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  • Question 1 - A 50-year-old man with long-standing insulin-dependent diabetes mellitus was on dialysis, secondary to...

    Correct

    • A 50-year-old man with long-standing insulin-dependent diabetes mellitus was on dialysis, secondary to end-stage renal disease (ESRD). Three months ago, he received a kidney transplant, with his old kidney left in place. The transplanted kidney is attached to the central circulation, mimicking natural circulation. There are absolutely no signs of rejection, and the kidney is working perfectly. The patient is surprised to find out that he no longer has ‘thin blood’ because it has been years since he has not required medical management for his anaemia.
      What is the main factor responsible for the normalization of his blood parameters and his recovery, following the kidney transplant?

      Your Answer: Erythropoietin (EPO)

      Explanation:

      The Role of Kidney Function in Anaemia of ESRD Patients

      Erythropoietin (EPO) is synthesized and secreted by the kidney, making it a crucial factor in maintaining haematopoiesis. Patients with end-stage renal disease (ESRD) often suffer from severe anaemia and require exogenous EPO to address this issue. A hypoproliferative disorder, ESRD may or may not be accompanied by anaemia of chronic disease or iron deficiency, leading to decreased reticulocytes. Iron supplementation is often necessary in conjunction with EPO to maintain haematopoiesis in dialysis patients.

      Renin, on the other hand, is not implicated in anaemia. Aldosterone, which is part of the renin-angiotensin pathway that originates in the kidney, is not directly involved in anaemia either. Any derangement in aldosterone levels secondary to ESRD would have been normalized by now in the kidney.

      Normalizing kidney function may improve the iron levels of the patient, but the primary effect of renal disease is insufficient EPO secretion, leading to anaemia. Patients with ESRD are typically phosphate-overloaded and calcium-deficient. While a transplant may lead to decreased phosphate levels due to increased clearance, this is not directly implicated in haematopoiesis.

    • This question is part of the following fields:

      • Renal
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  • Question 2 - A 69-year-old man, with CCF is admitted with SOB and a productive cough....

    Correct

    • A 69-year-old man, with CCF is admitted with SOB and a productive cough. Clinical findings, and a chest X-ray suggest a diagnosis of both pulmonary oedema and pneumonia. He is put on high flow oxygen and treated with furosemide, GTN spray and morphine, and started on antibiotics.
      His breathlessness improves, and a repeat chest X-ray shows decreased pulmonary oedema. An ABG shows the following:
      pH: 7.01 (normal 7.35–7.45)
      p(CO2): 8 kPa (normal 4.5–6.0 kPa)
      p(O2): 11 kPa (normal 10–14 kPa)
      HCO3–: 18 mmol (normal 24–30 mmol/l)
      base excess: 1.2 mmol/l (normal −2 to +2.0 mmol/l)
      sodium: 142 mmol/l (normal 135–145 mmol/l)
      potassium: 5.9 mmol/l (normal 3.5–5.0 mmol/l)
      glucose: 7.5 mmol/l (normal 5–5.5 mmol/l)
      lactate: 3.1 mmol/l (normal 2.2–5 mmol/l).
      Based on the patient, which of the following does he have that is an indication for acute dialysis?

      Your Answer: Metabolic acidosis

      Explanation:

      Indications for Acute Dialysis: Assessing the Patient’s Condition

      When considering whether a patient requires acute dialysis, several factors must be taken into account. Severe metabolic acidosis with a pH below 7.2 is a clear indication for dialysis. Similarly, severe refractory hyperkalaemia with levels above 7 mmol/l may require dialysis, although standard measures to correct potassium levels should be attempted first. However, if the patient’s potassium levels are only mildly elevated, dialysis may not be necessary.

      A raised lactate level is not an indication for acute dialysis. Refractory pulmonary oedema, which has not responded to initial treatment with diuretics, may require dialysis. However, if the patient’s pulmonary oedema has responded to treatment, dialysis may not be necessary.

      In summary, the decision to initiate acute dialysis depends on a careful assessment of the patient’s condition, taking into account factors such as metabolic acidosis, hyperkalaemia, lactate levels, and pulmonary oedema.

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      • Renal
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  • Question 3 - A 60-year-old woman presents for review of her chronic kidney disease.
    Her investigation results...

    Correct

    • A 60-year-old woman presents for review of her chronic kidney disease.
      Her investigation results show:
      Investigation Result Normal range
      Calcium 1.70 mmol/l 2.20–2.60 mmol/l
      Potassium 6 mmol/l 3.5–5.0 mmol/l
      Phosphate 2.5 mmol/l 0.70–1.40 mmol/l
      Urea 80 mmol/l 2.5–6.5 mmol/l
      Creatinine 400 μmol/l 50–120 μmol/l
      What is the mechanism for the low calcium?

      Your Answer: Reduced vitamin D hydroxylation

      Explanation:

      This patient has hypocalcaemia due to chronic renal failure, which reduces the production of calcitriol, the active form of vitamin D that plays a crucial role in calcium absorption. Calcitriol increases the permeability of tight junctions in the small intestine, allowing for the absorption of calcium through both passive and active pathways. In the active pathway, calcitriol stimulates the production of calbindin, which helps transport calcium into the enteral cells. However, in chronic kidney disease, the hydroxylation of calcidiol to calcitriol is impaired, leading to reduced calcium absorption and hypocalcaemia. Other potential causes of hypocalcaemia, such as increased tubular loss of calcium or a parathyroid tumour, have been ruled out in this patient.

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      • Renal
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  • Question 4 - A 63-year-old man presented with fever, body ache and pedal oedema for three...

    Incorrect

    • A 63-year-old man presented with fever, body ache and pedal oedema for three months. He was taking oral diclofenac frequently for the aches. He had no other drug history and had not travelled recently.
      On examination, there was sternal tenderness. His blood report revealed:
      Investigation Result Normal range
      Haemoglobin 76 g/l 135–175 g/l
      White cell count (WCC) 9 × 109/l 4–11 × 109/l
      Erythrocyte sedimentation rate (ESR) 134 mm/hr 0–10mm in the 1st hour
      Platelets 280 × 109/l 150–400 × 109/l
      Urea 13 mmol/l 2.5–6.0 mmol/l
      Calcium 2.8 mmol/l 2.2–2.6 mmol/l
      What is the most likely cause of renal failure in this case?

      Your Answer: Hyperuricaemia

      Correct Answer: Light chain deposition

      Explanation:

      Understanding the Causes of Renal Failure in Multiple Myeloma

      Multiple myeloma is a rare but possible diagnosis in young adults, with a higher incidence in black populations and men. Renal failure is a common complication of this disease, with various possible causes. While NSAID use, hypercalcaemia, hyperuricaemia, and infiltration of the kidney by myeloma cells are all potential factors, the most common cause of renal failure in multiple myeloma is light chain deposition. This can lead to tubular toxicity and subsequent renal damage. Therefore, understanding the underlying causes of renal failure in multiple myeloma is crucial for effective management and treatment of this disease.

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      • Renal
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  • Question 5 - A 30-year-old man presents to the general practitioner (GP) with hypertension which fails...

    Correct

    • A 30-year-old man presents to the general practitioner (GP) with hypertension which fails to fall into the normal range after three successive measurements at the practice nurse. These were 155/92 mmHg, 158/96 mmHg and 154/94 mmHg. He has a past history of some urinary tract infections as a child. The GP arranges some routine blood tests.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 139 g/l 135–175 g/l
      White cell count (WCC) 5.4 × 109/l 4–11 × 109/l
      Platelets 201 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine 187 μmol/l 50–120 μmol/l
      USS Left kidney 8.4 cm and appears scarred.
      Right kidney 10.3 cm
      Which of the following is the most likely diagnosis?

      Your Answer: Chronic reflux nephropathy

      Explanation:

      Differential Diagnosis for a 25-Year-Old Man with Renal Issues

      Upon reviewing the history and test results of a 25-year-old man with renal issues, several potential diagnoses can be considered. Chronic reflux nephropathy appears to be the most likely diagnosis, given the patient’s history of urinary tract infections as a child, ultrasound scan results, and elevated creatinine levels. Further testing, such as renal tract computed tomography and a voiding cystourethrogram, can confirm this diagnosis.

      Essential hypertension, while a risk factor for reno-vascular disease, would not explain the patient’s creatinine rise or asymmetrical kidneys. Renal artery stenosis, while potentially causing a unilaterally reduced kidney size, is rare in young patients and does not fit with the patient’s history of urinary tract infections. White coat hypertension, which is a transient rise in blood pressure in a medical setting, would not explain the patient’s creatinine rise or reduced kidney size and scarring.

      IgA nephropathy, which typically presents with haematuria following an upper respiratory or other infection, does not fit with the patient’s history of urinary tract infections or lack of haematuria. Therefore, chronic reflux nephropathy remains the most likely diagnosis for this patient.

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      • Renal
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  • Question 6 - A middle-aged woman with a history of renal cell carcinoma complains of swelling...

    Correct

    • A middle-aged woman with a history of renal cell carcinoma complains of swelling in both legs extending from the groin area and dilated veins around the belly button. What is the underlying mechanism responsible for these symptoms?

      Your Answer: Inferior vena cava obstruction

      Explanation:

      Causes of Bilateral Lower Limb Edema: Differential Diagnosis

      Bilateral lower limb edema can have various causes, and a thorough differential diagnosis is necessary to determine the underlying condition. In this case, the patient presents with inferior vena cava obstruction, which is caused by extrinsic compression from a renal mass. This obstruction prevents venous drainage of the lower limbs and leads to bilateral edema and distended superficial abdominal veins. Other causes of bilateral lower limb edema include hyponatremia, hypoalbuminemia, deep venous thrombosis, and heart failure. However, each of these conditions presents with distinct symptoms and signs. Hyponatremia and hypoalbuminemia cause generalized edema, while deep venous thrombosis presents with painful swelling and erythema in the affected limb. Heart failure also causes bilateral dependent edema but does not lead to venous engorgement and dilated veins around the umbilicus. Therefore, a careful evaluation of the patient’s history, physical examination, and laboratory tests is crucial to establish the correct diagnosis and initiate appropriate treatment.

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      • Renal
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  • Question 7 - A 20-year-old African-Caribbean woman with sickle-cell anaemia presents with acute kidney injury. Her...

    Correct

    • A 20-year-old African-Caribbean woman with sickle-cell anaemia presents with acute kidney injury. Her only medication is hydroxycarbamide (hydroxyurea).
      What is the most probable reason for her condition?

      Your Answer: Renal papillary necrosis

      Explanation:

      Causes of Acute Kidney Injury

      Acute kidney injury (AKI) can be caused by various factors. One of the causes is renal papillary necrosis, which is commonly associated with sickle-cell anaemia. This occurs when sickled red blood cells cause infarction and necrosis of renal papillae. Other causes of renal papillary necrosis include diabetes mellitus, acute pyelonephritis, and chronic paracetamol use.

      Another cause of AKI is hypoperfusion of renal tubules from hypotension. This happens when there is a decrease in blood pressure due to shock or dehydration, leading to the hypoperfusion of renal tubules and acute tubular necrosis.

      Drug-induced interstitial nephritis is also a cause of AKI. This occurs when there is an allergic reaction to certain drugs such as non-steroidal anti-inflammatory drugs, antibiotics, and loop diuretics. Eosinophils in the urine are associated with this type of AKI.

      Pyelonephritis from Salmonella species is not a cause of AKI in patients with sickle-cell disease. However, diffuse cortical necrosis is a rare cause of AKI associated with disseminated intravascular coagulation, especially in obstetric emergencies such as abruptio placentae.

      In conclusion, AKI can be caused by various factors, and it is important to identify the underlying cause to provide appropriate treatment.

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      • Renal
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  • Question 8 - A 70-year-old woman with type II diabetes mellitus presents to the Emergency Department....

    Correct

    • A 70-year-old woman with type II diabetes mellitus presents to the Emergency Department. She was found to be confused at home by her son. According to her son, the patient is independent and able to take care of herself. On examination she has a temperature of 38.1 °C. Her blood pressure is 136/74 mmHg, and her heart rate is 110 bpm. She is disorientated and not able to provide any history. Physical examination is unremarkable except for tenderness elicited at the right lower back.
      Urine dipstick results are shown below:
      Investigation Result Normal value
      Colour Turbid Clear
      pH 6.7 7.35–7.45
      Glucose 2+ Negative
      Bilirubin Negative Negative
      Ketone 1+ Negative
      Nitrite 2+ Negative
      Leukocytes 3+ Negative
      Blood 1+ Negative
      Which of the following is the most likely diagnosis?

      Your Answer: Acute pyelonephritis

      Explanation:

      Pyelonephritis is an infection of the upper urinary tract system, including the kidney and ureter. Symptoms include fever, chills, flank pain, and costovertebral angle tenderness. Elderly patients may present with confusion, delirium, or urinary retention/incontinence. Positive nitrite and leukocytes in the urine suggest a urinary infection, while glucose and ketones may indicate chronic diabetes or starvation. Cystitis, a bladder infection, presents with dysuria, urinary frequency, urgency, and suprapubic tenderness. Renal stones cause dull pain at the costovertebral angle and positive blood on urine dipstick, but negative leukocytes and nitrites. Acute appendicitis in an elderly patient may be difficult to diagnose, but costovertebral angle tenderness and a positive urine dipstick suggest pyelonephritis. Prolapsed intervertebral disc causes chronic back pain and leg symptoms, but does not typically cause fever or delirium, and the tenderness is specific to pyelonephritis.

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      • Renal
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  • Question 9 - A 76-year-old woman is admitted to the hospital feeling generally unwell. She has...

    Correct

    • A 76-year-old woman is admitted to the hospital feeling generally unwell. She has also developed a fever and diffuse erythematous rash over the last few days. Urinalysis is positive for blood and protein, and blood tests show raised eosinophils and creatinine. Her General Practitioner started her on a new medication two weeks ago, but she cannot remember the name or what it was for.
      Which of the following drugs would be safe to continue at present, given the suspected diagnosis?

      Your Answer: Prednisolone

      Explanation:

      Drug-Induced Acute Tubulointerstitial Nephritis: Common Culprits and Management Options

      Acute tubulointerstitial nephritis is a condition characterized by fever, rash, and abnormalities on urinalysis. It can be caused by various drugs, including non-steroidal anti-inflammatory drugs (NSAIDs), beta-lactam antibiotics, allopurinol, and proton pump inhibitors (PPIs). In this case, the patient’s raised eosinophil count suggests drug-induced acute tubulointerstitial nephritis.

      Prednisolone, a steroid commonly used to manage this condition, is safe to continue. However, NSAIDs like diclofenac should be stopped as they can inhibit prostaglandins that maintain the glomerular filtration rate. Allopurinol may also need to be withdrawn to determine if it is contributing to the symptoms. Beta-lactam antibiotics like amoxicillin are another common cause and may need to be stopped. PPIs like omeprazole are a relatively rare but known trigger and should be withdrawn promptly. It is important to remember that steroids should not be suddenly stopped in most patients.

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      • Renal
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  • Question 10 - A 45-year-old writer presents to his routine follow up at the Nephrology Clinic...

    Correct

    • A 45-year-old writer presents to his routine follow up at the Nephrology Clinic complaining of numbness and tingling sensation of his right fingers. This worsens when he types for more than an hour and slightly improves when he stops typing. He suffers from diabetes mellitus and end-stage kidney disease and has been on regular haemodialysis via brachiocephalic fistula on his right antecubital fossa. On examination, his right radial artery is palpable and he has reduced sensation in all his right fingers, predominantly affecting the fingertips. The numbness does not worsen with tapping over the wrist nor with forced flexion of his wrists. His capillary refill time over his right fingers is prolonged to three seconds.
      Which of the following is the most likely diagnosis?

      Your Answer: Fistula steal syndrome

      Explanation:

      Differential Diagnosis for Numbness in a Patient with Arteriovenous Fistula

      Fistula Steal Syndrome, Carpal Tunnel Syndrome, and Diabetic Neuropathy are Possible Causes of Numbness in a Patient with Arteriovenous Fistula

      Arteriovenous fistula is a common procedure for patients undergoing hemodialysis. However, up to 20% of patients may develop complications such as fistula steal syndrome, which occurs when the segment of artery distal to the fistula is narrowed, leading to reduced arterial blood flow to the limb extremities. This can cause numbness and worsening of symptoms on usage of the hands.

      Other possible causes of numbness in this patient include carpal tunnel syndrome, which is a common complication among patients on long-term renal replacement therapy due to protein deposition in the carpal tunnel, and diabetic neuropathy, which is a common complication of chronic diabetes mellitus. However, the loss of sensation in peripheral neuropathy in diabetic patients is symmetrical in nature, commonly following a glove and stocking pattern.

      Radial nerve palsy and ulnar styloid fracture are less likely causes of numbness in this patient, as they typically present with muscle weakness and a history of trauma, respectively. A thorough differential diagnosis is necessary to determine the underlying cause of numbness in patients with arteriovenous fistula.

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      • Renal
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  • Question 11 - A 59-year-old man has been undergoing regular haemodialysis for the past 6 years....

    Correct

    • A 59-year-old man has been undergoing regular haemodialysis for the past 6 years. He previously had an AV fistula in his left arm, but it became infected 4 years ago and was no longer functional. Currently, he is receiving dialysis through an AV fistula in his right forearm. He presents with pain in his right hand and wrist. Upon examination, there is redness and a necrotic ulcer on his right middle finger. His right hand strength is normal. He is not experiencing any constitutional symptoms and is not taking any medications. He had undergone uncomplicated dialysis the day before. What is the likely diagnosis?

      Your Answer: Distal hypoperfusion ischaemic syndrome (DHIS)

      Explanation:

      Possible Complications of AV Fistula in Dialysis Patients

      AV fistula is a common vascular access for patients undergoing dialysis. However, it can lead to various complications, including distal hypoperfusion ischaemic syndrome (DHIS). DHIS, also known as steal syndrome, occurs when blood flow is shunted through the fistula, causing distal ischaemia, which can result in ulcers and necrosis. Surgical revision or banding of the fistula may be necessary in severe cases. Older patients with atherosclerotic arteries are more prone to DHIS. Other possible complications include unrelated local pathology, infected AV fistula, infective endocarditis, and thrombosis with distal embolisation. It is important to identify and manage these complications promptly to prevent further harm to the patient.

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      • Renal
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  • Question 12 - A 49-year-old man presents to the doctor with a week history of frank...

    Correct

    • A 49-year-old man presents to the doctor with a week history of frank haematuria. He has no other symptoms to note and is otherwise well although he has been a little tired. He has a history of hypertension which is well controlled on with perindopril. He smokes 10 cigarettes a day and has done so since his teens.
      Examination of the abdomen reveals no abnormalities. A dipstick test of the urine reveals blood +++.
      The patient is especially concerned that he may have a kidney tumour, as his father died from the condition over 20 years ago.
      Which of the following malignancies of the kidney the most common in the adult population ?

      Your Answer: Renal cell carcinoma

      Explanation:

      Types of Kidney Tumors: An Overview

      Kidney tumors are abnormal growths that can develop in different parts of the kidney. The most common type of kidney cancer in adults is renal cell carcinoma, which accounts for about 80% of all renal malignancies. Risk factors for this condition include obesity, hypertension, smoking, and certain genetic conditions. Family history of renal cell carcinoma also increases the risk of developing the disease. Symptoms may include blood in the urine, flank pain, abdominal mass, fatigue, and weight loss. Treatment options depend on the stage of the tumor and may include surgery, immunotherapy, chemotherapy, and radiotherapy.

      Other types of kidney tumors are much rarer. Primary renal lymphoma, for instance, is a very uncommon cancer that affects less than 1% of patients. Transitional cell carcinoma, also known as urothelial carcinoma, accounts for about 15% of all adult renal tumors and often starts in the renal pelvis. Renal sarcoma is a rare tumor that makes up less than 2% of all renal tumors in adults. Finally, nephroblastoma, or Wilms tumor, is the most common type of kidney cancer in children but is very rare in adults.

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      • Renal
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  • Question 13 - A 4-year-old child is brought to their General Practitioner (GP) with failure to...

    Correct

    • A 4-year-old child is brought to their General Practitioner (GP) with failure to thrive. His parents complain that he drinks a lot of water and urinates frequently and is not growing very well. The GP does blood and urine tests and diagnoses Fanconi syndrome.
      Which of the following features would you most likely see in Fanconi syndrome?

      Your Answer: Hypokalaemia

      Explanation:

      Understanding Fanconi Syndrome: Symptoms and Causes

      Fanconi syndrome is a condition that affects the function of the proximal convoluted tubule (PCT) in the kidneys, leading to a general impairment of reabsorption of amino acids, potassium, bicarbonate, phosphate, and glucose. This can be caused by various factors, including inherited disorders, acquired tubule damage, or idiopathic reasons. Common symptoms of Fanconi syndrome include polyuria, hypophosphatemia, acidosis, and hypokalemia. It is important to note that patients with Fanconi syndrome may experience oliguria due to the lack of reabsorption of solutes, leading to water loss. Contrary to popular belief, patients with Fanconi syndrome may experience acidosis rather than alkalosis due to the lack of reabsorption of bicarbonate in the PCT. Additionally, hypophosphatemia, rather than hyperphosphatemia, is seen in patients with Fanconi syndrome, as the impaired reabsorption of phosphate through the proximal tubules is a common feature. Finally, patients with Fanconi syndrome tend to present with hypokalemia rather than hyperkalemia due to the impaired reabsorption and increased secretion of potassium caused by the disturbance of the PCT.

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      • Renal
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  • Question 14 - A 6-year-old boy presents to the Emergency Department with periorbital pain, ascites, and...

    Correct

    • A 6-year-old boy presents to the Emergency Department with periorbital pain, ascites, and oedema. He has no past medical history and is typically healthy, without recent illnesses. Upon examination, his serum urea is elevated and protein in his urine is ++++. What is the probable cause of his symptoms?

      Your Answer: Minimal change glomerulonephritis

      Explanation:

      Overview of Different Types of Glomerulonephritis

      Glomerulonephritis is a group of kidney diseases that affect the glomeruli, the tiny blood vessels in the kidneys that filter waste and excess fluids from the blood. Here are some of the different types of glomerulonephritis:

      1. Minimal Change Glomerulonephritis: This is the most common cause of nephrotic syndrome in children. It is caused by T-cell-mediated injury to the podocytes of the epithelial cells. The diagnosis is made by electron microscopy, and treatment is with steroids.

      2. Membranous Glomerulonephritis: This is the second most common cause of nephrotic syndrome in adults. It can be primary or secondary, and some causes of secondary membranous glomerulonephritis include autoimmune conditions, malignancy, viral infections, and drugs. On light microscopy, the basement membrane has characteristic spikes.

      3. Mesangiocapillary Glomerulonephritis: This is associated with immune deposition in the glomerulus, thickening of the basement membrane, and activation of complement pathways leading to glomerular damage. It presents with nephrotic syndrome and is seen in both the pediatric and adult population. It is the most common glomerulonephritis associated with hepatitis C.

      4. Post-Streptococcal Glomerulonephritis: This presents with haematuria, oedema, hypertension, fever, or acute kidney failure following an upper respiratory tract infection or pharyngitis from Streptococcus spp.

      5. IgA Nephropathy Glomerulonephritis: This is a condition associated with IgA deposition within the glomerulus, presenting with haematuria following an upper respiratory tract infection. It is the most common cause of glomerulonephritis in adults.

      Understanding the Different Types of Glomerulonephritis

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      • Renal
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  • Question 15 - A 55-year-old man with chronic kidney disease has recently received a renal transplant....

    Correct

    • A 55-year-old man with chronic kidney disease has recently received a renal transplant. After three months he starts to feel unwell with flu-like symptoms, fever, and pain over the transplant area.
      What is the most likely type of reaction that has occurred in the patient?

      Your Answer: Acute graft failure

      Explanation:

      Understanding Different Types of Graft Failure After Transplantation

      Acute graft failure is a type of graft failure that occurs within six months after transplantation. If a patient presents with symptoms such as fever, flu-like symptoms, and pain over the transplant after three months, it may indicate acute graft failure. This type of failure is usually caused by mismatched human leukocyte antigen and may be reversible with steroids and immunosuppressants.

      Wound infection is not a likely cause of symptoms after three months since any wounds from the transplant would have healed by then. Chronic graft failure, on the other hand, occurs after six months to a year following the transplant and is caused by a combination of B- and T-cell-mediated immunity, infection, and previous occurrences of acute graft rejections.

      Hyperacute rejection is a rare type of graft failure that occurs within minutes to hours after transplantation. It happens because of pre-existing antibodies towards the donor before transplantation. In cases of hyperacute rejection, removal of the organ and re-transplantation is necessary.

      It is important to understand the different types of graft failure after transplantation to properly diagnose and treat patients who may be experiencing symptoms.

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      • Renal
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  • Question 16 - A 35-year-old teacher is tested for compatibility to donate a kidney to his...

    Correct

    • A 35-year-old teacher is tested for compatibility to donate a kidney to his older brother, who has end-stage renal failure. To his joy, he is found to be a suitable match. The patient is then thoroughly counselled regarding the operative procedure, short- and long-term risks, and the implications of living with one healthy kidney. He is particularly interested to learn how his body will adapt to having only one kidney.
      What will be decreased in the donor after the kidney transplant?

      Your Answer: Creatinine clearance

      Explanation:

      Effects of Kidney Donation on Renal Function and Electrolytes

      Kidney donation involves the removal of one healthy kidney, which can have various effects on the donor’s renal function and electrolyte levels. One notable change is a decrease in creatinine clearance due to the reduced number of glomeruli. However, creatinine production remains unaffected by the surgery and depends on factors such as muscle mass, diet, and activity.

      Serum sodium levels should remain stable as long as the remaining kidney functions properly. Similarly, serum potassium levels should not change if the remaining kidney is healthy. However, plasma creatinine concentration may initially increase after kidney donation due to hyperfiltration, but it will eventually plateau and decrease over time.

      Overall, kidney donation can have significant effects on the donor’s renal function and electrolyte levels, but with proper monitoring and care, most donors can lead healthy and normal lives with one kidney.

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      • Renal
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  • Question 17 - A 35-year-old woman with haematuria underwent a kidney biopsy, but light microscopy results...

    Correct

    • A 35-year-old woman with haematuria underwent a kidney biopsy, but light microscopy results were inconclusive. As a result, the specimen was sent for electron microscopy. Which renal disease requires electron microscopy for diagnosis?

      Your Answer: Thin membrane disease

      Explanation:

      Renal Diseases and their Diagnostic Methods

      Renal diseases can be diagnosed through various methods, including electron microscopy, blood tests, and renal biopsy. Here are some examples:

      Thin Membrane Disease: Electron microscopy is crucial in diagnosing thin membrane disease, as well as Alport syndrome and fibrillary glomerulopathy.

      Anti-GBM Disease: Blood tests for anti-GBM can confirm Goodpasture’s syndrome, but a renal biopsy can also be taken to show IgG deposits along the basement membrane.

      Lupus Nephritis: While electron microscopy can show dense immune deposits in lupus nephritis, diagnosis can also be made through immunofluorescence without the need for electron microscopy.

      IgA Nephropathy: A renal biopsy can confirm IgA nephropathy, showing mesangium proliferation and IgA deposits on immunofluorescence.

      Churg-Strauss Syndrome: Also known as eosinophilic granulomatosis with polyangiitis (EGPA), Churg-Strauss syndrome can be diagnosed through blood tests showing high eosinophils and ANCA, as well as renal biopsy showing eosinophil granulomas.

      Diagnostic Methods for Renal Diseases

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  • Question 18 - A 12-year-old male patient is referred to the renal physicians after several episodes...

    Correct

    • A 12-year-old male patient is referred to the renal physicians after several episodes of frank haematuria. He does not recall any abdominal or loin pain. He had an upper respiratory tract infection a few days ago. Urine dipstick shows blood, and blood tests are normal.
      What is the most likely diagnosis?

      Your Answer: IgA nephropathy

      Explanation:

      Differentiating Glomerulonephritis and Other Possible Causes of Haematuria in a Young Patient

      Haematuria in a young patient can be caused by various conditions, including glomerulonephritis, post-streptococcal glomerulonephritis, minimal change disease, sexually transmitted infections, and bladder cancer. IgA nephropathy, also known as Berger’s Disease, is the most common glomerulonephritis in the developed world and commonly affects young men. It presents with macroscopic haematuria a few days after a viral upper respiratory tract infection. A renal biopsy will show IgA deposits in the mesangium, and treatment is with steroids or cyclophosphamide if renal function is deteriorating.

      Post-streptococcal glomerulonephritis, on the other hand, presents in young children usually one to two weeks post-streptococcal infection with smoky urine and general malaise. Proteinuria is also expected in a glomerulonephritis. Minimal change disease is the most common cause of nephrotic syndrome in children and is associated with an upper respiratory tract infection. However, nephrotic syndrome involves proteinuria, which this patient does not have.

      It is also important to exclude sexually transmitted infections, as many are asymptomatic, but signs of infection and inflammation would likely show up on urine dipstick. Bladder cancer is unlikely in such a young patient devoid of other symptoms. Therefore, a thorough evaluation and proper diagnosis are necessary to determine the underlying cause of haematuria in a young patient.

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      • Renal
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  • Question 19 - A 52-year-old man with an acute kidney injury has developed fluid overload and...

    Correct

    • A 52-year-old man with an acute kidney injury has developed fluid overload and treatment has been initiated. An ABCDE assessment is performed, and the findings are below:
      Airway Patent, speaking but confused in conversation
      Breathing Respiratory rate (RR) 24/min, SaO2 96% on 4 litres of O2/min, bibasal crackles heard on auscultation in the lower zones (up to mid-zones on admission)
      Circulation Heart rate (HR) 112 bpm, blood pressure (BP) 107/68 mmHg, heart sounds disturbed by a friction rub, ECG shows sinus tachycardia
      Disability Pupils equal and reactive to light, normal upper and lower limb neurology, Glasgow Coma Scale (GCS) 14 (E4 V4 M6)
      Exposure Temperature 36.8°C
      On initial bloods, the C-reactive protein (CRP) is within normal limits.
      The results of initial arterial blood gas and serum urea and electrolytes are shown below:
      Investigation Result Normal value
      pH 7.28 7.35–7.45
      pO2 10.7 kPa > 11 kPa
      pCO2 5.7 kPa 4.5–6.0 kPa
      Bicarbonate 20 mmol/l 22–26 mmol/l
      Lactate 1.8 mmol/l < 2 mmol/l
      Urea 53 mmol/l 2.5–7.8 mmol/l
      Creatinine 729 µmol/l 50–120 µmol/l
      Which one of the following is an indication for urgent dialysis in this patient?

      Your Answer: Urea of 53 mmol/l

      Explanation:

      A raised urea level of 53 mmol/l, along with an audible friction rub on heart auscultation and reduced Glasgow Coma Scale (GCS), suggests uraemic pericarditis and uraemic encephalopathy respectively. Urgent dialysis is necessary if symptoms or complications occur due to uraemia. Hyperkalaemia with a K+ level >6.5, refractory to medical therapies, or associated with ECG changes, requires urgent dialysis. Life-threatening hyperkalaemia should be treated with medical therapies such as calcium gluconate, insulin-dextrose, and salbutamol. Metabolic acidaemia with a pH <7.1, refractory to medical therapies, is an indication for dialysis. Creatinine levels do not indicate when dialysis is required. Bibasal crackles may represent pulmonary oedema due to fluid overload, but if they respond to medical treatment, urgent dialysis is not necessary. However, if they are refractory to medical therapy, dialysis may be warranted.

    • This question is part of the following fields:

      • Renal
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  • Question 20 - A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently...

    Correct

    • A 16-year-old adolescent presents to the clinic with gross haematuria. He is currently suffering from a sinus infection. Apparently he had a previous episode of haematuria some 2 years earlier which was put down by the general practitioner to a urinary tract infection. Examination of notes from a previous Casualty attendance after a football game revealed microscopic haematuria on urine testing. On examination, his blood pressure is 130/70 mmHg. Physical examination is unremarkable.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 133 g/l 135–175 g/l
      White cell count (WCC) 8.2 × 109/l 4–11 × 109/l
      Platelets 240 × 109/l 150–400 × 109/l
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
      Creatinine 110 μmol/l 50–120 µmol/l
      Urine Blood ++, protein +
      C3 Normal
      Serum IgA Slight increase
      Which of the following is the most likely diagnosis?

      Your Answer: IgA nephropathy

      Explanation:

      Differential Diagnosis for Haematuria: A Case Study

      Haematuria, or blood in the urine, can be a concerning symptom for patients. In this case study, a patient presents with haematuria and a recent history of respiratory tract infection. The following differential diagnoses are considered:

      1. IgA nephropathy: This is the most common primary glomerulonephritis in adults and is often associated with a recent respiratory tract infection. Despite haematuria, renal function is usually preserved.

      2. Post-streptococcal glomerulonephritis: This diagnosis typically presents 2-4 weeks after a respiratory or skin infection. As the patient is still experiencing respiratory symptoms, this diagnosis is less likely.

      3. Lupus nephritis: This is a serious diagnosis that presents with haematuria, oedema, joint pain, and high blood pressure. As the patient does not exhibit these additional symptoms, this diagnosis is unlikely.

      4. Henoch-Schönlein purpura: This diagnosis is characterized by a rash, which the patient does not exhibit, making it less likely.

      5. Alport syndrome: This is a genetic condition that presents with kidney disease, hearing loss, and eye abnormalities.

      In conclusion, the patient’s recent respiratory tract infection and preserved renal function suggest IgA nephropathy as the most likely diagnosis. However, further testing and evaluation may be necessary to confirm the diagnosis.

    • This question is part of the following fields:

      • Renal
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