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  • Question 1 - A 6-year-old girl is brought to her pediatrician by her father. Her father...

    Correct

    • A 6-year-old girl is brought to her pediatrician by her father. Her father reports that for the past 5 days, she has been experiencing swelling in her lower limbs. The girl is otherwise healthy, has not had any recent illnesses, and her blood pressure during the visit was normal. The results of her urinalysis are as follows:

      Leucocytes: Negative
      Nitrites: Negative
      Urobilinogen: Negative
      Proteins: 3+
      Blood: Negative
      Ketones: Negative
      Glucose: Negative

      What is the most probable diagnosis?

      Your Answer: Minimal change disease

      Explanation:

      The boy’s symptoms are typical of nephrotic syndrome, which is characterized by a triad of proteinuria, hypoalbuminaemia, and oedema. Oedema is usually seen in the lower limbs, and proteinuria may cause frothy urine. Minimal change disease, focal segmental glomerulosclerosis, and membranous nephropathy are examples of nephrotic syndrome. Minimal change disease is a common cause of nephrotic syndrome, and it is characterized by effacement of the podocyte foot processes, which increases the permeability of the glomerular basement membrane and causes proteinuria.

      It is important to differentiate nephrotic syndrome from nephritic syndrome, which is characterized by the presence of protein and blood in the urine. Nephritic syndrome typically presents with haematuria, oliguria, and hypertension. Alport syndrome is not a correct answer as it causes nephritic syndrome, and it is a genetic condition that affects kidney function, hearing, and vision. IgA nephropathy is also an incorrect answer as it causes nephritic syndrome and is typically associated with upper respiratory tract infections. A careful history is required to distinguish it from post-streptococcal glomerulonephritis, another cause of nephritic syndrome that occurs after a streptococcal infection.

      Understanding Nephrotic Syndrome and its Presentation

      Nephrotic syndrome is a condition characterized by a triad of symptoms, namely proteinuria, hypoalbuminaemia, and oedema. Proteinuria refers to the presence of excessive protein in the urine, typically exceeding 3g in a 24-hour period. Hypoalbuminaemia is a condition where the levels of albumin in the blood fall below 30g/L. Oedema, on the other hand, is the accumulation of fluid in the body tissues, leading to swelling.

      Nephrotic syndrome is associated with the loss of antithrombin-III, proteins C and S, and an increase in fibrinogen levels, which increases the risk of thrombosis. Additionally, the loss of thyroxine-binding globulin leads to a decrease in total thyroxine levels, although free thyroxine levels remain unaffected.

      The diagram below illustrates the different types of glomerulonephritides and how they typically present. Understanding the presentation of nephrotic syndrome and its associated risks is crucial in the diagnosis and management of this condition.

      [Insert diagram here]

      Overall, nephrotic syndrome is a complex condition that requires careful management to prevent complications. By understanding its presentation and associated risks, healthcare professionals can provide appropriate treatment and support to patients with this condition.

    • This question is part of the following fields:

      • Renal System
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  • Question 2 - A 50-year-old woman comes to the GP clinic with her husband after attempting...

    Correct

    • A 50-year-old woman comes to the GP clinic with her husband after attempting a dehydration detox. She appears confused and drowsy, and reports having vomited three times in the past 12 hours without passing urine. The patient has a medical history of allergic rhinitis, anxiety, hypothyroidism, type 2 diabetes mellitus, and chronic lower back pain.

      During the examination, you observe dry mucous membranes, a pulse rate of 112/min, a respiratory rate of 24/min, a blood pressure of 97/65 mmHg, a temperature of 37.1ºC, and O2 saturation of 98%.

      Given the patient's condition, you suspect that she requires immediate hospital care and refer her to the emergency department.

      What medication should be stopped immediately for this patient?

      Your Answer: Losartan

      Explanation:

      In cases of AKI, it is recommended to discontinue the use of angiotensin II receptor antagonists such as Losartan as they can worsen renal function by reducing renal perfusion. This is because angiotensin II plays a role in constricting systemic blood vessels and the efferent arteriole of the glomerulus, which increases GFR. Blocking angiotensin II can lead to a drop in systemic blood pressure and dilation of the efferent glomerular arteriole, which can exacerbate kidney impairment.

      Cetirizine is not the most important medication to discontinue in AKI, as it is a non-sedating antihistamine and is unlikely to be a major cause of drowsiness. Diazepam may be contributing to drowsiness and is excreted in the urine, but sudden discontinuation can result in withdrawal symptoms. Levothyroxine does not need to be stopped in AKI as thyroid hormones are primarily metabolized in the liver and are not considered high risk in renal impairment.

      Acute kidney injury (AKI) is a condition where there is a reduction in renal function following an insult to the kidneys. It was previously known as acute renal failure and can result in long-term impaired kidney function or even death. AKI can be caused by prerenal, intrinsic, or postrenal factors. Patients with chronic kidney disease, other organ failure/chronic disease, a history of AKI, or who have used drugs with nephrotoxic potential are at an increased risk of developing AKI. To prevent AKI, patients at risk may be given IV fluids or have certain medications temporarily stopped.

      The kidneys are responsible for maintaining fluid balance and homeostasis, so a reduced urine output or fluid overload may indicate AKI. Symptoms may not be present in early stages, but as renal failure progresses, patients may experience arrhythmias, pulmonary and peripheral edema, or features of uraemia. Blood tests such as urea and electrolytes can be used to detect AKI, and urinalysis and imaging may also be necessary.

      Management of AKI is largely supportive, with careful fluid balance and medication review. Loop diuretics and low-dose dopamine are not recommended, but hyperkalaemia needs prompt treatment to avoid life-threatening arrhythmias. Renal replacement therapy may be necessary in severe cases. Patients with suspected AKI secondary to urinary obstruction require prompt review by a urologist, and specialist input from a nephrologist is required for cases where the cause is unknown or the AKI is severe.

    • This question is part of the following fields:

      • Renal System
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  • Question 3 - A 57-year-old male presents to the urology clinic with painless haematuria and requires...

    Correct

    • A 57-year-old male presents to the urology clinic with painless haematuria and requires an urgent assessment. He undergoes a flexible cystoscopy, during which the neck and trigone of the bladder are visualised. What structures make up the trigone of the bladder?

      Your Answer: Two ureteric orifices and the internal urethral orifice

      Explanation:

      The triangular area of the bladder is made up of muscles and is located above the urethra. It is formed by the openings of the two ureters and the internal urethral opening.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
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  • Question 4 - A 40-year-old man visits his doctor for a routine check-up and is informed...

    Incorrect

    • A 40-year-old man visits his doctor for a routine check-up and is informed that his cholesterol levels are elevated. He has a significant family history of high cholesterol and genetic testing reveals that he is heterozygous for the affected allele. If he has a child with a woman who does not carry the affected allele, what is the probability that their child will inherit the condition?

      Your Answer: 25%

      Correct Answer: 50%

      Explanation:

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

      The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

    • This question is part of the following fields:

      • Renal System
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  • Question 5 - A 75-year-old man has been admitted to the renal ward with acute kidney...

    Incorrect

    • A 75-year-old man has been admitted to the renal ward with acute kidney injury. His blood test reveals low sodium levels and high potassium levels, likely due to his current renal function. You review his medications to ensure they are not exacerbating the situation. Which medication would you contemplate discontinuing due to its link with hyperkalemia?

      Your Answer: Salbutamol

      Correct Answer: Spironolactone

      Explanation:

      Spironolactone is a diuretic that helps to retain potassium in the body, which can lead to hyperkalaemia. It is important to discontinue its use in patients with hyperkalaemia. Furthermore, it should not be used in cases of acute renal insufficiency.

      Salbutamol, on the other hand, does not cause hyperkalaemia. In fact, it can be used to reduce high levels of potassium in severe cases.

      Paracetamol, when used as directed, does not have any impact on potassium levels.

      Verapamil is a medication that blocks calcium channels and does not affect potassium levels.

      Drugs and their Effects on Potassium Levels

      Many commonly prescribed drugs have the potential to alter the levels of potassium in the bloodstream. Some drugs can decrease the amount of potassium in the blood, while others can increase it.

      Drugs that can decrease serum potassium levels include thiazide and loop diuretics, as well as acetazolamide. On the other hand, drugs that can increase serum potassium levels include ACE inhibitors, angiotensin-2 receptor blockers, spironolactone, and potassium-sparing diuretics like amiloride and triamterene. Additionally, taking potassium supplements like Sando-K or Slow-K can also increase potassium levels in the blood.

      It’s important to note that the above list does not include drugs used to temporarily decrease serum potassium levels for patients with hyperkalaemia, such as salbutamol or calcium resonium.

      Overall, it’s crucial for healthcare providers to be aware of the potential effects of medications on potassium levels and to monitor patients accordingly.

    • This question is part of the following fields:

      • Renal System
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  • Question 6 - A 35-year-old woman, gravida 3 para 1, is scheduled for a caesarian-section. During...

    Incorrect

    • A 35-year-old woman, gravida 3 para 1, is scheduled for a caesarian-section. During the procedure, it is crucial to avoid damaging certain structures, such as the bladder and its vascular supply, to prevent complications. What is the female bladder's venous drainage structure?

      Your Answer: Vescicovaginal plexus

      Correct Answer: Vesicouterine venous plexus

      Explanation:

      The vesicouterine venous plexus is responsible for draining the bladder in females, while the vesicoprostatic venous plexus serves the same function in males by connecting the prostatic venous plexus and vesical plexuses. The pampiniform plexus is responsible for draining the ovaries in females. It is important to note that the terms vesicorectal and vesicovaginal plexuses are not accurate anatomical structures, but rather refer to fistulas that may form between the bladder and nearby structures.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
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  • Question 7 - An 71-year-old man arrives at the emergency department complaining of severe back pain...

    Incorrect

    • An 71-year-old man arrives at the emergency department complaining of severe back pain that started 2 hours ago. The pain is radiating from his flank to his groin and comes and goes in waves. He had a kidney stone 2 months ago. A CT scan reveals a hyperdense calculus in his left ureter. His serum calcium level is 2.1 mmol/L (normal range: 2.2-2.6) and his urine calcium level is 9.2 mmol/24hours (normal range: 2.5-7.5). What medication is the most appropriate to reduce the risk of further renal stones?

      Your Answer: Furosemide

      Correct Answer: Bendroflumethiazide

      Explanation:

      Thiazide diuretics, specifically bendroflumethiazide, can be used to decrease calcium excretion and stone formation in patients with hypercalciuria and renal stones. The patient’s urinary calcium levels indicate hypercalciuria, which can be managed with thiazide diuretics. Bumetanide and furosemide, both loop diuretics, are not effective in managing hypercalciuria and renal stones. Denosumab, an antibody used for hypercalcaemia associated with malignancy, is not used in the management of renal stones.

      Management and Prevention of Renal Stones

      Renal stones, also known as kidney stones, can cause severe pain and discomfort. The British Association of Urological Surgeons (BAUS) has published guidelines on the management of acute ureteric/renal colic. Initial management includes the use of NSAIDs as the analgesia of choice for renal colic, with caution taken when prescribing certain NSAIDs due to increased risk of cardiovascular events. Alpha-adrenergic blockers are no longer routinely recommended, but may be beneficial for patients amenable to conservative management. Initial investigations include urine dipstick and culture, serum creatinine and electrolytes, FBC/CRP, and calcium/urate levels. Non-contrast CT KUB is now recommended as the first-line imaging for all patients, with ultrasound having a limited role.

      Most renal stones measuring less than 5 mm in maximum diameter will pass spontaneously within 4 weeks. However, more intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality, and previous renal transplant. Treatment options include lithotripsy, nephrolithotomy, ureteroscopy, and open surgery. Shockwave lithotripsy involves generating a shock wave externally to the patient, while ureteroscopy involves passing a ureteroscope retrograde through the ureter and into the renal pelvis. Percutaneous nephrolithotomy involves gaining access to the renal collecting system and performing intra corporeal lithotripsy or stone fragmentation. The preferred treatment option depends on the size and complexity of the stone.

      Prevention of renal stones involves lifestyle modifications such as high fluid intake, low animal protein and salt diet, and thiazide diuretics to increase distal tubular calcium resorption. Calcium stones may also be due to hypercalciuria, which can be managed with thiazide diuretics. Oxalate stones can be managed with cholestyramine and pyridoxine, while uric acid stones can be managed with allopurinol and urinary alkalinization with oral bicarbonate.

    • This question is part of the following fields:

      • Renal System
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  • Question 8 - A 7-year-old child presents with subepithelial humps at the glomerular basement membrane on...

    Correct

    • A 7-year-old child presents with subepithelial humps at the glomerular basement membrane on electron microscopy. The child has a history of recent upper respiratory tract infection and no significant past medical or family history. They are not taking any regular medications.

      What is the most probable diagnosis?

      Your Answer: Post-streptococcal glomerulonephritis

      Explanation:

      Post-streptococcal glomerulonephritis is a condition that typically occurs 7-14 days after an infection caused by group A beta-haemolytic Streptococcus, usually Streptococcus pyogenes. It is more common in young children and is caused by the deposition of immune complexes (IgG, IgM, and C3) in the glomeruli. Symptoms include headache, malaise, visible haematuria, proteinuria, oedema, hypertension, and oliguria. Blood tests may show a raised anti-streptolysin O titre and low C3, which confirms a recent streptococcal infection.

      It is important to note that IgA nephropathy and post-streptococcal glomerulonephritis are often confused as they both can cause renal disease following an upper respiratory tract infection. Renal biopsy features of post-streptococcal glomerulonephritis include acute, diffuse proliferative glomerulonephritis with endothelial proliferation and neutrophils. Electron microscopy may show subepithelial ‘humps’ caused by lumpy immune complex deposits, while immunofluorescence may show a granular or ‘starry sky’ appearance.

      Despite its severity, post-streptococcal glomerulonephritis carries a good prognosis.

    • This question is part of the following fields:

      • Renal System
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  • Question 9 - You have been requested to evaluate a 45-year-old Caucasian individual who has recently...

    Incorrect

    • You have been requested to evaluate a 45-year-old Caucasian individual who has recently been diagnosed with hypertension. Despite making dietary modifications and engaging in physical activity, their blood pressure remains above 160/100 mmHg, prompting you to recommend medication.

      During the consultation, the patient inquires about the drug's mechanism of action. You clarify that the medication obstructs an enzyme responsible for converting a peptide hormone into its active state.

      Based on the medication you have prescribed, which of the following alterations is expected to happen?

      Your Answer: Increased bradykinin breakdown

      Correct Answer: Reduced ADH release

      Explanation:

      The drug in question is most likely an ACE inhibitor, which is commonly prescribed as first-line therapy for hypertension in older patients of certain races. ACE inhibitors work by inhibiting the enzyme responsible for converting angiotensin I to angiotensin II, which is a key component of the renin-angiotensin-aldosterone system that regulates blood pressure. Angiotensin II has several actions that help to counteract drops in blood pressure, including vasoconstriction, increased aldosterone secretion, and increased ADH release. ACE inhibitors have the opposite effect, leading to reduced levels of ADH. However, ACE inhibitors can also cause a buildup of bradykinin, which may result in a persistent dry cough as a side effect.

      The renin-angiotensin-aldosterone system is a complex system that regulates blood pressure and fluid balance in the body. The adrenal cortex is divided into three zones, each producing different hormones. The zona glomerulosa produces mineralocorticoids, mainly aldosterone, which helps regulate sodium and potassium levels in the body. Renin is an enzyme released by the renal juxtaglomerular cells in response to reduced renal perfusion, hyponatremia, and sympathetic nerve stimulation. It hydrolyses angiotensinogen to form angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme in the lungs. Angiotensin II has various actions, including causing vasoconstriction, stimulating thirst, and increasing proximal tubule Na+/H+ activity. It also stimulates aldosterone and ADH release, which causes retention of Na+ in exchange for K+/H+ in the distal tubule.

    • This question is part of the following fields:

      • Renal System
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  • Question 10 - A 67-year-old patient is being evaluated after being admitted for treatment of a...

    Incorrect

    • A 67-year-old patient is being evaluated after being admitted for treatment of a persistent Clostridium difficile infection. The patient had received treatment for a previous infection three weeks ago, but the symptoms did not subside, and she continued to experience diarrhoea. The patient was hospitalized three days ago due to a life-threatening Clostridium difficile infection.

      The patient has been receiving oral vancomycin and IV metronidazole for the past few days, but there has been no improvement in her symptoms. What would be the venous blood gas results in this case?

      Your Answer: Metabolic alkalosis + hypokalaemia

      Correct Answer: Metabolic acidosis + hypokalaemia

      Explanation:

      If a patient experiences prolonged diarrhoea, they may develop metabolic acidosis and hypokalaemia. This is likely the case for a patient with a history of prolonged Clostridium difficile infection, as the loss of bicarbonate ions from the GI tract during diarrhoea can lead to metabolic acidosis. Prolonged diarrhoea can also result in hypokalaemia due to the direct loss of potassium from the GI tract, which the body may be unable to compensate for. Therefore, metabolic acidosis and hypokalaemia are the expected outcomes in this scenario.

      Understanding Metabolic Acidosis

      Metabolic acidosis is a condition that can be classified based on the anion gap, which is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium. The normal range for anion gap is 10-18 mmol/L. If a question provides the chloride level, it may be an indication to calculate the anion gap.

      Hyperchloraemic metabolic acidosis is a type of metabolic acidosis with a normal anion gap. It can be caused by gastrointestinal bicarbonate loss, prolonged diarrhea, ureterosigmoidostomy, fistula, renal tubular acidosis, drugs like acetazolamide, ammonium chloride injection, and Addison’s disease. On the other hand, raised anion gap metabolic acidosis is caused by lactate, ketones, urate, acid poisoning, and other factors.

      Lactic acidosis is a type of metabolic acidosis that is caused by high lactate levels. It can be further classified into two types: lactic acidosis type A, which is caused by sepsis, shock, hypoxia, and burns, and lactic acidosis type B, which is caused by metformin. Understanding the different types and causes of metabolic acidosis is important in diagnosing and treating the condition.

    • This question is part of the following fields:

      • Renal System
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  • Question 11 - Sarah, who is in her 50s, has recently undergone a kidney transplant. A...

    Incorrect

    • Sarah, who is in her 50s, has recently undergone a kidney transplant. A few hours after the surgery, she begins to feel extremely sick, experiencing a fever of 39°C and overall discomfort. She also reports pain at the site of the transplant, and the medical staff have noted a significant decrease in her urine output. The consultant suggests that this could be due to pre-existing antibodies, given the timing of the symptoms.

      What is the most probable diagnosis in Sarah's case?

      Your Answer: Post-transplant acute tubular necrosis

      Correct Answer: Hyperacute transplant rejection

      Explanation:

      Based on the symptoms and timeframe, it is likely that the patient is experiencing hyperacute transplant rejection. This type of rejection is classified as a type II hypersensitivity reaction, which occurs when pre-existing IgG or IgM antibodies attack HLA or ABO antigens. This autoimmune response causes thrombosis in the vascular supply to the transplanted organ, leading to ischemia and necrosis. Unfortunately, the only treatment option is to remove the graft.

      Acute graft failure, on the other hand, typically occurs over several months and is often caused by HLA mismatch. This condition can be treated with immunosuppressants and steroids.

      Chronic graft failure is characterized by antibody- and cell-mediated mechanisms that lead to fibrosis of the transplanted organ over time. This process usually takes more than six months to develop.

      Post-transplant acute tubular necrosis is another possible complication that can cause reduced urine output and muddy brown casts on urinalysis. However, it does not typically present with the hyperacute symptoms described above.

      Lymphocele is a common post-transplant complication that is usually asymptomatic but can cause a mass and compress the ureter if it becomes large enough. It can be drained through percutaneous or intraperitoneal methods.

      The HLA system, also known as the major histocompatibility complex (MHC), is located on chromosome 6 and is responsible for human leucocyte antigens. Class 1 antigens include A, B, and C, while class 2 antigens include DP, DQ, and DR. When matching for a renal transplant, the importance of HLA antigens is ranked as DR > B > A.

      Graft survival rates for renal transplants are high, with a 90% survival rate at one year and a 60% survival rate at ten years for cadaveric transplants. Living-donor transplants have even higher survival rates, with a 95% survival rate at one year and a 70% survival rate at ten years. However, postoperative problems can occur, such as acute tubular necrosis of the graft, vascular thrombosis, urine leakage, and urinary tract infections.

      Hyperacute rejection can occur within minutes to hours after a transplant and is caused by pre-existing antibodies against ABO or HLA antigens. This type of rejection is an example of a type II hypersensitivity reaction and leads to widespread thrombosis of graft vessels, resulting in ischemia and necrosis of the transplanted organ. Unfortunately, there is no treatment available for hyperacute rejection, and the graft must be removed.

      Acute graft failure, which occurs within six months of a transplant, is usually due to mismatched HLA and is caused by cell-mediated cytotoxic T cells. This type of failure is usually asymptomatic and is detected by a rising creatinine, pyuria, and proteinuria. Other causes of acute graft failure include cytomegalovirus infection, but it may be reversible with steroids and immunosuppressants.

      Chronic graft failure, which occurs after six months of a transplant, is caused by both antibody and cell-mediated mechanisms that lead to fibrosis of the transplanted kidney, known as chronic allograft nephropathy. The recurrence of the original renal disease, such as MCGN, IgA, or FSGS, can also cause chronic graft failure.

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      • Renal System
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  • Question 12 - A 75-year-old woman is admitted for a laparoscopic cholecystectomy. As part of her...

    Correct

    • A 75-year-old woman is admitted for a laparoscopic cholecystectomy. As part of her pre-operative evaluation, it is discovered that she is taking furosemide to manage her high blood pressure. What is the location of action for this diuretic medication?

      Your Answer: Ascending limb of the loop of Henle

      Explanation:

      Furosemide and bumetanide are diuretics that work by blocking the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle, which decreases the reabsorption of NaCl.

      Diuretic drugs are classified into three major categories based on the location where they inhibit sodium reabsorption. Loop diuretics act on the thick ascending loop of Henle, thiazide diuretics on the distal tubule and connecting segment, and potassium sparing diuretics on the aldosterone-sensitive principal cells in the cortical collecting tubule. Sodium is reabsorbed in the kidney through Na+/K+ ATPase pumps located on the basolateral membrane, which return reabsorbed sodium to the circulation and maintain low intracellular sodium levels. This ensures a constant concentration gradient.

      The physiological effects of commonly used diuretics vary based on their site of action. furosemide, a loop diuretic, inhibits the Na+/K+/2Cl- carrier in the ascending limb of the loop of Henle and can result in up to 25% of filtered sodium being excreted. Thiazide diuretics, which act on the distal tubule and connecting segment, inhibit the Na+Cl- carrier and typically result in between 3 and 5% of filtered sodium being excreted. Finally, spironolactone, a potassium sparing diuretic, inhibits the Na+/K+ ATPase pump in the cortical collecting tubule and typically results in between 1 and 2% of filtered sodium being excreted.

    • This question is part of the following fields:

      • Renal System
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  • Question 13 - At what level is the hilum of the right kidney located? ...

    Correct

    • At what level is the hilum of the right kidney located?

      Your Answer: L1

      Explanation:

      Renal Anatomy: Understanding the Structure and Relations of the Kidneys

      The kidneys are two bean-shaped organs located in a deep gutter alongside the vertebral bodies. They measure about 11cm long, 5cm wide, and 3 cm thick, with the left kidney usually positioned slightly higher than the right. The upper pole of both kidneys approximates with the 11th rib, while the lower border is usually alongside L3. The kidneys are surrounded by an outer cortex and an inner medulla, which contains pyramidal structures that terminate at the renal pelvis into the ureter. The renal sinus lies within the kidney and contains branches of the renal artery, tributaries of the renal vein, major and minor calyces, and fat.

      The anatomical relations of the kidneys vary depending on the side. The right kidney is in direct contact with the quadratus lumborum, diaphragm, psoas major, and transversus abdominis, while the left kidney is in direct contact with the quadratus lumborum, diaphragm, psoas major, transversus abdominis, stomach, pancreas, spleen, and distal part of the small intestine. Each kidney and suprarenal gland is enclosed within a common layer of investing fascia, derived from the transversalis fascia, which is divided into anterior and posterior layers (Gerotas fascia).

      At the renal hilum, the renal vein lies most anteriorly, followed by the renal artery (an end artery), and the ureter lies most posteriorly. Understanding the structure and relations of the kidneys is crucial in diagnosing and treating renal diseases and disorders.

    • This question is part of the following fields:

      • Renal System
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  • Question 14 - A 95-year-old man is discovered collapsed in his residence and is transported to...

    Correct

    • A 95-year-old man is discovered collapsed in his residence and is transported to the hospital. Upon examination, he is diagnosed with dehydration and hypotension, prompting the release of renin by the juxtaglomerular cells. What is the mechanism of action of renin?

      Your Answer: Hydrolyse angiotensinogen to form angiotensin I

      Explanation:

      Angiotensin I is formed when renin breaks down angiotensinogen, which is a process that occurs within the renin-angiotensin-aldosterone system and is facilitated by juxtaglomerular cells.

      The renin-angiotensin-aldosterone system is a complex system that regulates blood pressure and fluid balance in the body. The adrenal cortex is divided into three zones, each producing different hormones. The zona glomerulosa produces mineralocorticoids, mainly aldosterone, which helps regulate sodium and potassium levels in the body. Renin is an enzyme released by the renal juxtaglomerular cells in response to reduced renal perfusion, hyponatremia, and sympathetic nerve stimulation. It hydrolyses angiotensinogen to form angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme in the lungs. Angiotensin II has various actions, including causing vasoconstriction, stimulating thirst, and increasing proximal tubule Na+/H+ activity. It also stimulates aldosterone and ADH release, which causes retention of Na+ in exchange for K+/H+ in the distal tubule.

    • This question is part of the following fields:

      • Renal System
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  • Question 15 - A 29-year-old female patient complains of dysuria and frequent urination for the past...

    Correct

    • A 29-year-old female patient complains of dysuria and frequent urination for the past 3 days. She denies experiencing any vaginal discharge or heavy menstrual bleeding. Upon urine dipstick examination, leukocytes and nitrites are detected. A urine culture reveals the presence of a urease-producing bacteria identified as Proteus mirabilis. The patient is prescribed antibiotics for treatment.

      What type of renal stones are patients at risk for developing with chronic and recurrent infections caused by this bacteria?

      Your Answer: Ammonium magnesium phosphate (struvite)

      Explanation:

      The formation of kidney stones is a common condition that involves the accumulation of mineral deposits in the kidneys. This condition is influenced by various risk factors such as low urine volume, dry weather conditions, and acidic pH levels. It is also closely linked to hyperuricemia, which is commonly associated with gout, as well as diseases that involve high cell turnover, such as leukemia.

      Renal stones can be classified into different types based on their composition. Calcium oxalate stones are the most common, accounting for 85% of all calculi. These stones are formed due to hypercalciuria, hyperoxaluria, and hypocitraturia. They are radio-opaque and may also bind with uric acid stones. Cystine stones are rare and occur due to an inherited recessive disorder of transmembrane cystine transport. Uric acid stones are formed due to purine metabolism and may precipitate when urinary pH is low. Calcium phosphate stones are associated with renal tubular acidosis and high urinary pH. Struvite stones are formed from magnesium, ammonium, and phosphate and are associated with chronic infections. The pH of urine can help determine the type of stone present, with calcium phosphate stones forming in normal to alkaline urine, uric acid stones forming in acidic urine, and struvate stones forming in alkaline urine. Cystine stones form in normal urine pH.

    • This question is part of the following fields:

      • Renal System
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  • Question 16 - In a 70 Kg person, what percentage of the entire body fluid will...

    Incorrect

    • In a 70 Kg person, what percentage of the entire body fluid will be provided by plasma?

      Your Answer: 25%

      Correct Answer: 5%

      Explanation:

      Understanding the Physiology of Body Fluid Compartments

      Body fluid compartments are essential components of the human body, consisting of intracellular and extracellular compartments. The extracellular compartment is further divided into interstitial fluid, plasma, and transcellular fluid. In a typical 70 Kg male, the intracellular compartment comprises 60-65% of the total body fluid volume, while the extracellular compartment comprises 35-40%. The plasma volume is approximately 5%, while the interstitial fluid volume is 24%. The transcellular fluid volume is approximately 3%. These figures are only approximate and may vary depending on the individual’s weight and other factors. Understanding the physiology of body fluid compartments is crucial in maintaining proper fluid balance and overall health.

    • This question is part of the following fields:

      • Renal System
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  • Question 17 - What electrolyte imbalance is probable in a patient experiencing diarrhea and a palpable...

    Correct

    • What electrolyte imbalance is probable in a patient experiencing diarrhea and a palpable soft mass during digital rectal examination?

      Your Answer: Hypokalaemia

      Explanation:

      Rectal secretions from large villous adenomas of the rectum can cause hypokalaemia due to their high potassium content, which is a result of the marked secretory activity of the adenomas.

      Understanding Hypokalaemia and its Causes

      Hypokalaemia is a condition characterized by low levels of potassium in the blood. Potassium and hydrogen ions are competitors, and as potassium levels decrease, more hydrogen ions enter the cells. Hypokalaemia can occur with either alkalosis or acidosis. In cases of alkalosis, hypokalaemia may be caused by vomiting, thiazide and loop diuretics, Cushing’s syndrome, or Conn’s syndrome. On the other hand, hypokalaemia with acidosis may be caused by diarrhoea, renal tubular acidosis, acetazolamide, or partially treated diabetic ketoacidosis.

      It is important to note that magnesium deficiency may also cause hypokalaemia. In such cases, normalizing potassium levels may be difficult until the magnesium deficiency has been corrected. Understanding the causes of hypokalaemia can help in its diagnosis and treatment.

    • This question is part of the following fields:

      • Renal System
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  • Question 18 - You are assisting in an open right adrenalectomy for a large adrenal adenoma...

    Incorrect

    • You are assisting in an open right adrenalectomy for a large adrenal adenoma in a slightly older patient. The consultant is momentarily distracted and you take the initiative to pull the adrenal into the wound to improve visibility. Unfortunately, this maneuver results in brisk bleeding. The most likely culprit vessel responsible for this bleeding is:

      - Portal vein
      - Phrenic vein
      - Right renal vein
      - Superior mesenteric vein
      - Inferior vena cava

      The vessel in question drains directly via a very short vessel and if not carefully sutured, it may become avulsed off the IVC. The best management approach for this injury involves the use of a Satinsky clamp and a 6/0 prolene suture.

      Your Answer: Right renal vein

      Correct Answer: Inferior vena cava

      Explanation:

      The vessel drains directly and is connected by a short pathway. If the sutures are not tied with caution, it could potentially detach from the IVC. In such a scenario, the recommended approach would be to use a Satinsky clamp and a 6/0 prolene suture to manage the injury.

      Adrenal Gland Anatomy

      The adrenal glands are located superomedially to the upper pole of each kidney. The right adrenal gland is posteriorly related to the diaphragm, inferiorly related to the kidney, medially related to the vena cava, and anteriorly related to the hepato-renal pouch and bare area of the liver. On the other hand, the left adrenal gland is postero-medially related to the crus of the diaphragm, inferiorly related to the pancreas and splenic vessels, and anteriorly related to the lesser sac and stomach.

      The arterial supply of the adrenal glands is through the superior adrenal arteries from the inferior phrenic artery, middle adrenal arteries from the aorta, and inferior adrenal arteries from the renal arteries. The right adrenal gland drains via one central vein directly into the inferior vena cava, while the left adrenal gland drains via one central vein into the left renal vein.

      In summary, the adrenal glands are small but important endocrine glands located above the kidneys. They have a unique blood supply and drainage system, and their location and relationships with other organs in the body are crucial for their proper functioning.

    • This question is part of the following fields:

      • Renal System
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  • Question 19 - A 5-year-old boy presents with symptoms of right sided loin pain, lethargy and...

    Incorrect

    • A 5-year-old boy presents with symptoms of right sided loin pain, lethargy and haematuria. On examination he is pyrexial and has a large mass in the right upper quadrant. What is the most probable underlying diagnosis?

      Your Answer: Renal cortical adenoma

      Correct Answer: Nephroblastoma

      Explanation:

      Based on the symptoms presented, it is highly probable that the child has nephroblastoma, while perinephric abscess is an unlikely diagnosis. Even if an abscess were to develop, it would most likely be contained within Gerota’s fascia initially, making anterior extension improbable.

      Nephroblastoma: A Childhood Cancer

      Nephroblastoma, also known as Wilms tumours, is a type of childhood cancer that typically occurs in the first four years of life. The most common symptom is the presence of a mass, often accompanied by haematuria (blood in urine). In some cases, pyrexia (fever) may also occur in about 50% of patients. Unfortunately, nephroblastomas tend to metastasize early, usually to the lungs.

      The primary treatment for nephroblastoma is nephrectomy, which involves the surgical removal of the affected kidney. The prognosis for younger children is generally better, with those under one year of age having an overall 5-year survival rate of 80%. It is important to seek medical attention promptly if any of the symptoms associated with nephroblastoma are present, as early detection and treatment can greatly improve the chances of a positive outcome.

    • This question is part of the following fields:

      • Renal System
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  • Question 20 - A 75-year-old male is brought to the emergency department after falling at home....

    Incorrect

    • A 75-year-old male is brought to the emergency department after falling at home. Upon admission, his blood tests reveal a sodium level of 128 mmol/l. Which medication is the most probable cause of this?

      Your Answer: Levothyroxine

      Correct Answer: Sertraline

      Explanation:

      Hyponatremia is a common side effect of SSRIs, including Sertraline, which can cause SIADH. However, medications such as Statins, Levothyroxine, and Metformin are not typically linked to hyponatremia.

      SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by various factors such as malignancy (particularly small cell lung cancer), neurological conditions like stroke or meningitis, infections like tuberculosis or pneumonia, certain drugs like sulfonylureas and SSRIs, and other factors like positive end-expiratory pressure and porphyrias. Treatment involves slowly correcting the sodium levels, restricting fluid intake, and using medications like demeclocycline or ADH receptor antagonists. It is important to correct the sodium levels slowly to avoid complications like central pontine myelinolysis.

    • This question is part of the following fields:

      • Renal System
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  • Question 21 - A 6-year-old girl is referred to the child assessment unit (CAU) for recurrent...

    Correct

    • A 6-year-old girl is referred to the child assessment unit (CAU) for recurrent urinary tract infections. The paediatric consultant on CAU orders a group of investigations to find out the underlying cause.

      What are the risk factors for UTIs in children, as the paediatrics trainee has asked the medical student?

      Your Answer: Posterior urethral valves

      Explanation:

      The risk of urinary tract infection is higher in individuals with posterior urethral valves.

      Posterior urethral valves are a frequent cause of blockage in the lower urinary tract in males. They can be detected during prenatal ultrasound screenings. Due to the high pressure required for bladder emptying during fetal development, the child may experience damage to the renal parenchyma, resulting in renal impairment in 70% of boys upon diagnosis. Treatment involves the use of a bladder catheter, and endoscopic valvotomy is the preferred definitive treatment. Cystoscopic and renal follow-up is necessary.

    • This question is part of the following fields:

      • Renal System
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  • Question 22 - A 65-year-old man is having a radical cystectomy for bladder carcinoma. Significant venous...

    Incorrect

    • A 65-year-old man is having a radical cystectomy for bladder carcinoma. Significant venous bleeding occurs during the surgery. What is the main location for venous drainage from the bladder?

      Your Answer: Internal iliac vein

      Correct Answer: Vesicoprostatic venous plexus

      Explanation:

      The urinary bladder is surrounded by a complex network of veins that drain into the internal iliac vein. During cystectomy, the vesicoprostatic plexus can be a significant source of venous bleeding.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
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  • Question 23 - A 58-year-old man has had a radical nephrectomy. Upon bisecting the kidney, the...

    Correct

    • A 58-year-old man has had a radical nephrectomy. Upon bisecting the kidney, the pathologist observes a pink fleshy tumor in the renal pelvis. What is the probable illness?

      Your Answer: Transitional cell carcinoma

      Explanation:

      Renal tumours typically have a yellow or brown hue, but TCCs stand out as they have a pink appearance. If a TCC is detected in the renal pelvis, a nephroureterectomy is necessary.

      Renal Lesions: Types, Features, and Treatments

      Renal lesions refer to abnormal growths or masses that develop in the kidneys. There are different types of renal lesions, each with its own disease-specific features and treatment options. Renal cell carcinoma is the most common renal tumor, accounting for 85% of cases. It often presents with haematuria and may cause hypertension and polycythaemia as paraneoplastic features. Treatment usually involves radical or partial nephrectomy.

      Nephroblastoma, also known as Wilms tumor, is a rare childhood tumor that accounts for 80% of all genitourinary malignancies in those under the age of 15 years. It often presents with a mass and hypertension. Diagnostic workup includes ultrasound and CT scanning, and treatment involves surgical resection combined with chemotherapy. Neuroblastoma is the most common extracranial tumor of childhood, with up to 80% occurring in those under 4 years of age. It is a tumor of neural crest origin and may be diagnosed using MIBG scanning. Treatment involves surgical resection, radiotherapy, and chemotherapy.

      Transitional cell carcinoma accounts for 90% of lower urinary tract tumors but only 10% of renal tumors. It often presents with painless haematuria and may be caused by occupational exposure to industrial dyes and rubber chemicals. Diagnosis and staging are done with CT IVU, and treatment involves radical nephroureterectomy. Angiomyolipoma is a hamartoma type lesion that occurs sporadically in 80% of cases and in those with tuberous sclerosis in the remaining cases. It is composed of blood vessels, smooth muscle, and fat and may cause massive bleeding in 10% of cases. Surgical resection is required for lesions larger than 4 cm and causing symptoms.

    • This question is part of the following fields:

      • Renal System
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  • Question 24 - Jill, who is in her mid-30s, has just completed a half marathon and...

    Correct

    • Jill, who is in her mid-30s, has just completed a half marathon and is now dehydrated. The decreased perfusion pressure in her kidneys is detected by baroreceptors, leading to the activation of the renin-angiotensin-aldosterone system (RAAS). As a result, renin cleaves angiotensinogen to angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme (ACE). What effect does angiotensin II have on the arteriole that branches off from the renal artery and carries blood away from the glomerulus? And how does this impact Jill's glomerular filtration rate (GFR)?

      Your Answer: Vasoconstriction - increases GFR

      Explanation:

      Angiotensin II causes vasoconstriction of the efferent arteriole, which increases the pressure difference between the afferent and efferent arterioles. This increase in pressure leads to an increase in filtration pressure and thus an increase in GFR. Therefore, efferent arteriole constriction increases GFR.

      Reabsorption and Secretion in Renal Function

      In renal function, reabsorption and secretion play important roles in maintaining homeostasis. The filtered load is the amount of a substance that is filtered by the glomerulus and is determined by the glomerular filtration rate (GFR) and the plasma concentration of the substance. The excretion rate is the amount of the substance that is eliminated in the urine and is determined by the urine flow rate and the urine concentration of the substance. Reabsorption occurs when the filtered load is greater than the excretion rate, and secretion occurs when the excretion rate is greater than the filtered load.

      The reabsorption rate is the difference between the filtered load and the excretion rate, and the secretion rate is the difference between the excretion rate and the filtered load. Reabsorption and secretion can occur in different parts of the nephron, including the proximal tubule, loop of Henle, distal tubule, and collecting duct. These processes are regulated by various hormones and signaling pathways, such as aldosterone, antidiuretic hormone (ADH), and atrial natriuretic peptide (ANP).

      Overall, reabsorption and secretion are important mechanisms for regulating the composition of the urine and maintaining fluid and electrolyte balance in the body. Dysfunction of these processes can lead to various renal disorders, such as diabetes insipidus, renal tubular acidosis, and Fanconi syndrome.

    • This question is part of the following fields:

      • Renal System
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  • Question 25 - A 25-year-old man presents to his GP with a complaint of blood in...

    Incorrect

    • A 25-year-old man presents to his GP with a complaint of blood in his urine. He reports that it began a day ago and is bright red in color. He denies any pain and has not observed any clots in his urine. The patient is generally healthy, but had a recent upper respiratory tract infection 2 days ago.

      Upon urine dipstick examination, +++ blood and + protein are detected. What histological finding would be expected on biopsy, given the likely diagnosis?

      Your Answer: Endothelial proliferation with neutrophils with 'starry sky' appearance on immunofluorescene

      Correct Answer: Mesangial hypercellularity with positive immunofluorescence for IgA & C3

      Explanation:

      The histological examination of IgA nephropathy reveals an increase in mesangial cells, accompanied by positive immunofluorescence for IgA and C3.

      Understanding IgA Nephropathy

      IgA nephropathy, also known as Berger’s disease, is the most common cause of glomerulonephritis worldwide. It typically presents as macroscopic haematuria in young people following an upper respiratory tract infection. The condition is thought to be caused by mesangial deposition of IgA immune complexes, and there is considerable pathological overlap with Henoch-Schonlein purpura (HSP). Histology shows mesangial hypercellularity and positive immunofluorescence for IgA and C3.

      Differentiating between IgA nephropathy and post-streptococcal glomerulonephritis is important. Post-streptococcal glomerulonephritis is associated with low complement levels and the main symptom is proteinuria, although haematuria can occur. There is typically an interval between URTI and the onset of renal problems in post-streptococcal glomerulonephritis.

      Management of IgA nephropathy depends on the severity of the condition. If there is isolated hematuria, no or minimal proteinuria, and a normal glomerular filtration rate (GFR), no treatment is needed other than follow-up to check renal function. If there is persistent proteinuria and a normal or only slightly reduced GFR, initial treatment is with ACE inhibitors. If there is active disease or failure to respond to ACE inhibitors, immunosuppression with corticosteroids may be necessary.

      The prognosis for IgA nephropathy varies. 25% of patients develop ESRF. Markers of good prognosis include frank haematuria, while markers of poor prognosis include male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, and ACE genotype DD.

      Overall, understanding IgA nephropathy is important for proper diagnosis and management of the condition. Proper management can help improve outcomes and prevent progression to ESRF.

    • This question is part of the following fields:

      • Renal System
      12
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  • Question 26 - A 72-year-old man visits his GP complaining of hesitancy, frequency, poor flow, and...

    Correct

    • A 72-year-old man visits his GP complaining of hesitancy, frequency, poor flow, and incomplete emptying for the past 8 months. During the examination, the GP discovers a hard, craggy, and enlarged prostate on one side. The GP urgently refers the patient to a urologist within 2 weeks and orders a prostate-specific antigen (PSA) test.

      Upon seeing the urologist, the patient is informed that his PSA level is 22ng/ml. The urologist repeats the digital rectal examination and requests a multiparametric MRI to confirm the diagnosis. The urologist prescribes medication to the patient, explaining that it will initially cause a flare of tumor growth before shrinking.

      What type of medication is the urologist describing that will cause this initial flare of tumor growth?

      Your Answer: Gonadotropin-releasing hormone agonists

      Explanation:

      Prostate cancer management involves inhibiting or down-regulating hormones involved in the hypothalamic-pituitary-gonadal axis at different stages to prevent tumour growth. Testosterone, converted to dihydrotestosterone (DHT) in the prostate, causes growth and proliferation of prostate cells.

      Gonadotropin-releasing hormone (GnRH) agonists like goserelin suppress both GnRH and LH production, causing downregulation of GnRH and LH after an initial stimulatory effect that can cause a flare in tumour growth. GnRH agonists outmatch the body’s natural production rhythm, leading to reduced LH and GnRH production.

      GnRH antagonists like abarelix suppress LH production by the anterior pituitary, preventing stimulation of testosterone production in the testes and reducing DHT production. This can cause the prostate to shrink instead of growing.

      Anti-androgens like bicalutamide directly block the actions of testosterone and DHT within the cells of the prostate, preventing growth. They are often prescribed alongside GnRH agonists to prevent the flare in tumour growth.

      5-a-reductase inhibitors, also known as DHT-blockers, shrink the prostate by stopping the conversion of testosterone to DHT. This prevents tumour growth and overall shrinkage of the prostate, but does not cause initial tumour growth.

      Prostate cancer management varies depending on the stage of the disease and the patient’s life expectancy and preferences. For localized prostate cancer (T1/T2), treatment options include active monitoring, watchful waiting, radical prostatectomy, and radiotherapy (external beam and brachytherapy). For localized advanced prostate cancer (T3/T4), options include hormonal therapy, radical prostatectomy, and radiotherapy. Patients may develop proctitis and are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer.

      In cases of metastatic prostate cancer, reducing androgen levels is a key aim of treatment. A combination of approaches is often used, including anti-androgen therapy, synthetic GnRH agonist or antagonists, bicalutamide, cyproterone acetate, abiraterone, and bilateral orchidectomy. GnRH agonists, such as Goserelin (Zoladex), initially cause a rise in testosterone levels before falling to castration levels. To prevent a rise in testosterone, anti-androgens are often used to cover the initial therapy. GnRH antagonists, such as degarelix, are being evaluated to suppress testosterone while avoiding the flare phenomenon. Chemotherapy with docetaxel is also an option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.

    • This question is part of the following fields:

      • Renal System
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  • Question 27 - What are the probable outcomes of the discharge of vasopressin from the pituitary...

    Incorrect

    • What are the probable outcomes of the discharge of vasopressin from the pituitary gland?

      Your Answer: Reduced permeability of the inner medullary portion of the collecting duct to urea

      Correct Answer: Increased water permeability of the distal tubule cells of the kidney

      Explanation:

      Aquaporin channels are inserted into the apical membrane of the distal tubule and collecting ducts as a result of ADH (vasopressin).

      The Loop of Henle and its Role in Renal Physiology

      The Loop of Henle is a crucial component of the renal system, located in the juxtamedullary nephrons and running deep into the medulla. Approximately 60 litres of water containing 9000 mmol sodium enters the descending limb of the loop of Henle in 24 hours. The osmolarity of fluid changes and is greatest at the tip of the papilla. The thin ascending limb is impermeable to water, but highly permeable to sodium and chloride ions. This loss means that at the beginning of the thick ascending limb the fluid is hypo osmotic compared with adjacent interstitial fluid. In the thick ascending limb, the reabsorption of sodium and chloride ions occurs by both facilitated and passive diffusion pathways. The loops of Henle are co-located with vasa recta, which have similar solute compositions to the surrounding extracellular fluid, preventing the diffusion and subsequent removal of this hypertonic fluid. The energy-dependent reabsorption of sodium and chloride in the thick ascending limb helps to maintain this osmotic gradient. Overall, the Loop of Henle plays a crucial role in regulating the concentration of solutes in the renal system.

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      • Renal System
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  • Question 28 - An 80-year-old woman is recuperating in the hospital after undergoing a right hemicolectomy....

    Correct

    • An 80-year-old woman is recuperating in the hospital after undergoing a right hemicolectomy. She has a medical history of hypertension, hypercholesterolemia, and a previous pulmonary embolism. On the fifth day following the surgery, she experiences confusion and has a NEWS2 score of 7, leading to suspicion of sepsis and initiation of the sepsis 6 protocol. The following day, she is diagnosed with AKI, with a sudden rise in serum creatinine and potassium levels.

      Which medication(s) should be discontinued due to the risk of exacerbating renal function?

      Your Answer: Gentamicin

      Explanation:

      Aminoglycosides, such as gentamicin, should be discontinued in cases of AKI as they may exacerbate renal function. Gentamicin may have been prescribed to treat suspected sepsis. Other medications that should be stopped for the same reason include NSAIDs, ACE inhibitors, angiotensin II receptor antagonists, and diuretics. Atenolol is safe to continue in AKI, but not recommended for use in asthma. Atorvastatin is also safe to continue in AKI, but not during pregnancy or breastfeeding. Paracetamol is generally safe to continue in AKI and is also safe during pregnancy and breastfeeding, unlike NSAIDs.

      Acute kidney injury (AKI) is a condition where there is a reduction in renal function following an insult to the kidneys. It was previously known as acute renal failure and can result in long-term impaired kidney function or even death. AKI can be caused by prerenal, intrinsic, or postrenal factors. Patients with chronic kidney disease, other organ failure/chronic disease, a history of AKI, or who have used drugs with nephrotoxic potential are at an increased risk of developing AKI. To prevent AKI, patients at risk may be given IV fluids or have certain medications temporarily stopped.

      The kidneys are responsible for maintaining fluid balance and homeostasis, so a reduced urine output or fluid overload may indicate AKI. Symptoms may not be present in early stages, but as renal failure progresses, patients may experience arrhythmias, pulmonary and peripheral edema, or features of uraemia. Blood tests such as urea and electrolytes can be used to detect AKI, and urinalysis and imaging may also be necessary.

      Management of AKI is largely supportive, with careful fluid balance and medication review. Loop diuretics and low-dose dopamine are not recommended, but hyperkalaemia needs prompt treatment to avoid life-threatening arrhythmias. Renal replacement therapy may be necessary in severe cases. Patients with suspected AKI secondary to urinary obstruction require prompt review by a urologist, and specialist input from a nephrologist is required for cases where the cause is unknown or the AKI is severe.

    • This question is part of the following fields:

      • Renal System
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  • Question 29 - A 59-year-old man comes to the GP complaining of lower back pain, weight...

    Correct

    • A 59-year-old man comes to the GP complaining of lower back pain, weight loss, an abdominal mass, and visible haematuria. The GP eliminates the possibility of a UTI and refers him through a 2-week wait pathway. An ultrasound reveals a tumour, and a biopsy confirms renal cell carcinoma. From which part of the kidney does his cancer originate?

      Your Answer: Proximal renal tubular epithelium

      Explanation:

      Renal cell carcinoma originates from the proximal renal tubular epithelium, while the other options, such as blood vessels, distal renal tubular epithelium, and glomerular basement membrane, are all parts of the kidney but not the site of origin for renal cell carcinoma. Transitional cell carcinoma, on the other hand, arises from the transitional cells in the lining of the renal pelvis.

      Renal cell cancer, also known as hypernephroma, is a primary renal neoplasm that accounts for 85% of cases. It originates from the proximal renal tubular epithelium and is commonly associated with smoking and conditions such as von Hippel-Lindau syndrome and tuberous sclerosis. The clear cell subtype is the most prevalent, comprising 75-85% of tumors.

      Renal cell cancer is more common in middle-aged men and may present with classical symptoms such as haematuria, loin pain, and an abdominal mass. Other features include endocrine effects, such as the secretion of erythropoietin, parathyroid hormone-related protein, renin, and ACTH. Metastases are present in 25% of cases at presentation, and paraneoplastic syndromes such as Stauffer syndrome may also occur.

      The T category criteria for renal cell cancer are based on tumor size and extent of invasion. Management options include partial or total nephrectomy, depending on the tumor size and extent of disease. Patients with a T1 tumor are typically offered a partial nephrectomy, while alpha-interferon and interleukin-2 may be used to reduce tumor size and treat metastases. Receptor tyrosine kinase inhibitors such as sorafenib and sunitinib have shown superior efficacy compared to interferon-alpha.

      In summary, renal cell cancer is a common primary renal neoplasm that is associated with various risk factors and may present with classical symptoms and endocrine effects. Management options depend on the extent of disease and may include surgery and targeted therapies.

    • This question is part of the following fields:

      • Renal System
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  • Question 30 - A 65-year-old woman visits her GP after experiencing painless frank haematuria. She reports...

    Correct

    • A 65-year-old woman visits her GP after experiencing painless frank haematuria. She reports that this happened two days ago and her urine looked like port wine. She has a smoking history of 30 pack-years and denies drinking alcohol.

      The patient is urgently referred for cystoscopy, which reveals a 2x3cm ulcerated lesion adjacent to the left ureteric orifice. The lesion is biopsied and diagnosed as transitional cell carcinoma.

      Which venous structure transmits blood from the tumour to the internal iliac veins?

      Your Answer: Vesicouterine plexus

      Explanation:

      The vesicouterine plexus is responsible for draining the bladder in females.

      Bladder Anatomy and Innervation

      The bladder is a three-sided pyramid-shaped organ located in the pelvic cavity. Its apex points towards the symphysis pubis, while the base lies anterior to the rectum or vagina. The bladder’s inferior aspect is retroperitoneal, while the superior aspect is covered by peritoneum. The trigone, the least mobile part of the bladder, contains the ureteric orifices and internal urethral orifice. The bladder’s blood supply comes from the superior and inferior vesical arteries, while venous drainage occurs through the vesicoprostatic or vesicouterine venous plexus. Lymphatic drainage occurs mainly to the external iliac and internal iliac nodes, with the obturator nodes also playing a role. The bladder is innervated by parasympathetic nerve fibers from the pelvic splanchnic nerves and sympathetic nerve fibers from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic fibers cause detrusor muscle contraction, while the sympathetic fibers innervate the trigone muscle. The external urethral sphincter is under conscious control, and voiding occurs when the rate of neuronal firing to the detrusor muscle increases.

    • This question is part of the following fields:

      • Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY

Renal System (16/30) 53%
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