of
isotonic sodium bicarbonate
• N-acetylcysteine has been given in the past but recent evidence
suggests it is not effective*
Blood ++++
Nitrites POS
Leucocytes +++
Protein ++
Xanthine
Calcium oxalate
Struvite
Cystine
O Urate
Submit answer
Reference ranges v
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o Q13 >/ p ©
A 47-year-old woman presents with loin pain and haematuria. Urine
dipstick demonstrates:
Blood ++++
Nitrites POS
Leucocytes +++
Protein ++
Xanthine
Calcium oxalate
Struvite
Cystine
Urate
BA
^ Discuss (1) Improve
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© Q3 p ©
A 50 year-old man with dialysis dependent chronic kidney disease is
awaiting renal transplant. He complains of fatigue. On examination you
note heart rate 95 beats per minute, soft ejection systolic murmur that
doesn't radiate and pallor. There were no other abnormal features.
Heart failure
Endocarditis
Uraemic encephalopathy
Anaemia
Hyperkalaemia
Submit answer
Reference ranges v
Score: 50%
2 X
3
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© Q3 v
' P3 ©
A 50 year -old man with dialysis dependent chronic kidney disease is
awaiting renal transplant. He complains of fatigue. On examination you
note heart rate 95 beats per minute, soft ejection systolic murmur that
doesn't radiate and pallor. There were no other abnormal features.
Heart failure
Endocarditis
Uraemic encephalopathy
Anaemia
Hyperkalaemia
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Next question >
Patients with chronic kidney disease (CKD) may develop anaemia due
to a variety of factors, the most significant of which is reduced
erythropoietin levels. This is usually a normochromic normocytic
anaemia and becomes apparent when the GFR is less than 35 ml / min
(other causes of anaemia should be considered if the GFR is > 60
ml/ min) . Anaemia in CKD predisposes to the development of left
ventricular hypertrophy - associated with a three fold increase in
mortality in renal patients
Management
• the 2011 NICE guidelines suggest a target haemoglobin of 10 - 12
g/ dl
• determination and optimisation of iron status should be carried
out prior to the administration of erythropoiesis-stimulating
agents (ESA). Many patients, especially those on haemodialysis,
will require IV iron
• ESAs such as erythropoietin and darbepoetin should be used in
those ' who are likely to benefit in terms of quality of life and
physical function'
Submit answer
Reference ranges v
Score: 66.7%
1
2 X
3
4
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A 29- year- old man has his renal function checked . The eGFR is
calculated to be 54 ml / min . Which one of the following factors is most
likely to explain this unexpectedly low result ?
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Factors which may affect the result
• pregnancy
• muscle mass (e.g. amputees, body-builders)
• eating red meat 12 hours prior to the sample being taken
CKD
stage GFR range
2 60-90 ml/ min with some sign of kidney damage (if kidney
tests* are normal, there is no CKD)
B / a A ""
"B
BB
BB
=~ Tlw SS '*' E c-o
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G Q9 P O
A 56-year-old man who suffers from biventricular cardiac failure comes
to the clinic for review. His symptoms are currently well controlled and
he is taking Ramipril 1 Omg, spironolactone 25mg, bisoprolol 1Omg, and
furosemide 40mg. His main complaint is of painful gynaecomastia that
he says has developed over the past 6 months. Physical exam reveals a
blood pressure of 125/ 80 mmHg, and no residual signs of cardiac
failure. Renal function is unchanged from 6 months earlier, with a stable
creatinine at 125 pmol /l.
Submit answer
Reference ranges
Score: 87.5%
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Which of the following is the most appropriate next step?
This man has stable heart failure, his medication should therefore
remain unaltered if possible. Spironolactone does however interfere
with binding of testosterone to androgen receptors, increase metabolic
clearance of testosterone, and results in increased metabolism of
androgens to estradiol. This is the likely cause of his gynaecomastia.
Eplerenone is an alternative aldosterone antagonist and is associated
with up to 20 times less symptom burden with respect to
gynaecomastia. It is therefore the most appropriate intervention here.
Spironolactone
Indications
• ascites: patients with cirrhosis develop a secondary
hyperaldosteronism. Relatively large doses such as 100 or 200mg
are often used
• hypertension: used in some patients as a NICE 'step 4' treatment
• heart failure (see RALES study below)
• nephrotic syndrome
• Conn's syndrome
Adverse effects
• hyperkalaemia
• gynaecomastia: less common with eplerenone
RALES
• NYHA III + IV, patients already taking ACE inhibitor
• low dose spironolactone reduces all cause mortality
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Q Q11 |cn ©
A 69-year -old woman is admitted with a third episode of urinary tract
infection over the past 12 months, proven on urine culture to be due to
Proteus mirabilis. She also has right loin pain. She has a past history of
hypertension and a previous creatinine tested one month earlier was
elevated at 145 micromol / l. A plain x -ray to display kidneys ureters and
bladder and an ultrasound of the urinary tract reveal a right staghorn
calculus.
Calcium phosphate
Urate
Cystine
Oxalate
Submit answer
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Urate
Cystine
Oxalate
f # Discuss Improve
Medication
• the BAUS recommend an NSAID as the analgesia of choice for
renal colic
• whilst diclofenac has been traditionally used the increased risk of
cardiovascular events with certain NSAIDs (e.g. diclofenac,
ibuprofen) should be considered when prescribing
• the CKS guidelines suggest for patients who require admission:
' Administer a parenteral analgesic (such as intramuscular
Initial investigations
• urine dipstick and culture
• serum creatinine and electrolytes: check renal function
• FBC / CRP: look for associated infection
• calcium/urate: look for underlying causes
• also: clotting if percutaneous intervention planned and blood
cultures if pyrexial or other signs of sepsis
Imaging
• BAUS now recommend that non-contrast CT KUB should be
performed on all patients, within 14 hours of admission
• if a patient has a fever, a solitary kidney or when the diagnosis is
nr»nr + oin nm immnrlio+n PT \/ \ IQ rhm ilrl kn nnrfnrmnrl In +hn nnnn
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Renal stones: management
Medication
• the BAUS recommend an NSAID as the analgesia of choice for
renal colic
• whilst diclofenac has been traditionally used the increased risk of
cardiovascular events with certain NSAIDs (e.g. diclofenac,
ibuprofen) should be considered when prescribing
• the CKS guidelines suggest for patients who require admission:
' Administer a parenteral analgesic (such as intramuscular
Initial investigations
• urine dipstick and culture
• serum creatinine and electrolytes: check renal function
• FBC / CRP: look for associated infection
• calcium/urate: look for underlying causes
• also: clotting if percutaneous intervention planned and blood
cultures if pyrexial or other signs of sepsis
Imaging
• BAUS now recommend that non-contrast CT KUB should be
performed on all patients, within 14 hours of admission
• if a patient has a fever, a solitary kidney or when the diagnosis is
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Imaging
• BAUS now recommend that non-contrast CT KUB should be
performed on all patients, within 14 hours of admission
• if a patient has a fever, a solitary kidney or when the diagnosis is
uncertain an immediate CT KUB should be performed. In the case
of an uncertain diagnosis, this is to exclude other diagnoses such
as ruptured abdominal aortic aneurysm
• CT KUB has a sensitivity of 97% for ureteric stones and a
specificity of 95%
• ultrasound still has a role but given the wider availability of CT
now and greater accurary it is no longer recommend first-line. The
sensitivity of ultrasound for stones is around 45% and specificity
is around 90%
Most renal stones measuring less than 5mm in maximum diameter will
typically pass within 4 weeks of symptom onset. More intensive and
urgent treatment is indicated in the presence of ureteric obstruction,
renal developmental abnormality such as horseshoe kidney and
previous renal transplant. Ureteric obstruction due to stones together
with infection is a surgical emergency and the system must be
decompressed. Options include nephrostomy tube placement, insertion
of ureteric catheters and ureteric stent placement.
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Shockwave lithotripsy
• A shock wave is generated external to the patient, internally
cavitation bubbles and mechanical stress lead to stone
fragmentation. The passage of shock waves can result in the
development of solid organ injury. Fragmentation of larger stones
may result in the development of ureteric obstruction. The
procedure is uncomfortable for patients and analgesia is required
during the procedure and afterwards.
Ureteroscopy
• A ureteroscope is passed retrograde through the ureter and into
the renal pelvis. It is indicated in individuals (e.g. pregnant
females) where lithotripsy is contraindicated and in complex
stone disease. In most cases a stent is left in situ for 4 weeks
after the procedure.
Percutaneous nephrolithotomy
• In this procedure, access is gained to the renal collecting system.
Once access is achieved, intra corporeal lithotripsy or stone
fragmentation is performed and stone fragments removed.
Therapeutic selection
Disease Option
Disease Option
Oxalate stones
• cholestyramine reduces urinary oxalate secretion
• pyridoxine reduces urinary oxalate secretion
izrotc* •ji
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Therapeutic selection
Disease Option
Oxalate stones
• cholestyramine reduces urinary oxalate secretion
• pyridoxine reduces urinary oxalate secretion
izrotc* •ji
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G Q15 P3 ©
A 20-year-old Nigerian female presents to the Emergency Department
with chest pain. She reports a long history of fatigue and joint pains.
Examination reveals a pericardial rub and bilateral pitting oedema.
Observations show only that she has a low grade pyrexia 37.7°C and
blood pressure 170 /100 mmHg. Urinalysis shows haematuria and
nephrotic-range proteinuria. A urine pregnancy test is negative. ECG
shows saddle-shaped ST-elevation in all leads. Of interest, her blood
results show:
eGFR 33ml/m /m 2
Membranous glomerulonephritis
Submit answer
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eGFR 33ml/ m/ m2
likely on renal
Which of the following histopathological findings is most
biopsy?
Membranous glomerulonephritis
This question requires you to diagnose the condition and then recall the
associated histopathology. Although they may not be encountered every
day in clinical practice, the glomerulonephritides are favourites of the
MRCP examiners .
0 Discuss (7)
* * Improve
i B
WHO classification
• class I: normal kidney
• class II: mesangial glomerulonephritis
• class III: focal (and segmental) proliferative glomerulonephritis
• class IV: diffuse proliferative glomerulonephritis
• class V: diffuse membranous glomerulonephritis
• class VI: sclerosing glomerulonephritis
• f 17 * - ram
v ^ • •• %
• fjt #
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Features
• nephrotic syndrome
• normotension - hypertension is rare
• highly selective proteinuria
o only intermediate-sized proteins such as albumin and
transferrin leak through the glomerulus
• renal biopsy
o normal glomeruli on light microscopy
Management
• majority of cases (80%) are steroid-responsive
• cyclophosphamide is the next step for steroid-resistant cases
B / a A =' TI" H GO
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G Q17 ©
A 65-year-old gentleman presents to the emergency department with
right upper quadrant pain, fatigue and malaise. He reports that he has
been having the abdominal discomfort for some time but the recent
increase in pain got him concerned. He has a background of recently
diagnosed renal cell carcinoma, hypertension and type-2 diabetes. His
biochemistry results are shown below:
ALT 30 u/ L (3 - 40)
Given the clinical and biochemical findings, what is the most likely
cause of his symptoms?
Cholangitis
Choledocholithiasis
Hepatocellular carcinoma
Hepatorenal failure
Submit answer
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Paraneoplastic hepatic dysfunction syndrome
Choledocholithiasis
Hepatocellular carcinoma
Hepatorenal failure
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Choledocholithiasis is the presence of a stone within the common bile
duct resulting in jaundice with a negative Murphy 's sign.
Associations*
• more common in middle-aged men
• smoking
• von Hippel-Lindau syndrome
• tuberous sclerosis
Features
• classical triad: haematuria, loin pain, abdominal mass
• pyrexia of unknown origin
• left varicocele (due to occlusion of left testicular vein)
• endocrine effects: may secrete erythropoietin (polycythaemia),
parathyroid hormone (hypercalcaemia), renin, ACTH
• 25% have metastases at presentation
• paraneoplastic hepatic dysfunction syndrome. Also known as
Stauffer syndrome. Typically presents as
cholestasis/ hepatosplenomegaly. It is thought to be secondary to
increased levels of IL-6
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Management
• for confined disease a partial or total nephrectomy depending on
the tumour size
• alpha-interferon and interleukin-2 have been used to reduce
tumour size and also treat patients with metatases
• receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have
been shown to have superior efficacy compared to interferon-
alpha
\
Coronal CT scan of a middle-aged woman with renal cell cancer.
Note the heterogeneously enhancing mass at the upper pole of
the right kidney
wmi
**frnr CamScanner
Arteriovenous fistulas
Arteriovenous fistulas are direct connections between arteries and veins. They
may occur pathologically but are generally formed surgically to allow access for
haemodialysis.
They are now regarded as the preferred method of access for haemodialysis
due to the lower rates of complications.
• stenosis
o may present with acute limb pain
• steal syndrome
From
dialysis
machine Vein Artery
\ t /
\
To
dialysis
nachine
Fistula
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Q Q1 P ©
A 4-year -old boy with recurrent urinary tract infections is referred to the
paediatric team due to worries over reflux nephropathy.
Intravenous pyelogram
Micturating cystography
Renal ultrasound
Renal biopsy
Submit answer
Reference ranges v
Score: 0%
All contents of this site are © 2020 Passmedicine Limited Back to top
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A 4-year -old boy with recurrent urinary tract infections is referred to the
paediatric team due to worries over reflux nephropathy.
Intravenous pyelogram
Micturating cystography
Renal ultrasound
Renal biopsy
T
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*4 t 0 Discuss Improve
Overview
• term used to chronic pyelonephritis secondary to vesico-uretic
reflux
• commonest cause of chronic pyelonephritis
• scarring usually occurs in first 5 years
• strong genetic disposition
• renal scar may produce increased quantities of renin causing
hypertension
Diagnosis
• micturating cystography
B / a A a
s ~ TIT SS " H c-o
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IgE
IgM
igG
IgD
IgA
Submit answer
Reference ranges v
Score: 100%
>/
2 >/
3 >/
4
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A 28-year -old female undergoes a renal transplant for focal segmental
glomerulosclerosis. Within hours of the operation the patient becomes
unwell with features consistent with severe systemic inflammatory
response syndrome. The patient is immediately taken back to theatre
and the transplanted kidney is removed. What type of immunoglobulins
are responsible for the graft rejection?
IgE
IgM
IgG
igD
IgA
The human leucocyte antigen (HLA) system is the name given to the
major histocompatibility complex (MHC) in humans. It is coded for on
chromosome 6.
Post-op problems
• ATN of graft
• vascular thrombosis
• urine leakage
• UTI
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' * ' El
o° •:< ? ® O i
^ iaiii -
OUJIS o
I PassMedicine
© Q7 p o
A 43-year-old man has a work-up for hypertension. He has found to
have blood + on a urine dipstick of a freshly voided sample. Which one
of the following may account for this finding?
Smoking
Exercise
Obesity
Use of ramipril
Submit answer
Reference ranges v
Score: 66.7%
1 V
2 V
3 >/
4 X
5 >/
6 X
7
<] o
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© Q7 p ©
A 43-year-old man has a work-up for hypertension. He has found to
have blood + on a urine dipstick of a freshly voided sample. Which one
of the following may account for this finding?
Smoking
Exercise
Obesity
Use of ramipril
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Management
Testing
• urine dipstick is the test of choice for detecting haematuria
• persistent non-visible haematuria is often defined as blood being
present in 2 out of 3 samples tested 2-3 weeks apart
• renal function, albumin:creatinine (ACR) or protein:creatinine ratio
(PCR) and blood pressure should also be checked
• urine microscopy may be used but time to analysis significantly
affects the number of red blood cells detected
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Testing
• urine dipstick is the test of choice for detecting haematuria
• persistent non-visible haematuria is often defined as blood being
present in 2 out of 3 samples tested 2-3 weeks apart
• renal function, albumin:creatinine (ACR) or protein:creatinine ratio
(PCR) and blood pressure should also be checked
• urine microscopy may be used but time to analysis significantly
affects the number of red blood cells detected
Previous radiotherapy
Methysergide
Sulphonamides
Submit answer
Reference ranges v
Score: 71.4%
1 V
2 >/
3
4 X
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Which one of the following is least associated with retroperitoneal
fibrosis?
Riedel's thyroiditis
Previous radiotherapy
Methysergide
Sulphonamides
4 8
f # Discuss Improve
Lower back / flank pain is the most common presenting feature. Fever
and lower limb oedema is also seen in some patients.
Associations
• Riedel's thyroiditis
• previous radiotherapy
• sarcoidosis
• inflammatory abdominal aortic aneurysm
• drugs: methysergide
Calciphylaxis
Kyrle disease
Glucagonoma
Submit answer
Reference ranges v
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Q9 p
Calciphylaxis
Kyrle disease
Glucagonoma
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Calciphylaxis lesion are intensely painful, purpuric patches with
an area of black necrotic tissue that may form bullae, ulcerate,
and leave a hard, firm eschar
Importance: 94
Kyrle disease is most frequently seen in persons with diabetes and end-
stage kidney disease. It can present with an individual papule or
numerous widespread hyperpigmented papules. The papules have an
umbilicated central core.
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Q10 p
Hypocalcaemia
Sickle-cell anaemia
Lithium
Hypokalaemia
Demeclocycline
Submit answer
Reference ranges v
Score: 66.7%
1 >/
2 V
3 >/
4 X
5 V
6 X
7
Q
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Q Q10 x ©
Each one of the following is a cause of nephrogenic diabetes insipidus,
except:
Hypocalcaemia
Sickle-cell anaemia
Lithium
Hypokalaemia
Demeclocycline
B6 t # Discuss Improve
HaiiQPQ nf rranipl HI
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Diabetes insipidus
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/ kg excludes diabetes insipidus
• water deprivation test
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• DIDMOAD is the association ot cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
B / B A HI
TI~ 0 co
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© Q11 p ©
A 55-year-old woman is seen in the Emergency Department, she was
previously well except poorly controlled hypertension and a 20 pack-
year smoking history. She has developed sudden shortness of breath
with a productive clear cough. On examination you find bilateral
dullness to percussion with fine crackles in both bases, no other
findings.
Malignancy
Asymmetric kidneys
Hydronephrosis
Nephrolithiasis
Normal kidneys
Submit answer
Reference ranges v
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© Q11 p ©
A 55-year-old woman is seen in the Emergency Department, she was
previously well except poorly controlled hypertension and a 20 pack-
year smoking history. She has developed sudden shortness of breath
with a productive clear cough. On examination you find bilateral
dullness to percussion with fine crackles in both bases, no other
findings.
Malignancy
Asymmetric kidneys
Hydronephrosis
Nephrolithiasis
Normal kidneys
She is female vouna. and a smoker all risk factors for fibromuscular
, ,
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This woman has presented to the emergency department with rapid
onset (flash) pulmonary oedema.
She is female, young, and a smoker, all risk factors for fibromuscular
dysplasia. Her hypertension is poorly controlled which suggests there
may be an underlying cause for the hypertension.
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U I 5L U 6 A I ) MI i p i u v e
^
Next question >
Fibromuscular dysplasia
Epidemiology
• 90% of patients are female
Features
• hypertension
• chronic kidney disease or more acute renal failure e.g. secondary
to ACE-inhibitor initiation
• 'flash' pulmonary oedema
B / a A • =Z ^ TI" H c-D
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Azathioprine
Ciclosporin
Cyclophosphamide
Methotrexate
Mycophenolate
Submit answer
Reference ranges v
Score: 63.6%
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UT7 x7
A 32-year -old woman comes to the immunology clinic for review. She
has a history of SLE and stopped her medication prior to getting
pregnant. She is now approaching 16 weeks gestation. Unfortunately
her joint pains have returned, creatinine has risen from 90 pmol/ l to 146
pmol/ l, with blood and proteinuria, despite high dose prednisolone.
Azathioprine
Ciclosporin
Cyclophosphamide
Methotrexate
Mycophenolate
lA Discuss ( A ) Imnrove
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Systemic lupus erythematosus: renal
complications
WHO classification
• class I: normal kidney
• class II: mesangial glomerulonephritis
• class III: focal (and segmental) proliferative glomerulonephritis
• class IV: diffuse proliferative glomerulonephritis
• class V: diffuse membranous glomerulonephritis
• class VI: sclerosing glomerulonephritis
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© Q13 p ©
A 33-year -old is admitted to the Emergency Department with suspected
renal colic. He has a ultrasound that shows a probable stone in the left
ureter. What is the most appropriate next step with respect to imaging?
Non-contrast CT (NCCT)
Micturating cystourethrogram
MRI
Submit answer
Reference ranges v
Score: 58.3%
1 V
2 V
3 V
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© Q13 p ©
A 33-year -old is admitted to the Emergency Department with suspected
renal colic. He has a ultrasound that shows a probable stone in the left
ureter. What is the most appropriate next step with respect to imaging?
Non-contrast CT (NCCT)
Micturating cystourethrogram
MRI
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A 54-year-old man who has end stage diabetic nephropathy is being
assessed for a renal transplant. When assessing the HLA matching
between donor and recipient what is the most important HLA antigen to
match?
DP
O DR
Submit answer
Reference ranges
Score: 61.5%
1 V
2 V
3
4 X
5 >/
6 X
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A 54-year-old man who has end stage diabetic nephropathy is being
assessed for a renal transplant . When assessing the HLA matching
between donor and recipient what is the most important HLA antigen to
match?
DP
DR
The human leucocyte antigen (HLA) system is the name given to the
major histocompatibility complex (MHC) in humans. It is coded for on
chromosome 6.
Bicarbonate 22 mmol/ l
Mesangiocapillary glomerulonephritis
Membranous glomerulonephritis
Submit answer
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Bicarbonate 22 mmol/ I
Mesangiocapillary glomerulonephritis
Membranous glomerulonephritis
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Which one of the following statements is true regarding autosomal
recessive polycystic kidney disease?
ARPKD
B / a A = - xr H - £D c-o
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Q2 p
Histiocytosis
Diabetes insipidus
Submit answer
Reference ranges v
Score: 100%
1 >/
All contents of this site are © 2020 Passmedicine Limited Back to top
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Q2 X ©
A mutation in the gene that encodes aquaporin 2 is most likely to result
in:
Histiocytosis
Alport ’s syndrome
Diabetes insipidus
Importance: 82
4
B f
8
# Discuss (1) Improve
Diabetes
AL amyloidosis
AA amyloidosis
Waldenstrom macroglobulinaemia
Submit answer
Reference ranges
Score: 50%
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© Q3 X P ©
82-year-old female with a background of rheumatoid arthritis on
maintenance dose prednisolone and sulfasalazine is admitted with
deteriorating renal function. Urine dip reveals protein +++. She has
previously suffered from a distal radial fracture and is currently
complaining of numbness and tingling down the lateral 3 1/ 2 digits of
the opposite hand.
Diabetes
AL amyloidosis
AA amyloidosis
Waldenstrom macroglobulinaemia
Examination today reveals bibasal crackles whilst the chest x-ray shows
upper lobe diversion and perihilar shadowing. The ECG and cardiac
enzymes are normal.
Infective endocarditis
Phaeochromocytoma
Fibromuscular dysplasia
Submit answer
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Flash pulmonary oedema, U&Es worse on ACE inhibitor,
asymmetrical kidneys
angiography
- renal artery stenosis - do MR
Investigation
• MR angiography is now the investigation of choice
• CT angiography
• conventional renal angiography is less commonly performed used
nowadays, but may still have a role when planning surgery
K+ 4.9 mmol/l
Add a beta-blocker
Add spironolactone
Stop ramipril
Submit answer
Reference ranges v
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© Q4 X p
Na + 139 mmol / l
K+ 4.9 mmol/l
eGFR 29 ml / min
Add a beta-blocker
Add spironolactone
Stop ramipril
The majority of patients with chronic kidney disease (CKD) will require
more than two drugs to treat hypertension. ACE inhibitors are first line
and are particularly helpful in proteinuric renal disease (e.g. diabetic
nephropathy). As these drugs tend to reduce filtration pressure a small
fall in glomerular filtration pressure (GFR) and rise in creatinine can be
expected. NICE suggest that a decrease in eGFR of up to 25% or a rise
in creatinine of up to 30% is acceptable, although any rise should
prompt careful monitoring and exclusion of other causes (e. g. NSAIDs) .
A rise greater than this may indicate underlying renovascular disease.
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© Q5 p
Urea 22 mmol/l
What is the most likely cause for the deterioration in renal function?
Statin nephropathy
Submit answer
Reference ranges v
Score: 50%
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Q Q5 >/ ©
A 45-year-old presents to the Emergency Department with chest pain.
An ECG shows anterior ST elevation and he is thrombolysed with
alteplase. His chest pain settles and he is started on aspirin,
atorvastatin, bisoprolol and ramipril. Four days later his blood results
are as follows:
Urea 22 mmol/I
What is the most likely cause for the deterioration in renal function?
Statin nephropathy
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Q Q2 P3 ©
A 19-year -old woman is referred to the nephrology department after
experiencing several episodes of visible haematuria. There is no history
of abdominal or loin pain. These typically seem to occur within a day or
two of developing tonsillitis. Blood pressure is 148 / 90 mmHg.
Na + 142 mmol/l
K+ 4.1 mmol/ l
Bicarbonate 24 mmol/l
Creatinine 71 pmol/l
Female gender
Hypertension
Frank haematuria
Absence of proteinuria
Submit answer
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Q2 X |o V
A 19-year -old woman is referred to the nephrology department after
experiencing several episodes of visible haematuria. There is no history
of abdominal or loin pain. These typically seem to occur within a day or
two of developing tonsillitis. Blood pressure is 148 / 90 mmHg.
Na + 142 mmol / l
K+ 4.1 mmol /l
Bicarbonate 24 mmol/ l
Creatinine 71 Mmol /l
Female gender
Hypertension
Frank haematuria
Absence of proteinuria
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Q3 P3
Chromosome 4
Chromosome 8
Chromosome 12
Chromosome 16
Chromosome 20
Submit answer
Reference ranges v
Score: 0%
1 X
2 X
3
i : Dorl/ tr» r
-
CamScanner -; Lig b
G Q3 V P ©
Autosomal dominant polycystic kidney disease type 2 is associated
with a gene defect in:
Chromosome 4
Chromosome 8
Chromosome 12
Chromosome 16
Chromosome 20
Chromosome 16 Chromosome 4
Management
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Q Q4 ©
A patient with type 1 diabetes mellitus is reviewed in the nephrology
outpatient clinic. He is known to have stage 1 diabetic nephropathy.
Which of the following best describes his degree of renal involvement ?
Latent phase
Hyperfiltration
Overt nephropathy
Microalbuminuria
Submit answer
Reference ranges v
Score: 33.3%
1 X
2 X
3 v>
4
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Hyperfiltration
Overt nephropathy
Microalbuminuria
For the purposes of the MRCR increase in the glomerular filtration rate
(GFR) is most characteristic of stage 1 diabetic nephropathy. It is
however known that elevation of the GFR usually persists into stage 2
Stage 1
• hyperfiltration: increase in GFR
• may be reversible
Stage 1
• hyperfiltration: increase in GFR
• may be reversible
Stage 5
• end-stage renal disease, GFR typically < 10ml / min
• renal replacement therapy needed
The timeline given here is for type 1 diabetics. Patients with type 2
diabetes mellitus (T 2DM) progress through similar stages but in a
different timescale - some T 2DM patients may progress quickly to the
later stages
Acute pyelonephritis
Tuberculosis
Syphilis
Submit answer
Score: 25%
1 X
2 X
3
4 X
5
CamScanner
Acute pyelonephritis
Tuberculosis
Syphilis
Causes
• chronic analgesia use
• sickle cell disease
• TB
• acute pyelonephritis
• diabetes mellitus
Features
• fever, loin pain, haematuria
• IVU - papillary necrosis with renal scarring - 'cup & spill
IgA nephropathy
Membranous glomerulonephritis
This man has IgA nephropathy which is associated with coeliac disease
ii f # Discuss Improve
Associated conditions
• alcoholic cirrhosis
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Q Q8 C
A 79-year-old complains of lower urinary tract symptoms. Which one of
the following statements regarding benign prostatic hyperplasia is
incorrect?
Submit answer
Reference ranges v
Score: 42.9%
1 X
2 X
3
4 X
5 X
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Goserelin is licensed for refractory cases
it f # Discuss (1 ) Improve
Risk factors
• age: around 50% of 50-year-old men will have evidence of BPH
and 30% will have symptoms . Around 80% of 80- year-old men
have evidence of BPH
• ethnicity: black > white > Asian
BPH typically presents with lower urinary tract symptoms (LUTS), which
may be categorised into:
• voiding symptoms (obstructive): weak or intermittent urinary flow,
straining, hesitancy, terminal dribbling and incomplete emptying
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BPH typically presents with lower urinary tract symptoms (LUTS), which
may be categorised into:
• voiding symptoms (obstructive): weak or intermittent urinary flow,
straining, hesitancy, terminal dribbling and incomplete emptying
• storage symptoms (irritative) urgency, frequency, urgency
incontinence and nocturia
• post-micturition: dribbling
• complications: urinary tract infection, retention, obstructive
uropathy
Management options
• watchful waiting
• medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The
use of combination therapy was supported by the Medical
Therapy Of Prostatic Symptoms (MTOPS) trial
• surgery: transurethral resection of prostate (TURP)
You are prescribing maintenance fluids for a 60-year -old woman who
has had a stroke. Her most recent blood results are shown below:
Na + 140 mmol/I
K+ 4.0 mmol/I
Creatinine 88 pmol /l
20 mmol
40 mmol
60 mmol
80 mmol
120 mmol
Submit answer
Reference ranges v
Score: 50%
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60 mmol
80 mmol
120 mmol
Converting this into real- world practice, NICE also recommends that
patients have 25-30ml/ kg/ day of water. As this patient weighs 62kg that
means the patient should receive approximately 1.5 - 2L of fluid in a 24
hour period. If the patient is receiving 1-litre bags of fluid then one
should contain 40 mmol and the other 20 mmol potassium to ensure an
adequate potassium intake.
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Fluid therapy
So, for a 80kg patient, for a 24 hour period, this would translate to:
• 2 litres of water
• 80mmol potassium
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and is having significant losses from drains will require more fluid
whereas a patient with heart failure should be given less fluid to avoid
precipitating pulmonary oedema .
Na+ Cl’
K+ HC03- Glucose
5 % glucose 50 g
Specific points
0.9% saline
• if large volumes are used there is an increased risk of
hyperchloraemic metabolic acidosis
Hartmann's
• contains potassium and therefore should not be used in patients
with hyperkalaemia
CT abdomen
Urine microscopy
Ultrasound abdomen
Submit answer
Reference ranges v
Score: 55.6%
1 X
2 X
3
4 X
5 X
6 v
'
7
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Ultrasound abdomen
ADPKD
85 % of cases 15 % of cases
Chromosome 16 Chromosome 4
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57 Q13 >/ Ia 57
A 33-year-old pregnant woman presents for advice. She is known to
have polycystic kidney disease but is currently well. Her father also has
polycystic kidneys and is on dialysis . What is the chance her child will
also have the disease?
50% if male
50%
25%
0%
100%
ADPKD
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G Q14 PJ ©
Why do patients with chronic kidney disease have a raised phosphate
level?
Hypervitaminosis D
Primary hyperparathyroidism
Submit answer
Reference ranges v
Score: 69.2%
1 X
2 X
3
4 X
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Why do patients with chronic kidney disease have a raised phosphate
level ?
Hypervitaminosis D
Primary hyperparathyroidism
t # Discuss (1 ) Improve
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Several clinical manifestations may result:
Adynamic
• reduction in cellular activity (both osteoblasts and osteoclasts) in
bone
• may be due to over treatment with vitamin D
Osteomalacia
• due to low vitamin D
Osteosclerosis
Osteoporosis
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© Q16 p o
Which one of the following statements regarding the assessment of
proteinuria in patients with chronic kidney disease is NOT true?
Submit answer
Reference ranges v
Score: 60%
X
2 X
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An ACR sample is collected over 24 hours
30 50 0.5
70 100 1
30 50 0.5
70 100 1
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Frequency of monitoring eGFR (number of times per year by eGFR and
ACR categories) for people with or at risk of CKD
ACR
eGFR categories categories
(mL/min/ 1.73 m2) (mg/ mmol)
G 3 a 45- 59 Mild to 1 1 2
moderate reduction
G 4 15-29 Severe 2 2 3
reduction
B / a A E: ^ Tr H" H GO
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© Q2 P
APC
GCK
INS
HNF1 A
AVPR 2
Submit answer
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AVPR 2
Importance: 50
INS (insulin gene) has been associated with the development of type 1
diabetes mellitus, where insulin production from beta cells is impaired.
A # Discuss Improve
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
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Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
=~ Tr H "' E C-D
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Q Q3 P O
A 44-year-old man is referred to the renal team. He has a long history of
chronic sinusitis and was investigated last year for haemoptysis but no
cause was found. A number of recent urine dipstick tests has shown
persistent microscopic haematuria.
K+ 4.8 mmol/l
ESR 61 mm/hr
CRP 30 mg/I
anti-GBM Negative
ANA Negative
Kimmelstiel-Wilson nodules
Crescentic glomerulonephritis
Membranous glomerulonephritis
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Crescentic glomerulonephritis
Membranous glomerulonephritis
Causes
• Goodpasture's syndrome
• Wegener's granulomatosis
• others: SLE, microscopic polyarteritis
Features
• nephritic syndrome: haematuria with red cell casts, proteinuria,
hypertension, oliguria
• features specific to underlying cause (e.g. haemoptysis with
Goodpasture's, vasculitic rash or sinusitis with Wegener 's)
© Q4 \C3
You are reviewing a 33-year -old man who has recently been diagnosed
with adult polycystic kidney disease in the renal clinic. You proceed to
examine his cardiovascular system. Which other feature are you most
likely to find on examination?
Dilated cardiomyopathy
Mitral stenosis
Aortic stenosis
Submit answer
Reference ranges v
Score: 66.7%
1 <
2 X
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G Q4 >/ P ©
You are reviewing a 33- year-old man who has recently been diagnosed
with adult polycystic kidney disease in the renal clinic. You proceed to
examine his cardiovascular system . Which other feature are you most
likely to find on examination?
Dilated cardiomyopathy
Mitral stenosis
Aortic stenosis
# Discuss (1 ) Improve
ADPKD: features
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B6 f # Discuss (1) Improve
Features
• hypertension
• recurrent UTIs
• abdominal pain
• renal stones
• haematuria
• chronic kidney disease
Extra-renal manifestations
• liver cysts (70% - the commonest extra-renal manifestation): may
cause hepatomegaly
• berry aneurysms (8%): rupture can cause subarachnoid
haemorrhage
• cardiovascular system: mitral valve prolapse, mitral/tricuspid
incompetence, aortic root dilation, aortic dissection
• cysts in other organs: pancreas, spleen; very rarely: thyroid,
oesophagus, ovary
© Q5 p ©
A 54-year-old truck driver presented to emergency department with a
new onset severe back pain radiating to his groin. He required 10 mg of
intravenous morphine to control his pain. He is not a smoker but drinks
10-12 pints on weekends. He has recently been diagnosed with
esophageal cancer and has undertaken his first chemotherapy session
the previous week . With regards to uric acid calculi, one of its
remarkable characteristic is:
Submit answer
Reference ranges v
Score: 75%
1 v
'
2 X
3 s/
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They are radiolucent
Radiograph
Type Frequency appearance
Radiograph
Type Frequency appearance
*stag-horn calculi involve the renal pelvis and extend into at least 2
calyces. They develop in alkaline urine and are composed of struvite
(ammonium magnesium phosphate, triple phosphate). Ureaplasma
urealyticum and Proteus infections predispose to their formation
B / a A H
E: ~ TIT H" s GO
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© Q7
Refer to a nephrologist
Submit answer
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Repeat the sample
NICE recommend 'if the initial ACR is between 3 mg/ mmol and 70
mg/ mmol, this should be confirmed by a subsequent early morning
sample. If the initial ACR is 70 mg/ mmol or more, a repeat sample need
not be tested.'
30 50 0.5
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Q8 p
Male gender
Hyperlipidaemia
Frank haematuria
ACE genotype DD
Submit answer
Reference ranges v
Score: 85.7%
1 >/
2 X
3 >/
4
5
'V
v
6 >/
7
Q
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© Q8 p ©
Which one of the following is associated with a better prognosis in
patients with IgA nephropathy ?
Male gender
Hyperlipidaemia
Frank haematuria
ACE genotype DD
Associated conditions
• alcoholic cirrhosis
• coeliac disease / dermatitis herpetiformis
• Hpnnrh-^rhnnlpin ni irm ira
.
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G Q1 P
Urine dip is positive for leukocytes, nitrates and the pH level is alkaline.
The sample is further sent for microscopy, culture and sensitivity, which
revealed numerous gram-negative motile rod- shaped bacteria indicating
Proteus mirabilis .
Cysteine stone
Struvite stone
Xanthine stone
Submit answer
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Struvite stone
Xanthine stone
Calcium oxalate stones are the most common types of stones in adults.
Low calcium diets and dehydration increase the risk of the development
of these stones.
Uric acid stones are the most common stones seen in patients with
gout. Dehydration and having acidic urine increase the risk of
developing these stones.
Uric acid stones are the most common stones seen in patients with
gout . Dehydration and having acidic urine increase the risk of
developing these stones .
Xanthogranulomatous pyelonephritis
B / B A •B
= w
Tr E co
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© Q3 p c
A 40-year-old man with a history of psychiatric problems and epilepsy
comes for review. He complains that he is drinking excessive amounts
of water and having to urinate frequently. He has not lost any weight
and states that he is compliant with his current medications. Blood
tests show the following:
K+ 4.1 mmol/l
Carbamazepine
Fluoxetine
Olanzapine
Sodium valproate
Lithium
Submit answer
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Lithium
insipidus
This patient has probably developed nephrogenic diabetes
secondary to lithium therapy. Polyuria, polydipsia and a
high-normal
Diabetes insipidus
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
CamScanner -;
, upuu m i u p n y «5
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uiaueuij ivieiiuuj cniu UCBIIICJJ MIUVVII
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm /kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
Save my notes
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o Q4 X p ©
A 62-year -old man attends your clinic. He has a history of hypertension
and atrial fibrillation for which he is anticoagulated with warfarin. A
urine dipstick taken 8 weeks ago during a routine hypertension clinic
appointment showed blood + with leucocytes +. Initial urine microscopy
and culture shows no growth. The urine dipstick has been repeated on
two further occasions with the same finding.
Refer to nephrology
Refer to urology
4 f # Discuss Improve
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Haematuria
Management
also be investigated.
Testing
• urine dipstick is the test of choice for detecting haematuria
being
• persistent non-visible haematuria is often defined as blood
present in 2 out of 3 samples tested 2-3 weeks apart
• renal function, albumin:creatinine ( ACR) or protein:creatinine ratio
(PCR) and blood pressure should also be checked
• urine microscopy may be used but time to analysis significantly
affects the number of red blood cells detected
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G Q6 P ©
Which one of the following is the most common type of SLE associated
renal disease?
Submit answer
Reference ranges v
Score: 60%
1
2 X
3 V
4 X
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© Q6 >/ ©
Which one of the following is the most common type of SLE associated
renal disease?
at t # Discuss Improve
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Systemic lupus erythematosus: renal
complications
WHO classification
• class I: normal kidney
• class II: mesangial glomerulonephritis
• class III: focal (and segmental) proliferative glomerulonephritis
• class IV: diffuse proliferative glomerulonephritis
• class V: diffuse membranous glomerulonephritis
• class VI: sclerosing glomerulonephritis
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deposits
• granular appearance on immunofluorescence
Management
• treat hypertension
• corticosteroids if clinical evidence of disease
• immunosuppressants e.g. azathioprine/ cyclophosphamide
B / a A =1 ^ TIT E GO
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Sparr.h tpvthnnk
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G Q1 P ©
A 22-year -old man presents to his GP with polyuria, nocturia and
polydipsia. He has no past medical history of note. Routine blood tests
including Hbalc and random glucose are unremarkable.
Craniopharyngioma
Haemochromatosis
Hypocalcaemia
Submit answer
Reference ranges v
A O/
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Inherited mutation in the vasopressin (ADH) receptor
This patient has presented with polyuria and polydipsia; the key
symptoms of diabetes insipidus. The water deprivation test is used to
confirm the diagnosis, and demonstrates an inability to concentrate
urine in affected individuals.
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Hypercalcaemia is a cause of nephrogenic diabetes insipidus.
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
CamScanner
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/ kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
Save my notes
Search
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© Q2 p ©
A 23 -year -old patient presents to the emergency department with a
head injury following a night out with his friends. He reports he drank
excess alcohol. His observations are within normal range, pupils equal
and reactive to light. CT head is normal. He complains of feeling thirsty
and needed to urinate excessively.
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at f # Discuss Improve
Polyuria
Infrequent (1 in 100)
• hypercalcaemia
• hyperthyroidism
Rare (1 in 1000)
• chronic renal failure
• primary polydipsia
• hypokalaemia
E I S A •
Hi
=P TP HP E C-D
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G Q1 P ©
A 34-year -old single mum has been referred for genetic testing
following her 8-months-old son being diagnosed with congenital
nephrogenic diabetes insipidus. She is asymptomatic and is not aware
of any family history of this condition.
Vasopressin receptor
Submit answer
Reference ranges v
Score: 0%
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Vasopressin receptor
Importance: 50
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Sodium-chloride co-transporter (NCCT) dysfunction is indicated in
Gitelman syndrome.
si ? 0 Discuss Improve
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
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Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm / kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
E I S A a MM
«^M =~ TI" E c-o
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Search textbook...
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A 38-year- old male with a background of adult polycystic kidney disease
and a preemptive renal transplant 8 years ago presents to the transplant
clinic with worsening bilateral hand tremor. His renal function remains
stable with no uraemia and denies any recent excessive alcohol intake.
Alcohol
Anxiety
Drug-induced parkinsonism
Essential tremor
Tacrolimus
Submit answer
Reference ranges v
Score: 0%
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Tacrolimus
4 f # Discuss Improve
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Renal transplant: immunosuppression
Example regime
• initial: ciclosporin/ tacrolimus with a monoclonal antibody
• maintenance: ciclosporin/ tacrolimus with MMF or sirolimus
• add steroids if more than one steroid responsive acute rejection episode
Ciclosporin
• inhibits calcineurin, a phosphotase involved in T cell activation
Tacrolimus
• lower incidence of acute rejection compared to ciclosporin
• also less hypertension and hyperlipidaemia
• however, high incidence of impaired glucose tolerance and diabetes
Sirolimus (rapamycin)
• blocks T cell proliferation by blocking the IL-2 receptor
• can cause hyperlipidaemia
Monoclonal antibodies
• selective inhibitors of IL-2 receptor
• daclizumab
• basilximab
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Monitoring
B / B A - •
m
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MB
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He has told your consultant that his brother and maternal uncle have
similar problems but he is the first to seek advice.
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IVIUIUI U I I O V/ l ^ l V^ O W I L I I V^ I V I V J L/ i y
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Importance: 50
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Nephrogenic diabetes insipidus is the correct answer. Patients often
present with polyuria and polydipsia and dehydration is common. With
no damage to the pituitary gland or hypothalamus, MRI brain is usually
normal. Urine osmolality is < 300mOsm / kg in nephrogenic diabetes
insipidus. The most common genetic mutation causing nephrogenic
diabetes insipidus affects the arginine vasopressin V 2 receptor
(AVPR 2).
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
CamScanner
Causes of cranial Dl
• idiopathic
• post head injury
• pituitary surgery
• craniopharyngiomas
• histiocytosis X
• DIDMOAD is the association of cranial Diabetes Insipidus,
Diabetes Mellitus, Optic Atrophy and Deafness (also known as
Wolfram's syndrome)
• haemochromatosis
Causes of nephrogenic Dl
• genetic: the more common form affects the vasopression (ADH)
receptor, the less common form results from a mutation in the
gene that encodes the aquaporin 2 channel
• electrolytes: hypercalcaemia, hypokalaemia
• drugs: demeclocycline, lithium
• tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features
• polyuria
• polydipsia
Investigation
• high plasma osmolality, low urine osmolality
• a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
• water deprivation test
Management
• nephrogenic diabetes insipidus: thiazides, low salt / protein diet
- central diabetes insipidus can be treated with desmopressin
K+ 4.2 mmol/L
Creatinine 79 pmol/ L
HbA1c 37 mmol/ L
Idiopathic
Head injury
Haemochromatosis
Wolfram syndrome
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14$
ii ijui y
Haemochromatosis
Wolfram syndrome
Importance: 50
Mutations in the gene that encode the vasopressin receptor are the only
nephrogenic cause listed.
B £ f # Discuss Improve
Submit answer
Reference ranges v
Score: 100%
1
2
3
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ascites. The consultant starts him on spironolactone to help with the
management of his ascites.
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Carbonic anhydrase inhibitors include dorzolamide and act in the
proximal tubules.
BA A # Discuss Improve
Spironolactone
Indications
• ascites: patients with cirrhosis develop a secondary
hyperaldosteronism. Relatively large doses such as 100 or 200mg
are often used
• hypertension: used in some patients as a NICE 'step 4' treatment
• heart failure (see RALES study below)
• nephrotic syndrome
• Conn's syndrome
Adverse effects
• hyperkalaemia
• gynaecomastia: less common with eplerenone
RALES
• NYHA III + IV, patients already taking ACE inhibitor
• low dose spironolactone reduces all cause mortality
B / a A =^ Tr H C-D
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