A 35-year-old man with a history of chronic hepatitis C infection presents with bilateral foot drop. He contracted hepatitis C perinatally.
On examination, there is bilateral weakness of ankle dorsiflexion and a purple, painful, non-blanching rash seen in both feet and the fingers of the left hand.
His urine dipstick reveals 2+ protein, 3+ blood, and 1+ leukocytes. What is the most likely histological appearance on renal biopsy?
MRCP2-4008
A 38-year-old woman presents with rapidly worsening lower limb edema. She complains of dull left loin pain. She has a history of two previous deep vein thromboses, one which occurred after a long plane flight, and the other in her first pregnancy. Her only regular medication is the progesterone only pill.
On examination, her BP is 150/90 mmHg, her pulse is 72 and regular. You confirm that she has dull left loin pain and bilateral pitting edema affecting both legs.
Investigations show:
Haemoglobin 122 g/L (115-165)
White cell count 8.8 ×109/L (4-11)
Platelets 210 ×109/L (150-400)
Serum sodium 141 mmol/L (135-146)
Serum potassium 5.2 mmol/L (3.5-5)
Creatinine 202 µmol/L (79-118)
Renal ultrasound Bilateral normal sized kidneys
Urine Protein ++
What is the most likely diagnosis?
MRCP2-4009
A 75-year-old African American man with a history of chronic kidney disease is curious about the factors that may impact the advancement of his renal dysfunction. What modifiable risk factor is most likely to have a significant effect on the progression of his renal impairment?
MRCP2-4010
A 30-year-old woman presents to the hospital with fevers, rigors, and right-sided flank pain. Her urine dipstick is positive for nitrites and leukocytes. She works in an office and is not on any regular medications. Her vital signs are as follows: pulse 110, blood pressure 130/80 mmHg, and temperature 38.5°C. She is diagnosed with pyelonephritis and started on intravenous antibiotics. Her laboratory results show a white cell count of 20 ×109/L (4-11), C reactive protein of 150 mg/L (<2), and creatinine of 80 µmol/L (60-110). An ultrasound scan of the renal tract reveals multiple cysts in both kidneys, consistent with polycystic kidney disease. The patient has no history of urinary tract infections, renal calculi, or previous surgeries. She is concerned about the need for brain imaging to look for cerebral aneurysms, despite having no neurological symptoms or family history of stroke or aneurysms. What is the most appropriate management step?
MRCP2-4011
A 75-year-old man, who has been diagnosed with multiple myeloma, is currently being investigated for a decline in his renal function. His laboratory results from a year ago and today are as follows:
To determine if the decline in renal function is associated with a complication of his myeloma, what stain should be performed during his renal biopsy?
MRCP2-4012
A 67-year-old man with a history of chronic renal failure due to diabetes presents to the clinic with complaints of increasing bone and muscle aches. He is currently taking ramipril, amlodipine, and indapamide for blood pressure control, atorvastatin for lipid management, and insulin for blood sugar control. On examination, his blood pressure is 148/80 mmHg, pulse is 79 and regular, and BMI is 28.
Investigations reveal a haemoglobin level of 107 g/L (135-177), white cell count of 8.2 ×109/L (4-11), platelets of 202 ×109/L (150-400), serum sodium of 140 mmol/L (135-146), serum potassium of 5.0 mmol/L (3.5-5), creatinine of 192 µmol/L (79-118), and calcium of 2.18 mmol/L (2.2-2.67). His phosphate level is elevated at 1.9 mmol/L (0.7-1.5) despite following a low phosphate diet.
What would be the most appropriate next step in controlling his phosphate levels?
MRCP2-4013
A patient in their 60s with stage 5 chronic kidney disease (CKD) visits the outpatient clinic to explore the option of a renal transplant.
Which of the following is not a commonly known adverse effect of ciclosporin?
MRCP2-4014
A 54-year-old man presents with severe abdominal pain and a medical history of stage III chronic kidney disease, aspergillosis, type two diabetes mellitus, and peripheral vascular disease. The surgical team orders a contrast CT scan, but the patient is currently taking aspirin, clopidogrel, metformin, paracetamol, amphotericin B, and insulin. His capillary blood glucose level is 8.2mmol/L, and he is given IV 0.9% saline before and after contrast administration. To prevent contrast-induced acute kidney injury, his metformin is discontinued. His blood tests reveal Na+ 139 mmol/l, K+ 4.1 mmol/l, urea 5.2 mmol/l, and creatinine 145 µmol/l.
What is the most effective additional measure to prevent contrast-induced acute kidney injury in this patient?
MRCP2-4015
A 54-year-old man presents to the hospital with symptoms of dysuria and frequency. He reports experiencing two episodes of visible haematuria and occasional loin pain with radiation into his flank. The patient has a medical history of hypertension and recurrent urinary tract infections. He also mentions having multiple renal stones in the past but has never seen a urologist. His current medications include candesartan in the morning and cefalexin at night. Relevant investigations reveal a mildly radio-opaque density at the level of the right renal pelvis on abdominal x-ray, and a high urinary ammonia level with a urinary pH of 7.32. What type of renal stone is likely responsible for these findings?
MRCP2-4016
A 50-year-old male of African–Caribbean descent presented to the emergency department complaining of leg swelling, shortness of breath, and nausea that had been progressively worsening over the past 6 weeks. He had recently relocated to the UK from South Africa about 3 months ago. The patient had a history of mild peripheral vascular disease and was taking atorvastatin and clopidogrel.
Upon examination, the patient was comfortable at rest but had significant pitting edema in both lower limbs and bilateral dullness to percussion at the lung bases. His blood pressure was 181/101 mmHg.
The urine dipstick showed 2+ blood and 4+ protein. Blood test results revealed a urea level of 21 mmol/L (2.0 – 7.0), creatinine level of 256 µmol/L (55 – 120), and albumin level of 24 g/L (35 – 50). The 24-hour urine protein measurement was 8g/day.
Further blood tests were conducted, including ANA, ANCA, complement (C3 and C4), hepatitis serology, HIV screening serology, and serum protein electrophoresis, which all came back negative. A renal ultrasound was performed, which showed an increased echogenicity bilaterally but no hydronephrosis. Peak flow velocities were normal and equal bilaterally. A renal biopsy was also performed, revealing segmental areas of scarring affecting some of the glomeruli, with no hypercellularity or crescents visible.
What is the appropriate management plan for this patient, given the likely diagnosis?