Archives: MRCP Part 2

MRCP2-4044

A 50-year-old man comes to the nephrology clinic for a routine follow-up after receiving a renal transplant three months ago. He has a medical history of hypertension and takes tacrolimus, prednisolone, amlodipine, ramipril, spironolactone, and doxazosin. He does not smoke or drink alcohol. On examination, there are no notable findings, and there is no tenderness over the transplanted kidney.

Blood tests taken a month ago showed a urea level of 5.2 mmol/L (2.0 – 7.0) and a creatinine level of 88 µmol/L (55 – 120). However, current blood tests reveal a urea level of 14.2 mmol/L (2.0 – 7.0) and a creatinine level of 189 µmol/L (55 – 120). Urinalysis shows protein ++, leucocytes +++, and no blood or nitrites. Glucose is also negative.

What is the probable diagnosis?

MRCP2-4045

A patient in their mid-50s presents to the MAU with worsening dyspnoea. They have a past medical history significant for chronic hepatitis B, which is regularly monitored but currently untreated. Upon further examination, there is widespread oedema with peripheral oedema extending to involve the scrotum and abdominal wall.

Urinalysis
Blood –
Protein +++
Glucose +
White cells –

Blood results:

Hb 9.8 g/dl
Platelets 540 * 109/l
WBC 10.2 * 109/l
ESR 72 mm/hr

Na+ 133 mmol/l
K+ 4.8 mmol/l
Urea 18.9 mmol/l
Creatinine 220 µmol/l
CRP 6 mg/l

Chest X-Ray Normal

What is the most likely diagnosis?

MRCP2-4046

A 35-year-old woman is referred by her primary care physician to the emergency department with sudden and severe right-sided flank pain. She has no history of cardiovascular or kidney disease. On examination, her BMI is 28 kg/m2 and pulse is 82 bpm and regular. Her jugular venous pressure is normal, heart sounds are regular, and her chest is clear. She has a mass in her right flank.
Investigations reveal the following:
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Urea 10.2 mmol/l 2.5–6.5 mmol/l
Creatinine 203 µmol/l 50–120 µmol/l
Haemoglobin (Hb) 150 g/l 135–175 g/l
White cell count (WCC) 5.1 × 109/l 4.0–11.0 × 109/l
Mean corpuscular volume (MCV) 81 fl 80–100 fl
Platelets (PLT) 243 × 109 /l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 8 mm/hour 1–20 mm/hour
Urine dipstick blood +++, protein +
What other condition is this patient most likely to be suffering from?

MRCP2-4047

A 68-year-old man is admitted electively for an inguinal hernia repair. He has a history of hypothyroidism, aortitis and hypertension. His regular medication consists of levothyroxine 75 micrograms daily, mycophenolate mofetil 1 gram twice daily, prednisolone 5mg daily maintenance, ramipril 5mg daily and amlodipine 5mg daily. He has no known allergies. His operation went well with no intra-operative complications.

The next morning his bloods show:

Sodium 139 mmol/L
Potassium 5.6 mmol/L
Urea 15.5 mmol/L
Creatinine 342 micromol/L

His pre-operative values were:

Sodium 137 mmol/L
Potassium 4.4 mmol/L
Urea 6.2 mmol/L
Creatinine 121 micromol/L

When you review the observations he has had an adequate blood pressure throughout the operation and since. He appears euvolaemic clinically with adequate urine output. He had suspended his mycophenolate therapy two weeks prior to the operation as instructed by his consultant in rheumatology. Otherwise, his medications were prescribed as above with some additional analgesia including tramadol and ibuprofen as required. You decide to suspend his nephrotoxic drugs and repeat his bloods the next morning.

As per NICE guidelines on the management of acute kidney injury (AKI), what should be the criteria for referral to nephrology in this case?

MRCP2-4048

A 20-year-old man arrives at the Emergency Department complaining of severe left flank pain that is radiating to his groin. He reports having experienced this pain before and attributes it to kidney stones. His medical records indicate that he has been admitted three times previously for ureteric calculi, with the most recent episode requiring ureteric stents and lithotripsy. He does not take any regular medications but drinks 3 liters of water per day as advised by his urologists.

During the examination, the patient appears restless and is pacing. He has a normal body temperature, a pulse rate of 93 bpm, and a blood pressure of 148/79 mmHg. His abdomen is soft, but there is tenderness over the left costovertebral angle upon percussion. A plain abdominal film reveals a semi-opaque, left proximal ureteral stone with a ‘ground glass’ appearance.

The patient’s 24-hour urine results are as follows:
– Calcium 3.1 mmol/day (2.5 – 7.5)
– Oxalate 0.28 mmol/day (0.11 – 0.46)
– Phosphate 17.4mmol/day (15 – 20)
– Urate 1.8 mmol/day (1.5 – 4.5)
– Cystine 1.9mmol/day (<0.13)
– pH 7.5

What is the most appropriate treatment for this likely diagnosis?

MRCP2-4049

A 35 year old male presents with sudden onset, sharp, right sided chest pain and a 5 month history of increasing leg swelling, weight gain and abdominal distension. He has no past medical history of note. On examination he is tachycardic at 105/min with otherwise normal observations. Cardiovascular and respiratory examinations are normal; there is shifting dullness on examination of the abdomen with no masses palpable. There is also bilateral pitting oedema to the groins. Electrocardiogram shows sinus tachycardia. Urine dip shows 3+ protein nil else. Chest X-ray is unremarkable. Blood tests show the following:

Hb 137 g/l Na+ 141 mmol/l Bilirubin 12 µmol/l
Platelets 275 * 109/l K+ 4.4 mmol/l ALP 89 u/l
WBC 9.2 * 109/l Urea 4.3 mmol/l ALT 33 u/l
Neuts 7.3 * 109/l Creatinine 86 µmol/l γGT 47 u/l
Lymphs 1.4 * 109/l Albumin 20 g/l

What is the most likely cause of his chest pain?

MRCP2-4050

A 65-year-old male Jehovah’s witness presents to the hospital with increasing fatigue and malaise over the past 4 weeks. He has been bedridden for the past day. The patient has a medical history of stage 5 chronic kidney disease, hypertension, and type 2 diabetes. Despite his kidney disease, he is still able to pass urine without renal replacement therapy, with a baseline creatinine of 260 µmol/l. Upon examination, he appears warm peripherally with conjunctival pallor. His heart sounds are normal, his chest is clear, and his abdomen is soft and non-tender. He has passed 800mls of urine in the last 24 hours. The following are his blood test results:

Hb 80 g/l
Platelets 201 * 109/l
WBC 6.7 * 109/l
Ferritin 4 ng/ml
Transferrin saturation 19%

Na+ 145 mmol/l
K+ 4.9 mmol/l
Urea 17.7 mmol/l
Creatinine 276 µmol/l

What is the most appropriate course of action?

MRCP2-4020

A 40-year-old man with type 1 diabetes has visited his doctor for his annual check-up. During the examination, his blood pressure is found to be high at 163/72 mmHg. His blood test results reveal a sodium level of 137 mmol/L (137-144), potassium level of 4.2 mmol/L (3.5-4.9), urea level of 9.5 mmol/L (2.5-7.5), and creatinine level of 125 μmol/L (60-110) with an estimated glomerular filtration rate (eGFR) of 58 ml/min/1.73m2. The doctor is concerned about the possibility of diabetic nephropathy leading to chronic kidney disease and wants to accurately measure the patient’s proteinuria. What is the most suitable test to suggest in this scenario?

MRCP2-4021

A 68-year-old woman presents with a cough and fever. She has been feeling unwell for four days with a worsening productive cough, chest pain, fever, and shortness of breath. Upon observation, she shows tachycardia, fever, and hypoxia. Her weight is 42kg. A chest x-ray reveals right middle lobe consolidation, and she is diagnosed with sepsis and a lower respiratory tract infection.

The patient is administered IV fluids, IV antibiotics, and a urinary catheter is inserted. During the post-take ward round, which is 8 hours later, it is noted that she has passed 141 ml of urine, which appears dark. Upon calculation, it is determined that she is passing urine at a rate of 0.42ml/kg/hr. Her creatinine level upon admission is 87µmol/L, and there are no previous records of creatinine levels.

What is the most appropriate way to describe her renal function?

MRCP2-4032

An 80 year-old man visited his GP complaining of swelling in his lower limbs that had developed over the past week. He also reported having frothy urine. The patient had a history of lung cancer and was about to start palliative chemotherapy. On examination, his blood pressure was 150/90 mmHg and his pulse was 88 beats per minute. Urinalysis showed 4+ protein and 1+ blood. The patient’s lab results revealed a hemoglobin level of 110 g/l, platelets of 375 * 109/l, and a WBC count of 4.9 * 109/l. His sodium level was 136 mmol/l, potassium was 4.6 mmol/l, urea was 23.0 mmol/l, creatinine was 420 µmol/l, serum albumin was 18 g/L, and his 24-hour urine protein was 4.5 g (<0.2). What is the most likely diagnosis?