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
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.
as does urine microscopy that reveals granular and red cell casts. Prednisolone is given in doses of around 1 mg/kg/day initially.
7. typically at weekly intervals.6. after which the dose is reduced rapidly. Typically. A 33-year-old man presents with rapid progressive glomerulonephritis and nephrotic syndrome. ie as rapidly progressive glomerulonephritis. There is consensus on how corticosteroids should be used. The combination of prednisolone and cyclophosphamide is now established as the standard induction therapy for patients with generalised Wegener’s granulomatosis or microscopic polyangiitis. 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. One of the most important functions of the PCT is: Bicarbonate secretion Glucose excretion Ammonia secretion Urine concentration
. A renal biopsy shows Wegener’s granulomatosis. although a few patients have disease that is more indolent. it presents with deteriorating renal function that progresses to renal failure within three months. 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. What is the most appropriate treatment? Blood transfusion Cyclophosphamide and prednisolone Methotrexate Antibiotics Cyclosporin
Focal necrotising glomerulonephritis is the characteristic renal lesion of generalised Wegener’s granulomatosis and microscopic polyangiitis. Proteinuria (typically 2 to 3 g/24 h. It plays a major role in water and electrolyte metabolism.
Treatment of choice for localised tumours is transurethral tumour resection. Laboratory investigations reveal:
. Ammonia is secreted by the distal tubule. A 47-year-old man attends the outpatient clinic complaining of swelling in the ankles and lethargy. for which she takes anti-inflammatories. At the time of diagnosis around 70% of carcinomas are still localised to the bladder. Some 80% of superficial bladder tumours are said to recur. Later-stage disease may also precipitate abdominal pain or renal failure due to obstruction. Sodium and glucose as well as amino acids are absorbed at the proximal tubule level. which may be gross. Routine bloods reveal increased plasma viscosity and mild anaemia. A 78-year-old retired textile worker is noted to have haematuria on routine urinary dipstick at her GP’s practice. Her only past history of note is arthritis.5 g/dl and a ferritin just below the normal range. In the Western world around 93% of bladder cancers are transitional cell (TCC) in type. Regulation of water secretion is by the distal tubule and the collecting ducts under the influence of vasopressin.
8. 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. with the use of intravesical chemotherapy where required. occupational exposure to dyes or petroleum products and chemical exposure to nitrosamines. with a haemoglobin of 10. Bladder cancer does have an increased association with cigarette smoking. squamouscell carcinomas (SCCs) comprise around 6% of the total and adenocarcinomas less than 1%. his blood pressure is 160/90 and he is found to have pitting oedema in both legs. Plain abdominal X-ray reveals no evidence of renal stones. or microscopic haematuria detected on dipstick in early-stage disease. 20% extend to involve regional lymph nodes and 3% present with distant metastases. On examination.
9.Sodium reabsorption Your answer Bicarbonate reabsorption is mediated at the proximal tubule level.
Hepatitis B virus surface antigen does not cause acute interstitial nephritis. 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. Most patients present with proteinuria. fever and skin lesions. hyperphosphaturia. three antihypertensive agents. Unfortunately resuscitation is unsuccessful.
10. SLE is more common in females and presents in more than two-thirds of patients with arthralgia. aspirin and has been receiving erythropoietin injections.Hb Urea Creatinine Hepatitis B antigen Anti-nuclear antibodies
11. Renal tubular acidosis presents with hypercalciuria.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. Which of the following is the commonest cause of death in renal dialysis patients? Gastrointestinal haemorrhage Occult malignancy
. On reviewing her drugs you note that she is taking a statin. hyperchloraemia and hypokalaemia.
these multiple risk factors lead to a process of accelerated atherosclerosis. which precipitated the need for haemodialysis. She presents with mild chronic renal failure. 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. A 56-year-old woman with a 15-year history of rheumatoid arthritis has been regularly taking diclofenac for pain relief. There is evidence that renal patients have chronically elevateds of C-reactive protein (CRP) and other inflammatory markers.
11. More often than not they are hypertensive and require a number of antihypertensive medications to control blood pressure. Many patients have co-morbidities that put them at high risk of vascular disease such as diabetes mellitus. Taken together. also known as ‘hyporeninaemic hypoaldosteronism’. An identical syndrome may be caused by the chronic ingestion of non-
. Blood tests show decreased plasma renin and aldosterone. is the most common of the renal tubular disorders. The cardinal features are hyperkalaemia and acidosis occurring in a patient with mild chronic renal insufficiency. usually caused by tubulointerstitial disease or diabetes. which include low high-density lipoprotein (HDL) cholesterol.Pulmonary embolus Cardiovascular disease Overwhelming sepsis
Patients undergoing haemodialysis have a number of risk factors associated with accelerated cardiovascular disease. hyperkalaemia and acidosis. They may have long standing vascular disease including renovascular disease. raised triglycerides and low-density lipoprotein (LDL) cholesterol levels due to chronic renal failure.
Atherosclerotic renal disease is progressive: in patients with > 60% stenosis.
13. Imaging may include a renal isotope scan. There may acute renal artery occlusion presenting with fever and flank pain.2–5% of all hypertensive patients. Which of the following statements best fits the explanation. Angioplasty may result in resolution of hypertension for some patients with fibromuscular hyperplasia. ultrasound to measure differential kidney size and angiography. A 33-year-old woman attended her GP for new-patient screening and was found to be hypertensive. 11% by year 2. 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. Angiography reveals concentric narrowing of the left renal artery. Renovascular hypertension is the cause of hypertension in 0.
12.steroidal anti-inflammatory drugs (NSAIDs). episodes of pulmonary oedema in older patients. Following referral. Fibromuscular hyperplasia may occur in young women commonly. or a chronic presentation associated with occult hypertension. an ultrasound scan reveals kidneys of broadly similar size within the normal range. which impair renin and aldosterone secretion. retinal changes consistent with hypertension. A 22-year-old pregnant woman presents with dysuria and increased frequency. What is the most appropriate step? No treatment
. BP 155/90 mmHg. Early retinal changes consistent with hypertension are seen on fundoscopy. with no evidence of atherosclerosis in the other areas of the vascular tree on imaging. Renal artery stenosis associated with fibromuscular hyperplasia does not progress. although BP control is clearly important to prevent associated complications. whereas renal artery stenosis associated with atherosclerosis tends to occur in an older population group. 5% progress to total occlusion by 1 year. mild hypokalaemia or renal failure following the initiation of angiotensin-converting enzyme (ACE)-inhibitor therapy. A urinary tract infection is diagnosed.
as 25% of patients will develop acute pyelonephritis. A 7-year-old boy presents with generalised oedema. Urinalysis shows marked albuminuria. 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
. A 2-year-old boy presents with recurrent urinary tract infections. Infections in pregnancy should be treated. The chief complaint of children with posterior urethral valves is a poor urinary stream. It is identified in approximately 40% of patients. Blood tests reveal hypoalbuminaemia and hyperlipidaemia. 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
The most common abnormality seen in a child with urinary tract infection in a micturating cystourethrogram is vesicoureteric reflux.
15. The other conditions occur later in life. A renal biopsy appears normal on light microscopy.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
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.
while thinning is noted in thin glomerular basement membrane disease. A 19-year-old woman complains of stiff joints and a facial rash. cannot cross the glomerular basement membrane and thus become deposited between the vascular endothelium and the GBM (‘subendothelial’). Circulating immune complexes.
16. Urinalysis shows +3 blood and +3 protein. Her blood pressure is 145/95 mmHg.9 g/dl and platelet count is 92 x 1012/l. which may in turn be dependent on the site of immune complex formation. These complexes are efficient at
. but light microscopic changes would also be evident in these conditions.The most common cause of nephrotic syndrome in children is minimal-change nephropathy. Hb is 8. Plasma creatinine is 92 µmol/l. which tend to be large and anionic. High titres of double-stranded DNA antibodies are detectable in her serum. she has +1 oedema. Splitting of the capillary basement membrane is seen in mesangiocapillary glomerulonephritis. slightly swollen metacarpophalangeal joints and some ulceration of her buccal mucosa. Loss of foot processes may be seen in other proteinuric states such as membranous glomerulonephritis and diabetic nephropathy. 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.
1. the urine sediment is bland. tend to deposit between the GBM and the epithelium of Bowman’s space (‘subepithelial’). creatinine 410 µmol/l. 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
18. These are also capable of activating complement. A 56-year-old man presents with flank pain and haematuria. which have direct access to the circulation and result in the influx of immune effector cells such as neutrophils and monocytes. pH 7.8 mmol/l and creatine kinase 17 000 IU/l. so continuous therapies that are slower and require anticoagulation are not ideal. This patient will probably require fasciotomy. potassium 7. with haematuria being prominent. thereby generating chemoattractants such as C3a and C5a. it is inappropriate. immune complexes that are formed in situ. This is manifested histologically by membranous nephropathy. There are also cysts scattered through the liver. His plasma creatinine concentration is 368 µmol/l and renal ultrasound reveals bilateral 14-cm kidneys with multiple cysts. Rapid correction of the life-threatening hyperkalaemia and acidosis is necessary and intermittent haemodialysis is the treatment of choice. although proteinuria may be massive. Thus. What is the most appropriate form of treatment? Continuous ambulatory peritoneal dialysis Dopamine Forced alkaline diuresis Haemodialysis High-dose diuretic therapy
This patient has rhabdomyolysis. Forced alkaline diuresis may prevent acute renal failure. bicarbonate 15 mmol/l.fixing complement. or that are cationic. On the other hand. which is suggested by the raised creatine kinase. but the presence of the GBM between them and the circulation prevents the free diffusion of chemoattractants and influx of circulating effector cells. but once renal failure is established with life-threatening hyperkalaemia. A 24-year-old patient is admitted after falling asleep drunk in a toilet cubicle. with little or no haematuria. Biochemistry reveals urea 38 mmol/l. The resulting renal failure is due to the toxic effects of myoglobin upon the renal tubular cells. There is ‘boggy’ tenderness of his right calf and both thigh muscles. On examination his BP 130/70. 17. These changes are manifested histologically by mesangial and proliferative glomerulonephritis and clinically by the nephritic syndrome. pulse 98 bpm and there is no pericardial rub.
Earlier in the day. Blood tests revealed a haemoglobin of 5. the transcriptional effects of which are unknown. defects in which result in von Hippel–Landau syndrome. 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. The presence of uraemic peripheral neuropathy is an indication for dialysis. Most of the remaining cases of ADPKD are associated with a defect in PKD2.Some 85% of cases of adult polycystic kidney disease (ADPKD) are associated with a mutation in the PKD1 gene. A 55-year-old lady with chronic renal failure presents with numbness and tingling in the lower limbs. You would avoid blood transfusion before haemodialysis due to the risk of fluid overload and subsequent decompensation. What is the most significant clinical presentation of distal renal
. 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
19.8 g/dl and a serum creatinine level of 540 µmol/l.
20. 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. The von Hippel–Landau gene is a tumour-suppressor gene on chromosome 3. This novel protein has unknown functions but may operate as a cell-membrane ion transporter. which results in the absence of functioning polycystin. she temporarily lost consciousness and was told that she had fits during that period. whereas patients with a PKD2 mutation tend to develop renal failure in the eighth decade of life. There is loss of sensation to pinpricks below both knees. Early dialysis may reverse the sensory deficits.
Blood urea and serum creatinine levels are raised. It is mostly bilateral and presents with acute loin pain and/or haematuria. A 40-year-old man with hypertension presents with frank haematuria. The urine pH will not lower below 5.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. hyperventilation and systemic acidosis are features of both types. On physical examination. Hypertension is an early and very common feature of this condition. There is a gradual decline in renal function and is a common cause of chronic renal failure. Type II is due to bicarbonate loss from the tubules and is commonly part of syndromes like Fanconi's syndrome or Wilson's disease. He gives a history that his uncle recently underwent a renal transplant and that his father died of renal 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. A smaller mass is felt in the left flank. 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.3 after ammonium chloride administration Metabolic acidosis is common Potassium depletion occurs
Normal anion gap.
.3 even with maximal acid load. Nephrocalcinosis is a feature of type I. a large mass is felt over the right lumbar area. growth failure.
Her serum creatinine level is normal.The average age of presentation of renal cell carcinoma is around 55 years. Frank haematuria is not a feature. which is most often associated with haematuria. nephritic syndrome or renal failure. Pain in ureteric calculus. A 35-year-old man presents with cough. there is thickening of the glomerular basement membrane and glomerulosclerosis that may be diffuse or nodular (Kimmelstiel–Wilson disease). What is the most likely cause for these features? Goodpasture’s syndrome Polyarteritis nodosa Wegener’s granulomatosis Kawasaki’s disease Microscopic polyangiitis
Both Wegener’s granulomatosis (WG) and Goodpasture’s syndrome can present with these clinical features.
22. Patients present with a classic triad of haematuria. The cancer usually appears in older men over the age of 60 years. What would be the most common renal complication in this case? Renal papillary necrosis Renal infarction Chronic pyelonephritis Glomerulosclerosis Obstructive uropathy
Diabetics are prone to atherosclerosis. anorexia and weight loss may occur and one-third of patients has hypertension. A 65-year-old woman with longstanding diabetes presents with proteinuria. urinary infection and papillary necrosis – but glomerular lesions cause most of the problems.
23. loin pain and a unilateral mass in the flank. Renal amyloidosis presents with asymptomatic proteinuria. haemoptysis and glomerulonephritis. but the presence of elevated levels of c-ANCA (cytoplasmic-
. is extremely severe. His cANCA [antimyeloperoxidase] levels are elevated. particularly to bone. Prostatic carcinoma presents with symptoms of lower urinary tract obstruction or of metastatic spread. Malaise. Typically.
The majority of patients have almost complete return of renal function following recovery. associated with hypertension and acute renal failure. Kawasaki’s disease is an acute systemic vasculitis mainly affecting children under 5 years of age. commonly directed against serine proteinase 3. The clinical features are fever lasting for 5 days or more. acute cervical lymphadenopathy. Which one of the following conditions is most commonly associated with large kidneys despite advanced renal failure? Amyloidosis Your answer
. The diagnostic accuracy of ANCA testing becomes greater in patients with the classic presentation. 25. Approximately 80-95% of all ANCA found in patients with WG is cANCA/anti–serine proteinase 3. A 14-year-old boy presents with hypertension and acute renal failure after an episode of diarrhoea. or it may occur in a sporadic (diarrhoeanegative) form. dryness and redness of the lips and oral cavity 3 days after onset. In some patients there appear to be inhibitors of prostaglandin production within the patient’s serum. bilateral conjunctival congestion. It may be found in an epidemic (diarrhoea-positive) form in association with acute gastroenteritis (eg due to verotoxin producing strains of Escherichia Coli). Almost all patients with active systemic WG have positive ANCA findings. plasma exchange. prostaglandin infusions and high-dose vitamin E. Although it may be a self-limiting process requiring supportive treatment alone. The prognosis is usually better in children and in those with the diarrhoeaassociated epidemic form. in whom c-ANCA has a 98% post-test probability of predicting the diagnosis WG. 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. polymorphic rash and redness and oedema of the palms and soles 2–5 days after onset. p-ANCA is elevated. Most of the remaining 5-20% isp-ANCA–positive with antibodies directed against myeloperoxidase. various specific treatments have been tried including infusions of freshfrozen plasma (FFP).antineutrophilic cytoplasmic antibodies) is in favour of the former. In Goodpasture’s syndrome.
24. polyarteritis nodosa and microscopic polyangiitis.
oedema. renal failure. It often follows an acute respiratory tract infection and usually follows a benign course over weeks or months. Complications include massive gastrointestinal haemorrhage. the platelets are normal. Joint pains and acute abdominal pain are common. The fault lies in the vasculature. rarely.
. She had an upper respiratory tract infection 2–3 weeks ago.Hypertensive nephrosclerosis Membranous glomerulonephritis Systemic sclerosis Analgesic nephropathy
Other causes include: • Stage 1 diabetic nephropathy • Hydronephrosis • Acromegaly • Renal vein thrombosis
26. Some one-third of patients has nephritis. It presents with a purpuric rash over the buttocks and extensor surfaces. What is the most likely diagnosis? Proliferative glomerulonephritis Goodpasture’s syndrome Wegener’s granulomatosis Henoch–Schönlein purpura Systemic lupus erythematosus
This girl most probably has Henoch–Schönlein purpura. ileus and. hypertension and proteinuria. A 15-year-old girl presents with red spots on her buttocks and legs. joint pains.
coli urinary tract infection. A 45-year-old woman presents with increased frequency of micturition. dialysis or transplantation occurring in 18%. coli. Outcome figures from one study suggested that recovery of renal function occurs in 68% of patients. Other risk factors of note include multiple myeloma. then the incidence of acute renal failure is said to be 100%. If renal function is impaired then the incidence increases to around 25%. He is admitted to A&E 2 days after discharge home. but purpura is not a feature of this condition. She is also using a barrier contraceptive. otitis media and pulmonary symptoms. rhinitis. 28. multiple contrast studies. If these patients have diabetes mellitus as well. Proliferative glomerulonephritis would present with macroscopic haematuria. Congestive cardiac failure carries a risk of contrast nephropathy of 7–8%. 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.
27. 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. 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%. particularly multiple nodules.Wegener’s granulomatosis would have additional features such as nasal ulceration. hypertension and proteinuria in 2–3 weeks time. with death. partial recovery in 14%. Renal involvement in systemic lupus erythematosus occurs in 50% of patients but is seldom so rapidly progressive as to cause oedema. pancreatitis. dysuria and suprapubic pain 5 days after completing antibacterial treatment for an E. Variable shadows may be seen on chest X-ray. You suspect contrast nephropathy. What is the most likely cause for her problem? Atrophic vaginitis Use of spermicidal jelly
. dehydration and jaundice. 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. Urine microscopy shows the presence of E. Lung involvement (pulmonary haemorrhage) is seen in Goodpasture’s syndrome: the chest X-ray may show diffuse infiltrates in the lower zones.
usually longer. It usually occurs in conditions in which it is difficult to eradicate the bacteria. Isotonic saline alone will not correct the potassium deficiency nor will acetazolamide. 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. which causes bicarbonate diuresis. such as stones. Urine cultures are sterile. potassium 3. urea 14 mmol/l.0 mmol/l. Investigations reveal: haemoglobin 12. Sodium bicarbonate and thiazide diuretics are useful in renal tubular acidosis. and implies failure to eradicate infection. 30.52. sodium 130 mmol/l.
29. Which investigation would be most useful in this case? Plain X-ray of the abdomen Excretion urography Computed tomography Micturating cystourethrography Retrograde pyelography
. bicarbonate 34 mmol/l. followed by recurrence of infection with the same or a different organism. Reinfection occurs when bacteriuria is absent after treatment for at least 14 days. Relapse is diagnosed by the recurrence of bacteriuria with the same organism within 7 days of completing antibacterial treatment. Treatment with oral potassium supplements is sufficient in this case. chloride 85 mmol/l and pH 7. dysuria and often severe suprapubic pain. A 35-year-old woman with a past medical history of peptic ulceration presents with a 3day history of vomiting. scarred kidneys. It presents with frequency.Renal stones Your answer Interstitial cystitis Chlamydial urethritis This patient has had a relapse. What treatment would be most appropriate in this condition? IV 5% dextrose IV normal saline with potassium supplementation Acetazolamide Sodium bicarbonate Thiazide diuretics
This patient has hypochloraemic alkalosis and hypokalaemia.2 g/dl. Interstitial cystitis commonly affects women over the age of 40 years.
An 8-year-old boy complains of nausea and vomiting and fatigue.5 g. 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. while patchy shadows in apical zones are typical of tuberculosis. but it also can occur in adults. A chest X-ray would show bilateral diffuse infiltrates often in the lower zones. It is not useful in adult women because by this time the reflux tends to disappear. Corticosteroids are the treatment of choice. What is the most probable diagnosis? Proliferative glomerulonephritis Membranous glomerulonephritis Minimal-change disease Acute tubular necrosis Amyloidosis of the kidneys
Minimal-change disease (MCD). Urine microscopy shows oval fat bodies. Amyloidosis is usually seen in middle-aged patients (ie those over 40 years of age). Renal biopsy shows the presence of antiglomerular basement membrane antibody. It typically is a disease of childhood. This represents areas of pulmonary haemorrhage. Bilateral hilar lymphadenopathy is a characteristic feature of sarcoidosis. he is oedematous and his blood pressure is 160/100 mmHg. 24-hour urine protein is 1. A young man presents with haematuria and recurrent haemoptysis. Steroid therapy is of no proven value in acute tubular necrosis. also known as lipoid nephrosis or nil disease.
. The other investigations are only useful for upper urinary tract disorders. 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
The diagnosis is Goodpasture’s syndrome. 32. leading to complete remission of proteinuria in the majority of cases. which he says will cure the condition.A micturating cystourethrography is used primarily in children to check for vesicoureteric reflux during voiding.
31. Lobar consolidation is seen in pneumonias. Pleural effusion does not occur in this condition. It refers to a histopathologic lesion in the glomerulus that almost always is associated with nephrotic syndrome. Blood urea and serum creatinine levels are normal. The doctor plans to start a course of corticosteroids. is the most common single form of nephrotic syndrome in children. On examination.
but there have been no controlled clinical trials to date. Folate levels are usually unaffected. but mortality may be high in the elderly. Renal vein thrombosis occurs in 15–20% of patients with nephrotic syndrome. serum creatinine is 290 µmol/l and urea is 17. A full blood count and film reveals evidence of red cell haemolysis and thrombocytopenia.0 mmol/l. Inherited recurrent HUS has been described with both dominant and recessive patterns of inheritance.
34. A 72-year-old woman presents acutely unwell to casualty. particularly E. She has been suffering from gastroenteritis for a few days. Some commentators propose that antibiotic treatment of E. fresh-frozen plasma. Most children recover spontaneously from the illness. Raised blood glucose indicates diabetes mellitus. 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.33. prostacyclins and platelet inhibitors have all been tried. There is associated hypercoagulability due to urinary loss of antithrombin-III. A 60-year-old man is undergoing investigation for suspected nephrotic syndrome. coli may actually have increased the risk of HUS. There is intravascular haemolysis. Treatment with heparin. and acute renal failure. thrombocytopenia. Past medical history of note includes furosemide and ramipril for mild heart failure and treatment for nose bleeds.
. coli 157. 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
Thyroxine levels are depressed in nephrotic syndrome due to the enhanced urinary excretion of thyroxine-binding globulin. proteins C and S and a concomitant increase in fibrinogen levels. It has been suggested that acute infection triggers endothelial damage in susceptible individuals.
The negative c-ANCA (result makes Wegener’s granulomatosis (one possible differential) much less likely. 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. urine culture is unremarkable. Penicillamine may be used for those patients with
. Slightly unusually. pulmonary haemorrhage and anti-GBM antibody.5 g/dl. these stones turn out to be cystine stones. some absorption of cystine in peptide form may occur. some heterozygotes may only have an increased excretion of lysine and cystine. Patients are encouraged to maintain a high fluid intake. the male:female ratio being 6:1. serum creatinine is 345 µmol/l. 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. Urinalysis reveals microscopic haematuria and proteinuria. Although jejunal cystine absorption is impaired. Chest X-ray reveals fluffy pulmonary infiltrates. In patients with severe renal failure. A 23-year-old man presents to his GP with rapidly increasing shortness of breath and haemoptysis for the second time within 3 weeks. There appear to be no predisposing factors and he is otherwise well. he has no other significant past medical history. A 21-year-old man presents to A&E for the third time with recurrent urinary stones. c-ANCA is negative. Some 80% of patients with Goodpasture’s syndrome are HLA-BR2 positive. including drinking fluids at night.35. Acute management may involve treatment with prednisolone and cyclophosphamide or plasma-exchange therapy. cystinuria is responsible for around 1–2% of all urinary calculi. at above 3 litres per day. Goodpasture’s syndrome predominantly affects young male smokers. ornithine and arginine. and Goodpasture’s syndrome accounts for 5% of all cases of rapidly progressive glomerulonephritis. Apart from smoking 20 cigarettes per day and having mild asthma. Haemoglobin is 10. Inheritance is recessive or incompletely recessive. In total. haemodialysis may be required
36. He is referred urgently to the medical oncall team.
Cystine deposits in the retinas and corneas occur. A 71-year-old diabetic woman is in her 6th year of haemodialysis. which appears to result in a clinical syndrome of median nerve compression and pain and stiffness in multiple joints. There is resulting amyloid deposition within the synovium. sodium is 119 mmol/l and bicarbonate is 17 mmol/l. His blood pressure is 90/45 mmHg and his peripheries are cool.
37. What is the likely cause of his deterioration? Acute tubular necrosis Acute interstitial nephritis secondary to cefotaxime Adrenal insufficiency Septic shock
.7 mmol/l. The syndrome resolves slowly after renal transplant.recurrent stones who are unable to keep their urinary cystine concentration low. urea is 29. he complained of flank pain and is now becoming drowsy and lethargic. treated with highdose cefotaxime. non-nephropathic form presents in young adults. This protein. potassium is 6. An 18-year-old man is recovering from meningococcal septicaemia. A less aggressive. Cystinosis occurs due to lysosomal cystine accumulation. He suffered gangrene in four toes. numbness and tingling in both hands during the early hours of the morning. the light chain of class-1 HLA antigens. Postoperatively. Spot urine Na+ is 136 mmol/l. and some benefit is seen in switching patients to dialysis with a biosynthetic dialysis membrane. leading to progressive renal impairment.6 mmol/l. There may be associated GI haemorrhage caused by amyloid deposition around submucosal blood vessels. She also complains of stiffness in her shoulders. hips and knees. which necessitated amputation. 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. Plasma creatinine is 156 µmol/l.
38. the nephropathic form presenting in the first year of life with failure to thrive. She visits her GP with symptoms of pain. is usually freely filtered at the glomerulus but is not cleared by cellulose-based dialysis membranes.
as demonstrated by the presence of proteinuria and haematuria. bowel and bronchus malignancy. and presentation is most common in adulthood.
. Associations include systemic lupus erythematosus (SLE). Approximately one-third of patients develop renal failure within 10–20 years of diagnosis. This was initially described in cases of meningococcaemia with disseminated intravascular coagulation (DIC) (Waterhouse–Friderichsen syndrome). and the best way to establish the underlying diagnosis is via renal biopsy. Basement membrane thickening caused by immune complex deposition is the main feature of the disease. There is a preponderance of male cases. There is a long history of hypertension and deranged renal function now. and hepatitis B infection.5 cm and right kidney 8. Investigations gave:
• • • •
Creatinine 280 mmol/l Urinalysis. Adrenal insufficiency results in mineralocorticoid deficiency and potentially life-threatening salt-wasting and a failure to excrete potassium.8 g/l Ultrasound scan of kidneys showed left kidney 8. Patients with heavy proteinuria and progressive renal impairment may benefit from immunosuppressive therapy. penicillamine therapy. A significant number of cases are idiopathic. hyponatraemia and metabolic acidosis should always suggest hypoadrenalism. A 62-year-old man with a long-standing history of hypertension is seen in the outpatient clinic. The combination of hyperkalaemia.
39. blood++ Protein 1.SIADH Bilateral adrenal haemorrhage may occur in the setting of septicaemia.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
This man has glomerulonephritis. which is compatible with a possible diagnosis of membranous glomerulonephritis. although in a recent series pseudomonas infection was the commonest cause.
Some 10% of patients with myeloma will also have renal amyloid deposition. decreased serum albumin In the nephrotic patient.and α2-globulin fractions. A monoclonal paraprotein band will also be present where myeloma is the underlying cause. There is an inverse relationship between potassium levels and blood pH. Adrenaline stimulates 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. Infection with Pneumococcus spp is relatively common in affected individuals. 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. thus increasing the plasma potassium level There is a direct relationship between potassium levels and blood pH Potassium is the main intracellular cation. while hyperkalaemia is seen in metabolic acidosis.40. increased serum albumin Increased α1. Potassium release from muscle cells leads to glycogenolysis. 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.and α2-globulin fractions. 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. You note she has a raised erythrocyte sedimentation rate (ESR) and arrange for serum protein electrophoresis as part of a routine blood screen. abnormal findings on serum electrophoresis include a decreased albumin level and an increase in the α2-globulin fraction. and vaccination should always be offered. Acidosis therefore leads to the movement of potassium from the intracellular to the extracellular fluid compartment. Possibly related to immunoglobulins lost in the urine. thus decreasing the plasma potassium level. decreased serum albumin Your answer Increased α2-globulin fraction. sepsis is an important complication of nephrotic syndrome. Thus hypokalaemia occurs during alkalosis. and there may be associated immune paresis with reduced concentrations of one or more of the immunoglobulins IgG. IgA or IgM.
41. Early recognition of sepsis and
Other management for this particular patient is likely to include central venous pressure monitoring. Renal replacement therapy may be considered as the final option.9). nebulised salbutamol may also have positive effects in reducing serum potassium. Continuous ECG monitoring is a prerequisite. ie because of the difficulties of withdrawing inappropriate treatment once it has been commenced. it should be reserved until the results of her fluid balance assessment and ultrasound scan are known.2 mmol/l (2. Although furosemide may be of use to drive renal potassium excretion. 50 ml of 50% dextrose containing 10 U of insulin should be considered as the next intervention. urea 31. Correction of severe acidosis may also redress some hyperkalaemia. What is the most probable diagnosis?
.5–4. it is important that an assessment of likely prognosis is determined first.5– 7. You are reviewing a 78-year-old woman who has been admitted in a dehydrated and confused state to the Emergency department.
43.2 mmol/l (3. creatinine 450 µ mol/l (60–110).aggressive treatment is the key to a positive outcome. Her bloods are markedly abnormal: potassium of 7. 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. You repeat the serum potassium and it is still markedly raised. Because insulin drives potassium ions from the extracellular to the intracellular compartment. 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. The b2-agonist salbutamol also drives potassium into the intracellular compartment.5). but may exacerbate fluid retention in patients in renal failure. She is afebrile. Intravenous administration of 10 ml 10% calcium gluconate should be considered for cardioprotection. but it would carry a significant risk of arrhythmia if given intravenously. A 50-year-old woman develops haematuria with exquisite right loin pain. her abdomen is soft with tenderness over the right lumbar region. the management pathway is clear.
42. On examination. However.
particularly those with diabetes and perhaps patients with myelomatosis. cause. A patient undergoes investigation for chronic upper urinary tract obstruction with intravenous urography. What is the most significant complication?
. Polycystic kidney disease may present with loin pain only if there is nephrolithiasis.Acute pyelonephritis Renal cell carcinoma Polycystic kidney disease Renal calculi Acute nephritic syndrome
A ureteric calculus will cause severe loin pain. are at particular risk. exposure to radiation (of particular concern in pregnant women and children). however. worsening of pain due to the diuretic effect of contrast medium when an upper tract (or tracts) is obstructed. 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. Its major disadvantage is that the technique carries a mortality owing to contrast hypersensitivity reaction of perhaps 1 in 200 000. and the potential for contrast nephrotoxicity. Patients with impaired renal function. The pain. The absence of fever rules out acute pyelonephritis. 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. Renal cell carcinoma may present with haematuria. A patient with chronic pain relieved by phenacetin (a NSAID) presents with progressive renal failure due to analgesic nephropathy.
45. loin pain and a mass in the flank. Such risk is minimised by employment of low osmolality contrast medium and the avoidance of prior dehydration. Pyrexia is present in about one-fifth of all patients.
44. Excruciating loin pain is not a feature of acute glomerulonephritis. It also involves an intravenous injection. is not so severe.
hyaline deposits consisting of IgM. a probable reflection of secondary haemodynamically mediated glomerular injury. A 65-year-old diabetic man presents with ascites and proteinuria. analgesic abuse is the most common cause of bladder cancer. What is the most probable diagnosis? Mesangioproliferative glomerulonephritis Focal glomerulosclerosis Kimmelstiel–Wilson disease Amyloidosis Multiple myeloma
Amyloid deposition in cases of primary renal amyloidosis is typically seen within the mesangium. C3. and urinalysis that may be normal or may reveal sterile pyuria and mild proteinuria (less than 1. In multiple myeloma. an otherwise unusual disorder in young women. In focal glomerulosclerosis. Hypertension and anaemia are commonly seen with moderate to advanced disease. IgA and C3 deposits are seen in the mesangium.
. IgA and fibrinogen are deposited in juxtamedullary capillaries. Blockage of tubules by casts accounts for the proteinuria and chronic renal failure. In mesangioproliferative glomerulonephritis. Amyloid light chain (AL amyloid) proteins are deposited. These masses consist of lipids and fibrin. In women under the age of 50. Urinary tract malignancy will develop in as many as 8–10% of patients with analgesic nephropathy.Urinary tract malignancy Bone tumours Liver fibrosis Pancreatitis Diabetes mellitus
The renal manifestations of analgesic nephropathy are usually non-specific: normal renal function or slowly progressive chronic renal failure. A renal biopsy shows mesangial deposits of monoclonal kappa and lambda light chains. but in well under 1% of phenacetin (a NSAID)-containing analgesic users without kidney disease.5 g/day). More prominent proteinuria that can exceed 3. IgG.
46. free kappa or lambda light chains are excreted.5 g/day can also occur at this time. Kimmelstiel–Wilson disease is characterised by hyaline masses in the mesangial core of the glomerular lobules. for example. This is made up of kappa and lambda chains.
he appears clinically well and he has a trace of peripheral oedema. such as fever. may also be associated with MCGN. Plasma creatinine is 140 µmol/l. whereas hepatorenal syndrome occurs in patients with advanced cirrhosis with marked peripheral oedema and cirrhosis. Complement C3 is 0. malaria and leprosy. schistosomiasis. an immune-complex deposition disorder that presents with a mixed nephritic–nephrotic picture associated with panhypocomplementaemia. bilirubin is 65 µmol/l. would usually be present.09 (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. although hypertension is unusual and other manifestations of infection. Infectious endocarditis is the principal differential diagnosis in this case and may present with haematuria and hypocomplementaemia. A 52-year-old woman has been visiting her GP for a while.27).47.3) and C4 is 0.5 (0. AST is 78 IU/l and his 24-hour urinary protein excretion rate is 4. HIV nephropathy is suggested by the presence of nephrotic syndrome. rapidly progressive renal impairment and large kidneys on ultrasound. Renal emboli tend to present with flank pain and haematuria. complaining of recurrent nosebleeds. such as hepatitis B. and presents for examination under anaesthetic to a private surgeon.1 g/24 h.5).12– 0. She has also consulted for cosmetic surgery advice about the shape of her nose as it seems to be dipping.5–15. and
. Other chronic sources of immune complexes. Preoperative blood testing reveals anaemia with Hb of 10. chronic abscess. Hepatitis C is endemic among the intravenous drug-using population. A 36-year-old man with a history of intravenous drug use is found to have dipstick-positive haematuria. Microscopy of the spun urine sediment reveals the presence of red-cell casts. His blood pressure is 170/90 mmHg.5 g/dl (11.
What could be the possible diagnosis? Diabetic nephropathy Membranous glomerulonephritis Henoch-Schönlein purpura Focal glomerulosclerosis IgA nephropathy Your answer
.5/100. with an incidence of 0. A 30-year-old man is found to have macroscopic haematuria. Lung involvement causes chest X-ray changes. Patients are often anaemic with a leucocytosis and there are urine changes similar to those described above.5 g/24 hours and a serum creatinine level of 153 µmol/l. it is said to consist of necrotising granulomatous lesions in the upper or lower respiratory tracts.urinalysis reveals haematuria. Individual manifestations with differing severity in certain organ systems may occur. Classically. these may be bilateral multiple nodules. 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. 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. cavitated mass lesions or pleural effusion in 20% of cases. Pulmonary function testing may reveal a restrictive lung defect. proteinuria of 1.
49. red blood cell casts and proteinuria. which represent a glomerulonephritis-type picture. Her surgery is cancelled. and further testing reveals a serum creatinine concentration of 195 m mol/l (60–110). Treatment of choice is cyclophosphamide and steroid therapy.000 individuals. The 5-year survival with aggressive treatment is around 80%.
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
This postmenopausal woman has symptoms caused by the urethral syndrome. Topical oestrogen cream often has a dramatic response.Macroscopic haematuria is uncommon in membranous glomerulonephritis and diabetic nephropathy. haematuria and proteinuria which may be exacerbated in the presence of respiratory infections.5 g/24 hours) in these conditions and in focal glomerulosclerosis.
50. Corticosteroids will again not be helpful.
. As there is no infection. The condition is common in elderly women due to dryness and atrophy of the urethral tissue. The urine culture is sterile. An 85-year-old woman complains of dysuria and increased frequency of micturition. Proteinuria would also be much greater (> 3. IgA nephropathy presents with hypertension. Henoch-Schönlein purpura would be associated with a petechial rash and systemic vasculitis. Urinalysis shows microscopic haematuria and 2–3 white cells per high power field. antibiotic therapy or alkalinisation of the urine will be of no benefit.