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Question 1
Incorrect
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A 35-year-old man with end-stage renal failure due to polycystic kidney disease is being evaluated for a possible kidney transplant. Donor screening, which involves human leukocyte antigen (HLA) testing, has been conducted on several family members. Which HLA class is the most crucial in minimizing rejection risk for this patient?
Your Answer: DQ
Correct Answer: DR
Explanation: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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This question is part of the following fields:
- Renal System
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Question 2
Incorrect
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A 60-year-old patient visits the renal clinic after being diagnosed with stage 4 chronic kidney disease due to hypertension and diabetes. She inquires about the recommended diet for her condition.
What dietary advice should be provided to the patient?Your Answer: Low potassium, high sodium
Correct Answer: Low protein, phosphate, potassium and sodium
Explanation:For individuals with chronic kidney disease, it is recommended to follow a diet that is low in protein, phosphate, potassium, and sodium. This is because protein can produce ammonia, which is not effectively excreted by the kidneys in CKD. Phosphate can combine with calcium to form kidney stones, while sodium can raise blood pressure and further damage the kidneys. Potassium is also not efficiently eliminated by failing kidneys and can lead to irregular heartbeats.
Dietary Recommendations for Chronic Kidney Disease Patients
Chronic kidney disease patients are recommended to follow a specific diet that is low in protein, phosphate, sodium, and potassium. This dietary advice is given to reduce the strain on the kidneys, as these substances are typically excreted by the kidneys. By limiting the intake of these nutrients, patients can help slow the progression of their kidney disease and manage their symptoms more effectively. It is important for patients to work closely with their healthcare provider or a registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions. With proper guidance and adherence to this diet, patients with chronic kidney disease can improve their overall health and quality of life.
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This question is part of the following fields:
- Renal System
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Question 3
Incorrect
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A 75-year-old man is brought to the Emergency Department after he was found on the floor at home following a fall. He reports being immobile and staying on the floor overnight, but was otherwise healthy with no chest pain or dizziness. He is slightly confused and dehydrated, and complains of hip pain. However, further investigation reveals no fracture, but elevated levels of creatine kinase, creatinine, and urea. He takes simvastatin and amlodipine for hypercholesterolaemia and hypertension.
What is the most probable cause of this sudden kidney injury?Your Answer: Statin-induced myopathy
Correct Answer: Acute tubular necrosis
Explanation:The most common cause of acute kidney injury is acute tubular necrosis, which may be caused by various factors. In this case, the patient is likely to have rhabdomyolysis due to muscle damage from a fall. The release of myoglobin from damaged muscles can cause renal ischaemia, leading to acute tubular necrosis. Treatment involves addressing the cause of renal ischaemia and administering intravenous fluids to manage dehydration.
While statins can cause rhabdomyolysis, the patient’s history suggests direct muscle trauma as the cause. Malignancy is a possibility, but the absence of prior symptoms and sudden onset of symptoms after a fall make it less likely than muscle trauma.
IgA nephropathy typically presents with haematuria following an upper respiratory tract infection, but this is not relevant to the current case.
Acute tubular necrosis (ATN) is a common cause of acute kidney injury (AKI) that affects the functioning of the kidney by causing necrosis of renal tubular epithelial cells. The condition is reversible in its early stages if the cause is removed. The two main causes of ATN are ischaemia and nephrotoxins, which can be caused by shock, sepsis, aminoglycosides, myoglobin secondary to rhabdomyolysis, radiocontrast agents, and lead. The features of ATN include raised urea, creatinine, and potassium levels, as well as muddy brown casts in the urine. Histopathological features include tubular epithelium necrosis, dilatation of the tubules, and necrotic cells obstructing the tubule lumen. ATN has three phases: the oliguric phase, the polyuric phase, and the recovery phase.
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This question is part of the following fields:
- Renal System
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Question 4
Incorrect
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A newborn with clubbed feet passes away shortly after birth due to severe respiratory distress. The mother did not receive any prenatal care. Autopsy reveals pulmonary hypoplasia.
What other clinical manifestations are likely to be present?Your Answer: Oesophageal atresia and oligohydramnios
Correct Answer: Bilateral renal agenesis and oligohydramnios
Explanation:Potter sequence is a condition characterized by oligohydramnios, which can be caused by renal diseases like bilateral renal agenesis, ARPKD, and ADPKD. This condition often leads to pulmonary hypoplasia, clubbed feet, and cranial anomalies in neonates. However, oesophageal atresia, which causes polyhydramnios, is not associated with Potter sequence.
Understanding Autosomal Recessive Polycystic Kidney Disease (ARPKD)
Autosomal recessive polycystic kidney disease (ARPKD) is a rare genetic disorder that affects the kidneys and liver. Unlike the more common autosomal dominant polycystic kidney disease (ADPKD), ARPKD is caused by a defect in a gene on chromosome 6 that encodes fibrocystin, a protein essential for normal renal tubule development.
ARPKD is typically diagnosed during prenatal ultrasound or in early infancy when abdominal masses and renal failure are observed. Newborns with ARPKD may also exhibit features consistent with Potter’s syndrome due to oligohydramnios. The disease progresses rapidly, and end-stage renal failure usually develops in childhood. In addition to kidney involvement, patients with ARPKD often have liver complications such as portal and interlobular fibrosis.
Renal biopsy is a common diagnostic tool for ARPKD, which typically shows multiple cylindrical lesions at right angles to the cortical surface. Early diagnosis and management are crucial in improving outcomes for patients with ARPKD.
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This question is part of the following fields:
- Renal System
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Question 5
Incorrect
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A 56-year-old man presents to the outpatient cardiology clinic complaining of fatigue and weight gain. He has been diagnosed with type II diabetes for 14 years and has been taking metformin to control his blood sugar levels. An echocardiogram reveals a globally dilated left ventricle with a reduced ejection fraction of approximately 30%, and his NT-proBNP level is 1256 (<125 pg/mL). The healthcare provider decides to initiate empagliflozin therapy due to its cardioprotective effects in patients with heart failure with reduced ejection fraction. What is the primary mechanism of action for this new medication?
Your Answer:
Correct Answer: Proximal convoluted tubule
Explanation:Glucose reabsorption within the nephron is mainly concentrated in the proximal convoluted tubule.
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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This question is part of the following fields:
- Renal System
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Question 6
Incorrect
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A 72-year-old male patient with heart failure experiences significant physical activity limitations. He is prescribed a medication that targets the collecting duct of the kidney, but is cautioned about potential breast tissue enlargement. What electrolyte imbalance could result from this medication?
Your Answer:
Correct Answer: Hyperkalaemia
Explanation:Hyperkalaemia may be caused by Spironolactone
Spironolactone is recognized for its potential to cause breast tissue growth as a side effect. As an aldosterone receptor antagonist, it hinders the elimination of potassium, making it a potassium-sparing diuretic.
Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200 mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. In addition, spironolactone has been shown to reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor, according to the RALES study.
However, spironolactone can cause adverse effects such as hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone. It is important to monitor potassium levels in patients taking spironolactone to prevent hyperkalaemia, which can lead to serious complications such as cardiac arrhythmias. Overall, spironolactone is a useful medication for treating various conditions, but its potential adverse effects should be carefully considered and monitored.
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This question is part of the following fields:
- Renal System
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Question 7
Incorrect
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A 45-year-old female is admitted to the hospital for investigation of recently developed hypertension, myalgia, and a facial rash. She experiences a decline in kidney function and complains of muscle aches and ankle swelling during her hospital stay. A kidney biopsy and urine sample are taken, revealing a proliferative 'wire-loop' glomerular lesion on histopathological assessment. The urinalysis shows proteinuria but no presence of leukocytes or nitrites. What is the most probable diagnosis?
Your Answer:
Correct Answer: Systemic lupus erythematosus
Explanation:Lupus nephritis is characterized by proliferative ‘wire-loop’ glomerular histology, proteinuria, and systemic symptoms. This condition occurs when autoimmune processes in SLE cause inflammation and damage to the glomeruli. Symptoms may include oedema, myalgia, arthralgia, hypertension, and foamy-appearing urine due to high levels of protein. Acute tubular necrosis primarily affects the tubules and does not typically present with proteinuria. Congestive heart failure and IgA nephropathy can cause proteinuria, but they do not result in the ‘wire-loop’ glomerular lesion seen in lupus nephritis. Pyelonephritis may also cause proteinuria, but it is an infectious process and would present with additional symptoms such as nitrites, leukocytes, and blood in the urine.
Renal Complications in Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) can lead to severe renal complications, including lupus nephritis, which can result in end-stage renal disease. Regular check-ups with urinalysis are necessary to detect proteinuria in SLE patients. The WHO classification system categorizes lupus nephritis into six classes, with class IV being the most common and severe form. Renal biopsy shows characteristic findings such as endothelial and mesangial proliferation, a wire-loop appearance, and subendothelial immune complex deposits.
Management of lupus nephritis involves treating hypertension and using glucocorticoids with either mycophenolate or cyclophosphamide for initial therapy in cases of focal (class III) or diffuse (class IV) lupus nephritis. Mycophenolate is generally preferred over azathioprine for subsequent therapy to decrease the risk of developing end-stage renal disease. Early detection and proper management of renal complications in SLE patients are crucial to prevent irreversible damage to the kidneys.
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This question is part of the following fields:
- Renal System
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Question 8
Incorrect
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A 58-year-old man visits his primary care physician with complaints of painful urination and difficulty in emptying his bladder. He has a history of urinary tract infection and atrial fibrillation. During the examination, the physician notes an enlarged and tender prostate. The patient's vital signs are as follows: blood pressure 125/85 mmHg, pulse rate 96 beats per minute, temperature 38.9 ºC, and respiratory rate 24 breaths per minute. Which of the following organisms is most likely responsible for his symptoms?
Your Answer:
Correct Answer: E.coli
Explanation:The predominant cause of acute bacterial prostatitis (ABP) is E.coli, according to available data. Pneumocystis jirovecii is an opportunistic pathogen that typically causes pneumonia in immunocompromised individuals, particularly those with HIV and a CD count below 200. Treatment for this infection involves co-trimoxazole. There is no evidence of ABP being caused by tuberculosis mycobacterium in the literature.
Understanding Acute Bacterial Prostatitis
Acute bacterial prostatitis is a condition that occurs when gram-negative bacteria enter the prostate gland through the urethra. The most common pathogen that causes this condition is Escherichia coli. Risk factors for acute bacterial prostatitis include recent urinary tract infection, urogenital instrumentation, intermittent bladder catheterisation, and recent prostate biopsy.
Symptoms of acute bacterial prostatitis include pain in various areas such as the perineum, penis, rectum, or back. Obstructive voiding symptoms may also be present, along with fever and rigors. During a digital rectal examination, the prostate gland may feel tender and boggy.
To manage acute bacterial prostatitis, a 14-day course of a quinolone is currently recommended by Clinical Knowledge Summaries. It is also important to consider screening for sexually transmitted infections. Understanding the symptoms and risk factors of acute bacterial prostatitis can help individuals seek prompt medical attention and receive appropriate treatment.
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This question is part of the following fields:
- Renal System
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Question 9
Incorrect
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A 64-year-old man is seen in the endocrinology clinic for review of his type II diabetes. He is currently on metformin and gliclazide, but his HbA1c is 68 mmol/mol. To improve his glycaemic control, you plan to initiate empagliflozin as a third agent. What is the site of action of this medication to achieve its mechanism of action?
Your Answer:
Correct Answer: Proximal convoluted tubule of the nephron
Explanation:The proximal convoluted tubule of the nephron is where the majority of glucose reabsorption occurs. Empagliflozin, which inhibits the SGLT-2 receptor, prevents glucose reabsorption in this area. Insulin receptors are found throughout the body, not SGLT-2 receptors. The distal convoluted tubule regulates sodium, potassium, calcium, and pH, while the loop of Henle is involved in water resorption. Sulphonylureas act on pancreatic beta cells to increase insulin production and improve glucose metabolism.
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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This question is part of the following fields:
- Renal System
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Question 10
Incorrect
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An 80-year-old man visits his GP for a follow up appointment after starting trimethoprim for a urinary tract infection 7 days ago. He mentions that his urinary symptoms have gone but that he has been feeling generally tired and weak for the last 4 weeks (before the urinary tract infection). He asks if this could be related to the new medication he started 5 weeks ago. Upon reviewing his medical history, you see that he was started on ramipril 5 weeks ago. He also mentions that his osteoarthritic pain has been quite bad recently, which caused him to miss his most recent medication review appointment, but he has been taking more paracetamol and ibuprofen than usual. Due to the combination of medication and his vague symptoms, you decide to perform an ECG. The ECG shows tall, tented T waves, prolonged PR interval, and bradycardia. What is the underlying cause of these ECG changes?
Your Answer:
Correct Answer: Hyperkalaemia
Explanation:The patient is most likely suffering from hyperkalaemia, as evidenced by their medication history which includes an increase in potassium-raising drugs such as trimethoprim, ramipril, and ibuprofen. The ECG results also show classic signs of hyperkalaemia, including tall tented T waves, bradycardia, and a prolonged PR interval.
Hyperkalaemia is a condition where there is an excess of potassium in the blood. The levels of potassium in the plasma are regulated by various factors such as aldosterone, insulin levels, and acid-base balance. When there is metabolic acidosis, hyperkalaemia can occur as hydrogen and potassium ions compete with each other for exchange with sodium ions across cell membranes and in the distal tubule. The ECG changes that can be seen in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.
There are several causes of hyperkalaemia, including acute kidney injury, drugs such as potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes.
It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. In contrast, beta-agonists such as Salbutamol are sometimes used as emergency treatment. Additionally, both unfractionated and low-molecular weight heparin can cause hyperkalaemia by inhibiting aldosterone secretion.
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This question is part of the following fields:
- Renal System
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Question 11
Incorrect
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A 60-year-old man with chronic kidney disease secondary to diabetes is scheduled to undergo a contrast-enhanced CT scan for a suspected brain lesion. His latest eGFR is 51ml/min/1.73m2. After a multidisciplinary team discussion, it was decided that using contrast in the scan was in the patient's best interests, despite the increased risk of contrast-induced acute kidney injury. What would be the most suitable approach to minimize the risk of contrast-induced acute kidney injury in this situation?
Your Answer:
Correct Answer: Offer IV hydration before and after infusion
Explanation:To reduce the risk of contrast-induced acute kidney injury in high-risk patients, NICE guidelines recommend administering sodium chloride at a rate of 1 mL/kg/hour for 12 hours before and after the procedure. While there is some evidence supporting the use of acetylcysteine via IV infusion, it is not strong enough to be recommended in the guidelines. In at-risk patients, it is important to discuss whether the contrast is necessary. Waiting for the patient’s eGFR to improve is not a realistic option in this scenario, as the patient has chronic kidney disease. While maintaining tight glycaemic control is important for long-term kidney function, it is less relevant in this setting. Potentially nephrotoxic medications such as NSAIDs should be temporarily stopped, and ACE inhibitor therapy should be considered for cessation in patients with an eGFR less than 40ml/min/1.73m2, according to NICE guidelines.
Contrast media nephrotoxicity is characterized by a 25% increase in creatinine levels within three days of receiving intravascular contrast media. This condition typically occurs between two to five days after administration and is more likely to affect patients with pre-existing renal impairment, dehydration, cardiac failure, or those taking nephrotoxic drugs like NSAIDs. Procedures that may cause contrast-induced nephropathy include CT scans with contrast and coronary angiography or percutaneous coronary intervention (PCI). Around 5% of patients who undergo PCI experience a temporary increase in plasma creatinine levels of more than 88 µmol/L.
To prevent contrast-induced nephropathy, intravenous 0.9% sodium chloride should be administered at a rate of 1 mL/kg/hour for 12 hours before and after the procedure. Isotonic sodium bicarbonate may also be used. While N-acetylcysteine was previously used, recent evidence suggests it is not effective. Patients at high risk for contrast-induced nephropathy should have metformin withheld for at least 48 hours and until their renal function returns to normal to avoid the risk of lactic acidosis.
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This question is part of the following fields:
- Renal System
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Question 12
Incorrect
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A 47-year-old man is under the care of an ophthalmologist for open angle glaucoma. He visits his GP to express his worries about the medication prescribed after reading online information. What is the medication that the ophthalmologist has prescribed, which can function as a diuretic by acting on the proximal convoluted tubule of the kidney?
Your Answer:
Correct Answer: Acetazolamide (carbonic anhydrase inhibitor)
Explanation: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.
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This question is part of the following fields:
- Renal System
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Question 13
Incorrect
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A 50-year-old male is undergoing evaluation for persistent proteinuria. He has a medical history of relapsed multiple myeloma. A renal biopsy is performed, and the Congo red stain with light microscopy shows apple-green birefringence under polarised light.
What is the probable diagnosis?Your Answer:
Correct Answer: Amyloidosis
Explanation:Understanding Amyloidosis
Amyloidosis is a medical condition that occurs when an insoluble fibrillar protein called amyloid accumulates outside the cells. This protein is derived from various precursor proteins and contains non-fibrillary components such as amyloid-P component, apolipoprotein E, and heparan sulphate proteoglycans. The accumulation of amyloid fibrils can lead to tissue or organ dysfunction.
Amyloidosis can be classified as systemic or localized, and further characterized by the type of precursor protein involved. For instance, in myeloma, the precursor protein is immunoglobulin light chain fragments, which is abbreviated as AL (A for amyloid and L for light chain fragments).
To diagnose amyloidosis, doctors may use Congo red staining, which shows apple-green birefringence, or a serum amyloid precursor (SAP) scan. Biopsy of skin, rectal mucosa, or abdominal fat may also be necessary. Understanding amyloidosis is crucial for early detection and treatment of the condition.
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This question is part of the following fields:
- Renal System
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Question 14
Incorrect
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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:
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.
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This question is part of the following fields:
- Renal System
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Question 15
Incorrect
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A 23-year-old male presents to the emergency department with decreased level of consciousness after a night of excessive alcohol intake. He is observed to have increased urine output. There is no history of substance abuse according to his companions.
What is the probable cause of the patient's polyuria?Your Answer:
Correct Answer: antidiuretic hormone inhibition
Explanation:Alcohol bingeing can result in the suppression of ADH in the posterior pituitary gland, leading to polyuria. This occurs because alcohol inhibits ADH, which reduces the insertion of aquaporins in the collecting tubules of the nephron. As a result, water reabsorption is reduced, leading to polyuria. The other options provided are incorrect because they do not accurately describe the mechanism by which alcohol causes polyuria. Central diabetes insipidus is a disorder of ADH production in the brain, while nephrogenic diabetes insipidus is caused by kidney pathology. Osmotic diuresis occurs when solutes such as glucose and urea increase the osmotic pressure in the renal tubules, leading to water retention, but this is not the primary mechanism by which alcohol causes polyuria.
Polyuria, or excessive urination, can be caused by a variety of factors. A recent review in the BMJ categorizes these causes by their frequency of occurrence. The most common causes of polyuria include the use of diuretics, caffeine, and alcohol, as well as diabetes mellitus, lithium, and heart failure. Less common causes include hypercalcaemia and hyperthyroidism, while rare causes include chronic renal failure, primary polydipsia, and hypokalaemia. The least common cause of polyuria is diabetes insipidus, which occurs in less than 1 in 10,000 cases. It is important to note that while these frequencies may not align with exam questions, understanding the potential causes of polyuria can aid in diagnosis and treatment.
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This question is part of the following fields:
- Renal System
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Question 16
Incorrect
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A 65-year-old man is being evaluated at the liver clinic of his local hospital. The physician in charge observes that he has developed ascites due to secondary hyperaldosteronism, which is common in patients with liver cirrhosis. To counteract the elevated aldosterone levels by blocking its action in the nephron, she intends to initiate a diuretic.
Which part of the nephron is the diuretic most likely to target in this patient?Your Answer:
Correct Answer: Cortical collecting ducts
Explanation:Spironolactone is a diuretic that acts as an aldosterone antagonist on the cortical collecting ducts. It is the first-line treatment for controlling ascites in this gentleman as it blocks the secondary hyperaldosteronism underlying the condition. The main site of action for spironolactone’s diuretic effects is the cortical collecting duct.
Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200 mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. In addition, spironolactone has been shown to reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor, according to the RALES study.
However, spironolactone can cause adverse effects such as hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone. It is important to monitor potassium levels in patients taking spironolactone to prevent hyperkalaemia, which can lead to serious complications such as cardiac arrhythmias. Overall, spironolactone is a useful medication for treating various conditions, but its potential adverse effects should be carefully considered and monitored.
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This question is part of the following fields:
- Renal System
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Question 17
Incorrect
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A 38-year-old man arrives at the emergency department with sudden-onset acute left flank pain that started an hour ago. He describes the pain as colicky and radiating down to his groin. The man is also experiencing nausea and vomiting and appears restless. He has no significant medical or surgical history and has never been hospitalized before. His body mass index is 31 kg per m2. Upon examination, his heart rate is 94 beats per minute, respiratory rate is 19 breaths per minute, and blood pressure is 136/79 mmHg. Radiographic studies confirm the presence of stones in the left ureter. What is a characteristic of the most common type of kidney stones?
Your Answer:
Correct Answer: Envelope-shaped crystals
Explanation:The patient displayed symptoms consistent with urolithiasis, specifically ureterolithiasis, as imaging revealed the presence of stones in the left ureter. Kidney stones are commonly composed of calcium oxalate, but can also consist of calcium phosphate, ammonium magnesium phosphate, uric acid, or cystine, depending on urine pH and other factors.
Uric acid stones are characterized by diamond or rhomboid-shaped crystals and are often found in individuals with hyperuricemia. Calcium oxalate stones, which have envelope-shaped crystals, are the most common type and are associated with low water intake and dehydration. Cystine stones, with hexagonal-shaped crystals, are prevalent in patients with the genetic condition COLA, which impairs the reabsorption of certain amino acids in the proximal convoluted tubule. Ammonium magnesium phosphate stones, also known as struvites, have coffin-lid shaped crystals and are common in individuals with urinary tract infections caused by urease-producing organisms, such as Klebsiella, Staphylococcus saprophyticus, and Proteus mirabilis. Preventive strategies should be a focus of future management for patients diagnosed with kidney stones.
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.
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This question is part of the following fields:
- Renal System
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Question 18
Incorrect
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A 33-year-old individual presents to the emergency department in an intoxicated state after a night of drinking. Although there are no immediate medical concerns, the patient is visibly under the influence of alcohol, exhibiting unsteady gait, reduced social inhibition, and mild slurring of speech. Additionally, the patient is observed to be urinating frequently.
What is the probable mechanism behind the increased frequency of urination in this patient?Your Answer:
Correct Answer: Suppression of antidiuretic hormone (ADH) release from the posterior pituitary gland
Explanation:Polyuria, or excessive urination, can be caused by a variety of factors. A recent review in the BMJ categorizes these causes by their frequency of occurrence. The most common causes of polyuria include the use of diuretics, caffeine, and alcohol, as well as diabetes mellitus, lithium, and heart failure. Less common causes include hypercalcaemia and hyperthyroidism, while rare causes include chronic renal failure, primary polydipsia, and hypokalaemia. The least common cause of polyuria is diabetes insipidus, which occurs in less than 1 in 10,000 cases. It is important to note that while these frequencies may not align with exam questions, understanding the potential causes of polyuria can aid in diagnosis and treatment.
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This question is part of the following fields:
- Renal System
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Question 19
Incorrect
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A 50-year-old man presents to a urology clinic with persistent haematuria. He has a smoking history of 30 pack years and you suspect bladder cancer. After performing a cystoscopy and biopsy, the lesion is found to be malignant. What is the probable cell type?
Your Answer:
Correct Answer: Transitional cell carcinoma
Explanation:Bladder cancer is a common urological cancer that primarily affects males aged 50-80 years old. Smoking and exposure to hydrocarbons increase the risk of developing the disease. Chronic bladder inflammation from Schistosomiasis infection is also a common cause of squamous cell carcinomas in countries where the disease is endemic. Benign tumors of the bladder, such as inverted urothelial papilloma and nephrogenic adenoma, are rare. The most common bladder malignancies are urothelial (transitional cell) carcinoma, squamous cell carcinoma, and adenocarcinoma. Urothelial carcinomas may be solitary or multifocal, with papillary growth patterns having a better prognosis. The remaining tumors may be of higher grade and prone to local invasion, resulting in a worse prognosis.
The TNM staging system is used to describe the extent of bladder cancer. Most patients present with painless, macroscopic hematuria, and a cystoscopy and biopsies or TURBT are used to provide a histological diagnosis and information on depth of invasion. Pelvic MRI and CT scanning are used to determine locoregional spread, and PET CT may be used to investigate nodes of uncertain significance. Treatment options include TURBT, intravesical chemotherapy, surgery (radical cystectomy and ileal conduit), and radical radiotherapy. The prognosis varies depending on the stage of the cancer, with T1 having a 90% survival rate and any T, N1-N2 having a 30% survival rate.
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This question is part of the following fields:
- Renal System
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Question 20
Incorrect
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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:
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.
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This question is part of the following fields:
- Renal System
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Question 21
Incorrect
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A 70-year-old male was admitted to the hospital due to delirium observed in the nursing home. Upon diagnosis, he was found to have a lower respiratory tract infection which progressed to sepsis. During his stay in the ICU, he was discovered to have severe hyponatremia. The medical team has prescribed tolvaptan along with other medications.
What is the mechanism of action of tolvaptan?Your Answer:
Correct Answer: Vasopressin V2 receptor antagonist
Explanation:Tolvaptan is a drug that blocks the action of vasopressin at the V2 receptor, which reduces water absorption and increases aquaresis without sodium loss. Vasopressin is a hormone that regulates water balance in the body.
Autosomal dominant polycystic kidney disease (ADPKD) is a commonly inherited kidney disease that affects 1 in 1,000 Caucasians. The disease is caused by mutations in two genes, PKD1 and PKD2, which produce polycystin-1 and polycystin-2 respectively. ADPKD type 1 accounts for 85% of cases, while ADPKD type 2 accounts for 15% of cases. ADPKD type 1 is caused by a mutation in the PKD1 gene on chromosome 16, while ADPKD type 2 is caused by a mutation in the PKD2 gene on chromosome 4. ADPKD type 1 tends to present with renal failure earlier than ADPKD type 2.
To screen for ADPKD in relatives of affected individuals, an abdominal ultrasound is recommended. The diagnostic criteria for ultrasound include the presence of two cysts, either unilateral or bilateral, if the individual is under 30 years old. If the individual is between 30-59 years old, two cysts in both kidneys are required for diagnosis. If the individual is over 60 years old, four cysts in both kidneys are necessary for diagnosis.
For some patients with ADPKD, tolvaptan, a vasopressin receptor 2 antagonist, may be an option to slow the progression of cyst development and renal insufficiency. However, NICE recommends tolvaptan only for adults with ADPKD who have chronic kidney disease stage 2 or 3 at the start of treatment, evidence of rapidly progressing disease, and if the company provides it with the agreed discount in the patient access scheme.
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This question is part of the following fields:
- Renal System
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Question 22
Incorrect
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A 16-year-old girl arrives at the emergency department with a sudden worsening of her asthma symptoms. The medical team administers nebulizers containing salbutamol and ipratropium bromide, along with IV steroids. Salbutamol is known to be a β2 receptor agonist. What metabolic impact should be monitored in response to this medication?
Your Answer:
Correct Answer: Hypokalaemia
Explanation:Salbutamol reduces serum potassium levels by acting as a β2 agonist when administered through nebulisation or intravenous routes.
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.
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This question is part of the following fields:
- Renal System
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Question 23
Incorrect
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A 13-year-old boy presents to his pediatrician with complaints of red-colored urine and foamy urine for a while. His parents also noticed puffiness in his face and high blood pressure for his age and sex. The boy has been complaining of hearing difficulties in class and requested to be seated in front. The doctor suspects a genetically inherited disease that is passed down from affected mothers to fifty percent of their daughters and from fathers to all their sons. What is the underlying pathology of this patient's condition?
Your Answer:
Correct Answer: Abnormal type IV collagen causing glomerular basement membrane splitting
Explanation:The patient’s symptoms suggest a combination of nephritic and nephrotic syndrome, along with hearing problems, indicating a likely diagnosis of Alport syndrome. This X-linked dominant condition is caused by a defect in type IV collagen, which forms the basement membrane. The glomerular basement membrane in Alport syndrome is characterized by thinning and thickening with areas of splitting, resulting in a basketweave appearance on electron microscopy. The condition is inherited from affected mothers to 50% of their daughters and from fathers to all their sons.
IgA nephropathy, also known as Berger disease, is characterized by IgA-based mesangial deposits on immunofluorescence and mesangial proliferation on light microscopy. Type 1 membranoproliferative glomerulonephritis presents with symptoms of both nephritic and nephrotic syndrome and is characterized by a tram-track appearance on periodic acid-Schiff stain due to mesangium proliferating into the glomerular basement membrane. Subendothelial immunocomplex deposits are seen on immunofluorescence. Poststreptococcal glomerulonephritis is a type of nephritic syndrome that occurs after a group A streptococcal infection and is characterized by enlarged and hypercellular glomeruli on light microscopy and subepithelial immunocomplexes on electron microscopy. Diffuse proliferative glomerulonephritis, often seen in SLE patients, presents with symptoms of both nephritic and nephrotic syndrome and is characterized by wire looping of capillaries on light microscopy and subendothelial immunocomplex deposits on electron microscopy. A granular appearance is found on immunofluorescence.
Alport’s syndrome is a genetic disorder that is typically inherited in an X-linked dominant pattern. It is caused by a defect in the gene responsible for producing type IV collagen, which leads to an abnormal glomerular-basement membrane (GBM). The disease is more severe in males, with females rarely developing renal failure. Symptoms usually present in childhood and may include microscopic haematuria, progressive renal failure, bilateral sensorineural deafness, lenticonus, retinitis pigmentosa, and splitting of the lamina densa seen on electron microscopy. In some cases, an Alport’s patient with a failing renal transplant may have anti-GBM antibodies, leading to a Goodpasture’s syndrome-like picture. Diagnosis can be made through molecular genetic testing, renal biopsy, or electron microscopy. In around 85% of cases, the syndrome is inherited in an X-linked dominant pattern, while 10-15% of cases are inherited in an autosomal recessive fashion, with rare autosomal dominant variants existing.
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This question is part of the following fields:
- Renal System
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Question 24
Incorrect
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A 50-year-old woman presents to her GP with a complaint of generalised puffiness. She has been feeling lethargic and noticed swelling in her hands, feet, and face over the past few weeks. Additionally, she has been experiencing shortness of breath on exertion and cannot lie flat, frequently waking up at night gasping for air. She also reports tingling and loss of sensation in both feet, which has now extended to her knees. She has no regular medications and is otherwise healthy.
Upon examination, the patient has decreased sensation over the distal lower limbs and hepatomegaly. Urine dipstick reveals protein +++ and urinalysis reveals hyperalbuminuria. Serology shows hypoalbuminaemia and hyperlipidaemia. An outpatient echocardiogram reveals both systolic and diagnostic heart failure, with a restrictive filling pattern. The Mantoux skin test was negative.
What is the probable mechanism behind this patient's condition?Your Answer:
Correct Answer: Deposition of light chain fragments
Explanation:The deposition of light chain fragments in various tissues is the most common cause of amyloidosis (AL), which can present with symptoms such as nephrotic syndrome, heart failure, and peripheral neuropathy.
Symptoms in the upper respiratory tract and kidneys are typically seen in granulomatosis with polyangiitis (GPA), which is caused by anti-neutrophil cytoplasmic antibody-induced inflammation. Therefore, this answer is not applicable.
Tuberculosis is caused by Mycobacterium, but the absence of pulmonary features and negative Mantoux skin test make it unlikely in this case. Therefore, this answer is not applicable.
Amyloidosis is a condition that can occur in different forms. The most common type is AL amyloidosis, which is caused by the accumulation of immunoglobulin light chain fragments. This can be due to underlying conditions such as myeloma, Waldenstrom’s, or MGUS. Symptoms of AL amyloidosis can include nephrotic syndrome, cardiac and neurological issues, macroglossia, and periorbital eccymoses.
Another type of amyloidosis is AA amyloid, which is caused by the buildup of serum amyloid A protein, an acute phase reactant. This form of amyloidosis is often seen in patients with chronic infections or inflammation, such as TB, bronchiectasis, or rheumatoid arthritis. The most common symptom of AA amyloidosis is renal involvement.
Beta-2 microglobulin amyloidosis is another form of the condition, which is caused by the accumulation of beta-2 microglobulin, a protein found in the major histocompatibility complex. This type of amyloidosis is often seen in patients who are on renal dialysis.
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This question is part of the following fields:
- Renal System
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Question 25
Incorrect
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A 25-year-old patient arrives at the emergency department with a head injury after a night of heavy drinking. All his vital signs are normal, and his pupils react to light equally. A CT scan of his head shows no abnormalities. He reports feeling thirsty and experiencing excessive urination.
What is causing his polyuria?Your Answer:
Correct Answer: Inhibition of posterior pituitary gland
Explanation:Excessive alcohol consumption can result in the suppression of ADH in the posterior pituitary gland, which can lead to polyuria.
Normally, dehydration causes an increase in plasma osmolality, which triggers the release of vasopressin (antidiuretic hormone) from the posterior pituitary gland. This hormone increases the insertion of aquaporin 2 channels in the distal convoluted tubules and collecting duct in the kidney, which in turn increases water reabsorption. This leads to a decrease in plasma osmolality and a reduction in the volume of urine produced, i.e., antidiuretic.
However, alcohol inhibits this mechanism, resulting in polyuria and dehydration. Polyuria can then cause thirst, i.e., polydipsia.
It is important to note that the sugars in alcohol do not typically cause osmotic diuresis unless there is an underlying condition such as diabetes and hyperglycemia.
Polyuria, or excessive urination, can be caused by a variety of factors. A recent review in the BMJ categorizes these causes by their frequency of occurrence. The most common causes of polyuria include the use of diuretics, caffeine, and alcohol, as well as diabetes mellitus, lithium, and heart failure. Less common causes include hypercalcaemia and hyperthyroidism, while rare causes include chronic renal failure, primary polydipsia, and hypokalaemia. The least common cause of polyuria is diabetes insipidus, which occurs in less than 1 in 10,000 cases. It is important to note that while these frequencies may not align with exam questions, understanding the potential causes of polyuria can aid in diagnosis and treatment.
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This question is part of the following fields:
- Renal System
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Question 26
Incorrect
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A 57-year-old man with a history of chronic myeloid leukaemia for which he has started receiving chemotherapy presents with left flank pain and oliguria. He has tenderness over his left renal angle. A working diagnosis of kidney stones is made. Both abdominal X-ray and CT scan are unremarkable and no stone is visible.
What is the most likely composition of his kidney stone?Your Answer:
Correct Answer: Uric acid
Explanation:Stones formed in the urinary tract due to infections with urease-positive bacteria, such as Proteus mirabilis, are known as struvite stones. These stones are caused by the hydrolysis of urea to ammonia, which alkalizes the urine. Struvite stones often take the shape of staghorn calculi and can be detected through radiography as they are radio-opaque.
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.
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This question is part of the following fields:
- Renal System
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Question 27
Incorrect
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A 56-year-old man with a history of alcohol excess and type 2 diabetes presents to the emergency department in an intoxicated state. He takes metformin and his recent HbA1c was 44 mmol/mol. On arrival, his blood sugar is 5.1 mmol/L and he frequently needs to urinate. The examination is unremarkable except for his intoxicated state. His blood test shows a creatinine level of 66 µmol/L (55 - 120). What is causing the patient's polyuria?
Your Answer:
Correct Answer: ADH suppression in the posterior pituitary gland
Explanation:Alcohol bingeing can result in the suppression of ADH in the posterior pituitary gland, leading to polyuria.
Polyuria, or excessive urination, can be caused by a variety of factors. A recent review in the BMJ categorizes these causes by their frequency of occurrence. The most common causes of polyuria include the use of diuretics, caffeine, and alcohol, as well as diabetes mellitus, lithium, and heart failure. Less common causes include hypercalcaemia and hyperthyroidism, while rare causes include chronic renal failure, primary polydipsia, and hypokalaemia. The least common cause of polyuria is diabetes insipidus, which occurs in less than 1 in 10,000 cases. It is important to note that while these frequencies may not align with exam questions, understanding the potential causes of polyuria can aid in diagnosis and treatment.
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This question is part of the following fields:
- Renal System
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Question 28
Incorrect
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A 25-year-old man visits his primary care physician worried about a lump on his testes. He has no significant medical history and has recently started a new job after completing his education. His cousin was diagnosed with testicular cancer last year, and he is anxious that he might have the same condition.
During the examination, the physician observes a diffuse swelling of the testes with tenderness on palpation.
After prescribing a short course of ibuprofen, the patient remains concerned about testicular cancer and inquires about its presenting features in young men.
What could be a possible presenting feature of testicular cancer in men in their mid-twenties?Your Answer:
Correct Answer: Hydrocele
Explanation:Testicular cancer in young men may manifest as a hydrocele, which is the accumulation of fluid around the testicle. Therefore, it is important to investigate all cases of hydrocele to rule out cancer. On the other hand, epididymitis, which is usually caused by a bacterial infection, is unlikely to be a presenting feature of testicular cancer. If a male patient presents with frank haematuria, urgent investigation is necessary to rule out bladder cancer. A chancre, which is a painless genital ulcer commonly seen in the primary stage of syphilis, is not a presenting feature of testicular cancer.
Testicular cancer is a common type of cancer that affects men between the ages of 20 and 30. The majority of cases (95%) are germ-cell tumors, which can be further classified as seminomas or non-seminomas. Non-germ cell tumors, such as Leydig cell tumors and sarcomas, are less common. Risk factors for testicular cancer include infertility, cryptorchidism, family history, Klinefelter’s syndrome, and mumps orchitis. Symptoms may include a painless lump, pain, hydrocele, and gynaecomastia.
Tumour markers can be used to diagnose testicular cancer. For germ cell tumors, hCG may be elevated in seminomas, while AFP and/or beta-hCG are elevated in non-seminomas. LDH may also be elevated in germ cell tumors. Ultrasound is the first-line diagnostic tool.
Treatment for testicular cancer depends on the type and stage of the tumor. Orchidectomy, chemotherapy, and radiotherapy may be used. Prognosis is generally excellent, with a 5-year survival rate of around 95% for Stage I seminomas and 85% for Stage I teratomas.
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This question is part of the following fields:
- Renal System
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Question 29
Incorrect
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A 6-year-old boy arrives at the paediatric emergency department with a non-blanching rash. He is limping and complaining of abdominal pain. He had a recent bout of tonsillitis but is typically healthy. Upon examination, there are numerous palpable purpura in a symmetrical pattern, mainly on his buttocks and the backs of his legs. A urine dipstick reveals mild proteinuria and 2+ blood.
What is the probable underlying pathophysiology of this presentation?Your Answer:
Correct Answer: IgA mediated small vessel vasculitis
Explanation:The correct answer is IgA mediated small vessel vasculitis, specifically Henoch-Schonlein purpura (HSP). This condition is characterized by palpable purpura, arthralgia, abdominal pain, and haematuria, and typically affects children aged 4-6 years. HSP is often triggered by infections such as streptococcal pharyngitis, but can also be caused by other infections like Mycoplasma pneumoniae, Epstein-Barr virus, and adenovirus.
The other options are incorrect. ANCA-associated vasculitis typically involves the respiratory and ENT systems, which this child does not have. Cryoglobulinaemic vasculitis is associated with hepatitis C, haematological malignancies, and autoimmune disease, none of which are present in this case. Deficiency of von Willebrand factor cleaving protein is a feature of TTP, which is rare in children and typically presents with a low platelet count. ITP is another autoimmune condition that can present similarly to HSP, but can be differentiated by a low platelet count.
Understanding Henoch-Schonlein Purpura
Henoch-Schonlein purpura (HSP) is a type of small vessel vasculitis that is mediated by IgA. It is often associated with IgA nephropathy, also known as Berger’s disease. HSP is commonly observed in children following an infection.
The condition is characterized by a palpable purpuric rash, which is accompanied by localized oedema over the buttocks and extensor surfaces of the arms and legs. Other symptoms include abdominal pain and polyarthritis. In some cases, patients may also experience haematuria and renal failure, which are indicative of IgA nephropathy.
Treatment for HSP typically involves analgesia for arthralgia. While there is inconsistent evidence for the use of steroids and immunosuppressants, supportive care is generally recommended for patients with nephropathy. The prognosis for HSP is usually excellent, particularly in children without renal involvement. However, it is important to monitor blood pressure and urinalysis to detect any signs of progressive renal involvement. Approximately one-third of patients may experience a relapse.
In summary, Henoch-Schonlein purpura is a self-limiting condition that is often seen in children following an infection. While the symptoms can be uncomfortable, the prognosis is generally good. However, it is important to monitor patients for any signs of renal involvement and provide appropriate supportive care.
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This question is part of the following fields:
- Renal System
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Question 30
Incorrect
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A 26-year-old man has been in a car accident and his right leg has been trapped for 5 hours during transportation. During examination, his foot is found to be insensate and there is only a weakly felt dorsalis pedis pulse. Which of the following biochemical abnormalities is most likely to be present?
Your Answer:
Correct Answer: Hyperkalaemia
Explanation:The patient is expected to suffer from compartment syndrome, which may lead to delayed diagnosis and muscle necrosis. Muscle necrosis can cause the release of potassium, and there is a high probability of renal dysfunction, which can result in elevated serum potassium levels.
Hyperkalaemia is a condition where there is an excess of potassium in the blood. The levels of potassium in the plasma are regulated by various factors such as aldosterone, insulin levels, and acid-base balance. When there is metabolic acidosis, hyperkalaemia can occur as hydrogen and potassium ions compete with each other for exchange with sodium ions across cell membranes and in the distal tubule. The ECG changes that can be seen in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.
There are several causes of hyperkalaemia, including acute kidney injury, drugs such as potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes.
It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. In contrast, beta-agonists such as Salbutamol are sometimes used as emergency treatment. Additionally, both unfractionated and low-molecular weight heparin can cause hyperkalaemia by inhibiting aldosterone secretion.
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This question is part of the following fields:
- Renal System
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