nephrology PT 1 2016 modif

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7/20/2016 MyPastest

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Question 1 of 316

A week after an episode of infective diarrhoea, a 10-year-old child presents with fever,

hypertension and haematuria You understand that he had been on a school visit to a modelfarm a short period before he became unwell Blood tests reveal anaemia with an Hb of 8.4g/dl, and an elevated creatinine of 185 μmol/l

A possible diagnosis could be:

Explanation

The answer is Haemolytic–uraemic syndrome –

Haemolytic–uraemic syndrome is characterised by microangiopathic haemolytic anaemiaand varying degrees of acute renal failure

In many cases, an infectious or immune-complex mediated cause has been proposed

Epidemics of bloody diarrhoea related to infection with a specific strain of

Escherichia coli (O157:H7) have been documented The bacteria release a verotoxin

that damages endothelial cells, particularly those of the kidney

Acute interstitial nephritis

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7/20/2016 MyPastest

Question 2 of 316

A 55-year-old man presents with pain in his right flank, nephrotic syndrome, azotaemia,

collateral abdominal veins and gross haematuria On examination, a mass is palpable in theright lumbar area Which one of the following is the most probable diagnosis?

Explanation

Renal-cell carcinoma (hypernephroma)

Diagnosis

The classic triad of haematuria, loin pain and abdominal mass, and the other clinical

features present in this case are suggestive of renal-cell carcinoma

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7/20/2016 MyPastest

Question 3 of 316

A 68-year-old man has a new-patient screen carried out by his GP He is noted to have

microscopic haematuria His GP also notes a raised ESR and a calcium concentration of 3.1mmol/l On examination he appears to have a varicocele Which one of the following

diagnoses fits best with this clinical picture?

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Prognosis is related to tumour staging: the 5-year survival rate is around 80–100% in

those with TNM stage-1 lesions, but this falls to 5–10% in those with stage-4 lesions

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The answer is Low back pain is the most common presenting symptom –

Retroperitoneal fibrosis is one of the multifocal fibrosclerotic syndromes, which also

includes mediastinal fibrosis, sclerosing cholangitis and Riedel’s thyroiditis It is more

common in males (2:1), with peak incidence in the fifth and sixth decades The process

usually begins over the promontory of the sacrum and extends laterally across the

ureters and as high as the second or third lumbar vertebra Hence low back is the most

common presenting symptom This may be accompanied by fever and weight loss

Diagnosis is suggested by the finding at intravenous pyelography of displacement of theureters toward the midline

Thromboembolism and hypertension are recognised complications

Methysergide, a semi-synthetic ergot alkaloid used to treat migraine headache, can cause

a similar syndrome Other drugs such as ß-blockers (methyldopa and hydralazine) are

Bilateral swelling of the legs is often due to inferior vena cava obstruction

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haematuria on dipstick urinalysis His daily urine albumin excretion rate is measured at 6.9g/24 h, creatinine is 130 μmol/l, serum albumin is 12 g/dl and Hb is 8.9 g/dl Further

investigation reveals a paraprotein band in his serum with kappa light chains demonstrated

on immunofixation Which one of the following is the most probable cause of the proteinuria?

Explanation

Renal disease in myeloma

The spectrum of renal disease in myeloma comprises a spectrum of presentations

including;

Cast nephropathy (presents as progressive renal insufficiency with Bence Jones

proteinuria – undetectable on urine dipstick – but little in the way of albuminuria)

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7/20/2016 MyPastest

Question 6 of 316

An 82-year-old man presents to his GP with increasing oedema and ascites He is

hypertensive, for which he takes amlodipine There is shortness of breath on exercise His

alcohol history is two cans of stout per day ECG is normal, and CXR reveals normal heart sizeand no signs of cardiac failure Serum albumin is 23 g/dl; urinary albumin excretion is 7 g/24

h, with no haematuria He has mild anaemia with a normal MCV Total cholesterol is elevated.Which one of the following diagnoses fits best with this clinical picture?

Explanation

Nephrotic syndrome

Diagnosis

Low albumin, abnormal cholesterol and increased urinary albumin excretion all point

towards nephrotic syndrome

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sediment reveals the presence of red-cell casts Complement C3 is 0.5 (0.7–1.3) and C4 is

0.09 (0.12–0.27) Which one of the following is the aetiology of the renal abnormalities?

Explanation

Mesangiocapillary glomerulonephritis

Aetiology

Hepatitis C is now considered the principal cause of ‘idiopathic’ mesangiocapillary

glomerulonephritis (MCGN), an immune-complex deposition disorder that presents with

a mixed nephritic–nephrotic picture associated with pan-hypocomplementaemia;

hepatitis C is endemic among the iv drug-using population It is also closely associated

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Electron microscopic diagnosis

There is loss of foot processes – these may also be seen in other proteinuric states such

Deposition of electron-dense material on the capillary basement membrane

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index and middle fingers of both hands The doctor advises her not to continue with the

pregnancy Which one of the following conditions is she most likely to be having?

Explanation

Pregnancy complications in systemic disease

Diffuse systemic sclerosis is associated with maternal deaths; reactivation of quiescentscleroderma can occur during pregnancy and the puerperium and the fetal prognosis ispoor Therapeutic abortion must be considered in these patients

In diabetic nephropathy, pregnancy does not accelerate functional loss

The prognosis is most favourable in systemic lupus erythematosus (SLE) if the diseasehas been in remission for at least 6 months before conception

Antiphospholipid syndrome may cause recurrent miscarriage but is not an indication

Systemic lupus erythematosus

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Renal insufficiency and anti-tubercular treatment

If the excretion of anti-tubercular drugs is hampered because of renal insufficiency theymay cause serious side-effects, for example:

isoniazid may cause hepatitis and polyneuropathy

pyrazinamide may precipitate hyperuricaemic gout and cause hepatic toxicity

ethambutol can cause dose-related optic retrobulbar neuritis

streptomycin can cause irreversible damage to the vestibular nerve

However, rifampicin is only mildly hepatotoxic and so it is a safe and effective drug forthe treatment of tuberculosis in the presence of renal insufficiency It should be

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7/20/2016 MyPastest

Question 11 of 316

You are asked to review a man who is being considered for peritoneal dialysis for chronic

renal failure He has a number of concerns before proceeding to surgery and placement of aTenckhoff catheter Regarding pitfalls and complications of peritoneal dialysis, which of thefollowing is a key consideration?

Explanation

Considerations in peritoneal dialysis

Peritoneal dialysis fluid contains a high concentration of glucose (standard fluid at a

concentration of 1.36%)

More concentrated dialysis fluid may contain glucose at concentrations of up to 6.36%,this means that patients with diabetes may require significantly more diabetes

treatment to reduce their blood glucose once dialysis is commenced

Due to the large fluid volume expansion once fluid is introduced, abdominal hernias

may significantly worsen once dialysis treatment is commenced, and should be

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7/20/2016 MyPastest

Question 12 of 316

You are asked by your surgical colleagues to review a 70-year-old man with acute

pancreatitis He is clearly very unwell, and the surgeons have noticed deteriorating renal

function His current urine output is around 5 ml/h, with a raised urine sodium concentration

of 55 mmol/l The surgeons have been keeping him well filled, and a recent central venouspressure was measured at 16 mmH O The latest serum creatinine that you have is 320 μmol/l(60–110) Which one of the following diagnoses fits best with this clinical picture?

vomiting and myocardial infarction

Aminoglycosides, non-steroidal anti-inflammatory drugs (NSAIDs),

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The mortality rate associated with ATN may be up to 50%, but this is largely dependent

on the precipitating illness

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bicarbonate 30 mmol/l and chloride 99 mmol/l Which one of the following is the most

characteristic physiological activity that retains sodium in the face of salt and water

overload?

Explanation

Mechanism of salt and water retention in chronic liver disease

In cirrhosis, arterial vasodilatation due to nitric oxide overactivity, coupled with

hypoalbuminaemia which drives low colloid osmotic pressure, leads to arterial

underfilling

This is perceived by the pressure and volume receptors as hypovolaemia

There is consequent activation of the sympathetic system, non-osmotic release of ADH

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medication of note includes the oral contraceptive and ramipril 10 mg daily for her blood

pressure On examination her BP is 155/92 mmHg Abdominal examination is unremarkable Investigations:

Hb 10.9 g/dl, WCC 8.9 × 10 /l, PLT 134 × 10 /l, Na 140 mmol/l, K 5.0 mmol/l, creatinine 167μmol/l, urine dipstick protein +++, blood +++, renal ultrasound scan, right kidney 11 cm, left 9.5

cm (normal 11–12 cm)

Which one of the following is the most appropriate investigation to confirm the diagnosis?

Explanation

Differential diagnosis of small kidney size

The presence of one smaller kidney on ultrasound scan raises the possibility of either

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Urine protein ++, blood +++

Renal biopsy necrotising glomerulonephritis

With which antibody is this clinical picture most likely to be associated?

9 9 +

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oligoanuric (urine output 250 ml/24 h) His blood pressure is 150/60 mmHg and he has +1

peripheral oedema Urinalysis shows a pH of 5.6 and +1 protein, and urine microscopy revealsnumerous reddish-brown, rosette-like crystals His plasma creatinine concentration is 200

μmol/l, calcium is 1.76 mmol/l and phosphate is 2.7 mmol/l Which one of the following is themost likely cause of the oliguria?

Explanation

Tumour lysis syndrome

Epidemiology and aetiology

Tumour lysis syndrome, often inappropriately called ‘acute urate nephropathy’, typicallyoccurs after chemotherapy for lymphoma with a large tumour burden

Ceftazidime-induced interstitial nephritis

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7/20/2016 MyPastest

Question 17 of 316

You are asked to review a 26-year-old woman who has been diagnosed with essential

hypertension by her GP, which is proving difficult to manage She has a past history of threepresentations with urinary tract infection as a child and two as a young adult A urine screen

by the GP has revealed asymptomatic bacteriuria, which he elected not to treat Her currenthypertension medication is amlodipine 10 mg po daily Her blood pressure in the clinic is

145/85 mmHg Which one of the following would be the most appropriate next course of

action?

Explanation

Multiple urinary tract infections

Aetiology

Chronic reflux nephropathy should be suspected in the presence of multiple urinary

tract infections, including during childhood

This may explain the presentation in the present case at a young age with treat hypertension

difficult-to-Repeat her urine sample and give antibiotics if necessary

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7/20/2016 MyPastest

Question 18 of 316

A 36-year-old man presents with a systemic vasculitis and renal failure

Which one of the following features makes granulomatosis with polyangiitis more likely thanpolyarteritis nodosa?

Explanation

The answer is Epistaxis –

All of the options, that is, skin lesions, epistaxis, retinopathy, pyrexia and peripheral

neuropathy, are features of the systemic vasculitides

The feature that makes granulomatosis with polyangiitis (previously referred to as

Wegener’s granulomatosis) more likely is upper respiratory involvement, particularly thenasal mucosa

Peripheral neuropathy (Option B) is incorrect The absence of upper respiratory involvementmakes granulomatosis with polyangiitis less likely

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7/20/2016 MyPastest

Question 19 of 316

A 27-year-old woman is in end-stage renal disease and has been started on regular

haemodialysis She complains of pain in her fingers An X-ray shows digital subperiosteal

erosions Which one of the following is a primary cause for her condition?

Explanation

End-stage renal disease

In renal failure, the stimuli for overproduction of parathyroid hormone (PTH) are

multifactorial; factors include:

These stimuli cause multigland hyperplasia, resulting in increased PTH production

Increased serum phosphate levels

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Renal tubular functions

Bicarbonate reabsorption is mediated at the proximal tubule level

Sodium and glucose as well as amino acids are also absorbed at the proximal tubule

level

Ammonia is secreted by the distal tubule

Regulation of water secretion is by the distal tubule and the collecting ducts under theinfluence of vasopressin

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