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  • Question 1 - A 58-year-old woman is having surgery for Conns syndrome and experiences bleeding due...

    Incorrect

    • A 58-year-old woman is having surgery for Conns syndrome and experiences bleeding due to damage to the middle adrenal artery. Where does this vessel originate from?

      Your Answer: Renal artery

      Correct Answer: Aorta

      Explanation:

      The aorta usually gives rise to the middle adrenal artery, while the renal vessels typically give rise to the lower adrenal artery.

      Adrenal Gland Anatomy

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

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

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

    • This question is part of the following fields:

      • Renal System
      21.9
      Seconds
  • Question 2 - A 72-year-old man, with a past medical history of diabetes, hypertension and stable...

    Incorrect

    • A 72-year-old man, with a past medical history of diabetes, hypertension and stable angina visits his family physician for a routine check-up. He is currently taking metoprolol, daily aspirin and insulin glargine. He lives alone and is able to manage his daily activities. He used to work as a teacher and his wife passed away from a stroke 5 years ago. During the examination, his heart rate is 60 beats per minute, respiratory rate is 14 breaths per minute and blood pressure is 125/80 mmHg. What is the direct effect of the metoprolol medication on this patient?

      Your Answer: Dilation of arterioles

      Correct Answer: Decrease in renin secretion

      Explanation:

      During the patient’s regular follow-up for diabetes and hypertension management, it was noted that both conditions increase the risk of cardiovascular complications and other related complications such as kidney and eye problems. To manage hypertension, the patient was prescribed metoprolol, a beta-blocker that reduces blood pressure by decreasing heart rate and cardiac output. Additionally, metoprolol blocks beta-1 adrenergic receptors in the juxtaglomerular apparatus of the kidneys, leading to a decrease in renin secretion. Renin is responsible for converting angiotensinogen to angiotensin I, which is further converted to angiotensin II, a hormone that increases blood pressure through vasoconstriction and sodium retention. By blocking renin secretion, metoprolol causes a decrease in blood pressure. Other antihypertensive medications work through different mechanisms, such as calcium channel blockers that dilate arterioles, ACE inhibitors that decrease angiotensin II secretion, and beta-blockers that decrease renin secretion.

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

    • This question is part of the following fields:

      • Renal System
      104.7
      Seconds
  • Question 3 - A patient with compromised kidney function is given a new medication that is...

    Incorrect

    • A patient with compromised kidney function is given a new medication that is typically eliminated through renal excretion. What factors might impact the excretion of the medication?

      Your Answer: Diffusivity across the basement membrane

      Correct Answer: Diffusivity across the basement membrane and tubular secretion/reabsorption

      Explanation:

      The clearance of a substance in the kidneys is influenced by two important factors: diffusivity across the basement membrane and tubular secretion/reabsorption. Additionally, the Loop of Henle plays a crucial role in generating a significant osmotic gradient, while the primary function of the collecting duct is to facilitate the reabsorption of water.

      The Loop of Henle and its Role in Renal Physiology

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

    • This question is part of the following fields:

      • Renal System
      157.6
      Seconds
  • Question 4 - A 30-year-old female visits her GP complaining of ankle swelling. During the examination,...

    Correct

    • A 30-year-old female visits her GP complaining of ankle swelling. During the examination, her blood pressure is found to be 180/110 mmHg and a urine dipstick reveals protein +++ levels. She is referred to a nephrologist who performs a renal biopsy. The biopsy results show basement membrane thickening on light microscopy and subepithelial spikes on silver staining. Immunohistochemistry confirms the presence of PLA2. What is the probable diagnosis?

      Your Answer: Membranous glomerulonephritis

      Explanation:

      Membranous glomerulonephritis is the most common type of glomerulonephritis in adults and is the third leading cause of end-stage renal failure. It typically presents with proteinuria or nephrotic syndrome. A renal biopsy will show a thickened basement membrane with subepithelial electron dense deposits, creating a spike and dome appearance. The condition can be caused by various factors, including infections, malignancy, drugs, autoimmune diseases, and idiopathic reasons.

      Management of membranous glomerulonephritis involves the use of ACE inhibitors or ARBs to reduce proteinuria and improve prognosis. Immunosuppression may be necessary for patients with severe or progressive disease, but many patients spontaneously improve. Corticosteroids alone are not effective, and a combination of corticosteroid and another agent such as cyclophosphamide is often used. Anticoagulation may be considered for high-risk patients.

      The prognosis for membranous glomerulonephritis follows the rule of thirds: one-third of patients experience spontaneous remission, one-third remain proteinuric, and one-third develop end-stage renal failure. Good prognostic factors include female sex, young age at presentation, and asymptomatic proteinuria of a modest degree at the time of diagnosis.

    • This question is part of the following fields:

      • Renal System
      37.8
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  • Question 5 - A 65-year-old man with type 2 diabetes mellitus is undergoing his annual diabetic...

    Correct

    • A 65-year-old man with type 2 diabetes mellitus is undergoing his annual diabetic examination. He reports feeling more fatigued than usual and has missed his previous three annual check-ups. His blood glucose control has been inadequate, and he has not been adhering to his medications. His blood pressure measures 170/90 mmHg, and a urinalysis reveals microalbuminuria. A blood test shows that his glomerular filtration rate (GFR) is 27mL/min per 1.73m².

      Assuming a renal biopsy is conducted on this patient, what are the anticipated findings?

      Your Answer: Nodular glomerulosclerosis and hyaline arteriosclerosis

      Explanation:

      The patient in question is suffering from T2DM that is poorly controlled, resulting in diabetic nephropathy. The histological examination reveals the presence of Kimmelstiel-Wilson lesions (nodular glomerulosclerosis) and hyaline arteriosclerosis, which are caused by nonenzymatic glycosylation.

      Amyloidosis is characterized by apple-green birefringence under polarised light.

      Acute post-streptococcal glomerulonephritis is identified by enlarged and hypercellular glomeruli.

      Rapidly progressive (crescentic) glomerulonephritis is characterized by crescent moon-shaped glomeruli.

      Diffuse proliferative glomerulonephritis (often due to SLE) is identified by wire looping of capillaries in the glomeruli.

      Understanding Diabetic Nephropathy: The Common Cause of End-Stage Renal Disease

      Diabetic nephropathy is the leading cause of end-stage renal disease in the western world. It affects approximately 33% of patients with type 1 diabetes mellitus by the age of 40 years, and around 5-10% of patients with type 1 diabetes mellitus develop end-stage renal disease. The pathophysiology of diabetic nephropathy is not fully understood, but changes to the haemodynamics of the glomerulus, such as increased glomerular capillary pressure, and non-enzymatic glycosylation of the basement membrane are thought to play a key role. Histological changes include basement membrane thickening, capillary obliteration, mesangial widening, and the development of nodular hyaline areas in the glomeruli, known as Kimmelstiel-Wilson nodules.

      There are both modifiable and non-modifiable risk factors for developing diabetic nephropathy. Modifiable risk factors include hypertension, hyperlipidaemia, smoking, poor glycaemic control, and raised dietary protein. On the other hand, non-modifiable risk factors include male sex, duration of diabetes, and genetic predisposition, such as ACE gene polymorphisms. Understanding these risk factors and the pathophysiology of diabetic nephropathy is crucial in the prevention and management of this condition.

    • This question is part of the following fields:

      • Renal System
      61.1
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  • Question 6 - A 65-year-old man visits the haemofiltration unit thrice a week for treatment. What...

    Incorrect

    • A 65-year-old man visits the haemofiltration unit thrice a week for treatment. What is responsible for detecting alterations in salt concentrations, such as sodium chloride, in normally functioning kidneys and adjusting the glomerular filtration rate accordingly?

      Your Answer: Juxtaglomerular cells

      Correct Answer: Macula densa

      Explanation:

      The macula densa is a specialized area of columnar tubule cells located in the final part of the ascending loop of Henle. These cells are in contact with the afferent arteriole and play a crucial role in detecting the concentration of sodium chloride in the convoluted tubules and ascending loop of Henle. This detection is affected by the glomerular filtration rate (GFR), which is increased by an increase in blood pressure. When the macula densa detects high sodium chloride levels, it releases ATP and adenosine, which constrict the afferent arteriole and lower GFR. Conversely, when low sodium chloride levels are detected, the macula densa releases nitric oxide, which acts as a vasodilator. The macula densa can also increase renin production from the juxtaglomerular cells.

      Juxtaglomerular cells are smooth muscle cells located mainly in the walls of the afferent arteriole. They act as baroreceptors to detect changes in blood pressure and can secrete renin.

      Mesangial cells are located at the junction of the afferent and efferent arterioles and, together with the juxtaglomerular cells and the macula densa, form the juxtaglomerular apparatus.

      Podocytes, which are modified simple squamous epithelial cells with foot-like projections, make up the innermost layer of the Bowman’s capsule surrounding the glomerular capillaries. They assist in glomerular filtration.

      The Loop of Henle and its Role in Renal Physiology

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

    • This question is part of the following fields:

      • Renal System
      33.9
      Seconds
  • Question 7 - A 42-year-old man visits the clinic complaining of a tickly cough that has...

    Correct

    • A 42-year-old man visits the clinic complaining of a tickly cough that has been bothering him for the past two weeks. He reports no other symptoms and his respiratory exam appears normal. The patient recently began taking an ACE inhibitor, which you suspect may be the cause of his cough. You decide to switch him to an angiotensin receptor blocker instead. Many antihypertensive medications target components of the renin-angiotensin-aldosterone system. Which enzyme catalyzes the hydrolysis of angiotensinogen to produce the hormone angiotensin I, an important player in this system?

      Your Answer: Renin

      Explanation:

      The kidneys produce renin in their juxtaglomerular cells, which plays a crucial role in the renin-angiotensin-aldosterone system. This enzyme converts angiotensinogen into angiotensin I through a hydrolysis reaction. More information on this system can be found below.

      Another important enzyme in this system is angiotensin-converting-enzyme (ACE), which is primarily located in the lungs but can also be found in smaller quantities in endothelial cells of the vasculature and kidney epithelial cells. ACE converts angiotensin I to angiotensin II and is the target of ACE inhibitors.

      Carbonic anhydrase is an enzyme that facilitates the reaction between water and carbon dioxide to form bicarbonate, and it can also catalyze the reverse reaction. Carbonic anhydrase inhibitors target this enzyme.

      Cyclooxygenase-2 (COX-2) is involved in the synthesis of prostaglandins, and NSAIDs are believed to work by inhibiting both COX-1 and COX-2 enzymes.

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

    • This question is part of the following fields:

      • Renal System
      50.6
      Seconds
  • Question 8 - A 20-year-old patient visits their GP complaining of non-specific malaise. The patient has...

    Incorrect

    • A 20-year-old patient visits their GP complaining of non-specific malaise. The patient has a medical history of recurrent haematuria during childhood with infections and fever, as well as bilateral mild sensorineural hearing loss. Due to frequent moves between countries, the patient has never had continuous medical care. Further investigations reveal proteinuria and haematuria, leading to a referral to secondary care and a subsequent renal biopsy. The biopsy results show splitting of the lamina densa on electron microscopy.

      What is the most common mode of inheritance for this likely diagnosis?

      Your Answer: X-linked recessive

      Correct Answer: X-linked dominant

      Explanation:

      Alport’s syndrome is a genetic disorder that is typically inherited in an X-linked dominant pattern. It is caused by a defect in the gene responsible for producing type IV collagen, which leads to an abnormal glomerular-basement membrane (GBM). The disease is more severe in males, with females rarely developing renal failure. Symptoms usually present in childhood and may include microscopic haematuria, progressive renal failure, bilateral sensorineural deafness, lenticonus, retinitis pigmentosa, and splitting of the lamina densa seen on electron microscopy. In some cases, an Alport’s patient with a failing renal transplant may have anti-GBM antibodies, leading to a Goodpasture’s syndrome-like picture. Diagnosis can be made through molecular genetic testing, renal biopsy, or electron microscopy. In around 85% of cases, the syndrome is inherited in an X-linked dominant pattern, while 10-15% of cases are inherited in an autosomal recessive fashion, with rare autosomal dominant variants existing.

    • This question is part of the following fields:

      • Renal System
      48.4
      Seconds
  • Question 9 - A 58-year-old man is diagnosed with benign prostatic hyperplasia and is prescribed finasteride....

    Incorrect

    • A 58-year-old man is diagnosed with benign prostatic hyperplasia and is prescribed finasteride. He is informed that the drug works by inhibiting the conversion of testosterone to dihydrotestosterone, thereby preventing further enlargement of the prostate. What is the mechanism of action of finasteride?

      Your Answer: Androgen antagonist

      Correct Answer: 5-alpha reductase inhibitor

      Explanation:

      The enzyme 5-alpha-reductase is responsible for converting testosterone into dihydrotestosterone (DHT) in the testes and prostate. DHT is a more active form of testosterone. Finasteride is a medication that inhibits 5-alpha-reductase, preventing the conversion of testosterone to DHT. This can help prevent further growth of the prostate and is why finasteride is used clinically.

      Alpha-1 agonist is an incorrect answer as it refers to adrenergic receptors and does not affect the conversion of testosterone to DHT. These drugs are used for benign prostate hyperplasia to relax smooth muscles in the bladder, reducing urinary symptoms. Tamsulosin is an example of an alpha-1 agonist.

      Androgen antagonist is also incorrect as these drugs block the action of testosterone and DHT by preventing their attachment to receptors. They do not affect the conversion of testosterone to DHT.

      Gonadotrophin-releasing hormone modulators are also an incorrect answer. These drugs affect the hypothalamus and the production of gonadotrophs, such as luteinizing hormone. They do not affect the conversion of testosterone to DHT.

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

    • This question is part of the following fields:

      • Renal System
      24.6
      Seconds
  • Question 10 - A 51-year-old man comes to the clinic to discuss the findings of his...

    Correct

    • A 51-year-old man comes to the clinic to discuss the findings of his ambulatory blood pressure test, which revealed an average blood pressure of 156/94mmHg. As a first-line treatment for hypertension in this age group, you suggest starting him on ACE inhibitors. These medications work by inhibiting the activity of angiotensin-converting-enzyme. What is the primary location of angiotensin-converting-enzyme in the body?

      Your Answer: Lungs

      Explanation:

      The lungs contain the majority of angiotensin-converting-enzyme, with smaller amounts found in endothelial cells of the vasculature and kidney epithelial cells. Its role in the renin-angiotensin-aldosterone system involves converting angiotensin I to angiotensin II.

      Aldosterone, produced in the zona glomerulosa of the adrenal cortex, is a crucial compound in the renin-angiotensin-aldosterone system. Angiotensinogen, the precursor to angiotensin I, is produced in the liver and converted by renin, which is produced in the juxtaglomerular cells of the kidneys.

      The pancreas does not play a role in the renin-angiotensin-aldosterone system, but produces and releases insulin and glucagon among other hormones. Based on the World Health Organisation classification of hypertension, the patient in the question has mild hypertension. Current NICE guidelines recommend lifestyle advice and ACE inhibitors for patients under 55 years old with mild hypertension.

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

    • This question is part of the following fields:

      • Renal System
      66.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Renal System (4/10) 40%
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