Nephrology- Pastest

1. You are asked by your orthopaedic colleagues to review a 28-year-old victim of blunt trauma after a motorcycle accident. He has suffered extensive lower limb damage and requires large amounts of analgesia. The orthopaedic surgeons are concerned about his blood results, his potassium some hours after the accident is 6.7 mmol/l, calcium is 2.05 mmol/l, urine is positive to dipstick testing for blood. What diagnosis fits best with this clinical picture? Acute sepsis Hypovolaemia leading to pre-renal failure Rhabdomyolysis Your answer Direct renal trauma with perinephric haematoma Analgesic nephropathy Rhabdomyolysis occurs after an extensive blunt trauma, such as that occurring after a motorcycle accident. Diagnosis is made by the presence of myoglobin on urine dipstick (shows as haematuria), raised serum creatine kinase (CK) levels, hyperkalaemia, hypocalcaemia, hyperphosphataemia and hyperuricaemia. Aggressive iv fluid replacement is required to prevent acute renal failure, which may occur in up to 30% of cases of rhabdomyolysis. The rise in CK levels is detectable a few hours after injury and peaks at the 48-h stage. Rhabdomyolysis is also common after electrical injury, compartment syndrome, prolonged limb or tourniquet anaesthesia, extensive surgical dissection and infectious or inflammatory myopathies.

2. A 30-year-old man presents with frank haematuria and haemoptysis. A blood test shows microcytic hypochromic anaemia. Chest X-ray reveals bilateral infiltrates in the lower zones. What is the most likely diagnosis? Renal cell carcinoma Renal calculus Bronchial carcinoma Renal tuberculosis Goodpasture’s syndrome Your answer This man most probably has Goodpasture’s syndrome. The disease often starts with an upper respiratory tract infection followed by cough and intermittent haemoptysis, tiredness and eventually anaemia. Chest X-ray shadows are usually due to intrapulmonary haemorrhage. These features usually precede the development of an acute glomerulonephritis by several

weeks or months. Renal cell carcinoma rarely presents before the age of 40 years, the average age of presentation being 55 years. Patients present with a classic triad of haematuria, loin pain and a mass in the flank. Malaise, anorexia and weight loss may occur, and one-third of patients have hypertension. Bony metastases are common in bronchial carcinoma. There is frequent involvement of the liver. Although deposits are frequently found in the adrenal glands, the kidneys are seldom involved. Tuberculosis of the urinary tract may present with frequency, dysuria and/or haematuria. Adult postprimary pulmonary tuberculosis presents with a gradual onset of tiredness, malaise, anorexia, loss of weight, fever and cough. Sputum may be mucoid, purulent or bloodstained. The chest X-ray typically shows patchy or nodular shadows in the upper zones, loss of volume and fibrosis, with or without cavitation. Calcification may be present.

3. A 65-year-old man presents with haematuria, right loin pain and night sweats. Physical examination reveals a mass in the right flank. Blood tests show normocytic normochromic anaemia. What is the most likely diagnosis? Renal tract calculi Adult polycystic kidney disease Renal carcinoma Your answer Renal amyloidosis Chronic pyelonephritis The average age of presentation of renal cell carcinoma is around 55 years. Patients present with a classic triad of haematuria, loin pain and a mass in the flank. Malaise, anorexia and weight loss may occur and one-third of patients has hypertension. Pain in ureteric calculus, which is most often associated with haematuria, is extremely severe. Night sweats do not occur in this condition. Renal amyloidosis presents with asymptomatic proteinuria, nephritic syndrome or renal failure. Haematuria is not a feature. Chronic pyelonephritis is also known as ‘reflux nephropathy’. This starts in infancy or early childhood, predisposes to recurrent infections and progressive renal fibrosis and loss of function. The kidneys are small, shrunken and scarred. Adult (autosomal-dominant) polycystic kidney disease is an inherited disorder usually presenting in adult life. It is mostly bilateral and presents with acute loin pain and/or haematuria. Night sweats are not characteristic of this disease. 4. A 27-year-old woman is in end-stage renal disease. She has been started on regular haemodialysis. She complains of pain in her fingers. An X-ray shows digital subperiosteal erosions. What is the primary cause for her condition? Increased serum phosphate levels Increased parathyroid hormone levels

Decreased renal 1α-hydroxylase enzyme levels Decreased serum calcium levels Increased serum alkaline phosphatase levels

Your answer

Decreased renal production of the 1α -hydroxylase enzyme results in reduced conversion of 25-dihydroxycholecalciferol to the more metabolically active 1,25dihydroxycholecalciferol. Receptors for this exist on the parathyroid glands, failure of occupancy of which leads to the increased release of parathyroid hormone. 1,25dihydroxycholecalciferol deficiency also results in gut calcium malabsorption. The other features are due to excess parathyroid hormone levels.

5. A 17-year-old young woman, who works in a crèche, presents for review. She complains of joint pains, vomiting, diarrhoea and crampy abdominal pain. She also has a purpuric rash on her legs and over her belt line. She has microscopic haematuria, proteinuria and red blood cell casts on urine testing. What is the most likely underlying diagnosis in this case? Idiopathic thrombocytopenic purpura Henoch–Schönlein purpura (HSP) Your answer Polyarteritis nodosa Meningococcal septicaemia Thrombotic thrombocytopenic purpura HSP is the most common vasculitis seen in children and young adults. It is most commonly seen in the 4–15 year age group but may be seen in young adults. There is a 2:1 male to female ratio, and peak incidence occurs in the spring. Key physical findings include palpable purpura of dependent areas, especially the lower limbs and areas exposed to skin pressure. There may also be subcutaneous oedema, arthralgias in up to 80% of patients, GI symptoms in 30% and renal insufficiency in 10–20% of patients. Anecdotal reports suggest that some cases may follow respiratory tract infection. Skin biopsy of lesions reveals a leukocytoclastic vasculitis. IgA levels are raised in approximately 50% of patients. Glomerulonephritis may be present and is identified by microscopic haematuria, proteinuria and red cell casts. Permanent renal insufficiency may unfortunately occur in up to 5% of patients. Prednisolone may be considered for severe disease, with the addition of azathioprine if glomerulonephritis is present and is associated with rapidly deteriorating renal function.

after which the dose is reduced rapidly. A renal biopsy shows Wegener’s granulomatosis. A 33-year-old man presents with rapid progressive glomerulonephritis and nephrotic syndrome. it presents with deteriorating renal function that progresses to renal failure within three months. as does urine microscopy that reveals granular and red cell casts. although a few patients have disease that is more indolent. Typically. Proteinuria (typically 2 to 3 g/24 h. What is the most appropriate treatment? Blood transfusion Cyclophosphamide and prednisolone Methotrexate Antibiotics Cyclosporin Your answer Focal necrotising glomerulonephritis is the characteristic renal lesion of generalised Wegener’s granulomatosis and microscopic polyangiitis. ie as rapidly progressive glomerulonephritis. typically at weekly intervals. Prednisolone is given in doses of around 1 mg/kg/day initially. It plays a major role in water and electrolyte metabolism. 7. but occasionally in the nephrotic range) and microscopic haematuria provide clinical evidence of glomerulonephritis. Controlled trials show that adding pulses of methyl prednisolone is unlikely to confer additional benefit. The combination of prednisolone and cyclophosphamide is now established as the standard induction therapy for patients with generalised Wegener’s granulomatosis or microscopic polyangiitis.6. but less so for cyclophosphamide. The proximal convoluted tubule (PCT) is made up of a single layer of cells that interdigitate with one another and are united by apical tight junctions. There is consensus on how corticosteroids should be used. One of the most important functions of the PCT is: Bicarbonate secretion Glucose excretion Ammonia secretion Urine concentration .

On examination. A 78-year-old retired textile worker is noted to have haematuria on routine urinary dipstick at her GP’s practice. 20% extend to involve regional lymph nodes and 3% present with distant metastases. occupational exposure to dyes or petroleum products and chemical exposure to nitrosamines. with the use of intravesical chemotherapy where required. Some 80% of superficial bladder tumours are said to recur. Plain abdominal X-ray reveals no evidence of renal stones. Regulation of water secretion is by the distal tubule and the collecting ducts under the influence of vasopressin. 8. At the time of diagnosis around 70% of carcinomas are still localised to the bladder. Bladder cancer does have an increased association with cigarette smoking. or microscopic haematuria detected on dipstick in early-stage disease. A 47-year-old man attends the outpatient clinic complaining of swelling in the ankles and lethargy.5 g/dl and a ferritin just below the normal range. for which she takes anti-inflammatories. Ammonia is secreted by the distal tubule.Sodium reabsorption Your answer Bicarbonate reabsorption is mediated at the proximal tubule level. Treatment of choice for localised tumours is transurethral tumour resection. Her only past history of note is arthritis. Later-stage disease may also precipitate abdominal pain or renal failure due to obstruction. 9. What is the diagnosis that fits best with this clinical picture? Chronic urinary tract infection Bladder cancer Your answer Interstitial cystitis Analgesic nephropathy Interstitial nephritis Bladder cancer characteristically presents with painless haematuria. his blood pressure is 160/90 and he is found to have pitting oedema in both legs. Sodium and glucose as well as amino acids are absorbed at the proximal tubule level. with a haemoglobin of 10. In the Western world around 93% of bladder cancers are transitional cell (TCC) in type. which may be gross. Routine bloods reveal increased plasma viscosity and mild anaemia. squamouscell carcinomas (SCCs) comprise around 6% of the total and adenocarcinomas less than 1%. Laboratory investigations reveal: .

hyperphosphaturia. SLE is more common in females and presents in more than two-thirds of patients with arthralgia. Renal tubular acidosis presents with hypercalciuria. Which of the following is the commonest cause of death in renal dialysis patients? Gastrointestinal haemorrhage Occult malignancy . three antihypertensive agents. hyperchloraemia and hypokalaemia. Membranous glomerulonephropathy is secondary in 25–30% of cases and may be caused by hepatitis B virus. You are called to a cardiac arrest in the Emergency Department where a patient who is known to the dialysis unit has been brought by ambulance. On reviewing her drugs you note that she is taking a statin.Hb Urea Creatinine Hepatitis B antigen Anti-nuclear antibodies 11. Unfortunately resuscitation is unsuccessful. 10. fever and skin lesions.5 g/dl 35 mmol/l 275 µmol/l Positive Negative What is the probable diagnosis? Membranous glomerulonephritis Your answer Hepatitis B infection Acute interstitial nephritis Renal tubular acidosis Systemic lupus erythematosus Anti-nuclear antibodies screening is a good test for systemic lupus erythematosus (SLE) as more than 90% of patients have positive tests. aspirin and has been receiving erythropoietin injections. Hepatitis B virus surface antigen does not cause acute interstitial nephritis. Most patients present with proteinuria.

also known as ‘hyporeninaemic hypoaldosteronism’.Pulmonary embolus Cardiovascular disease Overwhelming sepsis Your answer Patients undergoing haemodialysis have a number of risk factors associated with accelerated cardiovascular disease. More often than not they are hypertensive and require a number of antihypertensive medications to control blood pressure. which include low high-density lipoprotein (HDL) cholesterol. Many patients have co-morbidities that put them at high risk of vascular disease such as diabetes mellitus. She presents with mild chronic renal failure. Blood tests show decreased plasma renin and aldosterone. Taken together. An identical syndrome may be caused by the chronic ingestion of non- . usually caused by tubulointerstitial disease or diabetes. There is evidence that renal patients have chronically elevateds of C-reactive protein (CRP) and other inflammatory markers. 11. What is the most probable diagnosis? Type-1 renal tubular acidosis Type-2 renal tubular acidosis Type-4 renal tubular acidosis Your answer Uraemic acidosis Acute tubulointerstitial nephritis Type-4 renal tubular acidosis. The cardinal features are hyperkalaemia and acidosis occurring in a patient with mild chronic renal insufficiency. these multiple risk factors lead to a process of accelerated atherosclerosis. hyperkalaemia and acidosis. A 56-year-old woman with a 15-year history of rheumatoid arthritis has been regularly taking diclofenac for pain relief. which precipitated the need for haemodialysis. is the most common of the renal tubular disorders. raised triglycerides and low-density lipoprotein (LDL) cholesterol levels due to chronic renal failure. They may have long standing vascular disease including renovascular disease.

Angiography reveals concentric narrowing of the left renal artery. Imaging may include a renal isotope scan. or a chronic presentation associated with occult hypertension. There may acute renal artery occlusion presenting with fever and flank pain. 13. Renal artery stenosis associated with fibromuscular hyperplasia does not progress. 5% progress to total occlusion by 1 year. Angioplasty may result in resolution of hypertension for some patients with fibromuscular hyperplasia.steroidal anti-inflammatory drugs (NSAIDs). Following referral. A 33-year-old woman attended her GP for new-patient screening and was found to be hypertensive. Renovascular hypertension is the cause of hypertension in 0. which impair renin and aldosterone secretion. A 22-year-old pregnant woman presents with dysuria and increased frequency. treatment and outcome for her condition? Her renal artery narrowing is likely to be progressive Her renal artery narrowing is unlikely to progress Your answer Angioplasty is the treatment of choice for all patients with this clinical presentation She is likely to have atherosclerotic disease elsewhere Her hypertension is likely to be associated with reduced aldosterone secretion She fits the picture of a woman with fibromuscular hyperplasia of the renal artery. episodes of pulmonary oedema in older patients. Atherosclerotic renal disease is progressive: in patients with > 60% stenosis. retinal changes consistent with hypertension. Fibromuscular hyperplasia may occur in young women commonly. an ultrasound scan reveals kidneys of broadly similar size within the normal range. 11% by year 2. 12. ultrasound to measure differential kidney size and angiography. A urinary tract infection is diagnosed. Early retinal changes consistent with hypertension are seen on fundoscopy. What is the most appropriate step? No treatment . BP 155/90 mmHg. with no evidence of atherosclerosis in the other areas of the vascular tree on imaging. mild hypokalaemia or renal failure following the initiation of angiotensin-converting enzyme (ACE)-inhibitor therapy.2–5% of all hypertensive patients. whereas renal artery stenosis associated with atherosclerosis tends to occur in an older population group. although BP control is clearly important to prevent associated complications. Which of the following statements best fits the explanation.

14.Should always be treated in pregnancy Treatment if the c-reactive protein (CRP) is high Treatment if the erythrocyte sedimentation rate (ESR) is high Treatment if recurrence Your answer Urinary tract infection is usually diagnosed by a bacterial count of >100 000/ml at MSU but significant infections can occur with lesser counts (pure growth of 1 organism): the infection is usually limited to the lower urinary tract and deterioration of renal function is not seen. Blood tests reveal hypoalbuminaemia and hyperlipidaemia. The other conditions occur later in life. as 25% of patients will develop acute pyelonephritis. What is the most common cause for this problem in a child of this age? Posterior urethral valves Vesicoureteric reflux Neurogenic bladder Renal calculi Bilateral polycystic kidneys Your answer The most common abnormality seen in a child with urinary tract infection in a micturating cystourethrogram is vesicoureteric reflux. 15. What would be the most characteristic finding on electron microscopy? Deposition of electron-dense material on the capillary basement membrane Splitting of the capillary basement membrane Fusion of foot processes of the glomerular epithelial cells Thinning of the capillary basement membrane Fibrils of amyloid protein in the mesangium Your answer . Infections in pregnancy should be treated. Urinalysis shows marked albuminuria. It is identified in approximately 40% of patients. A 2-year-old boy presents with recurrent urinary tract infections. A 7-year-old boy presents with generalised oedema. A renal biopsy appears normal on light microscopy. The chief complaint of children with posterior urethral valves is a poor urinary stream.

Urinalysis shows +3 blood and +3 protein. while thinning is noted in thin glomerular basement membrane disease. which tend to be large and anionic. slightly swollen metacarpophalangeal joints and some ulceration of her buccal mucosa. cannot cross the glomerular basement membrane and thus become deposited between the vascular endothelium and the GBM (‘subendothelial’). Her blood pressure is 145/95 mmHg. High titres of double-stranded DNA antibodies are detectable in her serum. 16. A 19-year-old woman complains of stiff joints and a facial rash. What pathogenic feature leads to the renal lesion? Arteriolar vasculitis Circulating antibodies directed against the glomerular basement membrane Deposition of a linear dense deposit within the glomerular basement membrane Subendothelial deposition of immune complexes Subepithelial deposition of immune complexes The type of renal disease that develops in systemic lupus erythematosus (SLE) is dependent on the site of deposition of the immune deposit. Circulating immune complexes. Splitting of the capillary basement membrane is seen in mesangiocapillary glomerulonephritis.9 g/dl and platelet count is 92 x 1012/l. Plasma creatinine is 92 µmol/l.The most common cause of nephrotic syndrome in children is minimal-change nephropathy. she has +1 oedema. but light microscopic changes would also be evident in these conditions. which may in turn be dependent on the site of immune complex formation. These complexes are efficient at Your answer . Hb is 8. Loss of foot processes may be seen in other proteinuric states such as membranous glomerulonephritis and diabetic nephropathy.

tend to deposit between the GBM and the epithelium of Bowman’s space (‘subepithelial’). although proteinuria may be massive. Thus. On the other hand. Rapid correction of the life-threatening hyperkalaemia and acidosis is necessary and intermittent haemodialysis is the treatment of choice. immune complexes that are formed in situ. There is ‘boggy’ tenderness of his right calf and both thigh muscles. but the presence of the GBM between them and the circulation prevents the free diffusion of chemoattractants and influx of circulating effector cells.fixing complement. Forced alkaline diuresis may prevent acute renal failure. creatinine 410 µmol/l.8 mmol/l and creatine kinase 17 000 IU/l. or that are cationic. it is inappropriate. bicarbonate 15 mmol/l. His plasma creatinine concentration is 368 µmol/l and renal ultrasound reveals bilateral 14-cm kidneys with multiple cysts.1. These changes are manifested histologically by mesangial and proliferative glomerulonephritis and clinically by the nephritic syndrome. the urine sediment is bland. which is suggested by the raised creatine kinase. 18. These are also capable of activating complement. This patient will probably require fasciotomy. so continuous therapies that are slower and require anticoagulation are not ideal. with little or no haematuria. pulse 98 bpm and there is no pericardial rub. thereby generating chemoattractants such as C3a and C5a. A 24-year-old patient is admitted after falling asleep drunk in a toilet cubicle. pH 7. The resulting renal failure is due to the toxic effects of myoglobin upon the renal tubular cells. but once renal failure is established with life-threatening hyperkalaemia. A 56-year-old man presents with flank pain and haematuria. What is the cause of this condition? Bilateral ureteric reflux from childhood Genetic defect in the gene encoding polycystin Genetic defect in the von Hippel–Landau gene Genetic defect in the gene encoding type-IV collagen Genetic defect in the gene encoding cystinosin Your answer . with haematuria being prominent. Biochemistry reveals urea 38 mmol/l. This is manifested histologically by membranous nephropathy. 17. What is the most appropriate form of treatment? Continuous ambulatory peritoneal dialysis Dopamine Forced alkaline diuresis Haemodialysis High-dose diuretic therapy Your answer This patient has rhabdomyolysis. potassium 7. which have direct access to the circulation and result in the influx of immune effector cells such as neutrophils and monocytes. There are also cysts scattered through the liver. On examination his BP 130/70.

which results in the absence of functioning polycystin. You would avoid blood transfusion before haemodialysis due to the risk of fluid overload and subsequent decompensation. Early dialysis may reverse the sensory deficits. Patients with Alport’s syndrome (a condition not associated with renal cysts) have mutations in the α-5 chain of type-IV collagen and cystinosin is a lysosomal membrane transport protein that is defective in cystinosi 19. Mutations in PKD1 tend to result in a more severe phenotype with end-stage renal failure (ESRF) typically occurring in the fifth to sixth decade of life. whereas patients with a PKD2 mutation tend to develop renal failure in the eighth decade of life. She requires: Urgent blood transfusion Electroencephalography Carbamazepine therapy Renal dialysis Your answer Sodium bicarbonate supplements The symptoms are due to uraemia. Renal tubular acidosis (RTA) results from either a defect in reabsorption of bicarbonate in the proximal tubule or a failure of acidification of the urine in the distal tubule. What is the most significant clinical presentation of distal renal . she temporarily lost consciousness and was told that she had fits during that period. There is loss of sensation to pinpricks below both knees. defects in which result in von Hippel–Landau syndrome.Some 85% of cases of adult polycystic kidney disease (ADPKD) are associated with a mutation in the PKD1 gene. the transcriptional effects of which are unknown. This novel protein has unknown functions but may operate as a cell-membrane ion transporter.8 g/dl and a serum creatinine level of 540 µmol/l. Blood tests revealed a haemoglobin of 5. A 55-year-old lady with chronic renal failure presents with numbness and tingling in the lower limbs. Most of the remaining cases of ADPKD are associated with a defect in PKD2. Earlier in the day. The presence of uraemic peripheral neuropathy is an indication for dialysis. The von Hippel–Landau gene is a tumour-suppressor gene on chromosome 3. 20.

Nephrocalcinosis is a feature of type I. A 40-year-old man with hypertension presents with frank haematuria. A smaller mass is felt in the left flank. hyperventilation and systemic acidosis are features of both types. Blood urea and serum creatinine levels are raised. a large mass is felt over the right lumbar area. 21. .3 after ammonium chloride administration Metabolic acidosis is common Potassium depletion occurs Your answer Normal anion gap.tubular acidosis (type I) that differentiates it from proximal renal tubular acidosis (type II)? There is failure to thrive Renal stone formation Urinary pH in Type I can be lowered below pH 5.3 even with maximal acid load. Type Irenal tubular acidosis is severe and is due to failure of the collecting ducts to secrete hydrogen ions or to sustain the gradient for hydrogen ions between the luminal fluid and the tubular cell. He gives a history that his uncle recently underwent a renal transplant and that his father died of renal failure. growth failure. What is the most probable diagnosis? Renal cell carcinoma Adult polycystic kidney disease Your answer Renal calculi Prostatic carcinoma Renal amyloidosis Adult polycystic kidney disease is an autosomal-dominant condition. On physical examination. The urine pH will not lower below 5. Type II is due to bicarbonate loss from the tubules and is commonly part of syndromes like Fanconi's syndrome or Wilson's disease. There is a gradual decline in renal function and is a common cause of chronic renal failure. Hypertension is an early and very common feature of this condition. It is mostly bilateral and presents with acute loin pain and/or haematuria.

23. Malaise. urinary infection and papillary necrosis – but glomerular lesions cause most of the problems. Renal amyloidosis presents with asymptomatic proteinuria. Typically. What is the most likely cause for these features? Goodpasture’s syndrome Polyarteritis nodosa Wegener’s granulomatosis Kawasaki’s disease Microscopic polyangiitis Your answer Both Wegener’s granulomatosis (WG) and Goodpasture’s syndrome can present with these clinical features. haemoptysis and glomerulonephritis. Pain in ureteric calculus. anorexia and weight loss may occur and one-third of patients has hypertension. is extremely severe. What would be the most common renal complication in this case? Renal papillary necrosis Renal infarction Chronic pyelonephritis Glomerulosclerosis Obstructive uropathy Your answer Diabetics are prone to atherosclerosis. there is thickening of the glomerular basement membrane and glomerulosclerosis that may be diffuse or nodular (Kimmelstiel–Wilson disease). Prostatic carcinoma presents with symptoms of lower urinary tract obstruction or of metastatic spread. Frank haematuria is not a feature. particularly to bone. but the presence of elevated levels of c-ANCA (cytoplasmic- . Patients present with a classic triad of haematuria.The average age of presentation of renal cell carcinoma is around 55 years. 22. A 35-year-old man presents with cough. A 65-year-old woman with longstanding diabetes presents with proteinuria. nephritic syndrome or renal failure. which is most often associated with haematuria. His cANCA [antimyeloperoxidase] levels are elevated. Her serum creatinine level is normal. The cancer usually appears in older men over the age of 60 years. loin pain and a unilateral mass in the flank.

in whom c-ANCA has a 98% post-test probability of predicting the diagnosis WG. or it may occur in a sporadic (diarrhoeanegative) form. What is the most likely diagnosis? Haemolytic–uraemic syndrome IgA nephropathy HIV Legionellosis Salmonellosis Your answer Haemolytic–uraemic syndrome is characterised by a microangiopathic haemolytic anaemia. 24. The diagnostic accuracy of ANCA testing becomes greater in patients with the classic presentation. The clinical features are fever lasting for 5 days or more. It may be found in an epidemic (diarrhoea-positive) form in association with acute gastroenteritis (eg due to verotoxin producing strains of Escherichia Coli). Although it may be a self-limiting process requiring supportive treatment alone. Approximately 80-95% of all ANCA found in patients with WG is cANCA/anti–serine proteinase 3. Almost all patients with active systemic WG have positive ANCA findings. 25. prostaglandin infusions and high-dose vitamin E.antineutrophilic cytoplasmic antibodies) is in favour of the former. polymorphic rash and redness and oedema of the palms and soles 2–5 days after onset. bilateral conjunctival congestion. associated with hypertension and acute renal failure. dryness and redness of the lips and oral cavity 3 days after onset. A 14-year-old boy presents with hypertension and acute renal failure after an episode of diarrhoea. polyarteritis nodosa and microscopic polyangiitis. plasma exchange. In some patients there appear to be inhibitors of prostaglandin production within the patient’s serum. In Goodpasture’s syndrome. Which one of the following conditions is most commonly associated with large kidneys despite advanced renal failure? Amyloidosis Your answer . various specific treatments have been tried including infusions of freshfrozen plasma (FFP). Most of the remaining 5-20% isp-ANCA–positive with antibodies directed against myeloperoxidase. The majority of patients have almost complete return of renal function following recovery. p-ANCA is elevated. acute cervical lymphadenopathy. Kawasaki’s disease is an acute systemic vasculitis mainly affecting children under 5 years of age. The prognosis is usually better in children and in those with the diarrhoeaassociated epidemic form. commonly directed against serine proteinase 3.

rarely. What is the most likely diagnosis? Proliferative glomerulonephritis Goodpasture’s syndrome Wegener’s granulomatosis Henoch–Schönlein purpura Systemic lupus erythematosus Your answer This girl most probably has Henoch–Schönlein purpura. renal failure. A 15-year-old girl presents with red spots on her buttocks and legs. joint pains. The fault lies in the vasculature. hypertension and proteinuria. Complications include massive gastrointestinal haemorrhage. oedema. She had an upper respiratory tract infection 2–3 weeks ago. Some one-third of patients has nephritis. It often follows an acute respiratory tract infection and usually follows a benign course over weeks or months. ileus and.Hypertensive nephrosclerosis Membranous glomerulonephritis Systemic sclerosis Analgesic nephropathy Other causes include: • Stage 1 diabetic nephropathy • Hydronephrosis • Acromegaly • Renal vein thrombosis 26. Joint pains and acute abdominal pain are common. . the platelets are normal. It presents with a purpuric rash over the buttocks and extensor surfaces.

coli. with death. dehydration and jaundice. A 45-year-old woman presents with increased frequency of micturition. dysuria and suprapubic pain 5 days after completing antibacterial treatment for an E. What is the most likely cause for her problem? Atrophic vaginitis Use of spermicidal jelly . If these patients have diabetes mellitus as well. He is admitted to A&E 2 days after discharge home. Other risk factors of note include multiple myeloma. Lung involvement (pulmonary haemorrhage) is seen in Goodpasture’s syndrome: the chest X-ray may show diffuse infiltrates in the lower zones. Urine microscopy shows the presence of E. dialysis or transplantation occurring in 18%. You suspect contrast nephropathy. Outcome figures from one study suggested that recovery of renal function occurs in 68% of patients. pancreatitis.Wegener’s granulomatosis would have additional features such as nasal ulceration. Variable shadows may be seen on chest X-ray. particularly multiple nodules. 28. otitis media and pulmonary symptoms. but purpura is not a feature of this condition. Which of the following best describes the incidence of contrast nephropathy in such a patient? 5% 70% 8% 25% Your answer 50% In an unselected population the incidence of contrast nephropathy is said to be between 2 and 7%. In those patients with pre-existing renal disease without diabetes the incidence of contrast nephropathy is thought to be around 60% when the creatinine concentration is above 400 mmol/l. She is also using a barrier contraceptive. hypertension and proteinuria in 2–3 weeks time. Congestive cardiac failure carries a risk of contrast nephropathy of 7–8%. Proliferative glomerulonephritis would present with macroscopic haematuria. then the incidence of acute renal failure is said to be 100%. If renal function is impaired then the incidence increases to around 25%. Renal involvement in systemic lupus erythematosus occurs in 50% of patients but is seldom so rapidly progressive as to cause oedema. partial recovery in 14%. rhinitis. 27. multiple contrast studies. His creatinine concentration is now 470 µ mol/l and he has only passed 20 ml of urine since being catheterised some 3 h ago. coli urinary tract infection. A 67-year-old man with type-2 diabetes had a serum creatinine concentration of 250 µmol/l (60–110) before admission for radiographic investigation including intravenous contrast medium visualisation.

usually longer.2 g/dl. Sodium bicarbonate and thiazide diuretics are useful in renal tubular acidosis. urea 14 mmol/l. Relapse is diagnosed by the recurrence of bacteriuria with the same organism within 7 days of completing antibacterial treatment. sodium 130 mmol/l. which causes bicarbonate diuresis. Interstitial cystitis commonly affects women over the age of 40 years. Isotonic saline alone will not correct the potassium deficiency nor will acetazolamide. Urine cultures are sterile. Reinfection occurs when bacteriuria is absent after treatment for at least 14 days. dysuria and often severe suprapubic pain. and implies failure to eradicate infection. bicarbonate 34 mmol/l. A 35-year-old woman with a past medical history of peptic ulceration presents with a 3day history of vomiting. What treatment would be most appropriate in this condition? IV 5% dextrose IV normal saline with potassium supplementation Acetazolamide Sodium bicarbonate Thiazide diuretics Your answer This patient has hypochloraemic alkalosis and hypokalaemia. Investigations reveal: haemoglobin 12. scarred kidneys. followed by recurrence of infection with the same or a different organism.0 mmol/l. chloride 85 mmol/l and pH 7. 29. potassium 3. A 4 year old girl is suspected to have vesicoureteric reflux as she has had a number of urinary tract infections. polycystic disease or bacterial prostatitis. Treatment with oral potassium supplements is sufficient in this case.52. 30. such as stones. Which investigation would be most useful in this case? Plain X-ray of the abdomen Excretion urography Computed tomography Micturating cystourethrography Retrograde pyelography Your answer .Renal stones Your answer Interstitial cystitis Chlamydial urethritis This patient has had a relapse. It usually occurs in conditions in which it is difficult to eradicate the bacteria. It presents with frequency.

Retrograde pyelography is mainly used to investigate lesions of the ureter and to define the lower level of ureteral obstruction shown on excretion urography or ultrasound. Blood urea and serum creatinine levels are normal. The other investigations are only useful for upper urinary tract disorders.A micturating cystourethrography is used primarily in children to check for vesicoureteric reflux during voiding. Renal biopsy shows the presence of antiglomerular basement membrane antibody. but it also can occur in adults. Amyloidosis is usually seen in middle-aged patients (ie those over 40 years of age). 32. It refers to a histopathologic lesion in the glomerulus that almost always is associated with nephrotic syndrome. On examination. he is oedematous and his blood pressure is 160/100 mmHg.5 g. What is the most characteristic radiological finding on chest X-ray in this case? Bilateral hilar lymphadenopathy Lobar consolidation Patchy shadows in apical zones Bilateral diffuse infiltrates in the lower zones Pleural effusion Your answer The diagnosis is Goodpasture’s syndrome. Urine microscopy shows oval fat bodies. . Bilateral hilar lymphadenopathy is a characteristic feature of sarcoidosis. 24-hour urine protein is 1. This represents areas of pulmonary haemorrhage. An 8-year-old boy complains of nausea and vomiting and fatigue. Lobar consolidation is seen in pneumonias. Steroid therapy is of no proven value in acute tubular necrosis. while patchy shadows in apical zones are typical of tuberculosis. also known as lipoid nephrosis or nil disease. A young man presents with haematuria and recurrent haemoptysis. A chest X-ray would show bilateral diffuse infiltrates often in the lower zones. 31. It is not useful in adult women because by this time the reflux tends to disappear. leading to complete remission of proteinuria in the majority of cases. Corticosteroids are the treatment of choice. The doctor plans to start a course of corticosteroids. is the most common single form of nephrotic syndrome in children. Pleural effusion does not occur in this condition. It typically is a disease of childhood. What is the most probable diagnosis? Proliferative glomerulonephritis Membranous glomerulonephritis Minimal-change disease Acute tubular necrosis Amyloidosis of the kidneys Your answer Minimal-change disease (MCD). which he says will cure the condition.

but mortality may be high in the elderly. There is intravascular haemolysis. but there have been no controlled clinical trials to date. Most children recover spontaneously from the illness. . particularly E. It has been suggested that acute infection triggers endothelial damage in susceptible individuals.0 mmol/l. Treatment with heparin. She has been suffering from gastroenteritis for a few days. There is associated hypercoagulability due to urinary loss of antithrombin-III. prostacyclins and platelet inhibitors have all been tried. Past medical history of note includes furosemide and ramipril for mild heart failure and treatment for nose bleeds. Raised blood glucose indicates diabetes mellitus. coli may actually have increased the risk of HUS. A 72-year-old woman presents acutely unwell to casualty. serum creatinine is 290 µmol/l and urea is 17. coli 157.33. Renal vein thrombosis occurs in 15–20% of patients with nephrotic syndrome. Folate levels are usually unaffected. 34. thrombocytopenia. Some commentators propose that antibiotic treatment of E. A full blood count and film reveals evidence of red cell haemolysis and thrombocytopenia. Inherited recurrent HUS has been described with both dominant and recessive patterns of inheritance. proteins C and S and a concomitant increase in fibrinogen levels. and acute renal failure. What diagnosis fits best with this clinical picture? Acute dehydration Haemolytic–uraemic syndrome (HUS) Your answer Wegener’s granulomatosis Furosemide toxicity Renal artery stenosis HUS is associated with Escherichia coli infection. What would the results of a blood test be most likely to show? Increased antithrombin-III levels Decreased fibrinogen levels Decreased thyroxine levels Normal folate levels Raised blood glucose levels Your answer Thyroxine levels are depressed in nephrotic syndrome due to the enhanced urinary excretion of thyroxine-binding globulin. A 60-year-old man is undergoing investigation for suspected nephrotic syndrome. fresh-frozen plasma.

Urinalysis reveals microscopic haematuria and proteinuria. urine culture is unremarkable. Apart from smoking 20 cigarettes per day and having mild asthma. cystinuria is responsible for around 1–2% of all urinary calculi. Slightly unusually. In total. What diagnosis fits best with this clinical picture? Bronchopneumonia Goodpasture’s syndrome Your answer Wegener’s granulomatosis SLE Sarcoidosis Goodpasture’s syndrome is characterised by the triad of glomerulonephritis. haemodialysis may be required 36. pulmonary haemorrhage and anti-GBM antibody. he has no other significant past medical history.5 g/dl. including drinking fluids at night. There appear to be no predisposing factors and he is otherwise well. Haemoglobin is 10. What is the most likely diagnosis in this case? Cystinosis Cystinuria Your answer Familial iminoglycinuria Fanconi’s syndrome Hartnup’s disease Cystinuria is related to the defective tubular reabsorption and jejunal absorption of cystine and the other dibasic amino acids lysine. He is referred urgently to the medical oncall team. Chest X-ray reveals fluffy pulmonary infiltrates. Some 80% of patients with Goodpasture’s syndrome are HLA-BR2 positive. these stones turn out to be cystine stones. and Goodpasture’s syndrome accounts for 5% of all cases of rapidly progressive glomerulonephritis. some absorption of cystine in peptide form may occur. A 21-year-old man presents to A&E for the third time with recurrent urinary stones. In patients with severe renal failure. Penicillamine may be used for those patients with . serum creatinine is 345 µmol/l. The negative c-ANCA (result makes Wegener’s granulomatosis (one possible differential) much less likely. c-ANCA is negative. A 23-year-old man presents to his GP with rapidly increasing shortness of breath and haemoptysis for the second time within 3 weeks. at above 3 litres per day.35. some heterozygotes may only have an increased excretion of lysine and cystine. Although jejunal cystine absorption is impaired. Goodpasture’s syndrome predominantly affects young male smokers. Inheritance is recessive or incompletely recessive. ornithine and arginine. Patients are encouraged to maintain a high fluid intake. the male:female ratio being 6:1. Acute management may involve treatment with prednisolone and cyclophosphamide or plasma-exchange therapy.

There is resulting amyloid deposition within the synovium. hips and knees. Cystine deposits in the retinas and corneas occur. is usually freely filtered at the glomerulus but is not cleared by cellulose-based dialysis membranes. She visits her GP with symptoms of pain. he complained of flank pain and is now becoming drowsy and lethargic. There may be associated GI haemorrhage caused by amyloid deposition around submucosal blood vessels. sodium is 119 mmol/l and bicarbonate is 17 mmol/l. the light chain of class-1 HLA antigens. Postoperatively. An 18-year-old man is recovering from meningococcal septicaemia. non-nephropathic form presents in young adults.recurrent stones who are unable to keep their urinary cystine concentration low. potassium is 6. 37. A less aggressive.7 mmol/l. and some benefit is seen in switching patients to dialysis with a biosynthetic dialysis membrane. Cystinosis occurs due to lysosomal cystine accumulation. This protein. She also complains of stiffness in her shoulders.6 mmol/l. What diagnosis fits best with this clinical picture? Rheumatoid arthritis Dialysis amyloidosis Your answer Diabetic neuropathy Seronegative arthritis Uraemic neuropathy Dialysis amyloidosis occurs due to the failure of clearance of β2-microglobulin. The syndrome resolves slowly after renal transplant. treated with highdose cefotaxime. A 71-year-old diabetic woman is in her 6th year of haemodialysis. 38. Plasma creatinine is 156 µmol/l. which necessitated amputation. the nephropathic form presenting in the first year of life with failure to thrive. He suffered gangrene in four toes. urea is 29. What is the likely cause of his deterioration? Acute tubular necrosis Acute interstitial nephritis secondary to cefotaxime Adrenal insufficiency Septic shock Your answer . His blood pressure is 90/45 mmHg and his peripheries are cool. Spot urine Na+ is 136 mmol/l. which appears to result in a clinical syndrome of median nerve compression and pain and stiffness in multiple joints. numbness and tingling in both hands during the early hours of the morning. leading to progressive renal impairment.

hyponatraemia and metabolic acidosis should always suggest hypoadrenalism. bowel and bronchus malignancy. and the best way to establish the underlying diagnosis is via renal biopsy. There is a long history of hypertension and deranged renal function now.5 cm and right kidney 8.9 cm What is the best investigation to diagnose the cause of his renal impairment? Intravenous urogram (IVU) Isotope renogram Renal angiogram Renal biopsy Retrograde pyelogram Your answer This man has glomerulonephritis. which is compatible with a possible diagnosis of membranous glomerulonephritis.8 g/l Ultrasound scan of kidneys showed left kidney 8. although in a recent series pseudomonas infection was the commonest cause. penicillamine therapy. as demonstrated by the presence of proteinuria and haematuria. and presentation is most common in adulthood. 39. Adrenal insufficiency results in mineralocorticoid deficiency and potentially life-threatening salt-wasting and a failure to excrete potassium. Basement membrane thickening caused by immune complex deposition is the main feature of the disease. A 62-year-old man with a long-standing history of hypertension is seen in the outpatient clinic. Associations include systemic lupus erythematosus (SLE). The combination of hyperkalaemia. Approximately one-third of patients develop renal failure within 10–20 years of diagnosis. blood++ Protein 1. . There is a preponderance of male cases.SIADH Bilateral adrenal haemorrhage may occur in the setting of septicaemia. This was initially described in cases of meningococcaemia with disseminated intravascular coagulation (DIC) (Waterhouse–Friderichsen syndrome). A significant number of cases are idiopathic. Investigations gave: • • • • Creatinine 280 mmol/l Urinalysis. and hepatitis B infection. Patients with heavy proteinuria and progressive renal impairment may benefit from immunosuppressive therapy.

Potassium release from muscle cells leads to glycogenolysis. Infection with Pneumococcus spp is relatively common in affected individuals. increased serum albumin Increased α1. Possibly related to immunoglobulins lost in the urine. decreased serum albumin In the nephrotic patient. 41. while hyperkalaemia is seen in metabolic acidosis. A monoclonal paraprotein band will also be present where myeloma is the underlying cause. thus decreasing the plasma potassium level. Early recognition of sepsis and . Some 10% of patients with myeloma will also have renal amyloid deposition. You note she has a raised erythrocyte sedimentation rate (ESR) and arrange for serum protein electrophoresis as part of a routine blood screen.and α2-globulin fractions. Which of the following stems best fits the abnormalities that are typically seen on protein electrophoresis in patients with nephrotic syndrome? Increased serum albumin concentration Increased α1-globulin fraction Increased α1. what is the most important biochemical factor that should be kept in mind? Acidosis leads to the movement of potassium from the extracellular to the intracellular fluid compartment Tissue destruction or breakdown results in the release of intracellular Your potassium answer Potassium release from muscle cells leads to gluconeogenesis Adrenaline inhibits the entry of potassium into cells. While managing the serum potassium levels in a young man with acute renal failure following a road traffic accident. and there may be associated immune paresis with reduced concentrations of one or more of the immunoglobulins IgG. Thus hypokalaemia occurs during alkalosis.and α2-globulin fractions. IgA or IgM. There is an inverse relationship between potassium levels and blood pH. abnormal findings on serum electrophoresis include a decreased albumin level and an increase in the α2-globulin fraction. thus increasing the plasma potassium level There is a direct relationship between potassium levels and blood pH Potassium is the main intracellular cation. Acidosis therefore leads to the movement of potassium from the intracellular to the extracellular fluid compartment. decreased serum albumin Your answer Increased α2-globulin fraction. Adrenaline stimulates the entry of potassium into cells. You are reviewing a 46-year-old woman who is suffering from nephrotic syndrome secondary to the long-term use of penicillamine for rheumatoid arthritis. and vaccination should always be offered.40. sepsis is an important complication of nephrotic syndrome.

However.2 mmol/l (3. You are reviewing a 78-year-old woman who has been admitted in a dehydrated and confused state to the Emergency department. Intravenous administration of 10 ml 10% calcium gluconate should be considered for cardioprotection. A 50-year-old woman develops haematuria with exquisite right loin pain. ie because of the difficulties of withdrawing inappropriate treatment once it has been commenced. nebulised salbutamol may also have positive effects in reducing serum potassium. but may exacerbate fluid retention in patients in renal failure. it should be reserved until the results of her fluid balance assessment and ultrasound scan are known. 50 ml of 50% dextrose containing 10 U of insulin should be considered as the next intervention. What is the most probable diagnosis? .5). it is important that an assessment of likely prognosis is determined first. Other management for this particular patient is likely to include central venous pressure monitoring. Continuous ECG monitoring is a prerequisite. What is the most appropriate initial management in this case? Arrange continuous ECG monitoring and consider giving 10 ml of 10% Your calcium gluconate iv answer Arrange an urgent renal ultrasound scan Give intravenous salbutamol therapy Give 250 mg furosemide iv to reduce the potassium concentration Consider a third blood sample to confirm hyperkalaemia Once true hyperkalaemia is confirmed via a repeat blood sample. but it would carry a significant risk of arrhythmia if given intravenously. Correction of severe acidosis may also redress some hyperkalaemia.9). She is afebrile. Her bloods are markedly abnormal: potassium of 7. Renal replacement therapy may be considered as the final option.5–4. creatinine 450 µ mol/l (60–110).2 mmol/l (2. 42. You repeat the serum potassium and it is still markedly raised. her abdomen is soft with tenderness over the right lumbar region. The b2-agonist salbutamol also drives potassium into the intracellular compartment. the management pathway is clear. On examination.aggressive treatment is the key to a positive outcome. urea 31. Because insulin drives potassium ions from the extracellular to the intracellular compartment. 43. Although furosemide may be of use to drive renal potassium excretion. She is restless and is unable to find a comfortable position that would ease the pain. catheterisation for close monitoring of fluid balance and an urgent ultrasound scan to determine the underlying cause of her renal dysfunction.5– 7.

The absence of fever rules out acute pyelonephritis. Renal cell carcinoma may present with haematuria.Acute pyelonephritis Renal cell carcinoma Polycystic kidney disease Renal calculi Acute nephritic syndrome Your answer A ureteric calculus will cause severe loin pain. particularly those with diabetes and perhaps patients with myelomatosis. exposure to radiation (of particular concern in pregnant women and children). loin pain and a mass in the flank. Its major disadvantage is that the technique carries a mortality owing to contrast hypersensitivity reaction of perhaps 1 in 200 000. A patient undergoes investigation for chronic upper urinary tract obstruction with intravenous urography. What is the most significant complication? . and the potential for contrast nephrotoxicity. worsening of pain due to the diuretic effect of contrast medium when an upper tract (or tracts) is obstructed. however. Patients with impaired renal function. The pain. are at particular risk. Such risk is minimised by employment of low osmolality contrast medium and the avoidance of prior dehydration. 45. A patient with chronic pain relieved by phenacetin (a NSAID) presents with progressive renal failure due to analgesic nephropathy. The patient should be informed about which severe complication? Contrast hypersensitivity Ureter damage Skin reaction Bleeding Development of renal stones Your answer Intravenous urography will usually demonstrate the site. It also involves an intravenous injection. is not so severe. cause. Excruciating loin pain is not a feature of acute glomerulonephritis. Polycystic kidney disease may present with loin pain only if there is nephrolithiasis. and degree of obstruction and is much less operator dependent than ultrasound since the number of images checked by the clinician is equal to the number of images reported by the radiologist. Pyrexia is present in about one-fifth of all patients. 44.

5 g/day can also occur at this time. Urinary tract malignancy will develop in as many as 8–10% of patients with analgesic nephropathy. . In mesangioproliferative glomerulonephritis. This is made up of kappa and lambda chains. Kimmelstiel–Wilson disease is characterised by hyaline masses in the mesangial core of the glomerular lobules. analgesic abuse is the most common cause of bladder cancer. IgA and C3 deposits are seen in the mesangium. More prominent proteinuria that can exceed 3. for example. A 65-year-old diabetic man presents with ascites and proteinuria. free kappa or lambda light chains are excreted. but in well under 1% of phenacetin (a NSAID)-containing analgesic users without kidney disease. C3. These masses consist of lipids and fibrin. In focal glomerulosclerosis. hyaline deposits consisting of IgM. IgA and fibrinogen are deposited in juxtamedullary capillaries. A renal biopsy shows mesangial deposits of monoclonal kappa and lambda light chains. and urinalysis that may be normal or may reveal sterile pyuria and mild proteinuria (less than 1.5 g/day). Blockage of tubules by casts accounts for the proteinuria and chronic renal failure. IgG.Urinary tract malignancy Bone tumours Liver fibrosis Pancreatitis Diabetes mellitus Your answer The renal manifestations of analgesic nephropathy are usually non-specific: normal renal function or slowly progressive chronic renal failure. What is the most probable diagnosis? Mesangioproliferative glomerulonephritis Focal glomerulosclerosis Kimmelstiel–Wilson disease Amyloidosis Multiple myeloma Your answer Amyloid deposition in cases of primary renal amyloidosis is typically seen within the mesangium. Amyloid light chain (AL amyloid) proteins are deposited. an otherwise unusual disorder in young women. 46. In women under the age of 50. In multiple myeloma. Hypertension and anaemia are commonly seen with moderate to advanced disease. a probable reflection of secondary haemodynamically mediated glomerular injury.

although hypertension is unusual and other manifestations of infection. bilirubin is 65 µmol/l. AST is 78 IU/l and his 24-hour urinary protein excretion rate is 4. rapidly progressive renal impairment and large kidneys on ultrasound.5). he appears clinically well and he has a trace of peripheral oedema. would usually be present.5–15. an immune-complex deposition disorder that presents with a mixed nephritic–nephrotic picture associated with panhypocomplementaemia.5 (0.3) and C4 is 0. She has also consulted for cosmetic surgery advice about the shape of her nose as it seems to be dipping. schistosomiasis. malaria and leprosy. Renal emboli tend to present with flank pain and haematuria.12– 0. What is the aetiology of the renal abnormalities? Hepatorenal syndrome Infection with hepatitis C Your answer Infection with HIV Infectious endocarditis Renal emboli Hepatitis C is now considered the principal cause of ‘idiopathic’ mesangiocapillary glomerulonephritis. Microscopy of the spun urine sediment reveals the presence of red-cell casts. and presents for examination under anaesthetic to a private surgeon. whereas hepatorenal syndrome occurs in patients with advanced cirrhosis with marked peripheral oedema and cirrhosis. Plasma creatinine is 140 µmol/l. Preoperative blood testing reveals anaemia with Hb of 10. may also be associated with MCGN.09 (0.27). HIV nephropathy is suggested by the presence of nephrotic syndrome. A 52-year-old woman has been visiting her GP for a while. Infectious endocarditis is the principal differential diagnosis in this case and may present with haematuria and hypocomplementaemia. complaining of recurrent nosebleeds.5 g/dl (11. and . such as fever. His blood pressure is 170/90 mmHg. chronic abscess. A 36-year-old man with a history of intravenous drug use is found to have dipstick-positive haematuria. Hepatitis C is endemic among the intravenous drug-using population.1 g/24 h. 48. Complement C3 is 0.7–1. Other chronic sources of immune complexes. such as hepatitis B.47.

The 5-year survival with aggressive treatment is around 80%. Laboratory screening involves testing of cANCA (cytoplasmic antineutrophil cytoplasmic antibody). a focal necrotising vasculitis involving both arteries and veins and a focal glomerulonephritis of the kidneys.5/100. A 30-year-old man is found to have macroscopic haematuria. with an incidence of 0. red blood cell casts and proteinuria. these may be bilateral multiple nodules.5 g/24 hours and a serum creatinine level of 153 µmol/l. cavitated mass lesions or pleural effusion in 20% of cases. Classically. What could be the possible diagnosis? Diabetic nephropathy Membranous glomerulonephritis Henoch-Schönlein purpura Focal glomerulosclerosis IgA nephropathy Your answer . Individual manifestations with differing severity in certain organ systems may occur. proteinuria of 1. Her surgery is cancelled. and further testing reveals a serum creatinine concentration of 195 m mol/l (60–110).urinalysis reveals haematuria. Patients are often anaemic with a leucocytosis and there are urine changes similar to those described above. Treatment of choice is cyclophosphamide and steroid therapy. 49. Pulmonary function testing may reveal a restrictive lung defect.000 individuals. Lung involvement causes chest X-ray changes. What is the most likely diagnosis in this case? Churg–Strauss syndrome Sarcoidosis Goodpasture’s syndrome Recurrent bacterial sinusitis Wegener’s granulomatosis Your answer The mean onset of Wegener’s granulomatosis is 40 years of age. which represent a glomerulonephritis-type picture. it is said to consist of necrotising granulomatous lesions in the upper or lower respiratory tracts.

. Topical oestrogen cream often has a dramatic response. The condition is common in elderly women due to dryness and atrophy of the urethral tissue.Macroscopic haematuria is uncommon in membranous glomerulonephritis and diabetic nephropathy. antibiotic therapy or alkalinisation of the urine will be of no benefit. What treatment would be most appropriate in her case? Oral prednisolone Topical corticosteroid cream Alkalinisation of the urine Broad-spectrum antibiotic therapy Topical oestrogen cream Your answer This postmenopausal woman has symptoms caused by the urethral syndrome. haematuria and proteinuria which may be exacerbated in the presence of respiratory infections. 50. Urinalysis shows microscopic haematuria and 2–3 white cells per high power field. Henoch-Schönlein purpura would be associated with a petechial rash and systemic vasculitis. IgA nephropathy presents with hypertension. Proteinuria would also be much greater (> 3. As there is no infection. An 85-year-old woman complains of dysuria and increased frequency of micturition. The urine culture is sterile. Corticosteroids will again not be helpful.5 g/24 hours) in these conditions and in focal glomerulosclerosis.

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