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Question 1
Incorrect
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In the treatment of autoimmunity and to prevent rejection following solid organ transplantation, various immunosuppressant drugs are used, each with its own mechanism of action and specific side effects. However, all of them carry the risk of increased susceptibility to infection and malignancy. At what age is new onset of diabetes after transplantation (NODAT) commonly associated with medication?
Your Answer: Mycophenolate mofetil
Correct Answer: Tacrolimus
Explanation:New Onset Diabetes After Transplantation (NODAT)
New onset diabetes after transplantation (NODAT) is a condition that is becoming increasingly common among transplant recipients. It is estimated that between 5-20% of recipients develop NODAT within the first year after transplantation, and up to 30% in the longer term. The use of prednisolone is often associated with NODAT, especially in patients who had impaired glucose tolerance before the transplant. However, calcineurin inhibitors such as ciclosporin and tacrolimus are also known to increase the risk of NODAT. The risk of NODAT with ciclosporin is around 5%, while it can be as high as 20% with tacrolimus. Sirolimus, another immunosuppressive drug, is also believed to be diabetogenic, with similar rates to ciclosporin. It is worth noting that cyclophosphamide is not used in transplantation immunotherapy, while azathioprine and mycophenolate mofetil are not associated with NODAT.
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This question is part of the following fields:
- Nephrology
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Question 2
Incorrect
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Which patient has a creatinine level indicating CKD3?
Patient A:
Adjusted calcium - 2.3 mmol/L
Phosphate - 0.9 mmol/L
PTH - 8.09 pmol/L
Urea - 7.8 mmol/L
Creatinine - 145 μmol/L
Albumin - 36 g/L
Patient B:
Adjusted calcium - 2.9 mmol/L
Phosphate - 2.0 mmol/L
PTH - 4.2 pmol/L
Urea - 50 mmol/L
Creatinine - 280 μmol/L
Albumin - 38 g/L
Patient C:
Adjusted calcium - 2.0 mmol/L
Phosphate - 2.8 mmol/L
PTH - 12.53 pmol/L
Urea - 32.8 mmol/L
Creatinine - 540 μmol/L
Albumin - 28 g/L
Patient D:
Adjusted calcium - 2.5 mmol/L
Phosphate - 1.6 mmol/L
PTH - 2.05 pmol/L
Urea - 32.8 mmol/L
Creatinine - 367 μmol/L
Albumin - 40 g/L
Patient E:
Adjusted calcium - 2.2 mmol/L
Phosphate - 0.7 mmol/L
PTH - 5.88 pmol/L
Urea - 4.6 mmol/L
Creatinine - 81 μmol/L
Albumin - 18 g/LYour Answer: Patient D
Correct Answer: Patient A
Explanation:Renal Impairment and Calcium Homeostasis
Although interpreting creatinine levels can be challenging without information about body habitus and muscle mass, Patient A likely has CKD3 based on their creatinine level of 145. It is important to have a general of the severity of renal impairment based on creatinine levels. Patients with an eGFR of 30-59 ml/min/1.73m2 are classified as having CKD3. This classification applies to men and women between the ages of 20 and 80 years old.
Patients B, C, and D have more advanced renal disease, and depending on the clinical context, patients B and D may have acute renal failure. Patient E, on the other hand, does not have any renal impairment.
Patients with kidney disease often experience multiple abnormalities in calcium homeostasis. At the CKD3 stage, most patients have normal plasma concentrations of calcium and phosphate. However, as CKD3 progresses towards CKD 4, more subtle abnormalities may arise, such as a slight increase in PTH due to reduced hydroxylation of vitamin D by the kidney enzyme 1-alpha hydroxylase.
Although Patient A has suboptimal levels of vitamin D, this is not uncommon. Risk factors for vitamin D insufficiency include old age, immobility, institutionalization, and darker skin color.
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This question is part of the following fields:
- Nephrology
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Question 3
Incorrect
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A patient admitted for treatment of PD peritonitis has had their cloudy PD fluid sent for culture and has been started on empirical antibiotics while awaiting results. What is the most probable pathogen responsible for the infection?
Your Answer: S. aureus
Correct Answer: Coagulase negative staph
Explanation:Causes of PD Peritonitis
PD peritonitis is a common complication of peritoneal dialysis, with 50% of episodes caused by Gram positive organisms. The most frequent culprit is coagulase negative staph, which is often due to contamination from skin flora. While Staph. aureus is becoming more prevalent, it is still less common than coagulase negative staph. Gram negative organisms, such as E. coli, are responsible for only 15% of PD peritonitis cases. Pseudomonas is rare and challenging to treat. Fungal organisms cause peritonitis in less than 2% of patients. Overall, the causes of PD peritonitis is crucial for effective management and prevention of this complication.
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This question is part of the following fields:
- Nephrology
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Question 4
Incorrect
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A 49-year-old man visits his GP complaining of a weak and painful right leg that has been bothering him for a week. Upon examination, the GP observes a foot drop on the right side with 3/5 power for dorsiflexion, as well as a bilateral sensory peripheral neuropathy that is worse on the right side. The GP also notices weakness of wrist extension on the left, which the patient had not previously mentioned. The patient's chest, heart, and abdomen appear normal, and his urine dipstick is clear. His medical history is significant only for asthma, which was diagnosed four years ago.
The patient's FBC reveals a white cell count of 6.7 x109/l (normal range: 4 - 11), with neutrophils at 4.2 x109/l (normal range: 1.5 - 7), lymphocytes at 2.3 x109/l (normal range: 1.5 - 4), and eosinophils at 2.2 x109/l (normal range: 0.04 - 0.4). His ESR is 68mm/hr (normal range: 0 - 15), and his biochemistry is normal except for a raised CRP at 52 mg/l. Nerve conduction studies show reduced amplitude sensory signals bilaterally and patchy axonal degeneration on the right side with reduced motor amplitude.
What is the most likely diagnosis?Your Answer: B12 deficiency
Correct Answer: eosinophilic granulomatosis with polyangiitis (EGPA)
Explanation:Differential Diagnosis for Mononeuritis Multiplex
Mononeuritis multiplex is a condition characterized by the inflammation of multiple nerves, resulting in both sensory and motor symptoms. While several conditions can cause this, eGPA is the most likely diagnosis for this patient due to his history of adult onset asthma and significantly raised eosinophil count. The painful loss of function, raised inflammatory markers, and reduced amplitude nerve conduction studies also suggest an inflammatory cause of his neuropathy.
While amyloidosis is a possibility, the patient has no history of a disorder that might predispose to secondary amyloid, and no signs of systemic amyloidosis. B12 deficiency and diabetes mellitus are unlikely causes of mononeuritis multiplex, as they do not typically present with this pattern of neuropathy. Lyme disease is also unlikely, as the patient has no rash or arthritis and no history of tick bite.
In summary, while several conditions can cause mononeuritis multiplex, the patient’s history and test results suggest eGPA as the most likely diagnosis. It is important to consider other possibilities, such as amyloidosis, but the inflammatory nature of the patient’s symptoms points towards eGPA as the primary cause.
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This question is part of the following fields:
- Nephrology
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Question 5
Incorrect
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A 45-year-old man underwent a renal transplant four weeks ago. The transplant was complicated by delayed graft function, which required haemodialysis on days one and three post-surgery due to hyperkalaemia. By day six, the transplant began to function, and he was discharged on day 10 with decreasing creatinine levels. He is currently taking immunosuppressants (tacrolimus, azathioprine, prednisolone), prophylaxis against opportunistic infections (co-trimoxazole, valganciclovir), aspirin, and amlodipine. Despite regular clinic visits, his potassium levels remain persistently high at 6.5 mmol/l. Which medication is likely causing this issue?
Your Answer: Azathioprine
Correct Answer: Co-trimoxazole
Explanation:Co-trimoxazole and its Side Effects
Co-trimoxazole is a medication that is commonly used to treat and prevent Pneumocystis jiroveci pneumonia, which is more prevalent in immunocompromised individuals. It is a combination of two drugs, trimethoprim and sulfamethoxazole, and is known to cause side effects such as gastrointestinal discomfort, rashes, and hyperkalaemia. Hyperkalaemia is a condition where there is an excess of potassium in the blood, and it is a well-known side effect of co-trimoxazole. This is because the medication inhibits sodium channels in the distal nephron, similar to the potassium-sparing diuretic amiloride.
Although co-trimoxazole is generally safe, it can cause rare but serious side effects such as Stevens-Johnson syndrome, bone marrow depression, and agranulocytosis. Patients who have documented allergies to either component of the medication should avoid it and use pentamidine nebulisers as an alternative. Additionally, co-trimoxazole may be teratogenic, meaning it can cause harm to a developing fetus, so female patients should be advised to use contraception and stop taking the medication if they plan to become pregnant. Overall, co-trimoxazole is an effective medication for treating and preventing Pneumocystis jiroveci pneumonia, but patients should be aware of its potential side effects.
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This question is part of the following fields:
- Nephrology
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Question 6
Incorrect
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A 44-year-old man presents with nephrotic syndrome and is undergoing further investigations to determine the underlying cause.
Under what condition would corticosteroids be the most successful in reversing the nephrotic syndrome?Your Answer: Mesangial IgA disease
Correct Answer: Minimal change disease
Explanation:Treatment Options for Different Types of Glomerulonephritis
Glomerulonephritis (GN) is a group of kidney diseases that affect the glomeruli, the tiny blood vessels in the kidneys. While there is no known effective treatment for IgA nephropathy, long-term corticosteroid therapy has shown favourable response in some cases. On the other hand, 80% of adults with minimal change GN can respond to steroids, but it may take up to 16 weeks for remissions to occur. Unfortunately, membranous GN does not respond to steroid treatment. Lastly, there is no specific treatment available to cause regression of amyloid deposits. It is important to note that treatment options may vary depending on the type of GN and individual patient factors.
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This question is part of the following fields:
- Nephrology
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Question 7
Correct
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A 39-year-old man is discovered on the roadside after a single-vehicle car accident. The duration of his lying there is uncertain. Upon the arrival of paramedics, his GCS is 10, and his blood pressure is 92/66 mmHg with a pulse of 96 bpm. Upon arrival at the Emergency department, his blood test results reveal a urea level of 44 mmol/l (normal range: 2.5 - 7.5) and a creatinine level of 620 µmol/l (normal range: 60 - 110). A catheterization procedure produces 50 mls of brown-colored urine. What additional blood test should be requested to determine the cause of his kidney dysfunction?
Your Answer: Creatine kinase
Explanation:Rhabdomyolysis and Compartment Syndrome
Rhabdomyolysis is a condition that can occur as a result of various factors, including trauma, crush injury, compartment syndrome, ischaemia, severe electrolyte disturbances, bacterial and viral infections, inherited metabolic disorders, and certain drugs. In order to diagnose rhabdomyolysis, a CK test should be requested.
One of the common causes of rhabdomyolysis is trauma, such as a road traffic accident. In such cases, it is important to rule out compartment syndrome, which can develop due to the effects of rhabdomyolysis on muscle fibres. Compartment syndrome is characterized by a disruption to the oxygen supply to the muscle, leading to ATP depletion and a build-up of intracellular calcium. This can cause myocyte swelling and impaired function, leading to hypovolaemia and excess fluid sequestration.
Restoring the blood supply can cause reperfusion injury, which can further damage the myocytes and cause them to swell further, leading to the development of compartment syndrome. Therefore, it is crucial to address compartment syndrome in trauma patients in order to improve their clinical picture. By the causes and effects of rhabdomyolysis and compartment syndrome, healthcare professionals can provide appropriate treatment and management for their patients.
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This question is part of the following fields:
- Nephrology
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Question 8
Correct
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A 15-year-old girl comes to the clinic complaining of myalgia and brown-coloured urine. She has been diagnosed with rhabdomyolysis for the fourth time, and the cause is still unknown.
What investigation should be considered at this point?Your Answer: Muscle biopsy
Explanation:Investigating Recurrent Rhabdomyolysis: Genetic Causes and Diagnostic Tests
Rhabdomyolysis is a condition characterized by the breakdown of muscle tissue, leading to the release of muscle fibers into the bloodstream. This can cause kidney damage and other complications. In some cases, rhabdomyolysis may be caused by genetic polymorphisms or mutations that affect processes such as ATP production and calcium movement. Patients who have had recurrent episodes of unexplained rhabdomyolysis, especially those without obvious traumatic, drug-related, or toxic cause, should be investigated for genetic causes. Muscle biopsy is a useful diagnostic test in these cases.
Other diagnostic tests may also be helpful in certain situations. For example, the Gal-1 PUT test can be used to diagnose galactosaemia, a rare genetic disorder that can cause rhabdomyolysis in infants. Renin and aldosterone levels may be useful if primary hyperaldosteronism causing hypokalaemia is suspected as the cause of rhabdomyolysis, but this is rare in children. GFR testing is only necessary if there is renal impairment, and haemodialysis may be necessary in cases of severe renal failure.
In summary, recurrent rhabdomyolysis should be investigated for genetic causes, and muscle biopsy is a useful diagnostic test in these cases. Other diagnostic tests may be helpful in certain situations, but their use should be guided by the patient’s clinical presentation and history.
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This question is part of the following fields:
- Nephrology
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Question 9
Correct
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You are part of the transplant team on call and have been asked to assess a potential kidney donor. The patient is an 86-year-old man who has been in the ICU for ten days due to severe pneumonia. He has required ventilatory support, inotropes, and filtration during his stay. His creatinine levels have rapidly risen since admission, with a current level of 350 umol/l. However, a sample taken six months ago by his GP showed a creatinine level of 95 umol/l. The patient's medical history includes hypertension and a malignant melanoma that was treated to remission three years ago with a hemicolectomy, but no adjuvant therapy was required. His screening colonoscopies have been normal in the years since.
What factor would lead you to decide against this patient as a potential donor?Your Answer: History of malignancy
Explanation:Donor Evaluation for Organ Transplantation
This patient’s stay in the ICU has been complicated, but the only absolute contraindication to organ donation is malignancy. Although the patient had a limited malignancy without evidence of spread, the risk of cancer in the recipient is too high due to potential micrometastases and immunosuppression. The only other absolute contraindications are HIV or CJD associated illness.
Despite being elderly, a kidney from a relatively healthy 85-year-old donor could be a good match for an elderly recipient in their mid-70s. The patient’s creatinine levels suggest acute tubular necrosis and delayed graft function, but this is likely due to severe sepsis and the patient’s previous normal creatinine levels indicate good baseline renal function. The need for inotropes also suggests acute tubular necrosis, but this is consistent with the patient’s septic shock and acute illness, which could potentially improve after transplantation.
In summary, organ donation evaluation involves considering absolute contraindications such as malignancy, HIV, or CJD associated illness. Age and medical history of the donor and recipient are also important factors to consider. The patient’s current condition and potential for recovery after transplantation should also be taken into account.
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This question is part of the following fields:
- Nephrology
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Question 10
Correct
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What is the name of the newer induction drug that selectively targets B cells to quickly control ANCA associated vasculitides while sparing other lymphocytes?
Your Answer: Rituximab
Explanation:Treatment Options for ANCA Vasculitis
ANCA vasculitis is a condition that causes inflammation of blood vessels, leading to organ damage. There are several treatment options available for this condition, depending on the severity of the disease. Cyclophosphamide and rituximab are induction agents used in severe or very active disease. Cyclophosphamide is a chemotherapy drug that causes DNA crosslinking and apoptosis of rapidly dividing cells, including lymphocytes. Rituximab is a monoclonal antibody that causes profound B cell depletion.
Azathioprine and mycophenolate mofetil are maintenance agents used for their steroid sparing effect. They can also be used to induce remission in mild disease, but their maximal effect takes three to four weeks. Therefore, they are not appropriate for severe or very active disease. Ciclosporin is a calcineurin inhibitor that blocks IL-2 production and proliferation signals to T cells. However, it is not widely used in the treatment of ANCA vasculitis. Overall, the choice of treatment depends on the severity of the disease and the individual patient’s needs.
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This question is part of the following fields:
- Nephrology
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Question 11
Correct
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A 35-year-old man visits the renal clinic eight weeks after a successful renal transplant. He has some inquiries about his immunosuppression. The consultant explains that the typical regimen for renal transplant patients involves the use of an induction agent initially, followed by a combination of a calcineurin inhibitor, antimetabolite, and steroids. This combination is intended to prevent rejection of the transplanted kidney. Can you identify the agent that acts as a purine analogue to disrupt DNA synthesis and induce apoptosis in rapidly dividing cells?
Your Answer: Azathioprine
Explanation:Mechanisms of Action of Immunosuppressive Drugs
Azathioprine and mycophenolate mofetil are two immunosuppressive drugs that interrupt DNA synthesis and act as antimetabolites. However, they achieve this through different mechanisms. Mycophenolate indirectly inhibits purine synthesis by blocking inosine monophosphate dehydrogenase, while azathioprine is a pro-drug that is metabolized to 6-mercaptopurine, which is inserted into the DNA sequence instead of a purine. This triggers apoptosis by recognizing it as a mismatch.
Basiliximab is an anti-CD25 monoclonal antibody that blocks T cell proliferation by inhibiting CD25, the alpha chain of the IL-2 receptor. On the other hand, sirolimus inhibits mTOR, the mammalian target of rapamycin, which is a protein kinase that promotes T cell proliferation and survival downstream of IL-2 signaling. Finally, tacrolimus is a calcineurin inhibitor that reduces the activation of NFAT, a transcription factor that promotes IL-2 production. Since IL-2 is the main cytokine that drives T cell proliferation, tacrolimus effectively suppresses the immune response.
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This question is part of the following fields:
- Nephrology
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Question 12
Correct
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A 35-year-old male was given steroids after a kidney transplant. After two years, he experienced hip pain and difficulty walking. What is the most probable cause of his symptoms?
Your Answer: Avascular necrosis
Explanation:Avascular Necrosis and Its Causes
Avascular necrosis (AVN) is a condition that occurs when the blood supply to the bones is temporarily or permanently lost. This can be caused by various factors, including trauma or vascular disease. Some of the conditions that can lead to AVN include hypertension, sickle cell disease, caisson disease, and radiation-induced arthritis. Additionally, certain factors such as corticosteroid therapy, connective tissue disease, alcohol abuse, marrow storage disease (Gaucher’s disease), and dyslipoproteinaemia can also be associated with AVN in a more complex manner.
Of all the cases of non-traumatic avascular necrosis, 35% are associated with systemic (oral or intravenous) corticosteroid use. It is important to understand the causes of AVN in order to prevent and manage the condition effectively. By identifying the underlying factors that contribute to AVN, healthcare professionals can develop appropriate treatment plans and help patients manage their symptoms. With proper care and management, individuals with AVN can lead healthy and fulfilling lives.
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This question is part of the following fields:
- Nephrology
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Question 13
Correct
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A 67-year-old man presents to the hospital with acute chest pain. He reports experiencing increasing shortness of breath on exertion, a widespread itchy rash, palpitations over the past few days, and ankle swelling. He has not seen his GP in many years due to a lack of trust in doctors. Upon examination, he has a pericardial rub and crackles at both lung bases. Blood tests reveal abnormalities in haemoglobin, white cell count, potassium, urea, creatinine, and CRP levels, as well as baseline troponin. A chest radiograph shows blunting of both costophrenic angles, and an ECG shows widespread ST elevation. What is the most likely cause of his chest pain?
Your Answer: Uraemic pericarditis
Explanation:Diagnosis and Differential Diagnosis of a Patient with Severe Renal Impairment
This patient has presented with severe renal impairment and a rash that is indicative of either uraemia or hyperphosphataemia, both of which are consequences of renal impairment. The patient’s low haemoglobin levels and long history suggest that this may be a chronic condition. The patient’s ECG changes and borderline troponin levels are consistent with pericarditis, which is likely to be uraemic pericarditis rather than viral myocarditis due to the patient’s high urea levels. While a myocardial infarction is possible, ECG changes are typically limited to one coronary territory. Pulmonary emboli could cause ECG changes, but usually present with sinus tachycardia or signs of right heart strain. An atypical pneumonia is unlikely to cause ECG changes or a rise in troponin, and the patient’s clinical presentation does not support this diagnosis.
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This question is part of the following fields:
- Nephrology
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Question 14
Correct
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A 65-year-old man comes to the clinic with a history of mild anaemia. The physician orders several urine tests. The results are as follows:
- Negative for haemoglobin, urobilinogen, and bilirubin
- Positive for protein
- Negative for glucose, nitrites, and leucocytes
- Positive for ketones
- +++ for Bence Jones
What could be the possible reason for these results?Your Answer: Multiple myeloma
Explanation:Myeloma Diagnosis and Blood Results
Myeloma is a type of cancer that can be diagnosed through various tests. One of the most common indicators is a positive test for Bence Jones protein, which is a type of protein found in the urine. This cancer can also cause proteinuria, which is the presence of excess protein in the urine due to renal damage or overflow from high blood total protein. Additionally, longstanding anaemia is another sign of myeloma.
Blood results for a patient with myeloma are likely to show elevated total protein, possibly with low albumin. There may also be an abnormally high level of one type of globulin, while other immunoglobulins may be suppressed. Protein electrophoresis testing can reveal the presence of a monoclonal (paraprotein) band with immunosuppression. High serum calcium with suppressed parathyroid hormone consistent with hypercalcaemia of malignancy is also common. Furthermore, high phosphate levels are often seen in haematological malignancy where there is a large amount of cell turnover. Renal impairment is another common finding, usually due to the deposition of myeloma casts in the nephrons. However, hypercalcaemia can also cause dehydration in addition.
In summary, a diagnosis of myeloma can be made through various tests, including a positive Bence Jones protein test, proteinuria, and longstanding anaemia. Blood results for a patient with myeloma are likely to show elevated total protein, a monoclonal band, high serum calcium, high phosphate, and renal impairment.
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This question is part of the following fields:
- Nephrology
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Question 15
Incorrect
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A 60-year-old man visits the clinic with his 35-year-old son, who has been diagnosed with IgA nephropathy and is in CKD stage 5. The man wishes to be evaluated as a potential live kidney donor for his son. He has a history of mild hypertension that is managed with 2.5 mg of ramipril daily. He has never had any surgeries, does not smoke, and only drinks alcohol in moderation.
As part of the consent process for kidney donation, what advice should be provided to the patient?Your Answer: A 10% risk of major complications
Correct Answer: There is no significant increase in hypertension in donors compared to the general population
Explanation:The Health Benefits and Risks of Being a Kidney Donor
Surprisingly, being a kidney donor can have health benefits. Studies have shown that live donors have lower long-term morbidity and mortality rates than the general population. This is likely due to the rigorous screening process that selects only those with excellent overall health.
While reducing renal mass could potentially lead to a decrease in glomerular filtration rate and an increased risk of end-stage renal failure or hypertension, large-scale studies with up to 35 years of follow-up have shown no increased risk compared to the general population. However, potential donors should be warned about the possibility of end-stage renal failure, particularly those with borderline GFR for donation.
As with any surgery, there are risks involved in kidney donation. The risk of death is quoted at 1 in 3000, and there is a 1-2% risk of major complications such as pneumothorax, injury to other organs, renovascular injury, DVT, or PE. There is also a 20% risk of minor complications such as post-operative atelectasis, pneumonia, wound infection, hematoma, incisional hernia, or urinary tract infection.
To ensure the safety of potential donors, they undergo thorough screening, including a comprehensive medical history, family history, and physical examination. They also undergo extensive investigations of cardiovascular, respiratory, and psychological fitness, as well as multiple tests of renal function and anatomy to determine if it is safe to proceed and select the kidney to be removed.
In conclusion, kidney donation can have health benefits for the donor, but it is not without risks. Only the healthiest individuals are selected as donors, and they undergo rigorous screening to ensure their safety.
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This question is part of the following fields:
- Nephrology
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Question 16
Correct
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A 40-year-old male visits his doctor two days after finishing a marathon. He expresses worry about the reddish-brown hue of his urine and his overall feeling of illness. What is the pigment responsible for the urine discoloration?
Your Answer: Myoglobin
Explanation:Rhabdomyolysis and Myoglobinuria
Rhabdomyolysis is a common condition that occurs after extreme physical exertion, such as running a marathon. It is characterized by the breakdown of muscle tissue, which releases myoglobin into the bloodstream. Myoglobin is a small molecule that is normally found in muscle cells, but when released into the circulation, it can cause urine to turn a dark color.
There are several causes of rhabdomyolysis and myoglobinuria, including trauma, compartment syndrome, crush injuries, ischemia, severe electrolyte imbalances, bacterial and viral infections, and inherited metabolic disorders like McArdle’s disease. In rare cases, certain drugs like barbiturates and statins can also cause rhabdomyolysis.
It is important to recognize the signs and symptoms of rhabdomyolysis, such as muscle pain, weakness, and dark urine, as it can lead to serious complications like kidney failure if left untreated. Treatment typically involves addressing the underlying cause, such as rehydration and electrolyte replacement, and may require hospitalization in severe cases.
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This question is part of the following fields:
- Nephrology
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Question 17
Correct
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A patient who has been on peritoneal dialysis for three weeks has reported that despite instilling a full 2 litre bag of fluid, he only gets 1.9 litres back. Additionally, he has noticed swelling in his abdomen and tenderness upon palpation. What could be the probable cause of these issues?
Your Answer: Leak from catheter site
Explanation:Common Issues with Peritoneal Dialysis Catheters
Leakage is a common issue with peritoneal dialysis catheters, especially in patients who have had previous abdominal surgery. It can be noticed as fluid leaking around the exit site or causing mild swelling. Reducing fluid volumes may help, but catheter repair or replacement may be necessary. If patients show signs of fluid overload, a higher concentration of osmotic agent may be required. Catheter malposition is often painful and occurs early after insertion. Constipation is the most common cause of outflow obstruction, which tends to be consistent or worsening. Kinking of the catheter also occurs early after insertion and can cause problems with fluid inflow and outflow. Proper management of these issues is important for the success of peritoneal dialysis treatment.
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This question is part of the following fields:
- Nephrology
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Question 18
Incorrect
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A 42-year-old previously healthy teacher visits her doctor complaining of headache and itching. During her urine test, protein (3+) and blood (1+) are detected, but there are no splinter haemorrhages. What other bedside examination would be beneficial in evaluating her condition?
Your Answer: Electrocardiogram
Correct Answer: Blood pressure
Explanation:Assessment and Further Testing for Kidney Disease
Assessing kidney disease at the bedside involves several steps, including urinalysis, blood pressure measurement, and assessment of volume status. However, further testing is necessary to confirm the diagnosis and determine the underlying cause of the disease. Blood testing for U&Es, autoantibodies, glucose, HbA1c, complement, and ANCA serology, as well as hepatitis and HIV viral screening, can provide valuable information.
In this case, the patient presents with features consistent with kidney disease, including an abnormal urinalysis. While diabetes could be a possible cause, the patient’s age makes it less likely. Therefore, additional testing is necessary to determine the underlying cause of the disease. Checking the patient’s blood pressure is also important, as hypertension is often associated with renal diseases. Aggressive management of hypertension can help prevent the progression of chronic renal failure.
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This question is part of the following fields:
- Nephrology
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Question 19
Incorrect
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Dr. Patel is a nephrologist who has five patients attending his clinic. The patients' results are as follows:
Adam Ahmed Bella Brownie Charlie Chen David Davis
Urine protein mg/24 hrs: 150 4000 3000 200 300
Haematuria: Present Absent Present Present Absent
Oedema: Absent Present Present Absent Absent
Serum albumin g/l: 24 18 26 17 32
Serum creatinine µmol/l: 430 110 280 560 120
Which patient is diagnosed with nephrotic syndrome?Your Answer: Celia Creutzfeldt
Correct Answer: Bella Barnard
Explanation:Nephrotic Syndrome
Nephrotic syndrome is a condition characterized by low serum albumin levels, high urinary protein levels, and marked pitting edema. Only individuals who meet all three criteria are diagnosed with this syndrome. Other features of nephrotic syndrome include little or no hematuria, glomerular pathology as the cause, marked hyperlipidemia that increases cardiovascular risk, reduced immunoglobulins that increase the risk of infection, and loss of certain proteins that increase the risk of thrombosis, including renal vein thrombosis. Creatinine levels can be normal or elevated.
The causes of nephrotic syndrome include glomerulonephritis, such as minimal change disease and membranous glomerulonephritis, focal segmental glomerulosclerosis, diabetic nephropathy, amyloid (AL form), and connective tissue disease such as systemic lupus erythematosus. the diagnostic criteria and features of nephrotic syndrome is crucial for early detection and management of this condition.
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This question is part of the following fields:
- Nephrology
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Question 20
Incorrect
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A 40-year-old man has just finished a round of chemotherapy for leukemia. During a routine check-up, he is discovered to have proteinuria with a level of 1000 mg/24 hours. Upon examination, there are no red cell casts present in his urine. What could be the probable reason for his proteinuria?
Your Answer: Glomerular proteinuria
Correct Answer: Tubular proteinuria
Explanation:Causes of Tubular Proteinuria
Tubular proteinuria is a condition where proteins are excreted in the urine due to damage to the renal tubules. One common cause of this condition is chemotherapy, particularly ifosphamide and platinum-based agents. Other causes include Fanconi’s syndrome, heavy metal poisoning, tubulointerstitial disease, and the use of certain drugs such as gentamicin. Diabetes, infections, and transplant rejection can also lead to tubular proteinuria.
In summary, there are various factors that can cause tubular proteinuria, and it is important to identify the underlying cause in order to provide appropriate treatment. Patients who have undergone chemotherapy should be monitored for signs of renal tubular damage, and any medication that may contribute to the condition should be reviewed. Early detection and management of tubular proteinuria can help prevent further kidney damage and improve patient outcomes.
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This question is part of the following fields:
- Nephrology
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Question 21
Incorrect
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A patient is admitted from clinic eight weeks following a renal transplant. Despite feeling well, his creatinine has increased from a baseline of 120 umol/l to 170 umol/l in just one week. After a normal ultrasound scan, he undergoes a transplant biopsy which reveals linear C4d staining along the peritubular capillaries and widespread glomerulitis with neutrophil and macrophage infiltration. What is the probable diagnosis?
Your Answer: Cellular rejection
Correct Answer: Antibody mediated rejection
Explanation:C4d Staining as a Marker for Antibody Mediated Rejection
Linear staining for C4d is a useful tool in detecting complement activation via the classical pathway, which is mediated by antibodies. C4d is a breakdown component of C4 that binds to the basement membrane, indicating antibody mediated complement activation. In cases where antibody mediated rejection is suspected, C4d staining is highly sensitive for acute rejection. A serum sample for donor specific antibodies should be sent off urgently to confirm the diagnosis.
Chronic background antibody mediated rejection can also show C4d staining, but the presence of C4d along the peritubular capillaries is a strong indicator of acute antibody mediated rejection. This, along with the presence of glomerulitis and acute inflammatory infiltrate, supports the diagnosis of acute antibody mediated rejection.
Other conditions, such as acute tubular necrosis, bacterial pyelonephritis, acute viral infection, and acute cellular rejection, can be ruled out based on their distinct features. Acute tubular necrosis shows flattening of the tubular epithelium with sloughing of the cells, while bacterial pyelonephritis tends to cause a tubulointerstitial nephritis. Acute viral infection and acute cellular rejection both show lymphocytic infiltration rather than granulocyte infiltration, but can be distinguished through blood viral PCR and virus specific stains.
In summary, C4d staining is a valuable tool in detecting antibody mediated complement activation and can aid in the diagnosis of acute antibody mediated rejection. Other conditions can be ruled out based on their distinct features, and further testing may be necessary to confirm the diagnosis.
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This question is part of the following fields:
- Nephrology
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Question 22
Correct
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As an Emergency department doctor, a 50-year-old man presents with intense left flank pain that extends to his groin. He reports that the pain began yesterday. Upon conducting a urinalysis, the following results were obtained:
- Haemoglobin +++
- Urobilinogen Negative
- Bilirubin Negative
- Protein Negative
- Glucose Negative
- Nitrites Negative
- Leucocytes Negative
- Ketones +
What could be the possible cause of these findings?Your Answer: Renal calculus
Explanation:Renal Calculi: Causes and Symptoms
Renal calculi, commonly known as kidney stones, can be caused by various factors such as reduced urine output, changes in medication, and diet. These factors can lead to the formation of stones in the urinary tract, which can cause inflammation and damage to the lining of the urinary tract. Patients with renal calculi may experience symptoms such as blood in their urine due to the damage caused by the stones. Additionally, ketones may be present in the urine, indicating reduced oral intake due to severe pain.
In summary, renal calculi can be caused by various factors and can lead to symptoms such as blood in the urine and reduced oral intake. It is important for patients to seek medical attention if they suspect they may have renal calculi to receive proper diagnosis and treatment.
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This question is part of the following fields:
- Nephrology
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Question 23
Incorrect
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A 30-year-old man with end stage renal failure due to IgA nephropathy underwent a kidney transplant from a deceased brainstem donor and experienced successful primary graft function. After being discharged eight days post-surgery, his creatinine levels stabilized at 85 umol/l with regular clinic visits. However, at seven weeks post-transplant, his creatinine levels increased to 190 umol/l despite being asymptomatic. As a result, he was admitted for further evaluation. What would be your initial course of action?
Your Answer: Send serum for donor specific antibodies
Correct Answer: Request a renal ultrasound scan
Explanation:The patient’s sudden rise in creatinine after stent removal suggests obstruction leading to hydronephrosis. This is the most likely diagnosis, but other possibilities include acute rejection, calcineurin toxicity, infection, or surgical complications. A renal ultrasound is needed to confirm the diagnosis and rule out other issues before a renal biopsy can be considered. Donor specific antibodies may also be tested, but a biopsy is still necessary for confirmation and treatment.
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This question is part of the following fields:
- Nephrology
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Question 24
Incorrect
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A patient who has been on peritoneal dialysis for two years complains that her bags, previously clear, have become cloudy.
She is in good health, with slight abdominal discomfort, and has successfully instilled fluid, although she only removed 1.5 liters from a 2-liter bag instilled earlier. Her abdomen is soft and only slightly tender.
What is the probable complication?Your Answer: Catheter leakage
Correct Answer: Peritonitis
Explanation:Symptoms and Treatment of PD Peritonitis
Peritonitis in patients undergoing peritoneal dialysis (PD) may not present with typical symptoms seen in non-dialysis patients. Patients may only experience mild abdominal discomfort or tenderness, or may not have any symptoms at all. The most common sign of PD peritonitis is a cloudy bag, which indicates bacterial growth. In severe cases, the fluid may resemble pea soup. It is important to note that any patient with a cloudy bag should be treated for PD peritonitis immediately with antibiotics, such as vancomycin, administered intraperitoneally, and oral antibiotics, such as ciprofloxacin. PD exchanges should continue during treatment to flush out the peritoneal cavity.
While surgical problems, such as appendicitis, can occur in PD patients, they typically present with local peritonism and symptoms like vomiting. Constipation may cause abdominal discomfort and outflow problems, but it does not cause cloudy bags. Fibrin can block the catheter and cause abnormal fluid appearance, but it tends to appear as strands rather than a cloudy bag and does not cause abdominal discomfort or tenderness. It is important for PD patients to be aware of the symptoms of PD peritonitis and seek immediate treatment if they notice a cloudy bag or any other concerning symptoms.
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This question is part of the following fields:
- Nephrology
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Question 25
Correct
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As a locum GP, you are tasked with reviewing blood results for five patients you have never met before. The following results have been provided for each patient:
Patient A: Adjusted calcium - 2.3 mmol/L, Phosphate - 0.9 mmol/L, PTH - 8.09 pmol/L, Urea - 7.8 mmol/L, Creatinine - 132 μmol/L, Albumin - 36 g/L
Patient B: Adjusted calcium - 2.9 mmol/L, Phosphate - 0.5 mmol/L, PTH - 7.2 pmol/L, Urea - 5 mmol/L, Creatinine - 140 μmol/L, Albumin - 38 g/L
Patient C: Adjusted calcium - 2.0 mmol/L, Phosphate - 2.8 mmol/L, PTH - 12.53 pmol/L, Urea - 32.8 mmol/L, Creatinine - 540 μmol/L, Albumin - 28 g/L
Patient D: Adjusted calcium - 2.5 mmol/L, Phosphate - 1.6 mmol/L, PTH - 2.05 pmol/L, Urea - 32.8 mmol/L, Creatinine - 190 μmol/L, Albumin - 40 g/L
Patient E: Adjusted calcium - 2.2 mmol/L, Phosphate - 0.7 mmol/L, PTH - 5.88 pmol/L, Urea - 4.6 mmol/L, Creatinine - 81 μmol/L, Albumin - 18 g/L
Your task is to identify which patient is likely to have CKD 5.Your Answer: Patient C
Explanation:Interpretation of Patient C’s Lab Results
Patient C’s lab results indicate chronic kidney disease (CKD) rather than acute renal failure (ARF). The creatinine result corresponds to an eGFR of less than 15 ml/min/1.73m2, which is consistent with CKD 5 in a male or female aged 20-80-years-old. Additionally, the patient has hypocalcaemia, hyperphosphataemia, and an elevation of parathyroid hormone, which are metabolic changes commonly seen in CKD 4-5 but not in ARF of short duration. The relatively higher creatinine result compared to urea also suggests CKD rather than ARF, where dehydration can lead to even higher urea levels.
It is likely that this patient is already dialysis-dependent or will require regular review by a nephrology team. The decision to start dialysis is based on various factors, including fluid overload, hyperkalaemia, uraemic symptoms, life expectancy, and patient/clinician preference. Most patients start dialysis with an eGFR of around 10 ml/min/1.73m2.
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This question is part of the following fields:
- Nephrology
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Question 26
Correct
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A 25-year-old woman with a history of glomerulonephritis is scheduled to undergo a 24-hour urinary protein collection. What is the recommended starting time for the collection?
Your Answer: Start after the first morning void
Explanation:Guidelines for Accurate 24 Hour Urine Collection
Twenty four hour urine collections are essential for measuring urinary protein levels and diagnosing various conditions. However, the accuracy and reproducibility of the test can be limited due to the difficulty in performing it correctly. To ensure accurate results, laboratories provide guidelines to patients for the procedure of taking a 24 hour urine collection.
The guidelines advise patients to use the correct bottle for the test and to read the leaflet about dietary requirements during the test. Some analytes can be affected by diet before and during the test, so it is important to follow the instructions carefully. Patients should also be aware that some bottles contain acid, which prevents degradation of certain analytes and prevents false negative results. If there is a small amount of liquid already in the bottle, patients should not throw it out as it is usually there as a preservative.
To start the collection, patients should begin after the first void of the day and collect all urine for 24 hours, including the first void the following day. Although the start time does not technically matter, starting after the first void tends to be at a similar time on consecutive days, minimizing error.
The main errors made in urine collections are overcollection and undercollection. Overcollection occurs when patients collect for more than 24 hours, leading to a falsely high urine protein result. Patients should consider overcollection if urine volumes are greater than 3-4L/day. Undercollection occurs when patients collect for less than 24 hours, leading to a falsely low result. Patients should suspect undercollection if urine volumes are less than 1 L/day. By following these guidelines, patients can ensure accurate and reliable results from their 24 hour urine collection.
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This question is part of the following fields:
- Nephrology
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Question 27
Correct
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A 59-year-old man of Afro-Caribbean descent presented with bipedal oedema. He was a retired teacher with occasional international travel. On examination, his body weight was 40 kg with some oral ulcers.
Tests revealed:
Investigation Result Normal value
Haemoglobin 112g/l 135–175 g/l
White cell count (WCC) 5 × 109/l 4–11 × 109/l
Neutrophils 1.2 × 109/l 2.5–7.58 × 109/l
Lymphocytes 1.4 × 109/l 1.5–3.5 × 109/l
Eosinophils 0.8 × 109/l 0.1–0.4 × 109/l
Urine Protein 2+
Cholesterol 4.5 <5.2 mmol/l
Which of the following tests is next indicated for this patient?Your Answer: CD4 count
Explanation:Diagnosis and Management of HIV Nephropathy
HIV infection is a high possibility in a patient with risk factors and presenting with emaciation, oral ulcers, and lymphopenia. A CD4 count and HIV serological testing should be done urgently. HIV nephropathy is a common complication, with focal and segmental glomerulosclerosis being the most common pathological diagnosis. Other variants include membranoproliferative nephropathy, diffuse proliferative glomerulonephritis, minimal change disease, and IgA nephropathy. Treatment involves ACE inhibitors and antiretroviral therapy, with dialysis being necessary in end-stage disease. Renal biopsy is required to confirm the diagnosis, but HIV testing should be performed first. Serum IgA levels are elevated in IgA nephropathy, while serum complement levels and anti-nuclear factor are needed in SLE-associated nephropathy or other connective tissue diseases or vasculitis. However, the lack of systemic symptoms points away from these diagnoses.
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This question is part of the following fields:
- Nephrology
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Question 28
Correct
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A 14-year-old girl presents with proteinuria at 1500 mg/24 hours. Upon examination, her urine reveals the presence of significant amounts of large proteins, including albumin and transferrin. What could be the possible reason for her proteinuria?
Your Answer: Glomerular proteinuria
Explanation:Glomerular Proteinuria
Although a small amount of protein is typically found in urine, an elevated level of protein indicates a potential health issue. The diagram below illustrates the various sources of protein in urine, with glomerular proteinuria being the likely cause in this case due to the presence of larger proteins. This type of proteinuria can result in significant loss of protein through urine. It is important to identify the underlying cause of glomerular proteinuria and seek appropriate medical treatment to prevent further damage to the kidneys. Proper management can help reduce the risk of complications and improve overall health outcomes.
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This question is part of the following fields:
- Nephrology
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Question 29
Correct
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A 47-year-old patient arrives at the dialysis center for their thrice-weekly haemodialysis. They have end stage renal failure caused by membranous glomerulonephritis and no other health issues. The patient reports feeling fatigued but is otherwise in good health. During routine blood work, their haemoglobin level is found to be 89 g/L (115-165). If the anaemia is a result of their renal disease, what is the appropriate treatment for this patient?
Your Answer: Intravenous iron plus or minus parenteral erythropoietin
Explanation:Patients with end stage kidney disease have poor iron absorption and lack endogenous erythropoietin, making parenteral iron replacement and erythropoietin the best management. Anaemia is common in these patients due to poor oral iron absorption and GI blood loss. Acute packed red cell transfusion is extreme and renal transplant may be an option, but the patient’s haemoglobin can be modified with increased IV iron and epo doses. Oral iron tablets are poorly absorbed and tolerated.
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This question is part of the following fields:
- Nephrology
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Question 30
Incorrect
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A 20-year-old woman discovers she is pregnant and despite it being unplanned, she is excited to become a mother. During her initial check-up, her blood pressure is measured at 170/120 mmHg. She has a clean medical history, except for a childhood bout of Henoch-Schönlein purpura. Additionally, there is no relevant family history and she does not smoke. What could be the probable reason for her hypertension?
Your Answer: Membranous glomerulonephritis
Correct Answer: Chronic renal impairment
Explanation:Possible Causes of Hypertension in Pregnancy
This patient is experiencing hypertension during pregnancy, which is commonly associated with pre-eclampsia. However, pre-eclampsia usually occurs later in pregnancy and should not be present during the initial booking visit. The patient’s medical history of Henoch-Schölein purpura suggests the possibility of chronic kidney disease as a potential cause of her hypertension.
Congenital adrenal hyperplasia is a group of related disorders that can cause abnormal development of sexual characteristics, adrenal crisis, and hypertension. This condition is often diagnosed during puberty when girls experience virilization due to the production of androgens while cortisol levels remain deficient. As a result, many patients with congenital adrenal hyperplasia may have reduced fertility compared to their peers.
While stress can contribute to hypertension, it is less likely to explain consistently high blood pressure readings. Membranous glomerulonephritis is another potential cause of hypertension, but it is uncommon in a woman of this age. This condition can be caused by heavy metal toxicity, malignancy, or infection with hepatitis C virus.
In summary, hypertension during pregnancy can have various underlying causes, including pre-eclampsia, chronic kidney disease, congenital adrenal hyperplasia, stress, and membranous glomerulonephritis. Further investigation and medical evaluation are necessary to determine the specific cause and appropriate treatment for this patient.
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This question is part of the following fields:
- Nephrology
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