251. A 65-year-old man, who has been on haemodialysis for 12 years, presents with gradually increasing bone pain. He underwent subtotal parathyroidectomy 4 years ago. Current medications include alfacalcidol 1 µg/day and calcium carbonate 500 mg three times daily. His serum calcium concentration is 2.97 mmol/l, phosphate is 2.7 mmol/l and intact parathyroid hormone level is 90 pmol/l. What is the most probable cause of his symptoms? Adynamic bone disease Dialysis amyloid Hyperparathyroid bone disease Your answer Osteoporosis Vitamin D-induced hypercalcaemia
Adynamic bone disease is increasing in prominence as a cause of skeletal pathology in patients with renal failure, especially those on peritoneal dialysis. It is characterised by a low bone-turnover state, with PTH levels usually < 8 pmol/l, absence of excess osteoid formation (distinguishing it from osteomalacia), a tendency towards hypercalcaemia and easy fracture. However, despite his previous parathyroidectomy, this patient clearly has grossly elevated PTH levels in the presence of hypercalcaemia and hyperphosphataemia. This indicates tertiary hyperparathyroidism due to hyperplasia of retained parathyroid tissue. Indeed, even after total parathyroidectomy in end-stage renal failure, only 10% of patients have a total lack of parathyroid activity postoperatively. Residual parathyroid tissue may be detected using technetium-99 sestamibi scanning.
252. A 70-year-old man with a 6-month history of malaise and back pain is admitted to A&E with severe loin pain. Physical examination is unremarkable except for pallor. An Xray of the lower abdomen shows a ureteric calculus and lytic lesions and osteoporosis of the lumbar vertebrae. Blood urea, creatinine and uric acid levels are raised. What is the most likely diagnosis? Chronic renal failure Hyperparathyroidism Myeloma Acute pyelonephritis Chronic myeloid leukaemia
Myeloma is a plasma-cell neoplasm that produces diffuse bone marrow infiltration with a tendency to form localised osteolytic deposits. Anaemia, hypercalcaemia and raised urea, uric acid and creatinine levels are all features of this condition. Back pain is common. In chronic myeloid leukaemia, splenomegaly is often massive. Uric acid levels may be raised. Hyperparathyroidism presents with raised serum calcium levels and increased bone turnover seen as subperiosteal resorption (especially on hand X-rays). Lytic lesions do not occur in this condition. The clinical features are not suggestive of acute pyelonephritis. Hypocalcaemia is a characteristic feature of chronic renal failure. Urolithiasis does not occur in this condition.
253. A 28-year-old woman is reviewed by her GP. She had glycosuria identified on new patient screening. Her fasting blood glucose concentration was revealed to be 4.8 mmol/l (3.0–6.0). Body mass index (BMI) is 23 (18.5–24.9). Serum lipid screen, liver function testing and full blood count were normal. What diagnosis fits best with this clinical picture? Type-2 diabetes mellitus Type-1 diabetes mellitus Renal glycosuria Your answer Impaired glucose tolerance Impaired fasting glucose Glycosuria is unusual where no other urine abnormality is identified, the blood glucose concentration is normal and no other metabolic abnormalities are identified. Either there is a defect in the tubular threshold for glucose reabsorption in the proximal tubule (a so-called ‘splayed’ reabsorption curve) or a defect in the maximum tubular reabsorption of glucose. The abnormality appears to run in families in some cases and both autosomal-dominant and -recessive inheritance patterns have been described. In this case, renal glucose excretion appears to have no clinical significance. However, where glycosuria is present it is important to rule out diabetes mellitus or other tubular disorders such as the Fanconi’s syndrome.
dysuria. In type-1 distal renal tubular acidosis the anion gap is within normal limits. A 52-year-old diabetic patient on metformin complains of feeling unwell and is found to have a blood glucose of 4. Excretion urography may show cavitating lesions in the renal papillary areas. He appears drowsy and has altered consciousness. Plain X-ray of the chest may show evidence of pulmonary tuberculosis.
255. bicarbonate 15
. A middle-aged man is brought to the hospital. He has lost weight over the past few months and his girlfriend noticed that he has a chronic cough. His blood sugar levels are not suggestive of either hypoglycaemia or diabetic ketoacidosis.
256. A 27-year-old Asian man presents with frequency.254. His blood glucose is 5. Diabetic nephropathy is unlikely to cause metabolic acidosis unless there is renal failure. haematuria and fever. particularly in the Asian immigrant population of the UK. chloride 116 mmol/l. Which investigation would be most helpful in reaching a diagnosis? Plain X-ray chest Excretion urography Renal ultrasound Computed tomography Micturating cystourethrography
Tuberculosis of the urinary tract should be kept in mind in patients presenting with frequency.2 mmol/l and an anion gap of 20 mmol/l. which is usually the original focus of the infection.2 mmol/l. There may also be evidence of ureteral obstruction with hydronephrosis. haematuria and night sweats. commonly with calcification. What is the most likely cause for his illness? Hypoglycaemia Diabetic ketoacidosis Lactic acidosis Diabetic nephropathy Type-1 distal renal tubular acidosis
This patient most probably has lactic acidosis as a side-effect of metformin therapy. dysuria.
257. This is the only listed condition that can cause metabolic acidosis with a normal anion gap.2 mmol/l. pulmonary oedema due to salt and water retention is not uncommon. After inappropriate attempts to initiate a diuresis by infusion of normal saline without adequate monitoring of the patient’s volume status. potassium 3. phosphate 0.mmol/l.4 mmol/l and anion gap 3 mmol/l. A biopsy of the purpuric lesion reveals leucocytoclastic vasculitis in the small vessels. On examination he has a purpuric rash involving the legs. The patient also complains of arthralgia involving the knees and the ankles. A 10-year-old boy is hospitalised because of a recent malaena and fever
(38°C). a 30-year-old man has suffered considerable blood loss and is oliguric. Immediate treatment is mandatory in this case as his serum calcium concentration is over 3. assessment of extracellular fluid volume is essential to guide fluid and electrolyte replacement. What is the most probable diagnosis? Lactic acidosis Hyperparathyroidism Ethylene glycol poisoning Alcohol intoxication Salicylate poisoning
This patient has symptoms of hypercalcaemia. Following a motorcycle accident. Which one of the following statements is true about this boy’s illness?
. Urine osmolarity is usually low and urinary sodium is high in ATN.6 mmol/l. allowing distinction from hypovolaemic pre-renal failure. what finding will point to acute tubular necrosis that may not be reversed by fluid replacement? Raised urinary chloride excretion Increased urinary sodium excretion Decreased urinary urea excretion Decreased urinary osmolality Decreased urine volume
Oliguria is common in the early stages of acute tubular necrosis (ATN).5 mmol/l (ie 3.
258. sodium 131 mmol/l. calcium 3. Urinalysis discloses proteinuria with microscopic haematuria. Particularly in the early stages of management. In a urine sample.
HSP nephritis becomes clinically manifest in only 20–30% of cases. kidneys. What disease is she most likely to be suffering from? Rheumatoid arthritis
. A renal biopsy from a 56-year-old woman with progressive renal failure shows glomerular and vascular deposition of a pink amorphous material. HSP affects mainly children between the ages of 3– 10 years.The purpuric skin rash is due to associated thrombocytopenia Active urinary sediment with RBC casts indicates glomerulonephritis Identification of anti-glomerular basement membrane antibodies is expected in half of the cases pANCA is positive in two thirds of the cases Renal granulomas are pathognomonic for this disorder Henoch-Schönlein Purpura (HSP) is recognised as a systemic small vessel vasculitis mainly involving the blood vessels of the skin. The most consistent findings are the deposits of IgA in the mesangium. The deposits are positive for lambda light chains. Granuloma formation is not a feature of HSP. It is due to inflammation of dermal blood vessels and not thrombocytopenia. Most glomeruli may look normal by light microscopy with only a few showing mesangial proliferation. Other cases may show focal and segmental intra-capillary and extra capillary proliferation with adhesions in small crescents. GI tract. and joints.5:1) than females and in approximately two thirds of children an upper respiratory tract infection precedes the onset of HSP by one to three weeks.
259. This shows apple-green birefringence under polarised light after Congo red staining. It usually presents as macroscopic haematuria and proteinuria lasting days to weeks. Apart from raised circulating IgA the immunology profile including pANCA and anti-glomerular basement membrane antibody test is usually negative. which is seen in almost 100% of patients. Males are affected more often (1. The hallmark of the disease is the characteristic palpable purpura.
Lambda light chains are present in the AL type of amyloid protein. of nephritic syndrome because of the increased coagulability of blood and sluggish circulation due to hypovolaemia. hypochromic anaemia. he is found to have a left-sided varicocele. leukopaenia. The AL type of amyloid protein occurs in multiple myeloma. It is particularly likely to complicate membranous glomerulonephritis. which is associated with the AA type of amyloid protein. Renal vein thrombosis is a complication. rather than a cause. Which type of glomerular disease is most likely to have caused this problem? Minimal-change nephropathy Membranous glomerulonephritis Diffuse proliferative glomerulonephritis IgA nephropathy Focal segmental glomerulosclerosis
This man most probably has a left renal vein thrombosis.
261.Tuberculosis Systemic lupus erythematosus Multiple myeloma Secondary amyloidosis
This patient has renal amyloidosis. thrombocytopaenia and haematuria.
260. As the left testicular vein drains into the left renal vein. His blood pressure is 160/120 mmHg. which can occur as a complication of nephrotic syndrome. a left-sided varicocele may develop in these individuals. On examination. Investigations reveal that he has microcytic. What could be the possible cause for his symptoms? Bladder metastases Transitional cell carcinoma of bladder
. Systemic lupus erythematosus is not usually associated with renal amyloidosis. A 55-year-old man complains of swollen feet and puffy eyelids. Rheumatoid arthritis and tuberculosis cause secondary amyloidosis. A patient undergoing cancer chemotherapy complains of increased urinary frequency and suprapubic pain.
1 °C and flank pain. The investigations do not suggest bladder infection while bladder metastases and bleeding diathesis are usually asymptomatic. Surgical opinion may be required for recurrent infections or where there is evidence of vesicoureteric reflux on scanning. a full blood count. rigors. A 28-year-old woman presents to casualty with flank pain and a 48-h history of dysuria. dysuria. Gram-negative bacilli such as Escherichia coli or Klebsiella species are responsible in more than 95% of cases. flank pain. There is haematuria on urine dipstick testing. In young women with a first infection. urine culture may be all that is required. headache and diarrhoea. Unusual organisms may be responsible if there has been a history of urethral instrumentation. Standard antibiotic treatment is with oral trimethoprim or ciprofloxacin. The latter causes chemical cystitis and therefore excellent hydration must be maintained during therapy with cyclophosphamide. haematuria. Work-up includes urea and electrolytes measurement. blood cultures and renal ultrasound in compromised patients. What diagnosis fits best with this clinical picture? Nephrolithiasis Pelvic inflammatory disease Ovarian cyst pain Pyelonephritis Your answer Acute glomerulonephritis The two peaks of incidence in adults for pyelonephritis occur in young sexually active women and in men > 50 years of age. Staphylococcal urinary sepsis is usually indicative of haematological seeding of infection. Examination reveals a pyrexia of 38.
. nausea and vomiting.Cyclophosphamide therapy Your answer Urinary tract infection Bleeding diathesis Cyclophosphamide is inactive unless metabolised by the liver to 4-hydroxyl cyclophosphamide. She is not in a steady relationship at present. Symptoms include fever.
262. polyuria. Her past medical history includes polycystic ovarian syndrome. which decomposes into alkylating species as well as to chloroacetaldehyde and acrolein.
Grade V V V V V Age (years) <1 1–5 1–5 1–5 >5 Scarring No No No Yes Initial treatment Follow-up Antibiotic prophylaxis Surgery If unilateral: antibiotic prophylaxis Surgery If bilateral: surgery Surgery Surgery
Grading of vesicoureteric reflux: Grade I II III IV V Description Reflux into a non-dilated ureter Reflux into the upper collecting system without dilatation Reflux into a dilated ureter and/or blunting of calyceal fornices Reflux into a grossly dilated ureter Gross dilatation of the ureter. Following a road traffic accident. a man is brought to A&E.263. renal pelvis and calyces. A 6-month-old boy is found to have primary grade-V vesicoureteric reflux involving both kidneys. He is found to have oliguria and a diagnosis of acute renal tubular necrosis is made. antibiotic prophylaxis may be given first. calyces show loss of papillary impression
264. What would be the most appropriate management in this case? Antibiotic prophylaxis Ureteric implantation Cystoscopy followed by subureteric injection of Teflon Bilateral ureterostomies Bilateral percutaneous nephrostomies Your answer
As this boy is under 1 year of age. What is the most common complication and cause of death in this condition? Infection Electrolyte abnormalities Nephrotic syndrome Congestive heart failure Persistent hypertension Your answer
The latter frequently undergo malignant transformation such that these patients often end up on dialysis because of bilateral nephrectomy. when detected. pancreatic cysts. Neither the use of prophylactic antibiotics nor barrier nursing is considered appropriate. It is inherited as an autosomal-dominant trait. Bleeding into the angiomyolipoma is the most common means of presentation. which when bilateral and associated with epilepsy.Sepsis. which is composed primarily of fat. should be treated promptly. A 26-year-old woman with epilepsy and a low IQ presents with flank pain. Which of the following investigations would be most helpful in this case? Micturating cystourethrography Ultrasound of the bladder Excretion urography Uroflowmetry Your answer
. There are two similar lesions (without haemorrhage) in her left kidney. Infections. often with incomplete penetrance. bearing constantly in mind the need to avoid nephrotoxic drugs and to use drugs excreted by the kidneys – with appropriate precautions such as alteration of the dosage and monitoring of blood levels. phaeochromocytoma and renal cysts. particularly Gram-negative septicaemia. which is manifested by retinal and cerebellar haemangioblastomas. is highly suggestive of a diagnosis of tuberous sclerosis.
265. which is deficient in adult polycystic kidney disease. A CT scan of her abdomen shows a large haemorrhage into a mass in her right kidney. is the most frequent complication and cause of death in acute renal tubular necrosis while awaiting spontaneous recovery of renal function. one on chromosome 9 (TSC1) and one on chromosome 16 (TSC2). The principal differential diagnosis is von Hippel–Lindau disease. hypotension and anaemia. which tend to grow slowly over time and occasionally undergo malignant transformation. Interestingly. What is the underlying condition? Adult polycystic kidney disease Renal-cell carcinoma Tuberous sclerosis von Hippel–Lindau disease Xanthogranulomatous pyelonephritis
The CT scan appearance is typical of angiomyolipoma.
266. the latter is adjacent to the PKD1 gene. Renal function is normal. A 1-year-old boy presents with a poor urinary stream since birth. Two genetic defects have been identified. The renal lesions are hamartomas.
The best diagnostic method is a micturating cystourethrography.
268. The alkalosis is maintained by persistence of contraction of the extracellular fluid volume and secondary hyperaldosteronism. The most common cause in a male child is posterior urethral valves. A 65-year-old man with congestive heart failure who has received an excess amount of furosemide is now found to have hypochloraemic alkalosis.
267. The other option is endoscopy. which in turn enhances bicarbonate reabsorption. Potassium depletion leads to increased urinary acid excretion as ammonium. Oral ammonium chloride may achieve acidification. A 60-year-old man presents with heart failure and pedal oedema. Which of the following investigative results would be most characteristic of this disorder? Low serum bicarbonate level Expanded extracellular fluid volume Poor response to ammonium chloride Fall in pa(CO2) Hypokalaemia
Hypochloraemic alkalosis is associated with severe hypokalaemia and increased bicarbonate reabsorption. Diuretics acutely diminish the extracellular fluid volume.Computed tomography A poor urinary stream suggests a urinary tract obstruction (usually infravesical). The oedema occurs due to: Hypoalbuminaemia Increased release of renin Your answer Decreased filtration fraction Increased proximal tubular sodium reabsorption
. There is an increase in pa(CO2). Both these investigations would clearly show the site of obstruction.
The major target of aldosterone is the distal tubult of the kidney. Increased renal excretion of potassium. with a creatinine of 119 micromol/l at baseline. This is an osmotic effect directly related to increased resorption of sodium. This is converted to angiotensin II which is a potent vasoconstrictor and stimulant for aldosterone secretion. the period of acute hypotension has resulted in an episode of acute tubular necrosis (ATN) and he has undergone renal dialysis on a number of occasions in the past week. You are asked to see the relatives of a 68-year-old man who has undergone surgery for repair of a ruptured aortic aneurysm. where it stimulates exchange of sodium and potassium. in this case a period of severe hypotension resulting from the ruptured aneurysm.
Activation of the renin-angiotensin system as a result of decreased renal blood flow (usually due to decreased vascular volume) results in release of angiotensin II. Which of the following most accurately represents the chance of recovery of renal function to the level where dialysis is not required? 0% 95% 5% 50% 25%
ATN usually occurs after an acute ischaemic or toxic event. Increased release of renin from juxtaglomerular cells in the kidney leads to the release of angiotensin I from angiotensinogen. which stimulates aldosterone secretion. Increased resorption of water: with consequent expansion of extracellular fluid volume. Right heart failure is associated with peripheral oedema.Left heart failure
Decreased cardiac output stimulates renin release.
269. Only around 5% of patients require long-term renal replacement therapy. Although the operative procedure went well. This results in three primary physiologic effects:
Increased resorption of sodium: sodium loss in urine is decreased under aldosterone stimulation. Around 50% have some impairment of renal function
. which affects the ankles in ambulant patients. There is an increased filtration fraction caused by renal vasoconstriction in response to the diminished cardiac output. Prior to surgery he was well.
potassium 2. urea 3. bicarbonate 15 mmol/l. whether central or nephrogenic. Infections are the leading cause of death in acute renal failure.5 mmol/l and glucose 4. The plasma osmolality is 268 mOsmol/l and urine osmolality is 45 mOsmol/l. serum sodium is increased. urea 5. Blood tests show: sodium 130 mmol/l. chloride 115 mmol/l. What is the most probable diagnosis in this case? Type-1 renal tubular acidosis Type-2 renal tubular acidosis Type-4 renal tubular acidosis Chronic renal failure Ureteric stone Your answer
. Prognosis of ATN is poorer in patients with severe sepsis or trauma.4 mmol/l.on a permanent basis. potassium 3. The daily urine output is 6–8 litres.5 mmol/l.
270. there is low plasma osmolality with inappropriate urine osmolality.
271. around another 5% undergo a slow deterioration in their renal function. causes an increase in plasma osmolality and serum sodium. where mortality rates can approach 50–60%. In the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. A 33-year-old woman presents with polydipsia and polyuria. These symptoms started soon after a road traffic accident 6 months ago.5. The urinary pH is 6.5 mmol/l. The plasma biochemistry of a patient presenting with severe right flank pain is as follows: sodium 135 mmol/l.5 mmol/l. Her blood pressure is 120/80 mmHg with no postural drop. During the resolving or diuretic phase of acute tubular necrosis. whereas both are decreased in this case. which is higher than plasma osmolality. What is the most likely diagnosis? Central diabetes insipidus Nephrogenic diabetes insipidus Diuretic phase of acute tubular necrosis Primary polydipsia SIADH
Primary or hysterical polydipsia is a psychiatric disturbance that causes a fall in plasma sodium and osmolality and a concomitant low urine osmolality. Diabetes insipidus.
Blood pressure is 125/80 mmHg. A 34-year-old woman presents with vomiting. Light
. Typically urine pH remains > 5. Which of the following most accurately describes the pathological process? Crescentic glomerulonephritis Disseminated intravascular coagulation Malignant hypertension Pre-eclampsia Thrombotic microangiopathy
The history is typical of postpartum haemolytic–uraemic syndrome (HUS). the latter helping to distinguish it from the HELLP (haemolysis–elevated liver enzymes–low platelets) syndrome. The problem here is an inability to maximally acidify the urine. On both occasions the haematuria appears to have been closely associated with an upper respiratory tract infection.9 mmol/l.5 despite severe acidaemia ([HCO3] < 15 mmol/l). which is far more common.
272. A 32-year-old man is referred to the renal clinic by his GP after a second episode of gross haematuria. The pregnancy had been uncomplicated with no hypertension evident. The differential diagnosis of acute renal failure in the setting of pregnancy includes postpartum HUS. Her blood pressure is now 210/110 mmHg. All may be complicated by acute cortical necrosis. Haemoglobin is 7. low serum bicarbonate levels and relatively high urinary pH are characteristic of distal renal tubular acidosis.5. and is associated with relatively mild renal failure) and the HELLP syndrome (which is usually preceded by a history of pre-eclampsia and is characterised by evidence of disseminated intravascular coagulation). severe irreversible renal failure and hypertension. Some patients with less severe acidosis require acid loading tests (eg with NH4Cl) to assist in the diagnosis. this establishes the diagnosis.
273. If the acid load drops the plasma [HCO3] but the urine pH remains > 5. In cases of postpartum HUS it is important to consider the possibility of retained products of conception. normal clotting indices and lactate dehydrogenase levels of 800 IU/l.Renal stone formation and nephrocalcinosis are common in this condition. which usually occurs 4–6 weeks’ postpartum and is characterised by microangiopathic haemolytic anaemia.6 g/dl. resulting in oligoanuria. plasma creatinine is 650 µmol/l and potassium is 6. malaise and weakness 5 weeks after delivering a healthy male infant. Past history of note includes coeliac disease. thrombotic thrombocytopenic purpura (which occurs invariably antepartum and usually before 24 weeks. Schistocytes are evident on the blood film but the clotting indices are normal. reticulocytes of 7%. hypokalaemia.The presence of acidosis. haematuria and flank pain. associated with a platelet count of 65 × 109/l.
Chronic renal failure occurs in up to 2% of patients per year who have IgA nephropathy. As well as presenting with episodic gross haematuria.6 litres of urine over the next 24 hours. Renal ultrasound showed gross bilateral hydronephrosis with thin cortices. His serum Na+ is 150 mmol/l and urine osmolality is
. and use of prednisolone in patients with severe disease may also be of benefit. IgA deposits are seen on immunofluorescence. sometimes known as Berger’s disease.
274.microscopy of a renal biopsy specimen reveals diffuse mesangial proliferation and extracellular matrix expansion. IgA nephropathy is seen in up to one-third of patients with gluten enteropathy and is also associated with cirrhosis. His blood pressure is now 80/50 mmHg. other presentations include nephrotic syndrome with proteinuria and acute renal failure. he has no oedema and his neck veins are flat. during which time he received no supplemental iv fluid. An 80-year-old man with a long history of poor urinary stream and nocturia presented with malaise and vomiting. Medical treatment of IgA nephropathy includes angiotensin-converting enzyme (ACE) inhibition which as been shown to delay progression to renal failure. Which of the following diagnoses fits best with this clinical picture? Alport’s syndrome Lupus nephritis IgA nephropathy Your answer Goodpasture’s syndrome Wegener’s granulomatosis This patient gives a typical clinical picture of episodic haematuria associated with respiratory tract infection. and the light microscopy result is in keeping with IgA nephropathy. HIV infection and has a familial form. His plasma creatinine concentration was 1242 µmol/l and his urea 65 mmol/l. A urinary catheter was placed and he passed 7.
However. high renin In the setting of long-standing urinary tract obstruction. Hypovolaemia is a potent stimulus for renin production from the juxtaglomerular apparatus and hypernatraemia is a potent stimulus for ADH production from the posterior pituitary. the ability of the kidney to concentrate urine becomes severely impaired. high aldosterone. this situation should never be allowed to occur in practice. Replacing urine ml for ml.0 mmol/l and serum potassium of 6. but 36 h later her condition worsens and her bloods reveal a corrected calcium of 2. low renin Low ADH.
275.198 mOsm/l. low aldosterone. in the presence of a low urine osmolality indicates that the polyuria is pathological. Therefore. Which of the following most accurately describes the hormonal milieu? High ADH. one can infer that there is severe distal tubular damage with effective unresponsiveness to both ADH and aldosterone. resulting in partial nephrogenic diabetes insipidus. a rise in serum osmolality to > 300 mOsm/l.7 mmol/l. as in this case. as evidenced by the severity of uraemia and thin cortices. Much of the polyuria that occurs after urinary tract obstruction is relieved is an appropriate attempt by the kidneys to deal with salt and water overload. As there is nothing in this case to suggest adrenal disease. or even ‘output minus 30 ml/h’. with frequent assessment of fluid status.45% saline or alternating dextrose 5% and normal saline. She suffers from vomiting. The ability of the kidney to conserve Na+ is also impaired. A 22-year-old student commences chemotherapy for B-type acute lymphoblastic leukaemia. secondary hyperaldosteronism would be present. prolongs the duration of diuresis. high renin Low ADH. high aldosterone. Which of the following options is the best way to avoid this problem from occurring?
. Obviously. A reasonable approach in postobstructive diuresis is to replace half the volume of urine with 0. as the patient became clinically volume-depleted. low renin High ADH. high renin Your answer High ADH. high aldosterone. low aldosterone.
What is the probable diagnosis? Acute pyelonephritis Renal abscess Renal-cell carcinoma Transitional-cell carcinoma Xanthogranulomatous pyelonephritis Your answer This is the typical presentation of xanthogranulomatous pyelonephritis (XPN). although rare. which occurs rapidly after the commencement of chemotherapy due to necrosis of leukaemic cells.Pretreatment with furosemide therapy Adequate hydration pre-chemotherapy Allopurinol pre-chemotherapy Hydration and allopurinol pre-chemotherapy Furosemide and allopurinol pre-chemotherapy
This is the tumour-lysis syndrome. There is rapid electrolyte derangement with hypocalcaemia. fever. for which the only treatment is often haemodialysis. hyperphosphataemia and hyperkalaemia leading to a life-threatening situation. The rapid electrolyte changes exceed the rate of renal clearance. is increasing in incidence. Her white cell count is 17. Hb is 8. A 52-year-old woman with a history of recurrent urinary tract infection presents with a 3-week history of increasing left flank pain. On examination a left-sided abdominal mass is palpable.5 × 109/l. Furosemide may precipitate dehydration and actually increase the risk of tumour-lysis syndrome. It develops as an abnormal macrophage response to infection. which.1 g/dl and plasma creatinine is 190 µmol/l. anorexia and weight loss.
276. The risk of developing the tumour-lysis syndrome can be reduced by prehydration and treatment with allopurinol to reduce serum urate levels. particularly in the presence of urinary tract
. There is a significant growth of Klebsiella spp in her urine.
It will show the replacement of renal parenchyma by rounded. Symptoms include anorexia.
277. Patients with XGP often appear chronically ill. leucocytosis. CT scan is the investigation of choice to confirm the diagnosis. resulting in the onset of nephrotic syndrome. The cardinal features are acidosis. and hypophosphataemia. In these cases. The relatively rapid history. A flank mass is usually palpable. The disease is almost invariably unilateral. and occasionally mimicking renal cancer. thereby distinguishing it from simple acute pyelonephritis or renal abscess.5 despite systemic acidosis and the appearance of bicarbonate in the urine despite subnormal plasma bicarbonate helps differentiate between RTA type 1 and type 2. An inability to lower the urine pH below 5. extending over months or years. Slit-lamp examination shows a greenish-brown discoloration at the corneoscleral junctions. a rare inborn error of copper metabolism. fevers. What is the most common association with this condition? Hyperkalaemia Metabolic alkalosis Hypophosphataemia Your answer Increased serum bicarbonate Hypercalcaemia
This patient has Wilson’s disease. and it establishes the extent of the lesion (which may involve surrounding structures). A 23-year-old man has had recurrent attacks of hepatitis. hypokalaemia. AA amyloid may develop. then this is more suggestive of Type 2. and flank pain. If the urine can be acidified. The condition can cause type-2 proximal renal tubular acidosis (RTA). polyuria and polydipsia. weight loss. The course may also be indolent and protracted. and is pathologically related to malacoplakia.
.obstruction. muscle weakness. renal impairment and positive urine culture make XPN much more probable than cancer. He now presents with bone pain. low-density areas surrounded by a ring of enhancement.
An 18-year-old man was admitted to the emergency department having collapsed with occipital headache. It accounts for 3–10% of patients undergoing regular dialysis in the UK. as in this case. Which one of the following would be the most appropriate intervention in this case? Stop metformin Stop gliclazide Start atorvastatin 10 mg daily Your answer Transition to insulin therapy
. Total cholesterol is 5. She currently takes metformin and gliclazide and has an Hb A1c of 6. abdominal discomfort due to increasing kidney size or presentation with extrarenal manifestations such as subarachnoid haemorrhage. Other presentations may include the complications of hypertension or complications of associated liver cysts.
279.8%. A 45-year-old woman with type 2 diabetes presents for review.8 mmol/l. Symptoms may include loin pain due to a cyst haemorrhage or infection. characterised by the development of multiple renal cysts and cardiovascular abnormalities. but high-density lipoprotein (HDL) level is only 0.278. a second gene defect has been identified on chromosome 4. A scan revealed a massive subarachnoid haemorrhage.2 mmol/l. serum creatinine is 92 µmol/l. The commonest chromosomal defect is on chromosome 16 (85%). It is the commonest inherited nephropathy. Urine microalbumin stix are positive. Blood pressure is 142/82 mmHg on no antihypertensive medication. Further investigation during the following days revealed multiple bilateral renal cysts. which is responsible for the majority of other cases. A defect on which chromosome is likely to be responsible for this clinical syndrome? Chromosome 16 Your answer Chromosome 4 Chromosome 12 Chromosome 5 Chromosome 3 This is one presentation of autosomal-dominant polycystic kidney disease. with a prevalence rate of between 1:400 and 1:1000.
The CARDS study of atorvastatin 10 mg in patients with type 2 diabetes and average cholesterol has demonstrated benefit in cardiovascular event reduction. the kidneys are normal or increased in size. Her Hb A1c is already near target and there would be no additional benefit in converting her to insulin therapy. Patients with chronic glomerulonephritis usually have heavy proteinuria. This results from renal tubular defects caused by cystine deposits in the kidney. frank or occult haematuria and hypertension. His blood pressure is normal. Blood urea is 14 mmol/l. serum creatinine 145 µmol/l. which puts her in a patient group at high risk of cardiovascular complications. phosphate 2. Renal damage progresses and visual impairment occurs as a result of cystine deposits in the retina and cornea. sodium 120 mmol/l. Additionally. The consensus at the moment is that even this patient group may benefit from angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blockers (ARB) treatment. A 12-year-old boy is referred for evaluation of nocturnal enuresis and short stature.
. Ultrasound shows bilateral small kidneys. sensorineural hearing loss and bilateral lenticonus. In medullary sponge kidney. The clinical features and investigations are suggestive of this disorder. A micturating cystourethrogram is normal. The treatment of microalbuminuria in type 1 diabetes where the blood pressure is normal is a source of some debate. What is the most likely diagnosis? Alport’s syndrome Medullary sponge kidney Chronic glomerulonephritis Nephronophthisis Cystinosis
Nephronophthisis is an autosomal-recessive disorder. Cystinosis presents in the first year of life with failure to thrive. Alport’s syndrome presents with microscopic haematuria.
280. The age of presentation is usually in the third or fourth decade.2 mmol/l.Start bendroflumethiazide 2.5 mg This patient has microalbuminuria. Hence it would be correct to begin atorvastatin and also ramipril. Urinalysis shows trace proteinuria with hyaline casts.5 mmol/l and alkaline phosphatase 400 U/l. the HOPE study and a number of similar studies such as LIFE. showed the benefit of blockade of the renin– angiotensin system in reducing both cardiovascular events and renal progression. potassium 4.
282. What diagnosis fits best with this clinical picture? Rheumatoid arthritis with typical lung changes Tuberculosis Bronchial carcinoma Wegener’s granulomatosis Your answer Goodpasture’s syndrome She has evidence of chronic upper respiratory tract changes associated with Wegener’s granulomatosis. Renal changes include a focal glomerulonephritis. nasal crusting. mastoiditis. there are no immune complexes. Antiglomerular basement membrane antibodies that bind mainly to the non-collagenous domain of the a-3 chain of type-IV collagen cause Goodpasture’s syndrome. A 62-year-old woman has a history of chronic otitis media and mastoiditis over the past few months. again. These act locally on the parietal cells and inhibit the production and action of intrinsic factor. Chest Xray reveals cavitating mass lesions and evidence of multiple nodules with diffuse alveolar changes. In minimal-change nephropathy. epistaxis and eventually saddle-nose deformity. Urea and creatinine are both markedly raised. Blood testing shows the presence of circulating immune complexes. She smokes 30 cigarettes per day. Allergic rhinitis is. proteinuria and red-cell casts. haematuria and nephrotic syndrome. Urinalysis reveals haematuria. ESR and rheumatoid factor are elevated. Parietal cell and intrinsic factor antibodies are present in pernicious anaemia. Which of the following disorders is he most likely to be suffering from? Goodpasture’s syndrome Pernicious anaemia Allergic rhinitis Minimal-change glomerulonephritis Mesangiocapillary glomerulonephritis Your answer Circulating immune complexes are seen in mesangiocapillary (membranoproliferative) glomerulonephritis. associated with necrotising glomerular lesions. Lung changes may include multiple nodules and cavitating lesions with diffuse alveolar changes. c-ANCA positivity is the
. A 14-year-old boy presents with proteinuria.281. otitis. There have been one or two episodes of haemoptysis. The pathogenesis is unclear. but it may be possible that a factor produced by T lymphocytes increases the glomerular permeability to protein. these may include sinusitis. a local interaction between the inhaled allergen and adjacent molecules of the IgE antibody present on the surface of mast cells found in the nasal secretions and nasal epithelium.
There was no previous history of retinopathy. Management is with iv methylprednisolone and cyclophosphamide therapy. A 56-year-old diabetic man came in for acute breathlessness in the middle of the night. and his blood pressure (BP) was 180/112mmHg. Investigation: creatinine (Cr) 251 µ mol/l. urine dipstick protein 1+. assessment of renal function by estimation of creatinine clearance and quantification of proteinuria and renal imaging. initially by excretion urography. Which of the following would best explain the above findings? Chronic glomerulonephritis Renal artery stenosis Nephrotic syndrome Renal vein thrombosis Acute urinary tract infection Your answer
Diabetic nephropathy does not normally present with microscopic haematuria as well as proteinuria. His HbA1c is 8. hence the combination of haematuria and proteinuria suggests glomerulonephritis as a possible cause. Crucial to the management of this patient is adequate control of blood pressure.
. blood 1+. Assessment of aetiology involves urine microscopy for red-cell casts. the presence of haematuria and proteinuria is strongly predictive of a non-diabetic cause (positive predictive value 94%).4%.confirmatory immunology test for Wegener’s granulomatosis.
283. Unfortunately. Renal function may deteriorate to the stage where renal replacement therapy is required. in these cases some residual renal insufficiency after recovery is common. Renal biopsy may be useful to further elucidate the underlying cause. Chest X-ray revealed evidence of pulmonary oedema. In the absence of retinopathy. Presentation with pulmonary oedema is secondary to cardiac failure related to hypertension.