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Question 1
Correct
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A 30-year-old man presents to the general practitioner (GP) with hypertension which fails to fall into the normal range after three successive measurements at the practice nurse. These were 155/92 mmHg, 158/96 mmHg and 154/94 mmHg. He has a past history of some urinary tract infections as a child. The GP arranges some routine blood tests.
Investigations:
Investigation Result Normal value
Haemoglobin 139 g/l 135–175 g/l
White cell count (WCC) 5.4 × 109/l 4–11 × 109/l
Platelets 201 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
Creatinine 187 μmol/l 50–120 μmol/l
USS Left kidney 8.4 cm and appears scarred.
Right kidney 10.3 cm
Which of the following is the most likely diagnosis?Your Answer: Chronic reflux nephropathy
Explanation:Differential Diagnosis for a 25-Year-Old Man with Renal Issues
Upon reviewing the history and test results of a 25-year-old man with renal issues, several potential diagnoses can be considered. Chronic reflux nephropathy appears to be the most likely diagnosis, given the patient’s history of urinary tract infections as a child, ultrasound scan results, and elevated creatinine levels. Further testing, such as renal tract computed tomography and a voiding cystourethrogram, can confirm this diagnosis.
Essential hypertension, while a risk factor for reno-vascular disease, would not explain the patient’s creatinine rise or asymmetrical kidneys. Renal artery stenosis, while potentially causing a unilaterally reduced kidney size, is rare in young patients and does not fit with the patient’s history of urinary tract infections. White coat hypertension, which is a transient rise in blood pressure in a medical setting, would not explain the patient’s creatinine rise or reduced kidney size and scarring.
IgA nephropathy, which typically presents with haematuria following an upper respiratory or other infection, does not fit with the patient’s history of urinary tract infections or lack of haematuria. Therefore, chronic reflux nephropathy remains the most likely diagnosis for this patient.
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This question is part of the following fields:
- Renal
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Question 2
Incorrect
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A 54-year-old woman with a long-standing history of poorly controlled type 2 diabetes mellitus presents to clinic complaining of swelling in her ankles, face and fingers. She states she can no longer wear her wedding ring because her fingers are too swollen. On examination, her blood pressure is 150/90 mmHg; she has pitting oedema in her ankles and notably swollen fingers and face. Her blood results show:
Investigation Results Normal value
Creatinine 353.6 μmol/l 50–120 μmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Phosphate 1.9 mmol/l 0.70–1.40 mmol/l
Parathyroid hormone (PTH) Elevated
Urinalysis 3+ glucose, 3+ protein
Which of the following is the most likely mechanism of this woman's increased PTH?Your Answer: Increased 1, 25-dihydroxycholecalciferol
Correct Answer: Decreased glomerular filtration rate (GFR)
Explanation:Understanding the Causes of Secondary Hyperparathyroidism
Secondary hyperparathyroidism is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH) in response to low calcium levels in the blood. This can be caused by a variety of factors, including chronic renal failure, vitamin D excess, and the use of certain medications like diuretics.
In cases of chronic renal failure, decreased glomerular filtration rate (GFR) can lead to raised creatinine levels and proteinuria. This can cause diabetic nephropathy, which can result in hyperphosphataemia and secondary hyperparathyroidism. Over time, this can also lead to osteoporosis as a long-term complication of hyperparathyroidism.
Vitamin D excess is another cause of secondary hyperparathyroidism, but it is associated with low phosphate levels rather than hyperphosphataemia. In cases of parathyroid adenoma, a less likely cause in this patient, there is an overproduction of PTH by a benign tumor in the parathyroid gland.
Finally, the use of diuretics can increase phosphate excretion, leading to hypophosphataemia. This can also contribute to the development of secondary hyperparathyroidism.
Understanding the various causes of secondary hyperparathyroidism is important for proper diagnosis and treatment. By addressing the underlying condition, it may be possible to reduce the production of PTH and prevent further complications.
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This question is part of the following fields:
- Renal
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Question 3
Incorrect
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A 35-year-old woman with haematuria underwent a kidney biopsy, but light microscopy results were inconclusive. As a result, the specimen was sent for electron microscopy. Which renal disease requires electron microscopy for diagnosis?
Your Answer: Anti-GBM (glomerular basement membrane) disease
Correct Answer: Thin membrane disease
Explanation:Renal Diseases and their Diagnostic Methods
Renal diseases can be diagnosed through various methods, including electron microscopy, blood tests, and renal biopsy. Here are some examples:
Thin Membrane Disease: Electron microscopy is crucial in diagnosing thin membrane disease, as well as Alport syndrome and fibrillary glomerulopathy.
Anti-GBM Disease: Blood tests for anti-GBM can confirm Goodpasture’s syndrome, but a renal biopsy can also be taken to show IgG deposits along the basement membrane.
Lupus Nephritis: While electron microscopy can show dense immune deposits in lupus nephritis, diagnosis can also be made through immunofluorescence without the need for electron microscopy.
IgA Nephropathy: A renal biopsy can confirm IgA nephropathy, showing mesangium proliferation and IgA deposits on immunofluorescence.
Churg-Strauss Syndrome: Also known as eosinophilic granulomatosis with polyangiitis (EGPA), Churg-Strauss syndrome can be diagnosed through blood tests showing high eosinophils and ANCA, as well as renal biopsy showing eosinophil granulomas.
Diagnostic Methods for Renal Diseases
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This question is part of the following fields:
- Renal
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Question 4
Correct
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A 35-year-old woman presents with an incidental finding of a blood pressure of 180/130 mmHg on three separate occasions. Her cardiovascular examination is unremarkable, but further investigation reveals a significantly smaller left kidney with a 'string of beads' appearance in the left renal artery. What is the most appropriate management option for this patient?
Your Answer: Balloon angioplasty
Explanation:Management of Renal Artery Stenosis: Fibromuscular Dysplasia
Fibromuscular dysplasia is a rare cause of renal artery stenosis, typically affecting young women and presenting with hypertension. The characteristic ‘string of beads’ appearance on CT imaging helps in diagnosis. While atherosclerotic disease is the most common cause of renal artery stenosis, a combination of antihypertensive therapy and renal artery balloon angioplasty is curative for fibromuscular dysplasia. Kidney transplantation is not usually required, but it is important to recognize the condition in donors to prevent complications in recipients. Nephrectomy is not typically necessary, and surgical reconstruction is rarely recommended. Statins are not used in the management of fibromuscular dysplasia, but may be used in atherosclerotic renal artery stenosis.
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This question is part of the following fields:
- Renal
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Question 5
Incorrect
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What is the correct statement regarding the juxtaglomerular apparatus?
Your Answer: Renin is secreted in response to a raised sodium level at the macula densa
Correct Answer: A fall in pressure in the afferent arteriole promotes renin secretion
Explanation:Renin secretion and the role of the macula densa and juxtaglomerular cells
Renin is an enzyme that plays a crucial role in regulating blood pressure and fluid balance in the body. It is secreted by juxtaglomerular cells, which are modified smooth muscle cells located in the wall of the afferent arterioles. Renin secretion is stimulated by a fall in renal perfusion pressure, which can be detected by baroreceptors in the afferent arterioles. Additionally, reduced sodium delivery to the macula densa, a specialized region of the distal convoluted tubule, can also stimulate renin production. However, it is important to note that the macula densa itself does not secrete renin. Understanding the mechanisms behind renin secretion can help in the diagnosis and treatment of conditions such as hypertension and kidney disease.
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This question is part of the following fields:
- Renal
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Question 6
Correct
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A 59-year-old man has been undergoing regular haemodialysis for the past 6 years. He previously had an AV fistula in his left arm, but it became infected 4 years ago and was no longer functional. Currently, he is receiving dialysis through an AV fistula in his right forearm. He presents with pain in his right hand and wrist. Upon examination, there is redness and a necrotic ulcer on his right middle finger. His right hand strength is normal. He is not experiencing any constitutional symptoms and is not taking any medications. He had undergone uncomplicated dialysis the day before. What is the likely diagnosis?
Your Answer: Distal hypoperfusion ischaemic syndrome (DHIS)
Explanation:Possible Complications of AV Fistula in Dialysis Patients
AV fistula is a common vascular access for patients undergoing dialysis. However, it can lead to various complications, including distal hypoperfusion ischaemic syndrome (DHIS). DHIS, also known as steal syndrome, occurs when blood flow is shunted through the fistula, causing distal ischaemia, which can result in ulcers and necrosis. Surgical revision or banding of the fistula may be necessary in severe cases. Older patients with atherosclerotic arteries are more prone to DHIS. Other possible complications include unrelated local pathology, infected AV fistula, infective endocarditis, and thrombosis with distal embolisation. It is important to identify and manage these complications promptly to prevent further harm to the patient.
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This question is part of the following fields:
- Renal
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Question 7
Correct
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A 68-year-old woman was admitted to hospital seven days ago with moderate symptoms of community-acquired pneumonia and was treated with amoxicillin. She has developed a fever, maculopapular skin rash and haematuria over the last two days. You suspect that her new symptoms may be due to acute tubulointerstitial nephritis caused by a reaction to the amoxicillin she was given.
Which of the following investigations would provide a definitive diagnosis?Your Answer: Kidney biopsy
Explanation:Investigations for Tubulointerstitial Nephritis
Tubulointerstitial nephritis is a condition that affects the kidneys and can lead to renal failure if left untreated. There are several investigations that can be done to help diagnose this condition.
Kidney Biopsy: This is the most definitive investigation for tubulointerstitial nephritis. It involves taking a small sample of kidney tissue for examination under a microscope. This is usually only done if other tests have been inconclusive or if the diagnosis is unclear.
Full Blood Count: This test can help identify the presence of eosinophilia, which is often seen in cases of tubulointerstitial nephritis. However, the absence of eosinophilia does not rule out the condition.
Kidney Ultrasound: This test can help rule out other conditions such as chronic renal failure, hydronephrosis, or renal calculi. In cases of tubulointerstitial nephritis, the kidneys may appear enlarged and echogenic due to inflammation.
Serum Urea and Electrolytes: This test measures the levels of urea and creatinine in the blood, which can be elevated in cases of tubulointerstitial nephritis.
Urinalysis: This test can detect the presence of low-grade proteinuria, white blood cell casts, and sterile pyuria, which are all indicative of tubulointerstitial nephritis. However, it is not a definitive diagnostic tool.
In conclusion, a combination of these investigations can help diagnose tubulointerstitial nephritis and guide appropriate treatment.
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This question is part of the following fields:
- Renal
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Question 8
Correct
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A 42-year-old accountant presents to the General Practitioner (GP) with flank pain and an episode of frank haematuria. She has a history of recurrent urinary tract infections (UTIs) and has had similar symptoms before. She attributes this episode to another UTI. She also has hypertension which is well controlled with ramipril. The doctor is concerned regarding the history of recurrent UTIs, and patient is further investigated for her symptoms with blood tests and ultrasound imaging. Results of the bloods and ultrasound confirms a diagnosis of polycystic kidney disease (PKD). Which of the following is true regarding PKD?
Your Answer: Is associated with berry aneurysms of the circle of Willis
Explanation:Polycystic Kidney Disease: Causes, Symptoms, and Associations
Polycystic kidney disease (PKD) is a genetic disorder that affects the kidneys and other organs. It is caused by mutations in either the PKD1 or PKD2 gene, which leads to the formation of multiple cysts in the kidneys. Here are some important facts about PKD:
Associations with other conditions: PKD is associated with cerebral berry aneurysms, liver cysts, hepatic fibrosis, diverticular disease, pancreatic cysts, and mitral valve prolapse or aortic incompetence.
Inheritance: PKD is usually inherited as an autosomal dominant condition, meaning that a person only needs to inherit one copy of the mutated gene from one parent to develop the disease. Autosomal recessive PKD is rare and has a poor prognosis.
Kidney involvement: Both kidneys are affected by PKD, with cysts replacing the functioning renal parenchyma and leading to renal failure.
Age of onset: PKD usually presents in adult life, but cysts start to develop during the teenage years. The mean age of ESRD is 57 years in PKD1 cases and 69 years in PKD2 cases.
PKD is a complex disorder that can have serious consequences for affected individuals. Early diagnosis and management are crucial for improving outcomes.
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This question is part of the following fields:
- Renal
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Question 9
Incorrect
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A 67-year-old retired bus driver presents to the Emergency Department with end-stage renal disease due to diabetic nephropathy. What is the most probable histological finding on kidney biopsy for this patient?
Your Answer: Rouleaux formation
Correct Answer: Kimmelstiel–Wilson nodules
Explanation:Renal Biopsy Findings in Diabetic Nephropathy and Other Renal Diseases
Diabetic nephropathy is a progressive kidney disease that damages the glomerular filtration barrier, leading to proteinuria. Renal biopsy is a diagnostic test that can reveal various findings associated with different renal diseases.
Kimmelstiel–Wilson nodules are a hallmark of diabetic nephropathy, which are nodules of hyaline material that accumulate in the glomerulus. In contrast, immune complex deposition is commonly found in crescentic glomerulonephritis, anti-GBM disease, lupus, and IgA/post-infectious GN.
Rouleaux formation, the abnormal stacking of red blood cells, is not associated with diabetic nephropathy but can cause diabetic retinopathy. Clear cells, a classification of renal cell carcinoma, are not a finding associated with diabetic nephropathy either.
Finally, mesangial amyloid deposits are not associated with diabetic nephropathy but may be found in the mesangium, glomerular capillary walls, interstitium, or renal vessels in amyloidosis. Renal biopsy is a valuable tool in diagnosing and managing various renal diseases, including diabetic nephropathy.
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This question is part of the following fields:
- Renal
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Question 10
Correct
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A 40-year-old piano teacher presented to the Emergency Department with an acute kidney injury (AKI) and was referred to the renal team for urgent haemodialysis. Which of the following is not a reason for immediate dialysis?
Your Answer: Alkalosis
Explanation:Indications for Urgent Dialysis in Renal Failure Patients
Dialysis is a life-saving treatment for patients with renal failure. Urgent dialysis is required in certain situations to prevent serious complications. Acidosis, not alkalosis, is an urgent indication for dialysis. Pulmonary edema caused by furosemide-resistant fluid overload is another indication for urgent dialysis. Severe hyperkalemia, with potassium levels greater than 6.5 mmol/l or less if electrocardiographic changes are apparent, is also an indication for dialysis. Severe uraemia, with symptoms such as vomiting, encephalopathy, and urea levels greater than 60 mmol/l, requires urgent dialysis. Uraemic pericarditis is another indication for urgent dialysis. It is important to recognize these indications and initiate dialysis promptly to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Renal
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Question 11
Correct
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A 70-year-old woman with type II diabetes mellitus presents to the Emergency Department. She was found to be confused at home by her son. According to her son, the patient is independent and able to take care of herself. On examination she has a temperature of 38.1 °C. Her blood pressure is 136/74 mmHg, and her heart rate is 110 bpm. She is disorientated and not able to provide any history. Physical examination is unremarkable except for tenderness elicited at the right lower back.
Urine dipstick results are shown below:
Investigation Result Normal value
Colour Turbid Clear
pH 6.7 7.35–7.45
Glucose 2+ Negative
Bilirubin Negative Negative
Ketone 1+ Negative
Nitrite 2+ Negative
Leukocytes 3+ Negative
Blood 1+ Negative
Which of the following is the most likely diagnosis?Your Answer: Acute pyelonephritis
Explanation:Pyelonephritis is an infection of the upper urinary tract system, including the kidney and ureter. Symptoms include fever, chills, flank pain, and costovertebral angle tenderness. Elderly patients may present with confusion, delirium, or urinary retention/incontinence. Positive nitrite and leukocytes in the urine suggest a urinary infection, while glucose and ketones may indicate chronic diabetes or starvation. Cystitis, a bladder infection, presents with dysuria, urinary frequency, urgency, and suprapubic tenderness. Renal stones cause dull pain at the costovertebral angle and positive blood on urine dipstick, but negative leukocytes and nitrites. Acute appendicitis in an elderly patient may be difficult to diagnose, but costovertebral angle tenderness and a positive urine dipstick suggest pyelonephritis. Prolapsed intervertebral disc causes chronic back pain and leg symptoms, but does not typically cause fever or delirium, and the tenderness is specific to pyelonephritis.
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This question is part of the following fields:
- Renal
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Question 12
Incorrect
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A 63-year-old man presented with fever, body ache and pedal oedema for three months. He was taking oral diclofenac frequently for the aches. He had no other drug history and had not travelled recently.
On examination, there was sternal tenderness. His blood report revealed:
Investigation Result Normal range
Haemoglobin 76 g/l 135–175 g/l
White cell count (WCC) 9 × 109/l 4–11 × 109/l
Erythrocyte sedimentation rate (ESR) 134 mm/hr 0–10mm in the 1st hour
Platelets 280 × 109/l 150–400 × 109/l
Urea 13 mmol/l 2.5–6.0 mmol/l
Calcium 2.8 mmol/l 2.2–2.6 mmol/l
What is the most likely cause of renal failure in this case?Your Answer: Hyperuricaemia
Correct Answer: Light chain deposition
Explanation:Understanding the Causes of Renal Failure in Multiple Myeloma
Multiple myeloma is a rare but possible diagnosis in young adults, with a higher incidence in black populations and men. Renal failure is a common complication of this disease, with various possible causes. While NSAID use, hypercalcaemia, hyperuricaemia, and infiltration of the kidney by myeloma cells are all potential factors, the most common cause of renal failure in multiple myeloma is light chain deposition. This can lead to tubular toxicity and subsequent renal damage. Therefore, understanding the underlying causes of renal failure in multiple myeloma is crucial for effective management and treatment of this disease.
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This question is part of the following fields:
- Renal
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Question 13
Incorrect
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A 28-year-old man presents with sudden onset severe pain in his right loin. The pain began 3 hours ago just below the right side of his rib cage and has gradually moved down to his right groin, radiating into his right testis. He denies any visible haematuria. He is unable to tolerate physical examination and is writhing around on his bed.
What is the most appropriate initial management?Your Answer: Morphine po
Correct Answer: Diclofenac im
Explanation:The recommended pain relief for renal or ureteric colic is an im injection of diclofenac (75 mg), according to current NICE guidelines. If pain is severe, morphine can be used, but pethidine should be avoided due to its increased risk of vomiting. While paracetamol is appropriate for mild pain according to the WHO pain ladder, diclofenac has more evidence for relieving renal colic pains. Morphine is the top step on the WHO pain ladder, but its administration has several complications, including nausea and vomiting, constipation, confusion, and addiction. Diazepam could be the next step on the WHO pain ladder as a weak opioid, but morphine would be the next option if diclofenac failed to control pain.
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This question is part of the following fields:
- Renal
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Question 14
Incorrect
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A 76-year-old woman is admitted to the hospital feeling generally unwell. She has also developed a fever and diffuse erythematous rash over the last few days. Urinalysis is positive for blood and protein, and blood tests show raised eosinophils and creatinine. Her General Practitioner started her on a new medication two weeks ago, but she cannot remember the name or what it was for.
Which of the following drugs would be safe to continue at present, given the suspected diagnosis?Your Answer: Allopurinol
Correct Answer: Prednisolone
Explanation:Drug-Induced Acute Tubulointerstitial Nephritis: Common Culprits and Management Options
Acute tubulointerstitial nephritis is a condition characterized by fever, rash, and abnormalities on urinalysis. It can be caused by various drugs, including non-steroidal anti-inflammatory drugs (NSAIDs), beta-lactam antibiotics, allopurinol, and proton pump inhibitors (PPIs). In this case, the patient’s raised eosinophil count suggests drug-induced acute tubulointerstitial nephritis.
Prednisolone, a steroid commonly used to manage this condition, is safe to continue. However, NSAIDs like diclofenac should be stopped as they can inhibit prostaglandins that maintain the glomerular filtration rate. Allopurinol may also need to be withdrawn to determine if it is contributing to the symptoms. Beta-lactam antibiotics like amoxicillin are another common cause and may need to be stopped. PPIs like omeprazole are a relatively rare but known trigger and should be withdrawn promptly. It is important to remember that steroids should not be suddenly stopped in most patients.
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This question is part of the following fields:
- Renal
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Question 15
Correct
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A 56-year-old teacher presents to the Emergency Department with nausea and vomiting, with associated lethargy. She has mild asthma which is well controlled with a steroid inhaler but has no other medical history of note. She does not smoke but drinks up to 20 units of alcohol a week, mostly on the weekends. Observations are as follows:
Temperature is 37.2 oC, blood pressure is 110/70 mmHg, heart rate is 90 bpm and regular.
On examination, the patient appears to be clinically dehydrated, but there are no other abnormalities noted.
Blood tests reveal:
Investigation Result Normal Values
Haemoglobin (Hb) 140 g/l 135–175 g/l
White cell count (WCC) 7.8 × 109/l 4–11 × 109/l
Urea 8.5 mmol/l 2.5–6.5 mmol/l
Creatinine 190 µmol/l
(bloods carried out one year
previously showed a creatinine
of 80) 50–120 µmol/l
Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
Sodium (Na+) 133 mmol/l 135–145 mmol/l
Which of the following is most suggestive of acute kidney injury rather than chronic renal failure?Your Answer: Oliguria
Explanation:Signs and Symptoms of Acute and Chronic Renal Failure
Renal failure can be acute or chronic, and it is important to differentiate between the two. Acute renal failure may present with symptoms such as acute lethargy, dehydration, shortness of breath, nausea and vomiting, oliguria, acute onset peripheral edema, confusion, seizures, and coma. On the other hand, chronic renal failure may present with symptoms such as anemia, pruritus, long-standing fatigue, weight loss, and reduced appetite. A history of underlying medical conditions such as diabetes or hypertension is also a risk factor for chronic kidney disease.
Oliguria is a clinical hallmark of renal failure and can be one of the early signs of acute renal injury. Raised parathyroid hormone levels are more commonly found in chronic renal failure, while peripheral neuropathy is likely to be present in patients with chronic renal failure due to an underlying history of diabetes. Nocturia or nocturnal polyuria is often found in patients with chronic kidney disease, while in acute injury, urine output tends to be reduced rather than increased. Small kidneys are seen in chronic renal failure, while the kidneys are more likely to be of normal size in acute injury.
Understanding the Signs and Symptoms of Acute and Chronic Renal Failure
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This question is part of the following fields:
- Renal
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Question 16
Incorrect
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A 38-year-old woman with a history of systemic lupus erythematosus and recently diagnosed with CKD stage G3a (GFR 45 ml/min/1.73 m2) is seen by her GP. The GP notes that the patient has a BP of 152/90 mmHg, which is persistently elevated on two further readings taken on separate occasions by the practice nurse. The patient has no past history of hypertension. What is the most appropriate management for the patient's hypertension?
Your Answer: Lisinopril and losartan
Correct Answer: Lisinopril
Explanation:Management of Hypertension in Chronic Kidney Disease
Chronic kidney disease (CKD) requires careful management of hypertension to slow the progression of renal disease. The recommended first-line treatment for hypertension in CKD is angiotensin-converting enzyme inhibitors (ACEis), which should maintain systolic BP < 140 mmHg and diastolic BP < 90 mmHg. Before starting ACEi treatment, serum potassium concentrations and estimated glomerular filtration rate (GFR) should be measured and monitored regularly. While ACEis and angiotensin receptor antagonists (ARBs) may be used as first-line treatments, they should not be used concurrently due to the risk of hyperkalaemia and hypotension. Potassium-sparing diuretics, such as amiloride, should also be avoided in renal impairment due to the risk of hyperkalaemia. In addition to medication, dietary modification and exercise advice can also help manage hypertension in CKD patients. If hypertension is not controlled with an ACEi or ARB alone, thiazide diuretics like bendroflumethiazide may be added as second-line therapy. Overall, careful management of hypertension is crucial in CKD patients to slow the progression of renal disease and improve outcomes.
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This question is part of the following fields:
- Renal
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Question 17
Correct
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A 27-year-old woman presents to you with bilateral palpable flank masses and headaches. Her blood pressure is 170/100 mmHg and creatinine is 176.8 μmol/l. She has no past medical history of this, but her family history is significant for renal disease requiring transplant in her mother, brother and maternal grandmother.
On which chromosome would genetic analysis most likely find an abnormality?Your Answer: Chromosome 16
Explanation:This information provides a summary of genetic disorders associated with specific chromosomes and genes. For example, adult polycystic kidney disease is an autosomal dominant condition linked to mutations in the polycystin 1 (PKD1) gene on chromosome 16. This disease is characterized by the formation of multiple cysts in the kidneys, which can lead to renal failure and other symptoms such as hypertension, urinary tract infections, and liver and pancreatic cysts. Other important chromosome/disease pairs include BRCA2 on chromosome 13, which is associated with breast/ovarian/prostate cancers and Fanconi anemia, and the VHL gene on chromosome 3, which is linked to von Hippel-Lindau syndrome, a condition characterized by benign and malignant tumor formation on various organs of the body. Additionally, mutations in the FXN gene on chromosome 9 can result in Friedreich’s ataxia, a degenerative condition involving the nervous system and the heart, while a deletion of 22q11 on chromosome 22 can cause di George syndrome, a condition present at birth associated with cognitive impairment, facial abnormalities, and cardiac defects.
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This question is part of the following fields:
- Renal
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Question 18
Incorrect
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A 72-year-old man comes to the Emergency Department with haematuria and haemoptysis. His vital signs are heart rate 88 bpm, blood pressure 170/110 mmHg, respiratory rate 22 breaths per minute, and temperature 37.8 °C. Urinalysis shows protein and red cell casts. Serum testing reveals antibodies to the glomerular basement membrane. A renal biopsy is conducted.
What is the probable finding in the renal biopsy?Your Answer: Immune complex deposition in the basement membrane
Correct Answer: Linear immunofluorescence
Explanation:Different Renal Pathologies and their Histological Features
Nephritic syndrome is a condition characterized by proteinuria, haematuria, and hypertension. Anti-glomerular basement membrane antibodies suggest hypersensitivity angiitis (Goodpasture’s syndrome) as the underlying cause. In hypersensitivity angiitis, crescents are seen on light microscopy of a renal biopsy specimen. Immunofluorescence shows linear IgG deposits along the basement membrane.
Diffuse membranous glomerulonephritis is characterized by ‘wire looping’ of capillaries. Hereditary nephritis (Alport syndrome) shows splitting of the basement membrane and is associated with deafness. Acute post-streptococcal glomerulonephritis, typically seen in children, shows a ‘lumpy bumpy’ appearance of the glomeruli. Immunoglobulin A (IgA) nephropathy is characterized by immune complex deposition in the basement membrane.
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This question is part of the following fields:
- Renal
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Question 19
Incorrect
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A 32-year-old computer programmer presented with blood in the urine. It was painless and not associated with any obstructive feature. On examination, his blood pressure was found to be 166/90 mmHg, although his earlier medical check-up 1 year ago was normal. His only past history was nephrotic syndrome 6 years ago, which was diagnosed histologically as minimal change disease and treated successfully. Urine examination revealed blood only with a trace of protein. He is not currently taking any drugs.
What is the probable diagnosis?Your Answer: None of the above
Correct Answer: Renal arteriovenous (AV) fistula
Explanation:Possible Causes of Hypertension and Haematuria in a Patient with a History of Nephrotic Syndrome
Renal arteriovenous (AV) fistula is a possible cause of hypertension and haematuria in a patient with a history of nephrotic syndrome. This condition may develop after renal biopsy or trauma, which are risk factors for the formation of renal AVMs. Acquired causes account for 70-80% of renal AVMs, and up to 15% of patients who undergo renal biopsy may develop renal fistulae. However, most patients remain asymptomatic. Hypertension in renal AVM is caused by relative renal hypoperfusion distal to the malformation, which activates the renin-angiotensin system. Pre-existing kidney disease is a risk factor for the development of AVM after biopsy. Renal AVMs may produce bruits in the flanks and vermiform blood clots in the urine. Sudden pain in a patient with renal AVM may be due to intrarenal haemorrhage or blood clot obstruction of the ureters. Renal vein thrombosis is unlikely in a patient in remission from nephrotic syndrome. Renal stones are not a likely cause of painless haematuria in this patient. Bladder carcinoma is not a likely cause of hypertension in a young patient without relevant environmental risk factors. Therefore, an AV fistula formation after biopsy is the most likely diagnosis.
Possible Causes of Hypertension and Haematuria in a Patient with a History of Nephrotic Syndrome
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This question is part of the following fields:
- Renal
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Question 20
Incorrect
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A 12-year-old male patient is referred to the renal physicians after several episodes of frank haematuria. He does not recall any abdominal or loin pain. He had an upper respiratory tract infection a few days ago. Urine dipstick shows blood, and blood tests are normal.
What is the most likely diagnosis?Your Answer: Post-streptococcal glomerulonephritis
Correct Answer: IgA nephropathy
Explanation:Differentiating Glomerulonephritis and Other Possible Causes of Haematuria in a Young Patient
Haematuria in a young patient can be caused by various conditions, including glomerulonephritis, post-streptococcal glomerulonephritis, minimal change disease, sexually transmitted infections, and bladder cancer. IgA nephropathy, also known as Berger’s Disease, is the most common glomerulonephritis in the developed world and commonly affects young men. It presents with macroscopic haematuria a few days after a viral upper respiratory tract infection. A renal biopsy will show IgA deposits in the mesangium, and treatment is with steroids or cyclophosphamide if renal function is deteriorating.
Post-streptococcal glomerulonephritis, on the other hand, presents in young children usually one to two weeks post-streptococcal infection with smoky urine and general malaise. Proteinuria is also expected in a glomerulonephritis. Minimal change disease is the most common cause of nephrotic syndrome in children and is associated with an upper respiratory tract infection. However, nephrotic syndrome involves proteinuria, which this patient does not have.
It is also important to exclude sexually transmitted infections, as many are asymptomatic, but signs of infection and inflammation would likely show up on urine dipstick. Bladder cancer is unlikely in such a young patient devoid of other symptoms. Therefore, a thorough evaluation and proper diagnosis are necessary to determine the underlying cause of haematuria in a young patient.
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This question is part of the following fields:
- Renal
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Question 21
Incorrect
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A 62-year-old woman with a history of type II diabetes comes in for her yearly check-up. Her most recent early morning urinary albumin : creatinine ratio (ACR) is 4 mg/mmol (normal for women: < 3.5 mg/mmol). What should be the target blood pressure for managing her diabetic nephropathy?
Your Answer: 140/80 mmHg
Correct Answer: 130/80 mmHg
Explanation:Blood Pressure Targets for Patients with Diabetes
Blood pressure targets vary depending on the type of diabetes and the presence of co-morbidities. For patients with type II diabetes and signs of end-organ damage, the target is 130/80 mmHg. Ideal blood pressure for most people is between 90/60 mmHg and 120/80 mmHg. Patients with type I diabetes without albuminuria or > 2 features of metabolic syndrome have a target of 135/85 mmHg. Type II diabetics without signs of end-organ damage have a target of 140/80 mmHg. For patients over 80 years old, the target is 150/90 mmHg. It is important for patients with diabetes to work with their healthcare provider to determine their individual blood pressure target.
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This question is part of the following fields:
- Renal
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Question 22
Correct
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A 7-year-old girl presents with haematuria, hearing loss, and poor eyesight caused by lens dislocation. After conducting additional tests, the diagnosis of Alport syndrome is made. What type of collagen is typically affected by a molecular defect in this disease?
Your Answer: Type IV
Explanation:Types and Effects of Collagen Defects on Human Health
Collagen is an essential protein that provides structural support to various tissues in the human body. Defects in different types of collagen can lead to various health conditions. Type IV collagen is crucial for the integrity of the basement membrane, and mutations in its genes can cause Alport syndrome, resulting in haematuria, hearing loss, and visual disturbances. Type III collagen defects cause Ehlers–Danlos syndrome, characterized by joint hypermobility, severe bruising, and blood vessel defects. Type I collagen defects lead to osteogenesis imperfecta, characterized by brittle bones, abnormal teeth, and weak tendons. Kniest dysplasia is caused by defects in type II collagen, leading to short stature, poor joint mobility, and eventual blindness. Kindler syndrome is characterized by the absence of epidermal anchoring fibrils due to defects in type VII collagen, resulting in skin fragility. Understanding the effects of collagen defects on human health is crucial for diagnosis and treatment of these conditions.
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This question is part of the following fields:
- Renal
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Question 23
Correct
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A 43-year-old man is suspected of having a renal calculus. He has some investigations carried out by the general practitioner to monitor the effects of his medication. The following results are obtained:
Plasma
Na+ 138 mmol/l (135–145 mmol/l)
K+ 3.1 mmol/l (3.5–5 mmol/l)
24-hour urine sample:
Ca2+ 40 mg/day (100–300 mg/day)
Given the results above, which one of the following is the patient most likely taking?Your Answer: Bendroflumethiazide
Explanation:Overview of Different Types of Diuretics and Their Effects on Electrolytes and Renal Calculi Formation
Diuretics are medications that increase urine output and are commonly used to treat conditions such as hypertension and edema. However, different types of diuretics have varying effects on electrolyte balance and renal calculi formation.
Thiazide diuretics, such as bendroflumethiazide, work in the distal tubule of the nephron and result in sodium and potassium loss in urine, with calcium resorption. This makes them useful in controlling chronic renal calculi formation. However, they can also cause hypokalemia and hypercalcemia.
Loop diuretics, such as furosemide, work in the thick ascending limb of the loop of Henle and result in sodium, potassium, and calcium loss in urine. This can increase the risk of renal calculi formation.
Carbonic anhydrase inhibitors, such as acetazolamide, work in the proximal convoluted tubule and produce alkaline urine rich in bicarbonate. Continued use can lead to metabolic acidosis and an increased risk of renal calculi formation.
Aldosterone antagonists, such as spironolactone, work in the distal part of the distal tubule and collecting tubules and inhibit aldosterone-mediated sodium absorption and potassium excretion. This can result in hyperkalemia.
Mannitol, a osmotic diuretic, may cause hyponatremia but does not usually affect plasma potassium or urinary calcium excretion.
Overall, understanding the different types of diuretics and their effects on electrolyte balance and renal calculi formation is important in selecting the appropriate medication for a patient’s specific needs.
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This question is part of the following fields:
- Renal
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Question 24
Incorrect
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A 69-year-old man, with CCF is admitted with SOB and a productive cough. Clinical findings, and a chest X-ray suggest a diagnosis of both pulmonary oedema and pneumonia. He is put on high flow oxygen and treated with furosemide, GTN spray and morphine, and started on antibiotics.
His breathlessness improves, and a repeat chest X-ray shows decreased pulmonary oedema. An ABG shows the following:
pH: 7.01 (normal 7.35–7.45)
p(CO2): 8 kPa (normal 4.5–6.0 kPa)
p(O2): 11 kPa (normal 10–14 kPa)
HCO3–: 18 mmol (normal 24–30 mmol/l)
base excess: 1.2 mmol/l (normal −2 to +2.0 mmol/l)
sodium: 142 mmol/l (normal 135–145 mmol/l)
potassium: 5.9 mmol/l (normal 3.5–5.0 mmol/l)
glucose: 7.5 mmol/l (normal 5–5.5 mmol/l)
lactate: 3.1 mmol/l (normal 2.2–5 mmol/l).
Based on the patient, which of the following does he have that is an indication for acute dialysis?Your Answer: Hyperkalaemia
Correct Answer: Metabolic acidosis
Explanation:Indications for Acute Dialysis: Assessing the Patient’s Condition
When considering whether a patient requires acute dialysis, several factors must be taken into account. Severe metabolic acidosis with a pH below 7.2 is a clear indication for dialysis. Similarly, severe refractory hyperkalaemia with levels above 7 mmol/l may require dialysis, although standard measures to correct potassium levels should be attempted first. However, if the patient’s potassium levels are only mildly elevated, dialysis may not be necessary.
A raised lactate level is not an indication for acute dialysis. Refractory pulmonary oedema, which has not responded to initial treatment with diuretics, may require dialysis. However, if the patient’s pulmonary oedema has responded to treatment, dialysis may not be necessary.
In summary, the decision to initiate acute dialysis depends on a careful assessment of the patient’s condition, taking into account factors such as metabolic acidosis, hyperkalaemia, lactate levels, and pulmonary oedema.
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This question is part of the following fields:
- Renal
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Question 25
Correct
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A 35-year-old teacher is tested for compatibility to donate a kidney to his older brother, who has end-stage renal failure. To his joy, he is found to be a suitable match. The patient is then thoroughly counselled regarding the operative procedure, short- and long-term risks, and the implications of living with one healthy kidney. He is particularly interested to learn how his body will adapt to having only one kidney.
What will be decreased in the donor after the kidney transplant?Your Answer: Creatinine clearance
Explanation:Effects of Kidney Donation on Renal Function and Electrolytes
Kidney donation involves the removal of one healthy kidney, which can have various effects on the donor’s renal function and electrolyte levels. One notable change is a decrease in creatinine clearance due to the reduced number of glomeruli. However, creatinine production remains unaffected by the surgery and depends on factors such as muscle mass, diet, and activity.
Serum sodium levels should remain stable as long as the remaining kidney functions properly. Similarly, serum potassium levels should not change if the remaining kidney is healthy. However, plasma creatinine concentration may initially increase after kidney donation due to hyperfiltration, but it will eventually plateau and decrease over time.
Overall, kidney donation can have significant effects on the donor’s renal function and electrolyte levels, but with proper monitoring and care, most donors can lead healthy and normal lives with one kidney.
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This question is part of the following fields:
- Renal
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Question 26
Correct
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A 6-year-old boy presents to the Emergency Department with periorbital pain, ascites, and oedema. He has no past medical history and is typically healthy, without recent illnesses. Upon examination, his serum urea is elevated and protein in his urine is ++++. What is the probable cause of his symptoms?
Your Answer: Minimal change glomerulonephritis
Explanation:Overview of Different Types of Glomerulonephritis
Glomerulonephritis is a group of kidney diseases that affect the glomeruli, the tiny blood vessels in the kidneys that filter waste and excess fluids from the blood. Here are some of the different types of glomerulonephritis:
1. Minimal Change Glomerulonephritis: This is the most common cause of nephrotic syndrome in children. It is caused by T-cell-mediated injury to the podocytes of the epithelial cells. The diagnosis is made by electron microscopy, and treatment is with steroids.
2. Membranous Glomerulonephritis: This is the second most common cause of nephrotic syndrome in adults. It can be primary or secondary, and some causes of secondary membranous glomerulonephritis include autoimmune conditions, malignancy, viral infections, and drugs. On light microscopy, the basement membrane has characteristic spikes.
3. Mesangiocapillary Glomerulonephritis: This is associated with immune deposition in the glomerulus, thickening of the basement membrane, and activation of complement pathways leading to glomerular damage. It presents with nephrotic syndrome and is seen in both the pediatric and adult population. It is the most common glomerulonephritis associated with hepatitis C.
4. Post-Streptococcal Glomerulonephritis: This presents with haematuria, oedema, hypertension, fever, or acute kidney failure following an upper respiratory tract infection or pharyngitis from Streptococcus spp.
5. IgA Nephropathy Glomerulonephritis: This is a condition associated with IgA deposition within the glomerulus, presenting with haematuria following an upper respiratory tract infection. It is the most common cause of glomerulonephritis in adults.
Understanding the Different Types of Glomerulonephritis
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This question is part of the following fields:
- Renal
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Question 27
Incorrect
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A 55-year-old man with chronic kidney disease has recently received a renal transplant. After three months he starts to feel unwell with flu-like symptoms, fever, and pain over the transplant area.
What is the most likely type of reaction that has occurred in the patient?Your Answer: Chronic graft failure
Correct Answer: Acute graft failure
Explanation:Understanding Different Types of Graft Failure After Transplantation
Acute graft failure is a type of graft failure that occurs within six months after transplantation. If a patient presents with symptoms such as fever, flu-like symptoms, and pain over the transplant after three months, it may indicate acute graft failure. This type of failure is usually caused by mismatched human leukocyte antigen and may be reversible with steroids and immunosuppressants.
Wound infection is not a likely cause of symptoms after three months since any wounds from the transplant would have healed by then. Chronic graft failure, on the other hand, occurs after six months to a year following the transplant and is caused by a combination of B- and T-cell-mediated immunity, infection, and previous occurrences of acute graft rejections.
Hyperacute rejection is a rare type of graft failure that occurs within minutes to hours after transplantation. It happens because of pre-existing antibodies towards the donor before transplantation. In cases of hyperacute rejection, removal of the organ and re-transplantation is necessary.
It is important to understand the different types of graft failure after transplantation to properly diagnose and treat patients who may be experiencing symptoms.
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This question is part of the following fields:
- Renal
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Question 28
Correct
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A 49-year-old man presents to the doctor with a week history of frank haematuria. He has no other symptoms to note and is otherwise well although he has been a little tired. He has a history of hypertension which is well controlled on with perindopril. He smokes 10 cigarettes a day and has done so since his teens.
Examination of the abdomen reveals no abnormalities. A dipstick test of the urine reveals blood +++.
The patient is especially concerned that he may have a kidney tumour, as his father died from the condition over 20 years ago.
Which of the following malignancies of the kidney the most common in the adult population ?Your Answer: Renal cell carcinoma
Explanation:Types of Kidney Tumors: An Overview
Kidney tumors are abnormal growths that can develop in different parts of the kidney. The most common type of kidney cancer in adults is renal cell carcinoma, which accounts for about 80% of all renal malignancies. Risk factors for this condition include obesity, hypertension, smoking, and certain genetic conditions. Family history of renal cell carcinoma also increases the risk of developing the disease. Symptoms may include blood in the urine, flank pain, abdominal mass, fatigue, and weight loss. Treatment options depend on the stage of the tumor and may include surgery, immunotherapy, chemotherapy, and radiotherapy.
Other types of kidney tumors are much rarer. Primary renal lymphoma, for instance, is a very uncommon cancer that affects less than 1% of patients. Transitional cell carcinoma, also known as urothelial carcinoma, accounts for about 15% of all adult renal tumors and often starts in the renal pelvis. Renal sarcoma is a rare tumor that makes up less than 2% of all renal tumors in adults. Finally, nephroblastoma, or Wilms tumor, is the most common type of kidney cancer in children but is very rare in adults.
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This question is part of the following fields:
- Renal
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Question 29
Incorrect
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A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever, left mid-back pain and occasional chills. He has no dysuria or haematuria. The left renal angle is tender. The white cell count is 27.8 × 109/l, with 92% of neutrophils (54–62%). What is the most appropriate diagnostic tool to confirm the suspected diagnosis?
Your Answer: Urine culture
Correct Answer: Blood culture
Explanation:Diagnosing and Treating Infection in Kidney Cysts: Medical Tests and Procedures
Infection in kidney cysts is a common complication in patients with polycystic kidney disease (PKD). However, diagnosing and treating this condition can be challenging. Here are some medical tests and procedures that are commonly used to diagnose and treat infection in kidney cysts.
Blood Culture
Blood cultures are more reliable than urine cultures in detecting infection in kidney cysts. Gram-negative bacteria are the most common cause of infection in these cases. Antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. Treatment may last for 4-6 weeks, and surgical drainage may be necessary in some cases.Computed Tomography (CT) Scan of the Abdomen
CT scans can detect internal echoes in one or more cysts, but they cannot differentiate between infection and hemorrhage. Therefore, CT scans alone cannot confirm an infection.Urine Culture
Urine cultures may be unreliable in detecting infection in kidney cysts because cysts often have no communication with the collecting system.Ultrasonography of the Kidneys
Ultrasonography can detect internal echoes within a cyst, but it cannot differentiate between infection and hemorrhage.Scintiscan of the Kidneys
Scintiscans are not used to diagnose infected cysts.In conclusion, diagnosing and treating infection in kidney cysts can be challenging. Blood cultures are the most reliable test for detecting infection, and antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. CT scans and ultrasonography can detect internal echoes in cysts, but they cannot differentiate between infection and hemorrhage.
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This question is part of the following fields:
- Renal
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Question 30
Correct
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A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently suffering from a sinus infection. Apparently he had a previous episode of haematuria some 2 years earlier which was put down by the general practitioner to a urinary tract infection. Examination of notes from a previous Casualty attendance after a football game revealed microscopic haematuria on urine testing. On examination, his blood pressure is 130/70 mmHg. Physical examination is unremarkable.
Investigations:
Investigation Result Normal value
Haemoglobin 133 g/l 135–175 g/l
White cell count (WCC) 8.2 × 109/l 4–11 × 109/l
Platelets 240 × 109/l 150–400 × 109/l
Sodium (Na+) 141 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Creatinine 110 μmol/l 50–120 µmol/l
Urine Blood ++, protein +
C3 Normal
Serum IgA Slight increase
Which of the following is the most likely diagnosis?Your Answer: IgA nephropathy
Explanation:Differential Diagnosis for Haematuria: A Case Study
Haematuria, or blood in the urine, can be a concerning symptom for patients. In this case study, a patient presents with haematuria and a recent history of respiratory tract infection. The following differential diagnoses are considered:
1. IgA nephropathy: This is the most common primary glomerulonephritis in adults and is often associated with a recent respiratory tract infection. Despite haematuria, renal function is usually preserved.
2. Post-streptococcal glomerulonephritis: This diagnosis typically presents 2-4 weeks after a respiratory or skin infection. As the patient is still experiencing respiratory symptoms, this diagnosis is less likely.
3. Lupus nephritis: This is a serious diagnosis that presents with haematuria, oedema, joint pain, and high blood pressure. As the patient does not exhibit these additional symptoms, this diagnosis is unlikely.
4. Henoch-Schönlein purpura: This diagnosis is characterized by a rash, which the patient does not exhibit, making it less likely.
5. Alport syndrome: This is a genetic condition that presents with kidney disease, hearing loss, and eye abnormalities.
In conclusion, the patient’s recent respiratory tract infection and preserved renal function suggest IgA nephropathy as the most likely diagnosis. However, further testing and evaluation may be necessary to confirm the diagnosis.
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This question is part of the following fields:
- Renal
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15
Correct
15
Incorrect
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