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  • Question 1 - A 20-year-old man visits his GP clinic with a chief complaint of headaches....

    Incorrect

    • A 20-year-old man visits his GP clinic with a chief complaint of headaches. During the physical examination, no abnormalities are detected, but his blood pressure is found to be 178/90 mmHg. The doctor suspects a renal origin for the hypertension and wants to perform an initial screening test for renovascular causes. What is the most appropriate investigation for this purpose?

      Your Answer: Urine albumin : creatinine ratio

      Correct Answer: Abdominal duplex ultrasound

      Explanation:

      Diagnostic Tests for Renal Hypertension

      Renal hypertension, or high blood pressure caused by kidney disease, can be diagnosed through various diagnostic tests. The appropriate initial screening investigation is an abdominal duplex ultrasound, which can detect renal vascular or anatomical pathologies such as renal artery stenosis or polycystic kidney disease. If abnormalities are found, more advanced testing such as a CTA, magnetic resonance angiography, or nuclear medicine testing may be necessary. However, an ultrasound is the best initial screening investigation for renal hypertension.

      A CTA is a follow-up test that may be performed if an initial abdominal duplex ultrasound suggests a renal cause for the hypertension. It is an advanced, specialist test that would not be appropriate as an initial screening investigation. On the other hand, a magnetic resonance angiography is an advanced, gold-standard test that can be performed if an initial abdominal duplex ultrasound suggests a renal cause for the hypertension.

      HbA1c is a blood test that tests your average blood glucose levels over the last 2–3 months. It can indicate if diabetes may have contributed to the hypertension, but will not clarify whether there is a renal cause. Lastly, a urine albumin: creatinine ratio tests for the presence of protein in the urine, which is a reflection of kidney disease, but does not give us any indication of the cause.

    • This question is part of the following fields:

      • Renal
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  • Question 2 - A 35-year-old woman presents with an incidental finding of a blood pressure of...

    Incorrect

    • A 35-year-old woman presents with an incidental finding of a blood pressure of 180/130 mmHg on three separate occasions. Her cardiovascular examination is unremarkable, but further investigation reveals a significantly smaller left kidney with a 'string of beads' appearance in the left renal artery. What is the most appropriate management option for this patient?

      Your Answer: Kidney transplantation

      Correct Answer: Balloon angioplasty

      Explanation:

      Management of Renal Artery Stenosis: Fibromuscular Dysplasia

      Fibromuscular dysplasia is a rare cause of renal artery stenosis, typically affecting young women and presenting with hypertension. The characteristic ‘string of beads’ appearance on CT imaging helps in diagnosis. While atherosclerotic disease is the most common cause of renal artery stenosis, a combination of antihypertensive therapy and renal artery balloon angioplasty is curative for fibromuscular dysplasia. Kidney transplantation is not usually required, but it is important to recognize the condition in donors to prevent complications in recipients. Nephrectomy is not typically necessary, and surgical reconstruction is rarely recommended. Statins are not used in the management of fibromuscular dysplasia, but may be used in atherosclerotic renal artery stenosis.

    • This question is part of the following fields:

      • Renal
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      Seconds
  • Question 3 - A patient with chronic kidney disease has a creatinine of 350 μmol/l and...

    Correct

    • A patient with chronic kidney disease has a creatinine of 350 μmol/l and has persistent proteinuria.
      Which one of the following drugs is most likely of benefit to his renal prognosis?

      Your Answer: Angiotensin converting enzyme (ACE) inhibitors

      Explanation:

      Treatment Options for Proteinuria and Renal Prognosis

      Proteinuria, the presence of excess protein in the urine, can be a sign of kidney damage or disease. Patients with proteinuria of any cause are at increased cardiovascular risk and require attention to modifiable risk factors such as smoking and hyperlipidemia. However, the renal prognosis can improve with the use of angiotensin converting enzyme (ACE) inhibitors, which are known to be effective in treating proteinuria. Aspirin and clopidogrel are not considered effective in improving renal outcomes for proteinuria. Blood pressure control is crucial in improving renal outcomes, and doxazosin may be useful in the right context. Methotrexate is not a recommended treatment option for proteinuria. Overall, ACE inhibitors remain the most effective treatment option for improving renal prognosis in patients with proteinuria.

    • This question is part of the following fields:

      • Renal
      19
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  • Question 4 - A 27-year-old woman presents to you with bilateral palpable flank masses and headaches....

    Incorrect

    • A 27-year-old woman presents to you with bilateral palpable flank masses and headaches. Her blood pressure is 170/100 mmHg and creatinine is 176.8 μmol/l. She has no past medical history of this, but her family history is significant for renal disease requiring transplant in her mother, brother and maternal grandmother.
      On which chromosome would genetic analysis most likely find an abnormality?

      Your Answer: Chromosome 3

      Correct Answer: Chromosome 16

      Explanation:

      This information provides a summary of genetic disorders associated with specific chromosomes and genes. For example, adult polycystic kidney disease is an autosomal dominant condition linked to mutations in the polycystin 1 (PKD1) gene on chromosome 16. This disease is characterized by the formation of multiple cysts in the kidneys, which can lead to renal failure and other symptoms such as hypertension, urinary tract infections, and liver and pancreatic cysts. Other important chromosome/disease pairs include BRCA2 on chromosome 13, which is associated with breast/ovarian/prostate cancers and Fanconi anemia, and the VHL gene on chromosome 3, which is linked to von Hippel-Lindau syndrome, a condition characterized by benign and malignant tumor formation on various organs of the body. Additionally, mutations in the FXN gene on chromosome 9 can result in Friedreich’s ataxia, a degenerative condition involving the nervous system and the heart, while a deletion of 22q11 on chromosome 22 can cause di George syndrome, a condition present at birth associated with cognitive impairment, facial abnormalities, and cardiac defects.

    • This question is part of the following fields:

      • Renal
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  • Question 5 - An 80-year-old man comes to his General Practitioner complaining of loin pain, haematuria...

    Incorrect

    • An 80-year-old man comes to his General Practitioner complaining of loin pain, haematuria and a palpable abdominal mass. He is diagnosed with renal clear cell carcinoma. Upon staging, it is discovered that the tumour has spread to the adrenal gland. What would be the primary management option for this patient?

      Your Answer: Radiofrequency ablation

      Correct Answer: Immunomodulatory drugs

      Explanation:

      Treatment Options for Stage 4 Renal Cancer with Metastases

      Loin pain, haematuria, and a palpable abdominal mass are the classic symptoms of renal cancer, which is not very common. When the cancer has metastasized to the adrenal gland, it becomes a stage 4 tumor. Targeted molecular therapy is the first-line treatment for stage 4 renal cancer with metastases. Immunomodulatory drugs such as sunitinib, temsirolimus, and nivolumab are commonly used for this purpose.

      Other treatment options for renal cancer include cryotherapy, partial nephrectomy, radiofrequency ablation, and radical nephrectomy. Cryotherapy uses liquid nitrogen to freeze cancerous cells, but it is usually only used for early-stage disease and is not first-line here. Partial nephrectomy is reserved for patients with small renal masses, usually stage 1. Radiofrequency ablation can be used for non-surgical candidates with small renal masses without metastasis, usually stage 1 or 2. Radical nephrectomy involves removal of the entire kidney, which is primarily done for stage 2 and 3 renal cell cancers.

    • This question is part of the following fields:

      • Renal
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  • Question 6 - A 54-year-old woman presents with back and flank pain affecting both sides. She...

    Correct

    • A 54-year-old woman presents with back and flank pain affecting both sides. She has been diagnosed some years ago with antiphospholipid antibody syndrome and has suffered from a previous deep vein thrombosis. On assessment, temperature is 36.7oC, heart rate is 76 bpm, blood pressure 128/80 mmHg and she is still passing urine.
      Investigations:
      Investigation Result Normal value
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 6.3 mmol/l 3.5–5.0 mmol/l
      Urea 17.3 mmol/l 2.5–6.5 mmol/l
      Creatinine 325 μmol/l 50–120 µmol/l
      Urine proteinuria +++
      Which of the following diagnoses fits best with this clinical scenario?

      Your Answer: Bilateral renal vein thrombosis

      Explanation:

      Possible Causes of Bilateral Flank Pain, Renal Failure, and Proteinuria

      Bilateral flank pain, renal failure, and marked proteinuria can be caused by various conditions. One possible diagnosis is bilateral renal vein thrombosis, especially if the patient has a history of antiphospholipid antibody syndrome and previous deep vein thrombosis. Other causes of renal vein thrombosis include extrinsic compression of the renal vein by a tumour or a retroperitoneal mass, invasion of the renal vein or inferior vena cava by a tumour, or nephrotic syndrome that increases coagulability. Abdominal ultrasound and angiography can help diagnose renal vein thrombosis, and anticoagulation is the main treatment.

      Bilateral ureteric obstruction can cause anuria, while bilateral pyelonephritis can cause sepsis and leukocytes and nitrites in the urine. Medullary sponge kidney, a congenital disorder that causes cystic dilation of the collecting ducts in one or both kidneys, may present with haematuria or nephrocalcinosis but does not affect renal function. Bilateral renal artery stenosis can cause uncontrollable hypertension and reduced renal function but not pain. Therefore, a thorough evaluation is necessary to determine the underlying cause of the patient’s symptoms.

    • This question is part of the following fields:

      • Renal
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  • Question 7 - A 32-year-old computer programmer presented with blood in the urine. It was painless...

    Incorrect

    • A 32-year-old computer programmer presented with blood in the urine. It was painless and not associated with any obstructive feature. On examination, his blood pressure was found to be 166/90 mmHg, although his earlier medical check-up 1 year ago was normal. His only past history was nephrotic syndrome 6 years ago, which was diagnosed histologically as minimal change disease and treated successfully. Urine examination revealed blood only with a trace of protein. He is not currently taking any drugs.
      What is the probable diagnosis?

      Your Answer: None of the above

      Correct Answer: Renal arteriovenous (AV) fistula

      Explanation:

      Possible Causes of Hypertension and Haematuria in a Patient with a History of Nephrotic Syndrome

      Renal arteriovenous (AV) fistula is a possible cause of hypertension and haematuria in a patient with a history of nephrotic syndrome. This condition may develop after renal biopsy or trauma, which are risk factors for the formation of renal AVMs. Acquired causes account for 70-80% of renal AVMs, and up to 15% of patients who undergo renal biopsy may develop renal fistulae. However, most patients remain asymptomatic. Hypertension in renal AVM is caused by relative renal hypoperfusion distal to the malformation, which activates the renin-angiotensin system. Pre-existing kidney disease is a risk factor for the development of AVM after biopsy. Renal AVMs may produce bruits in the flanks and vermiform blood clots in the urine. Sudden pain in a patient with renal AVM may be due to intrarenal haemorrhage or blood clot obstruction of the ureters. Renal vein thrombosis is unlikely in a patient in remission from nephrotic syndrome. Renal stones are not a likely cause of painless haematuria in this patient. Bladder carcinoma is not a likely cause of hypertension in a young patient without relevant environmental risk factors. Therefore, an AV fistula formation after biopsy is the most likely diagnosis.

      Possible Causes of Hypertension and Haematuria in a Patient with a History of Nephrotic Syndrome

    • This question is part of the following fields:

      • Renal
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  • Question 8 - A 43-year-old man is suspected of having a renal calculus. He has some...

    Correct

    • A 43-year-old man is suspected of having a renal calculus. He has some investigations carried out by the general practitioner to monitor the effects of his medication. The following results are obtained:
      Plasma
      Na+ 138 mmol/l (135–145 mmol/l)
      K+ 3.1 mmol/l (3.5–5 mmol/l)
      24-hour urine sample:
      Ca2+ 40 mg/day (100–300 mg/day)
      Given the results above, which one of the following is the patient most likely taking?

      Your Answer: Bendroflumethiazide

      Explanation:

      Overview of Different Types of Diuretics and Their Effects on Electrolytes and Renal Calculi Formation

      Diuretics are medications that increase urine output and are commonly used to treat conditions such as hypertension and edema. However, different types of diuretics have varying effects on electrolyte balance and renal calculi formation.

      Thiazide diuretics, such as bendroflumethiazide, work in the distal tubule of the nephron and result in sodium and potassium loss in urine, with calcium resorption. This makes them useful in controlling chronic renal calculi formation. However, they can also cause hypokalemia and hypercalcemia.

      Loop diuretics, such as furosemide, work in the thick ascending limb of the loop of Henle and result in sodium, potassium, and calcium loss in urine. This can increase the risk of renal calculi formation.

      Carbonic anhydrase inhibitors, such as acetazolamide, work in the proximal convoluted tubule and produce alkaline urine rich in bicarbonate. Continued use can lead to metabolic acidosis and an increased risk of renal calculi formation.

      Aldosterone antagonists, such as spironolactone, work in the distal part of the distal tubule and collecting tubules and inhibit aldosterone-mediated sodium absorption and potassium excretion. This can result in hyperkalemia.

      Mannitol, a osmotic diuretic, may cause hyponatremia but does not usually affect plasma potassium or urinary calcium excretion.

      Overall, understanding the different types of diuretics and their effects on electrolyte balance and renal calculi formation is important in selecting the appropriate medication for a patient’s specific needs.

    • This question is part of the following fields:

      • Renal
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  • Question 9 - A 42-year-old accountant presents to the General Practitioner (GP) with flank pain and...

    Incorrect

    • A 42-year-old accountant presents to the General Practitioner (GP) with flank pain and an episode of frank haematuria. She has a history of recurrent urinary tract infections (UTIs) and has had similar symptoms before. She attributes this episode to another UTI. She also has hypertension which is well controlled with ramipril. The doctor is concerned regarding the history of recurrent UTIs, and patient is further investigated for her symptoms with blood tests and ultrasound imaging. Results of the bloods and ultrasound confirms a diagnosis of polycystic kidney disease (PKD). Which of the following is true regarding PKD?

      Your Answer: Is usually inherited as an autosomal recessive condition

      Correct Answer: Is associated with berry aneurysms of the circle of Willis

      Explanation:

      Polycystic Kidney Disease: Causes, Symptoms, and Associations

      Polycystic kidney disease (PKD) is a genetic disorder that affects the kidneys and other organs. It is caused by mutations in either the PKD1 or PKD2 gene, which leads to the formation of multiple cysts in the kidneys. Here are some important facts about PKD:

      Associations with other conditions: PKD is associated with cerebral berry aneurysms, liver cysts, hepatic fibrosis, diverticular disease, pancreatic cysts, and mitral valve prolapse or aortic incompetence.

      Inheritance: PKD is usually inherited as an autosomal dominant condition, meaning that a person only needs to inherit one copy of the mutated gene from one parent to develop the disease. Autosomal recessive PKD is rare and has a poor prognosis.

      Kidney involvement: Both kidneys are affected by PKD, with cysts replacing the functioning renal parenchyma and leading to renal failure.

      Age of onset: PKD usually presents in adult life, but cysts start to develop during the teenage years. The mean age of ESRD is 57 years in PKD1 cases and 69 years in PKD2 cases.

      PKD is a complex disorder that can have serious consequences for affected individuals. Early diagnosis and management are crucial for improving outcomes.

    • This question is part of the following fields:

      • Renal
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  • Question 10 - A 40-year-old piano teacher presented to the Emergency Department with an acute kidney...

    Correct

    • A 40-year-old piano teacher presented to the Emergency Department with an acute kidney injury (AKI) and was referred to the renal team for urgent haemodialysis. Which of the following is not a reason for immediate dialysis?

      Your Answer: Alkalosis

      Explanation:

      Indications for Urgent Dialysis in Renal Failure Patients

      Dialysis is a life-saving treatment for patients with renal failure. Urgent dialysis is required in certain situations to prevent serious complications. Acidosis, not alkalosis, is an urgent indication for dialysis. Pulmonary edema caused by furosemide-resistant fluid overload is another indication for urgent dialysis. Severe hyperkalemia, with potassium levels greater than 6.5 mmol/l or less if electrocardiographic changes are apparent, is also an indication for dialysis. Severe uraemia, with symptoms such as vomiting, encephalopathy, and urea levels greater than 60 mmol/l, requires urgent dialysis. Uraemic pericarditis is another indication for urgent dialysis. It is important to recognize these indications and initiate dialysis promptly to prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Renal
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  • Question 11 - A 56-year-old teacher presents to the Emergency Department with nausea and vomiting, with...

    Correct

    • A 56-year-old teacher presents to the Emergency Department with nausea and vomiting, with associated lethargy. She has mild asthma which is well controlled with a steroid inhaler but has no other medical history of note. She does not smoke but drinks up to 20 units of alcohol a week, mostly on the weekends. Observations are as follows:
      Temperature is 37.2 oC, blood pressure is 110/70 mmHg, heart rate is 90 bpm and regular.
      On examination, the patient appears to be clinically dehydrated, but there are no other abnormalities noted.
      Blood tests reveal:
      Investigation Result Normal Values
      Haemoglobin (Hb) 140 g/l 135–175 g/l
      White cell count (WCC) 7.8 × 109/l 4–11 × 109/l
      Urea 8.5 mmol/l 2.5–6.5 mmol/l
      Creatinine 190 µmol/l
      (bloods carried out one year
      previously showed a creatinine
      of 80) 50–120 µmol/l
      Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
      Sodium (Na+) 133 mmol/l 135–145 mmol/l
      Which of the following is most suggestive of acute kidney injury rather than chronic renal failure?

      Your Answer: Oliguria

      Explanation:

      Signs and Symptoms of Acute and Chronic Renal Failure

      Renal failure can be acute or chronic, and it is important to differentiate between the two. Acute renal failure may present with symptoms such as acute lethargy, dehydration, shortness of breath, nausea and vomiting, oliguria, acute onset peripheral edema, confusion, seizures, and coma. On the other hand, chronic renal failure may present with symptoms such as anemia, pruritus, long-standing fatigue, weight loss, and reduced appetite. A history of underlying medical conditions such as diabetes or hypertension is also a risk factor for chronic kidney disease.

      Oliguria is a clinical hallmark of renal failure and can be one of the early signs of acute renal injury. Raised parathyroid hormone levels are more commonly found in chronic renal failure, while peripheral neuropathy is likely to be present in patients with chronic renal failure due to an underlying history of diabetes. Nocturia or nocturnal polyuria is often found in patients with chronic kidney disease, while in acute injury, urine output tends to be reduced rather than increased. Small kidneys are seen in chronic renal failure, while the kidneys are more likely to be of normal size in acute injury.

      Understanding the Signs and Symptoms of Acute and Chronic Renal Failure

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      • Renal
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  • Question 12 - A 67-year-old retired bus driver presents to the Emergency Department with end-stage renal...

    Incorrect

    • A 67-year-old retired bus driver presents to the Emergency Department with end-stage renal disease due to diabetic nephropathy. What is the most probable histological finding on kidney biopsy for this patient?

      Your Answer: Mesangial amyloid deposits

      Correct Answer: Kimmelstiel–Wilson nodules

      Explanation:

      Renal Biopsy Findings in Diabetic Nephropathy and Other Renal Diseases

      Diabetic nephropathy is a progressive kidney disease that damages the glomerular filtration barrier, leading to proteinuria. Renal biopsy is a diagnostic test that can reveal various findings associated with different renal diseases.

      Kimmelstiel–Wilson nodules are a hallmark of diabetic nephropathy, which are nodules of hyaline material that accumulate in the glomerulus. In contrast, immune complex deposition is commonly found in crescentic glomerulonephritis, anti-GBM disease, lupus, and IgA/post-infectious GN.

      Rouleaux formation, the abnormal stacking of red blood cells, is not associated with diabetic nephropathy but can cause diabetic retinopathy. Clear cells, a classification of renal cell carcinoma, are not a finding associated with diabetic nephropathy either.

      Finally, mesangial amyloid deposits are not associated with diabetic nephropathy but may be found in the mesangium, glomerular capillary walls, interstitium, or renal vessels in amyloidosis. Renal biopsy is a valuable tool in diagnosing and managing various renal diseases, including diabetic nephropathy.

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      • Renal
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  • Question 13 - A 58-year-old man is admitted with severe shortness of breath during the early...

    Incorrect

    • A 58-year-old man is admitted with severe shortness of breath during the early hours of the morning. Past history of note includes difficult-to-manage hypertension, for which he now takes amlodipine 10 mg, indapamide 1.5 mg and doxazosin 8 mg. He failed a trial of ramipril 1 year earlier due to a rise in his creatinine of 40% at the 1-week post-initiation stage. On examination, he has a blood pressure of 185/100 mmHg and a pulse of 100 bpm regular and is in frank pulmonary oedema. When you review his old notes, you find this is the second episode during the past 6 months. Echocardiography has shown a preserved ejection fraction. An electrocardiogram (ECG) reveals no abnormalities.
      Which of the following is the most likely diagnosis in this case?

      Your Answer: Nephritic syndrome

      Correct Answer: Renal artery stenosis

      Explanation:

      Differential diagnosis of hypertension with rising creatinine and pulmonary oedema

      When a patient presents with difficult-to-control hypertension and rising creatinine, accompanied by episodes of pulmonary oedema without signs of myocardial infarction, the differential diagnosis should include renovascular disease. Abdominal ultrasound may reveal kidneys of different sizes due to poor arterial supply to one side, but angiography or magnetic resonance angiograms are needed for confirmation. Vascular intervention, mainly via angioplasty, may improve the condition, but patients may have other arterial stenoses and be at risk of other vascular events.

      Renal vein thrombosis is another possible cause of rising creatinine, especially in nephrotic syndrome, but it tends to have an insidious onset. Phaeochromocytoma, a rare tumor that secretes catecholamines, can present with hypertension, palpitations, and flushing, but it is unlikely to cause a rise in creatinine after starting an ACE inhibitor. Myocardial infarction is ruled out by a normal ECG and preserved left ventricular ejection fraction. Nephritic syndrome, which is associated with hypertension and oedema, is also unlikely to cause a rise in creatinine after an ACE inhibitor trial.

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      • Renal
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  • Question 14 - An 80-year-old woman with a history of cervical carcinoma has been brought to...

    Correct

    • An 80-year-old woman with a history of cervical carcinoma has been brought to the Emergency Department in a confused and dehydrated state. Her blood tests reveal significant abnormalities, including a potassium level of 7.2 mmol/l (NR 3.5–4.9), creatinine level of 450 μmol/l (NR 60–110), and urea level of 31.2 mmol/l (NR 2.5–7.5). Upon retesting, her serum potassium remains elevated. What is the most appropriate initial management for this patient?

      Your Answer: Arrange continuous ECG monitoring and consider giving 10 ml of 10% calcium gluconate intravenous (IV)

      Explanation:

      Managing Hyperkalaemia in a Patient with Renal Dysfunction

      Hyperkalaemia is a medical emergency that requires prompt management. Once confirmed via a repeat blood sample, continuous ECG monitoring is necessary. For cardioprotection, 10 ml of 10% calcium gluconate IV should be considered. Insulin can also be administered to drive potassium ions from the extracellular to the intracellular compartment. A third blood sample is not necessary and may delay treatment. An urgent ultrasound scan should be arranged to determine the underlying cause of renal dysfunction. Furosemide should be reserved until fluid balance assessment results are known. Renal replacement therapy may be considered as a final option, but prognosis should be assessed first. Nebulised salbutamol may also have positive effects in reducing serum potassium, but IV administration carries a significant risk of arrhythmia. Correction of severe acidosis may exacerbate fluid retention in patients with kidney disease.

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      • Renal
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  • Question 15 - A 28-year-old man presents with sudden onset severe pain in his right loin....

    Incorrect

    • A 28-year-old man presents with sudden onset severe pain in his right loin. The pain began 3 hours ago just below the right side of his rib cage and has gradually moved down to his right groin, radiating into his right testis. He denies any visible haematuria. He is unable to tolerate physical examination and is writhing around on his bed.
      What is the most appropriate initial management?

      Your Answer: Morphine iv

      Correct Answer: Diclofenac im

      Explanation:

      The recommended pain relief for renal or ureteric colic is an im injection of diclofenac (75 mg), according to current NICE guidelines. If pain is severe, morphine can be used, but pethidine should be avoided due to its increased risk of vomiting. While paracetamol is appropriate for mild pain according to the WHO pain ladder, diclofenac has more evidence for relieving renal colic pains. Morphine is the top step on the WHO pain ladder, but its administration has several complications, including nausea and vomiting, constipation, confusion, and addiction. Diazepam could be the next step on the WHO pain ladder as a weak opioid, but morphine would be the next option if diclofenac failed to control pain.

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      • Renal
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  • Question 16 - A 60-year-old man has been asked to visit his GP because of abnormal...

    Correct

    • A 60-year-old man has been asked to visit his GP because of abnormal renal function tests for the past two months. His GFR reading has been consistently 35 ml/min. What stage of CKD is this patient exhibiting?

      Your Answer: This patient does not meet the criteria for CKD

      Explanation:

      Understanding Chronic Kidney Disease Stages

      Chronic Kidney Disease (CKD) is a condition that affects the kidneys and their ability to filter waste from the blood. To diagnose CKD, a patient must have a GFR (glomerular filtration rate) of less than 60 ml/min for at least three months. This is the primary criteria for CKD diagnosis.

      There are five stages of CKD, each with different GFR values and symptoms. Stage 1 CKD presents with a GFR greater than 90 ml/min and some signs of kidney damage. Stage 3a CKD presents with a GFR of 45-59 ml/min, while stage 3b CKD patients have a GFR of 30-44 ml/min. However, both stage 3a and 3b require the GFR to be present for at least three months.

      There is no stage 4a CKD. Instead, stage 4 CKD patients have a GFR of 15-29 ml/min. It is important to understand the different stages of CKD to properly diagnose and treat patients with this condition.

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      • Renal
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  • Question 17 - A 68-year-old woman was admitted to hospital seven days ago with moderate symptoms...

    Incorrect

    • A 68-year-old woman was admitted to hospital seven days ago with moderate symptoms of community-acquired pneumonia and was treated with amoxicillin. She has developed a fever, maculopapular skin rash and haematuria over the last two days. You suspect that her new symptoms may be due to acute tubulointerstitial nephritis caused by a reaction to the amoxicillin she was given.
      Which of the following investigations would provide a definitive diagnosis?

      Your Answer: Full blood count

      Correct Answer: Kidney biopsy

      Explanation:

      Investigations for Tubulointerstitial Nephritis

      Tubulointerstitial nephritis is a condition that affects the kidneys and can lead to renal failure if left untreated. There are several investigations that can be done to help diagnose this condition.

      Kidney Biopsy: This is the most definitive investigation for tubulointerstitial nephritis. It involves taking a small sample of kidney tissue for examination under a microscope. This is usually only done if other tests have been inconclusive or if the diagnosis is unclear.

      Full Blood Count: This test can help identify the presence of eosinophilia, which is often seen in cases of tubulointerstitial nephritis. However, the absence of eosinophilia does not rule out the condition.

      Kidney Ultrasound: This test can help rule out other conditions such as chronic renal failure, hydronephrosis, or renal calculi. In cases of tubulointerstitial nephritis, the kidneys may appear enlarged and echogenic due to inflammation.

      Serum Urea and Electrolytes: This test measures the levels of urea and creatinine in the blood, which can be elevated in cases of tubulointerstitial nephritis.

      Urinalysis: This test can detect the presence of low-grade proteinuria, white blood cell casts, and sterile pyuria, which are all indicative of tubulointerstitial nephritis. However, it is not a definitive diagnostic tool.

      In conclusion, a combination of these investigations can help diagnose tubulointerstitial nephritis and guide appropriate treatment.

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      • Renal
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  • Question 18 - A 38-year-old woman with a history of systemic lupus erythematosus and recently diagnosed...

    Correct

    • A 38-year-old woman with a history of systemic lupus erythematosus and recently diagnosed with CKD stage G3a (GFR 45 ml/min/1.73 m2) is seen by her GP. The GP notes that the patient has a BP of 152/90 mmHg, which is persistently elevated on two further readings taken on separate occasions by the practice nurse. The patient has no past history of hypertension. What is the most appropriate management for the patient's hypertension?

      Your Answer: Lisinopril

      Explanation:

      Management of Hypertension in Chronic Kidney Disease

      Chronic kidney disease (CKD) requires careful management of hypertension to slow the progression of renal disease. The recommended first-line treatment for hypertension in CKD is angiotensin-converting enzyme inhibitors (ACEis), which should maintain systolic BP < 140 mmHg and diastolic BP < 90 mmHg. Before starting ACEi treatment, serum potassium concentrations and estimated glomerular filtration rate (GFR) should be measured and monitored regularly. While ACEis and angiotensin receptor antagonists (ARBs) may be used as first-line treatments, they should not be used concurrently due to the risk of hyperkalaemia and hypotension. Potassium-sparing diuretics, such as amiloride, should also be avoided in renal impairment due to the risk of hyperkalaemia. In addition to medication, dietary modification and exercise advice can also help manage hypertension in CKD patients. If hypertension is not controlled with an ACEi or ARB alone, thiazide diuretics like bendroflumethiazide may be added as second-line therapy. Overall, careful management of hypertension is crucial in CKD patients to slow the progression of renal disease and improve outcomes.

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      • Renal
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  • Question 19 - A 7-year-old girl presents with haematuria, hearing loss, and poor eyesight caused by...

    Correct

    • A 7-year-old girl presents with haematuria, hearing loss, and poor eyesight caused by lens dislocation. After conducting additional tests, the diagnosis of Alport syndrome is made. What type of collagen is typically affected by a molecular defect in this disease?

      Your Answer: Type IV

      Explanation:

      Types and Effects of Collagen Defects on Human Health

      Collagen is an essential protein that provides structural support to various tissues in the human body. Defects in different types of collagen can lead to various health conditions. Type IV collagen is crucial for the integrity of the basement membrane, and mutations in its genes can cause Alport syndrome, resulting in haematuria, hearing loss, and visual disturbances. Type III collagen defects cause Ehlers–Danlos syndrome, characterized by joint hypermobility, severe bruising, and blood vessel defects. Type I collagen defects lead to osteogenesis imperfecta, characterized by brittle bones, abnormal teeth, and weak tendons. Kniest dysplasia is caused by defects in type II collagen, leading to short stature, poor joint mobility, and eventual blindness. Kindler syndrome is characterized by the absence of epidermal anchoring fibrils due to defects in type VII collagen, resulting in skin fragility. Understanding the effects of collagen defects on human health is crucial for diagnosis and treatment of these conditions.

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      • Renal
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  • Question 20 - A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever,...

    Incorrect

    • A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever, left mid-back pain and occasional chills. He has no dysuria or haematuria. The left renal angle is tender. The white cell count is 27.8 × 109/l, with 92% of neutrophils (54–62%). What is the most appropriate diagnostic tool to confirm the suspected diagnosis?

      Your Answer: Urine culture

      Correct Answer: Blood culture

      Explanation:

      Diagnosing and Treating Infection in Kidney Cysts: Medical Tests and Procedures

      Infection in kidney cysts is a common complication in patients with polycystic kidney disease (PKD). However, diagnosing and treating this condition can be challenging. Here are some medical tests and procedures that are commonly used to diagnose and treat infection in kidney cysts.

      Blood Culture
      Blood cultures are more reliable than urine cultures in detecting infection in kidney cysts. Gram-negative bacteria are the most common cause of infection in these cases. Antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. Treatment may last for 4-6 weeks, and surgical drainage may be necessary in some cases.

      Computed Tomography (CT) Scan of the Abdomen
      CT scans can detect internal echoes in one or more cysts, but they cannot differentiate between infection and hemorrhage. Therefore, CT scans alone cannot confirm an infection.

      Urine Culture
      Urine cultures may be unreliable in detecting infection in kidney cysts because cysts often have no communication with the collecting system.

      Ultrasonography of the Kidneys
      Ultrasonography can detect internal echoes within a cyst, but it cannot differentiate between infection and hemorrhage.

      Scintiscan of the Kidneys
      Scintiscans are not used to diagnose infected cysts.

      In conclusion, diagnosing and treating infection in kidney cysts can be challenging. Blood cultures are the most reliable test for detecting infection, and antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. CT scans and ultrasonography can detect internal echoes in cysts, but they cannot differentiate between infection and hemorrhage.

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      • Renal
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  • Question 21 - A 54-year-old woman with a long-standing history of poorly controlled type 2 diabetes...

    Incorrect

    • A 54-year-old woman with a long-standing history of poorly controlled type 2 diabetes mellitus presents to clinic complaining of swelling in her ankles, face and fingers. She states she can no longer wear her wedding ring because her fingers are too swollen. On examination, her blood pressure is 150/90 mmHg; she has pitting oedema in her ankles and notably swollen fingers and face. Her blood results show:
      Investigation Results Normal value
      Creatinine 353.6 μmol/l 50–120 μmol/l
      Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
      Phosphate 1.9 mmol/l 0.70–1.40 mmol/l
      Parathyroid hormone (PTH) Elevated
      Urinalysis 3+ glucose, 3+ protein
      Which of the following is the most likely mechanism of this woman's increased PTH?

      Your Answer: Increased 1, 25-dihydroxycholecalciferol

      Correct Answer: Decreased glomerular filtration rate (GFR)

      Explanation:

      Understanding the Causes of Secondary Hyperparathyroidism

      Secondary hyperparathyroidism is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH) in response to low calcium levels in the blood. This can be caused by a variety of factors, including chronic renal failure, vitamin D excess, and the use of certain medications like diuretics.

      In cases of chronic renal failure, decreased glomerular filtration rate (GFR) can lead to raised creatinine levels and proteinuria. This can cause diabetic nephropathy, which can result in hyperphosphataemia and secondary hyperparathyroidism. Over time, this can also lead to osteoporosis as a long-term complication of hyperparathyroidism.

      Vitamin D excess is another cause of secondary hyperparathyroidism, but it is associated with low phosphate levels rather than hyperphosphataemia. In cases of parathyroid adenoma, a less likely cause in this patient, there is an overproduction of PTH by a benign tumor in the parathyroid gland.

      Finally, the use of diuretics can increase phosphate excretion, leading to hypophosphataemia. This can also contribute to the development of secondary hyperparathyroidism.

      Understanding the various causes of secondary hyperparathyroidism is important for proper diagnosis and treatment. By addressing the underlying condition, it may be possible to reduce the production of PTH and prevent further complications.

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  • Question 22 - A 30-year-old woman presents to the Renal Clinic for review. She has suffered...

    Incorrect

    • A 30-year-old woman presents to the Renal Clinic for review. She has suffered from two recent urinary tract infections, and asymptomatic haematuria has been noted on urine dipstick testing on two separate occasions. She reports costovertebral angle tenderness on a few occasions in the past year. On examination, there is no residual tenderness today. Her blood pressure is 145/92 mmHg.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 119 g/l 115–155 g/l
      White cell count (WCC) 6.2 × 109/l 4–11 × 109/l
      Platelets 256 × 109/l 150–400 × 109/l
      Sodium (Na+) 145 mmol/l 135–145 mmol/l
      Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Abdominal plain X-ray Multiple pre-calyceal calcifications
      affecting both kidneys, with a
      ‘bunch of grapes’ appearance
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer: Autosomal dominant polycystic kidney disease

      Correct Answer: Medullary sponge kidney

      Explanation:

      Understanding Medullary Sponge Kidney: Symptoms and Differential Diagnosis

      Medullary sponge kidney is a condition that is often asymptomatic and has a benign course. However, some patients may experience haematuria, urinary tract infections, or costovertebral angle pain due to renal stone formation. The diagnosis can be confirmed through abdominal X-ray, which shows characteristic findings consistent with medullary sponge kidney.

      Recurrent urinary tract infections would not be associated with the X-ray findings, and neither would autosomal dominant polycystic kidney disease, which is a serious condition that leads to renal failure. Renal tuberculosis is unlikely to present with the X-ray findings, and reflux nephropathy, which is often diagnosed in childhood, would not lead to the same X-ray results.

      Patients with medullary sponge kidney who are asymptomatic can be reassured about the benign nature of the condition. Those with recurrent urinary tract infections or stone formation should be advised to increase their oral fluid intake. Understanding the symptoms and differential diagnosis of medullary sponge kidney is important for proper management and treatment.

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      • Renal
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  • Question 23 - A 62-year-old woman with a history of type II diabetes comes in for...

    Incorrect

    • A 62-year-old woman with a history of type II diabetes comes in for her yearly check-up. Her most recent early morning urinary albumin : creatinine ratio (ACR) is 4 mg/mmol (normal for women: < 3.5 mg/mmol). What should be the target blood pressure for managing her diabetic nephropathy?

      Your Answer: 140/80 mmHg

      Correct Answer: 130/80 mmHg

      Explanation:

      Blood Pressure Targets for Patients with Diabetes

      Blood pressure targets vary depending on the type of diabetes and the presence of co-morbidities. For patients with type II diabetes and signs of end-organ damage, the target is 130/80 mmHg. Ideal blood pressure for most people is between 90/60 mmHg and 120/80 mmHg. Patients with type I diabetes without albuminuria or > 2 features of metabolic syndrome have a target of 135/85 mmHg. Type II diabetics without signs of end-organ damage have a target of 140/80 mmHg. For patients over 80 years old, the target is 150/90 mmHg. It is important for patients with diabetes to work with their healthcare provider to determine their individual blood pressure target.

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      • Renal
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  • Question 24 - What is the correct statement regarding the juxtaglomerular apparatus? ...

    Correct

    • What is the correct statement regarding the juxtaglomerular apparatus?

      Your Answer: A fall in pressure in the afferent arteriole promotes renin secretion

      Explanation:

      Renin secretion and the role of the macula densa and juxtaglomerular cells

      Renin is an enzyme that plays a crucial role in regulating blood pressure and fluid balance in the body. It is secreted by juxtaglomerular cells, which are modified smooth muscle cells located in the wall of the afferent arterioles. Renin secretion is stimulated by a fall in renal perfusion pressure, which can be detected by baroreceptors in the afferent arterioles. Additionally, reduced sodium delivery to the macula densa, a specialized region of the distal convoluted tubule, can also stimulate renin production. However, it is important to note that the macula densa itself does not secrete renin. Understanding the mechanisms behind renin secretion can help in the diagnosis and treatment of conditions such as hypertension and kidney disease.

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      • Renal
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  • Question 25 - A 72-year-old man comes to the Emergency Department with haematuria and haemoptysis. His...

    Incorrect

    • A 72-year-old man comes to the Emergency Department with haematuria and haemoptysis. His vital signs are heart rate 88 bpm, blood pressure 170/110 mmHg, respiratory rate 22 breaths per minute, and temperature 37.8 °C. Urinalysis shows protein and red cell casts. Serum testing reveals antibodies to the glomerular basement membrane. A renal biopsy is conducted.
      What is the probable finding in the renal biopsy?

      Your Answer: Immune complex deposition in the basement membrane

      Correct Answer: Linear immunofluorescence

      Explanation:

      Different Renal Pathologies and their Histological Features

      Nephritic syndrome is a condition characterized by proteinuria, haematuria, and hypertension. Anti-glomerular basement membrane antibodies suggest hypersensitivity angiitis (Goodpasture’s syndrome) as the underlying cause. In hypersensitivity angiitis, crescents are seen on light microscopy of a renal biopsy specimen. Immunofluorescence shows linear IgG deposits along the basement membrane.

      Diffuse membranous glomerulonephritis is characterized by ‘wire looping’ of capillaries. Hereditary nephritis (Alport syndrome) shows splitting of the basement membrane and is associated with deafness. Acute post-streptococcal glomerulonephritis, typically seen in children, shows a ‘lumpy bumpy’ appearance of the glomeruli. Immunoglobulin A (IgA) nephropathy is characterized by immune complex deposition in the basement membrane.

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      • Renal
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SESSION STATS - PERFORMANCE PER SPECIALTY

Renal (10/25) 40%
Passmed