Chronic Kidney Disease

Question 1

What is the aetiology of CKD?

Answer 1

• Diabetes (diabetic nephropathy)
• Hypertension (Hypertensive nephropathy)
• Infections
• Renal disease (RPGN/GN/PCKD)
• Obesity/Dyslipidemia/Hypertriglyceridemia/Metabolic Syndrome
• Obstruction
• Drugs/Toxins

Question 2


What is prevalence?

Answer 2

Number of affected persons present in the population at a specific time divided by the population at the time

Question 3

What is incidence?

Answer 3

Number of individuals developing a specific disease/illness over a particular time period

Question 4

List the potential ways of treatment in chronic kidney failure and the ethical implications of each.

Answer 4

1) Guidelines for RRT and Organ Donation/Transplantation
• Systematic
• Fair
• Efficient

• Expensive (RRT is £17,500 peritoneal dialysis cf £35,000 hemodialysis): £20,000 QALY

2) Live donations
• Willing volunteers (autonomy)

• Ethics: Informed consent
• Safety

3) Peri-mortem donations
• Willing volunteers (autonomy)

• Ethics
• Sensitivity to situation/Dignity

Question 5

What is a QALY?

Answer 5

cost-utility health-economics measurement used to compare an intervention/treatment against another or against none in order to decide if it is cost-effective and viable both for the patient and hospital/healthcare sector.

Question 6

Define a QALY in simple terms.

Answer 6

• Years of perfect/full health equivalent to greater number of years in a worse state cf full health
• 10 years x 0.5 full health = 5 QALYs
• 30 years x 0.66 full health = 20 QALYs
• Measured regarding ADL, freedom of pain and mental disturbance

Question 7

Outline the public health approach in the context of kidney disease.

Answer 7

Public Health Approach
•	Surveillance: ID Problem
•	RF ID: Aetiology 
•	Intervention: Management approaches 
•	Implementation: Management plan (How to do it)

Question 8

What makes a finding interpreted from data ‘apparent’ or ‘real’?

Answer 8

Apparent: Data collection or analysis generates the finding 
- More investigation required to confirm 



Real: Finding is due to genuine factors 

- Prevalence of condition 

- Accessibility 

- Co-morbidities 

- Different clinical practice

Question 9

What approach works for donated blood?

Answer 9

• Systematic
• Ethics
• Donor safety: screening, safe environment
• Recipient safety: Not infected/contaminated; correct blood group

Question 10

Define Hypertension and its values for all the main categories of readings.

Answer 10

High blood pressure (> 140/90mmHg) taken by sphygmomanometry or HBPM +/- confirmed with ABPM (if between 140/90 and 180/120mmHg)

Question 11

Outline the classification of HTN.

Answer 11

• 1º HTN (idiopathic/essential): Unknown cause (90%)

* 2º HTN: Known cause (10%)

Question 12

State 3 causes of 2º HTN.

Answer 12

• 2º HTN: Known cause (10%)

• Renal disease: RVD/PKD/GN
• Vascular: RAS/CoA
• Endocrine: Cushing’s/Pheochromocytoma/Thyrotoxicosis/Hyperaldosteronism (Conn Syndrome)
• Other: OSA/ Drug-induced

Question 13

What is the kidney?

Answer 13

Bilateral bean-shaped organ which is reddish-brown in colour, is retroperitoneal and located in the posterior abdomen at T12-L3 which is responsible for filtration, excretion and blood pressure control.

Question 14

What are the physiological functions of the kidney? List 5

Answer 14

• Regulation of body fluid volume and osmolality
• Maintenance of ion balance
• Acid-base balance
• Waste excretion
• Vitamin D hydroxylation (25-hydroxycholecalficerol + 1a hydroxylase  1,25 a hydroxycholecalciferol (calcitriol))
• EPO

• Renin production

Question 15

What is blood pressure? What is the equation for blood pressure?

Answer 15

= pressure exerted by ventricles (circulatory system) against arterial walls

BP = CO x TPR

Question 16

What is cardiac output? What is the equation for cardiac output?

Answer 16

= rate of blood pumped out of LV into systemic circulation (L/min)

CO = HR x SV

Question 17

What factors contribute towards cardiac output?

Answer 17

• Heart Rate:

• PSNS (Brake)
• SNS (Accelerator)
• Adrenaline
• Drugs

• Stroke Volume:

• SNS (increased)
• EDV (SNS veins/ BV/ skeletal muscle pump/ respiratory pump ≈ venous pressure ≈ venous return)

Question 18

Give 3 factors contributing to EDV.

Answer 18

Vasomotor tone of veins (SNS)

Skeletal muscle pump

Respiratory pump

Question 19

Outline the process by which the RAAS rectifies a reduction in blood pressure.

Answer 19

• Hypovolemia ± low osmotic pressure -> reduced BP + increased Na+ -> macula densa detects elevated salts -> reduced baroreceptor firing = reduced SNS drive (= NA) -> renin release (kidney) = angiotensinogen (liver) -> angiotensin I + ACE (lungs) -> angiotensin II…

Question 20

List the changes AGT II brings about in the body regarding blood pressure regulation. Give a mnemonic for this.

Answer 20

• Arteriolar vasoconstriction (TPR increases)
• Efferent glomerular arteriole vasoconstriction (increase GFR and salt reabsorption)
• ADH secretion (AGT II binds posterior pituitary)
• Salt + water reabsorption via aldosterone release (AGT II binds zona glomerulosa of adrenal cortex = aldosterone release)

Mnemonic: ‘Pressure to get 4As’ 
Aldosterone release (zona glomerulosa) 
Arteriolar vasoconstriction 
Arteriole (glomerular efferent) vasoconstriction 
ADH release (posterior pituitary)

Question 21

Outline the process by which the RAAS rectifies a reduction in blood pressure.

Answer 21

• Low osmotic pressure (increased osmolarity) ± reduced blood volume -> reduced BP -> hypothalamic osmoreceptors detect ∆ -> neuronal afferents to posterior pituitary gland = ADH/AVP released:

• Increased water permeability (renal collecting ducts) = increased blood volume + reduced urinary output
• Vasoconstriction = increased TPR
• Dipsogenic: Hypothalamic thirst center

Question 22

List the 3 main effects of ADH on the body regarding blood pressure regulation. Give a mnemonic for this.

Answer 22

• Increased water permeability (renal collecting ducts) = increased blood volume + reduced urinary output
• Vasoconstriction = increased TPR
• Dipsogenic: Hypothalamic thirst center

Mnemonic: People Value Dipsogenesis
Permeability
Vasoconstriction
Dipsogenic

Question 23

Outline how ANP rectifies an aberrant change in blood pressure.

Answer 23

• Increased osmotic pressure/increased blood volume -> increased BP -> detected by atrial cardiopulmonary baroreceptors in atrial cardia = increased baroreceptor firing -> ANP release -> afferent arteriole vasodilation + increased flow through vasa recta (reduce osmolarity of medullary interstitium) + increase collecting duct Na+ excretion -> reduce blood volume = reduce BP

Question 24

List the effects ANP has on the body regarding blood pressure regulation. Give a mnemonic for this.

Answer 24

• Natriuresis:
• Arteriole (afferent) vasodilation
• Aldosterone reduced (zona glomerulosa)
• Vasodilation (vascular)
• Fibrosis (anti-fibrotic)

Mnemonic: FAVourite NA
Fibrosis reduced
Arteriole (afferent) vasodilation
Vasodilation

Natriuresis
Aldosterone reduced

Question 25

Outline the effects PGs have on renal regulation of blood pressure.

Answer 25

• Reduced blood volume (hypovolemia) -> reduced O2 availability ≈ Hypoxia -> HIF-2 -> EPO enhancer -> EPO production (liver) -> increased erythropoiesis ≈ increased Hematocrit (increased MCV; reduced MCHC?) = increased BP

Question 26

What is Mean Cell Volume? Give the equation. State the 3 categories and give an example of a disease for each.

Answer 26

MCV = Hct/ RBC • Average volume of RBCs - Microcytic (60-80fl): iron deficiency, thalassemia - Normocytic (80-100fl): blood loss, chronic disease anaemia, renal impairment - Macrocytic (100-120fl): megaloblastic anaemia, B12/folate deficiency, myelodysplasia

Question 27

What is Mean Cell Haemoglobin? Give the equation.

Answer 27

MCH = Hb/RBC | • Average mass of Hemoglobin per red blood cell

Question 28

What is Mean Cell Haemoglobin Concentration? Give the equation. State the two scenarios/categories.

Answer 28

MCHC = Hb/Hct • Average concentration of Hemoglobin per volume of red blood cells - Normochromic: Cells with normal [Hb] - Hypochromic: Cells with low [Hb]

Question 29

What are the effects of Angiotensin II and where do these occur (sites)?

Answer 29

Renal retention of salt and water + vasoconstriction ≈ increased arterial pressure 

1) Resistance vessels: vasoconstriction ≈ increase total peripheral resistance 

 2) Kidneys: constricts renal arteries ≈ reduce blood flow ≈ reduce glomerular filtration rate 

 3) Adrenal gland: Aldosterone release from adrenal cortex ≈ increase sodium and water reabsorption 

 4) Pituitary: ADH release

Question 30

List 3 main examples which lead to renin secretion.

Answer 30


1) SNS nerve activation due to baroreceptor feedback 

2) Renal artery hypotension via JGM 

3) Decreased sodium in kidney distal tubules detected by osmoreceptors

Question 31

What two main renal mechanisms influencing blood pressure control? List the factors that influence each of these and indicate whether they increase of decrease these factors).

Answer 31

``` ECF Volume: 
- Fall in GFR (+) 
 - Salt reabsorption (+) 
- SNS (≈ salt reabsorption ≈ +)
 - RAAS (≈ salt-reabsorption ≈ +)

 ``` Vasoconstriction: 
- SNS (+)
- RAAS (+) 
- Endothelin (+) 
 - Renal PGs (e.g. other vasodilators) (-)

Question 32

What is hypertension? State the classification and types.

Answer 32

High blood pressure (> 140/90mmHg) taken by sphygmomanometry or HBPM +/- confirmed with ABPM (if between 140/90 and 180/120mmHg) 

Classification: Aetiology 

1) 1º Hypertension (Idiopathic): 
- Unknown origin 
 - 90% cases 

 2) 2º Hypertension
 - Known cause 
- 10% cases

Question 33

What are the risk factors for hypertension? How may they be stratified?

Answer 33

``` Risk factors: Modifiable and Non-modifiable • Smoking • Salt intake • Physical inactivity • Obesity • Metabolic Syndrome • Diabetes Mellitus • OSA • High cholesterol • Alcohol intake • Dietary fibre • Iatrogenic (COC, Steroids, NSAIDs, Adrenaline, Salbutamol) ``` * Age (> 65 years) * Ethnicity: Black ancestry * Family History of HTN or CAD

Question 34

What is the pathophysiology of hypertension?

Answer 34

Salt retention: abnormal salt retention + reabsorption of sodium ≈ water into intravascular compartment by osmosis ≈ increase intravascular volume ≈ baroreceptors ≈ ANP release ≈ acts on SMCs ≈ vasoconstriction ≈ increase TPR 


Question 35

What is the diagnosis of HTN according to NICE when considering different categories?

Answer 35

Clinical: 1) < 140/90 mmHg: Check every 5 years 2) 140/90 – 179/119 mmHg: ABPM/HBPM; Investigate for target organ damage + assess CVD % 3) > 180/120 mmHg: % Target organ damage, drug treatment, refer for review ABPM/HBPM: 1) < 135/85 mmHg: Check every 5 years 2) 135/85 – 149/94 mmHg: Drug treatment/Consideration/Lifestyle factors 3) > 150/95mmHg: Lifestyle + Drug treatment

Question 36

List the main investigations for blood pressure.

Answer 36

* Sphygmomanometry: Clinical/HBPM/ABPM * Urinalysis: Albumin/Creatinine/Blood/Leukocytes * Blood tests: HbA1c/U+E/GFR/Cholesterol/Thyroid/Aldosterone/Cortisol ``` Context dependent: • ECG • Ophthalmoscopy • Ultrasound • Biopsy ```

Question 37

List 5 examples of complications from hypertension.

Answer 37

a) CV 
 - Congestive heart failure
 - Dilated cardiomyopathy 
- Hypertrophic cardiomyopathy 
 - Coronary artery disease and myocardial infarction 
 - Atrial fibrillation 
- Aortic aneurysm 
- Aortic dissection 
 - Carotid Artery Stenosis 
- Peripheral Artery Disease 
- Atherosclerosis 

 b) Brain 
- Stroke, TIA 
- Cognitive changes e.g. Memory Loss 

 c) Kidneys 
- Hypertensive nephrosclerosis 

d) Eyes 
- Hypertensive retinopathy 
- Papilledema

Question 38

What are the key lifestyle changes in the prevention and management of hypertension?

Answer 38

* Weight loss: BMI 25-35 (5-10%); BMI 35 < (15-20%) * Physical activity increased: 150 CME + x2 resistance exercise * Improve dietary intake: DASH diet = fruit + veg, low fat dairy, wholegrain, fish, nuts and poultry * Reduce alcohol intake: < 14 units per week + education * Stress: Advise mindfulness or social prescribing

Question 39

What approach should be taken to encourage behavioural change in patients?

Answer 39

5As of Ask, Assess, Advise, Agree, Assist

Question 40

What tool can be used to help set goals with patients? Which stage of the 5As would this fit under best?

Answer 40

SMART Goals which can be used in the Agree stage of the 5As ``` Specific
 Measurable
 Achievable 
Rewarding 
Timely ```

Question 41

List some drugs which may cause hypertension. What is this called?

Answer 41

Drug-induced Hypertension (iatrogenic) 
- NSAIDs (afferent arteriole vasoconstriction ≈ reduced GFR ≈ reduced natriuresis + diuresis ≈ increase intravascular volume and osmolality ≈ increase pressure) 
- Oral Steroids 
 - Venlafaxine (increase norepinephrine and potentiation of noradrenergic neurotransmission) 
 - Oral sympathomimetic decongestants (Pseudoephedrine - Sudafed) 
 - Soluble or dispersible drugs (contain Salt) 
- Illicit Drug Use (cocaine, amphetamines)

Question 42

List tools which may be used to assess a patient’s CV risk. What is estimation of cardiovascular (CV) risk based on?

Answer 42

``` Assessing CV risk: ASSIGN / Q-Risk • Blood pressure • Age • Weight/height • Gender • Smoking • Cholesterol • Ethnicity • Social class • FHx • Diabetes/RA/Renal function ```

Question 43

List some clinical features of hypertension.

Answer 43

• Incidental find*** --> Require regular screening * Headache * Dizziness * Tinnitus * Flushed appearance * Epistaxis * Chest discomfort * Palpitations * Nervousness * Fatigue/sleep disturbances * Raised JVP * Vision disturbances * Ankle oedema * Ascites

Question 44

State the stages of hypertension.

Answer 44

Stage 1: 140-159/90-99 Stage 2: 160-179/99-109 Stage 3: 180-209/109-119 Stage 4: ≥210/≥120

Question 45

A patient presents with a blood pressure of 153/95. She is aged 64 years old, has no other morbidities and is Caucasian. Give the stage of her hypertension, the advice you would give and the drug choice you may Rx. What is her blood pressure target you would encourage her to aim for?

Answer 45

Stage 1 HTN Find reason: ABPM/HBPM; Investigate for target organ damage + assess CVD % (ASSIGN/Q-Risk) CCB as over 55 and no T2DM - Amlodipine - Diltiazem - Verapamil Aim for 140/90mmHg or 135/85mmHg

Question 46

A patient presents with a blood pressure of 165/103. She is aged 54 years old, has no other morbidities other than Type 2 Diabetes Mellitus and is Caucasian. Give the stage of her hypertension, the advice you would give and the drug choice you may Rx. What is her blood pressure target you would encourage her to aim for?

Answer 46

Stage 2 HTN Find reason: ABPM/HBPM; Investigate for target organ damage + assess CVD % (ASSIGN/Q-Risk) ACEi/ARB (54 < 55 + T2DM) - Lisinopril/Ramipril/Captopril - Losartan/Candesartan Aim for 140/90mmHg or 135/85mmHg

Question 47

A patient presents with a blood pressure of 180/119. He is aged 54 years old, has no other morbidities other than atrial fibrillation and is Caucasian. Give the stage of his hypertension, the advice you would give and the drug choice you may Rx. What is his blood pressure target you would encourage her to aim for?

Answer 47

Stage 3 HTN Treat straight away as ≥ 180mmHg systolic blood pressure CCB (no T2DM): Choose a rate-limiting CCB that affects heart + vasculature - Diltiazem - Verapamil Aim for 140/90mmHg or 135/85mmHg

Question 48

A patient presents with a blood pressure of 214/125. He is aged 84 years old, has no other morbidities other than atrial fibrillation and is from the West Indies.. Give the stage of his hypertension, the advice you would give and the drug choice you may Rx. What is his blood pressure target you would encourage her to aim for?

Answer 48

Stage 4 HTN Treat straight away as ≥ 180mmHg systolic blood pressure CCB (Caribbean + Age > 55): Rate-limiting for his AF - Diltiazem - Verapamil 150/90mmHg or 145/85mmHg as over 80 years old

Question 49

Outline the MOA of ACEi. Give an example of an ACEi. List 3 side effects. List 3 contraindications.

Answer 49

Inhibit ACE enzyme to reduce AGT II production * Ramipril
 * Lisinopril * 
Captopril ``` SEs: • Dry cough 
 • Dizziness
 • Tiredness
 • Headaches 
 • Angiooedema (AfroCab) • 
Hyperkalemia • 
Renal impairment ``` Contraindications: • Allergy/Hypersensitivity • 
Angioneurotic oedema PMHx 
Bilateral renal artery stenosis or renal artery stenosis • Pregnancy

Question 50

Outline the MOA of ARBs. Give an example of an ARB. List 3 side effects. List 3 contraindications.

Answer 50

Antagonist to AT II-R which reduced AGT II mediating effects of vascular growth, vasoconstriction and salt-retention * Losartan 
 * Candesartan * 
Irbesartan ``` SEs: • Dizziness • 
Headaches 
 • Back/Leg Pain 
 • Hyperkalemia 
 • Renal impairment 
 ``` Contraindications: • Allergy/Hypersensitivity
 • Angioneurotic oedema PMHx 
Bilateral renal artery stenosis or renal artery stenosis • Pregnancy

Question 51

Outline the MOA of CCBs. Give an example of an CCBs. List 3 side effects. List 3 contraindications.

Answer 51

Block L-type CaVg channels to reduce vasomotor tone (PR) +(chronotropy) + power (inotropy) * Amlodipine
 * Felodipine * 
Lercanidipine


 * Verapamil * 
Diltiazem ``` SEs: • Headaches 
 • Ankle oedema 
 • Dizziness 
 • Flushes (increased vasodilation) --> Bradycardia if rate-limiting ``` ``` Contraindications: • Uncontrolled heart failure • Cardiogenic shock (MI) 
 • Significant aortic stenosis • Unstable angina 
 • Pregnancy ```

Question 52

Outline the MOA of thiazide diuretics. Give an example of an thiazide diuretics. List 3 side effects. List 3 contraindications.

Answer 52

Relax vascular smooth muscle + Block apical NCC transporter (DCT) to reduce movement causing increased luminal ion concentration with osmosis and diuresis, reducing intravascular volume and blood pressure * Indapamide 
 * Bendroflumethiazide ``` SEs: • Electrolyte imbalance: Low K+, Na+, Mg++ 
 • Calcium retention/hypocalciuria • 
Metabolic alkalosis 
 • Gout • 
Erectile dysfunction 
 • Hyperglycaemia
Hyperlipidemia ``` ``` Contraindications: • Hypercalcaemia • Hyponatraemia • Hypokalaemia 
 • Symptomatic hyperuricaemia 
Addison’s Disease 
 • Diabetes ```

Question 53

Outline the MOA of loop diuretics. Give an example of an loop diuretics. List 3 side effects. List 3 contraindications.

Answer 53

Bind apical NKCC2 to reduce activity and absorption, elevating tubular luminal ion concentration resulting in water movement by osmosis and diuresis, reducing intravascular volume and blood pressure • Furosemide ``` SEs: • Electrolyte imbalance: Low K+, Na+, Mg++ • 
Calcium retention/hypocalciuria • 
Dizziness 
 • Fatigue • 
Metabolic alkalosis • Muscle spasms 
 • Nausea ``` ``` Contraindications: • Hypercalcaemia • Hyponatraemia • Hypokalaemia 
 • Symptomatic hyperuricaemia 
Urinary retention (may cause prostatic hyperplasia) 
 • Hypovolemia 
 • Gout 
 • Hypotension ```

Question 54

Outline the MOA of aldosterone (mineralocorticoid receptor) antagonists.. Give an example of an MR antagonists. List 3 side effects. List 3 contraindications.

Answer 54

Bind aldosterone-specific Na,K-ATPase to reduce electrochemical gradient then less Na+ absorbed, increased osmolarity of tubular filtrate causing water in by osmosis and diuresis to reduce sodium reabsorption and potassium excretion * Spironolactone 
 * Eplerenone ``` SEs: • Hypotension 
 • Renal impairment • 
Electrolyte imbalance: Hyperkalemia and Hyponatremia
 • GI Upset 
 • Metabolic acidosis 
 • Gynaecomastia (Spironolactone) ``` Contraindications: • Addison’s Disease 
 • Anuria/Renal failure • 
Hyperkalemia 



Question 55

Outline the MOA of NCB (sodium channel blockers). Give an example of an NCB. List 3 side effects. List 3 contraindications.

Answer 55

Block apical epithelial sodium channel in collecting tubule causing reduced sodium absorption, increased osmolarity then water out by osmosis and increase natriuresis and diuresis to reduce intravascular volume and blood pressure • Amiloride ``` SEs: • Hypotension 
 • Renal impairment 
 • Electrolyte imbalance: Hyperkalemia and Hyponatremia
 • GI Upset 
 • Metabolic acidosis ``` Contraindications: • Addison’s Disease 
 • Anuria/Renal failure • 
Hyperkalemia 


Question 56

Outline the MOA of ß-blockers. Give an example of an ß-blockers. List 3 side effects. List 3 contraindications.

Answer 56

Antagonist of ß1-adrenoceptor causing reduced cAMP production, reducing sympathetic drive: reduced contractility of cardiac tissue + vasomotor tone + reduces renin release * Atenolol 
 * Bisoprolol 
 * Carvedilol ``` SEs: • Fatigue 
 • Cold peripheries 
 • Bradycardia • 
Peripheral Vascular Disease 
 • Bronchospasm 
GI Upset • 
Erectile Dysfunction 
 • Heart failure 
 • Sleep disorders ``` ``` Contraindications: • Asthma 
 • Cardiogenic Shock/Uncompensated HF • 
Hypotension • Marked Bradycardia 
 • Severe Peripheral Arterial Dise ```

Question 57

Outline the MOA of a-blockers. Give an example of an a-blockers. List 3 side effects. List 3 contraindications.

Answer 57

Antagonist of a1-adrenoceptor in SMC which reduces vasoconstriction causing vasodilation and reduced TPR and blood pressure * Doxazosin 
 * Prazosin ``` SEs: • Postural Hypotension • 
Dizziness 
 • Lethargy 
 • GI Upset • 
Headache 
 • Peripheral oedema ``` Contraindications: • History of micturition syncope 
 • Postural Hypotension

Question 58

What is multi-drug treatment?

Answer 58

Multidrug therapy is using two or more drugs in combination

Question 59

List the advantages and disadvantages of multi-drug treatment.

Answer 59

Advantages: 
+ Reduced mortality/morbidity 
+ Numerous sites/targets of action 
 + Reduce dose burden of individual drugs ≈ minimise side-effects Disadvantages: 
 - Concordance 
 - Side effects may increase 
- Cost

Question 60

Which aide-memoir can be used for producing a differential diagnosis in pathology such as CKD?

Answer 60

* Trauma: Physical (Acute, Chronic or Complex) * Tumor: Non-neoplastic, Benign, Malignant (1º or 2º) * Tubercle: Chronic inflammation or immune-response related * Inflammation: Acute, Infection, Immunological * Stone: Metabolic or Genetic

Question 61

List the potential anatomical regions where pathology may occur giving rise to CKD.

Answer 61

CKD may affect any part of urogenital tract: kidney/ureter/bladder/prostate/urethra

Question 62

Describe the cause of haematuria.

Answer 62

Damage to the glomerulus (or Bowman’s Capsule) results in pathologically increased permeability to blood cells passing resulting in blood present in the urine (haematuria) which is a feature of nephritic syndrome

Question 63

Describe the causes of proteinuria.

Answer 63

Damage to the glomerulus (or Bowman’s Capsule) results in pathologically increased permeability with increased protein passing resulting in protein present in the urine (proteinuria) which is a feature of nephrotic syndrome.

Question 64

Define HTN.

Answer 64

High blood pressure (> 140/90mmHg) taken by sphygmomanometry or HBPM +/- confirmed with ABPM (if between 140/90 and 180/120mmHg)

Question 65

Classify the types of HTN.

Answer 65

• 1º HTN (idiopathic/essential): Unknown cause (90%) • 2º HTN: Known cause (10%) - Renal disease: RVD/PKD/GN - Vascular: RAS/CoA - Endocrine: Cushing’s/Pheochromocytoma/Thyrotoxicosis/Hyperaldosteronism (Conn Syndrome) - Other: OSA/ Drug-induced

Question 66

List 8 risk factors for Hypertension.

Answer 66

* Smoking * Salt intake * Physical inactivity * Obesity * Metabolic Syndrome * Diabetes Mellitus * OSA * High cholesterol * Alcohol intake * Dietary fibre * Iatrogenic (COC, Steroids, NSAIDs, Adrenaline, Salbutamol) * Age (> 65 years) * Ethnicity: Black ancestry * Family History of HTN or CAD * Gender

Question 67

Outline the pathophysiology of Hypertension.

Answer 67

• Salt retention  water into intravascular compartment via osmosis  increase intravascular volume  baroreceptors  ANP release  acts on SMCs ≈ vasoconstriction = increase TPR

Question 68

List the signs and symptoms of Hypertension. Are they always seen?

Answer 68

• Incidental find***  Require regular screening * Headache * Dizziness * Tinnitus * Flushed appearance * Epistaxis * Chest discomfort * Palpitations * Nervousness * Fatigue/sleep disturbances * Raised JVP * Vision disturbances * Ankle oedema * Ascites

Question 69

Outline the diagnostic categories of hypertension.

Answer 69

Clinical: 1) < 140/90 mmHg: Check every 5 years 2) 140/90 – 179/119 mmHg: ABPM/HBPM; Investigate for target organ damage + assess CVD % 3) > 180/120 mmHg: % Target organ damage, drug treatment, refer for review ABPM/HBPM: 1) < 135/85 mmHg: Check every 5 years 2) 135/85 – 149/94 mmHg: Drug treatment/Consideration/Lifestyle factors 3) > 150/95mmHg: Lifestyle + Drug treatment

Question 70

Outline the clinical stages of Hypertension.

Answer 70

Stage 1: 140-159/90-99 Stage 2: 160-179/100-109 Stage 3: 180-209/110-119 Stage 4: >210/>120

Question 71

Outline the factors involved in assessing cardiovascular risk. Which two decision making tools are there.

Answer 71

``` Assessing CV risk: ASSIGN / Q-Risk • Blood pressure • Age • Weight/height • Gender • Smoking • Cholesterol • Ethnicity • Social class • FHx • Diabetes/RA/Renal function ```

Question 72

Outline the investigations which can be used in Hypertension and its complications.

Answer 72

* Sphygmomanometry: Clinical/HBPM/ABPM * Urinalysis: Albumin/Creatinine/Blood/Leukocytes * Blood tests: HbA1c/U+E/GFR/Cholesterol/Thyroid/Aldosterone/Cortisol ``` Context dependent: • ECG • Ophthalmoscopy • Ultrasound • Biopsy ```

Question 73

List 5 non-pharmacological ways to manage hypertension.

Answer 73

* Weight loss: BMI 25-35 (5-10%); BMI 35 < (15-20%) * Physical activity increased: 150 CME + x2 resistance exercise * Improve dietary intake: DASH diet = fruit + veg, low fat dairy, wholegrain, fish, nuts and poultry * Reduce alcohol intake: < 14 units per week + education * Stress: Advise mindfulness or social prescribing

Question 74

Outline 5 pharmacological classes of treatments for Hypertension. For each class, give two examples.

Answer 74

* ACEi: Ramipril/Lisinopril/Captopril * ARBs: Losartan/Candesartan * CCBs: Amlodipine/Lercanidipine/Verapamil/Diltiazem * Thiazide diuretics: Indapamide/Bendroflumethiazide * Loop diuretics: Furosemide * Aldosterone (MR) antagonists: Spironolactone/Eplerenone * NaCB: Amiloride * Beta blockers: Atenolol/Bisoprolol * Alpha 1 antagonists: Doxazosin/Prazosin

Question 75

What aide-memoir could be used for identifying the DDx of CKD?

Answer 75

* Trauma: Physical (Acute, Chronic or Complex) * Tumor: Non-neoplastic, Benign, Malignant (1º or 2º) * Tubercle: Chronic inflammation or immune-response related * Inflammation: Acute, Infection, Immunological * Stone: Metabolic or Genetic

Question 76

Describe the glomerulus.

Answer 76

glomerular tuft surrounded by Bowman’s capsule, consists of: afferent and efferent arteriole, endothelium held by mesangium and surrounded by basement membrane, parietal epithelial cells and podocytes. * Endothelial cells of glomerular capillaries (fenestrations + glycocalyx): filtering + negatively charges ≈ electrostatic repulsion * Glomerular basement membrane: type IV collagen + heparin sulphate ≈ negatively charged * Podocytes (Epithelial cells of Bowman’s Capsule): specialized epithelial cells forming visceral layer of capsule --> filtration slits + negative ≈ filtration + electrostatic repulsion

Question 77

List the 3 main features of the glomerulus.

Answer 77

* Endothelial cells of glomerular capillaries (fenestrations + glycocalyx): filtering + negatively charges ≈ electrostatic repulsion * Glomerular basement membrane: type IV collagen + heparin sulphate ≈ negatively charged * Podocytes (Epithelial cells of Bowman’s Capsule): specialized epithelial cells forming visceral layer of capsule --> filtration slits + negative ≈ filtration + electrostatic repulsion

Question 78

Outline the key differences between a nephritic syndrome and a nephrotic syndrome.

Answer 78

``` Nephritic: • Pain • Hematuria • Oliguria • Little proteinuria ``` ``` Nephrotic: • Massive proteinuria (<3g/100mL) • Lipid proteins elevated • Oedema • Hypertension ```

Question 79

List the 3 differentiations of CKD based on location. Give examples for each category.

Answer 79

i) Pre-Renal • Atherosclerosis • Real hypoplasia • Bilateral renal agenesis (Potters Syndrome) ``` ii) Renal • Glomerulonephritis • Diabetes Mellitus • Hypertension • Polycystic Kidney Disease ``` iii) Post-renal • Obstruction

Question 80

Outline the pathophysiology of renal hypoplasia.

Answer 80

• ∆RDGs + Environmental factors + Drugs (ACEi/ARBs) ≈ ∆ embryonic development ≈ reduced nephron number

Question 81

State 3 symptoms and 5 signs of renal hypoplasia.

Answer 81

• Asymptomatic * Oligohydramnios * Prematurity * Low birth weight * IUGR * Polyuria * Enuresis (urinary incontinence) * Urinary urgency * Nocturia * UTI

Question 82

A newborn presents with oligohydramnios, low birth weight and IUGR. Give 3 investigations you would order. On a voiding cystourethrogram, retrograde urine movement is seen. Give your DDx and outline the management plan for this newborn.

Answer 82

* Urinalysis: Haematuria/Proteinuria/Urea/Creatinine * Metabolic profile: Urea/eGFR/LFTs * US: Anatomical abnormalities * IV Pyelogram (fluoroscopy): Anatomical anomalies Renal hypoplasia Management: • RRT: Dialysis/Transplantation • IV fluids and electrolytes • Diuretics: Thiazide diuretics (bendroflumethiazide/Indapamide); Loop diuretics (Spironolactone/Eplerenone)

Question 83

Outline the pathophysiology of Bilateral Renal Agenesis (Potter's Syndrome).

Answer 83

• ∆RDGs + Environment/Drugs ≈ ∆ ureteric bud development + X differentiation of metanephric blastema (both structures develop to kidney) ≈ kidney fails to develop

Question 84

List 5 symptoms a child with Potters Syndrome (Bilateral Renal Agenesis).

Answer 84

* Proteinuria * Hypertension * Oligohydroamnios * Extra-renal manifestations (Potter Sequence): oligohydroamnios + talipes equinovarus (clubbed feet), pulmonary hypoplasia, craniofacial abnormalities. * Pulmonary hypoplasia * Club feet (Talipes equinovarus) * Renal insufficiency

Question 85

List the symptoms in Potters Sequence.

Answer 85

Talipes Equinovarus Oligohydramnios Pulmonary hypoplasia Craniofacial abnormalities

Question 86

A neonate presents with difficulty breathing following a pregnancy which had known oligohydramnios. O/E you notice talipes equinovarus, hypertension and proteinuria. What investigations would you order? What might you expect to see? Give a DDx and outline the management for this child. Why does this disease occur?

Answer 86

Investigations: • Metabolic profile: Creatinine (elevated)/Urea (elevated)/eGFR (low) • US: Absent kidney(s) Seen: - Hypercreatinemia - Uremia - eGFR low - Absent kidneys bilateral DDx: Bilateral renal agenesis Cause: RDGs ∆ + Environment/Drugs ≈ ∆ ureteric bud development + X differentiation of metanephric blastema ≈ kidneys fail to develop Management: • RRT: Dialysis/Transplantation • IV Fluids and electrolytes • Diuretics: Thiazide diuretics (bendroflumethiazide/Indapamide); Loop diuretics (Spironolactone/Eplerenone)

Question 87

What is polycystic kidney disease?

Answer 87

Congenital disease which results in cysts developing in the kidneys, compromising renal function and predisposing to chronic renal disease

Question 88

Outline the pathophysiology of Polycystic Kidney Disease.

Answer 88

• ∆PKD1 or PKD2 gene (Autosomal recessive/ dominant) ≈ ∆ cell cycle or ∆ calcium channel ≈ cysts in epithelial organs

Question 89

Give the sigs and symptoms of PCKD for both types of PCKD.

Answer 89

ARPKD: • Haematuria • Proteinuria • Abdominal distension (renal enlargement) • Extra-renal manifestations (Potter Sequence): oligohydroamnios + talipes equinovarus (clubbed feet), pulmonary hypoplasia, craniofacial abnormalities. • Obligate liver involvement (portal fibrosis + portal hypertension) • Hypertension ADPKD: • Haematuria • Proteinuria • Abdominal Distension (Renal enlargement) • Recurrent UTI • Extra-renal manifestations: Potter’s Sequence (TE/OH/PH/CFA); HTN/ epithelial tissue cysts; colon diverticula; cerebral berry aneurysm

Question 90

A patient presents with pain/tenderness in the abdomen. He says it is present in his tummy and feels worse when he has the urge to go to the bathroom. O/E you notice abdominal distension in RH and talipes equinovarus. He has no other medical history other than oligohydramnios in utero and pulmonary hypoplasia at birth. He has no family history other than polycystic kidney disease on both maternal and paternal sides of the family. What investigations would you order? What might you expect to see regarding the context of this patient. His urinalysis shows proteinuria and haematuria. As well as this, the US shows enlarged kidneys bilaterally. Give a DDx. Outline the management for his queried diagnosis.

Answer 90

* US: Enlarged kidneys bilaterally – increased echogenicity + anechoic masses (liquid-filled cysts) * CT * IV Pyelogram (IVP): Obstructions in renal pelvis + urinary tract * Liver biopsy * Genetic testing: PKD1 or PKD2 DDx: Polycystic Kidney Disease - Recessive - Dominant - -> Determine via genetic test ``` Management: • Supportive (delay progression): Monitoring/Avoid nephrotoxic substances/Treat arterial hypertension/Treat UTIs • Treat liver failure • Genetic counselling • RRT: Dialysis/Kidney transplantation ```

Question 91

What is Rapidly Progressive Glomerulonephritis?

Answer 91

syndrome of kidney disease characterised by deposition of antibodies (IgG/IgM) at the basement membrane (anti-GBM antibodies) which results in a decline in GFR within 3 months with glomerular crescent formation seen. Can be caused by a variety of diseases such as Goodpasture Syndrome, Systemic Lupus Erythematosus or Granulomatosis with Polyangiitis.

Question 92

Outline the pathophysiology of Rapidly Progressive Glomerulonephritis. List the pathological manifestations due to the disease.

Answer 92

complex deposition (type III hypersensitivity) with collagen antigens in plasma depsited in fixed tissues (glomerular BM) --> activate complement system generating by-products --> attract leukocytes + monocytes and C3a + C5a increase vascular permeability and MAC ≈ disruption in BM --> Plasma leak into urinary space (Bowman’s Capsule) • Sieve effect: Gross leaks due to numerous sites of BM damaged • Fibrin leakage • RBC leakage (haematuria) • Glomerular crescents: Cell proliferation in confined space ≈ reduced capillary and glomerulus • Urine output reduced • Necrosis (perfusion --> ischaemia)

Question 93

Which is true for Glomerulonephritis? A. It is a nephrotic syndrome which can progress to Nephritic Signs later B. It is a nephritic syndrome which may progress to Nephrotic signs later C. It is a nephrotic syndrome only D. It is a nephritic syndrome only

Answer 93

B. It is a nephritic syndrome which may progress to Nephrotic signs later

Question 94

List the signs and symptoms of Rapidly Progressive Glomerulonephritis.

Answer 94

* Fatigue * Fever * Nausea + Vomiting * Pain (flank/abdominal * Haematuria * Oliguria (≤ 0.4L/24 hours)/ Anuria (≤ 0.1L/24 hours) * Proteinuria * Casts in urine * Hypertension * Oedema

Question 95

A patient presents with sudden fatigue, fever and acute, severe pain. He describes the pain as severe and 'on his sides', radiating towards his groin. He has also mentioned coughing up blood which is fresh and red, in small quantities. He mentions no changes to his bowel movements however he has been urinating less. He has no other morbidities. He mentions his father's side of the family have a few members with autoimmune diseases but he cannot remember which. O/E you notice hypertension and oedema. Additionally you notice crackles on lung examination. What investigations would you order? What might you expect to see. You get a positive result for anti-GBM antibodies. What is your DDx? Outline a management plan for the patient.

Answer 95

* Urinalysis: Proteinuria/Leukocytes/Haematuria/pH (acidic)/RBC or WBC casts * Metabolic Profile: Creatinine (elevated)/Urea (raised)/Bicarbonate * Inflammatory markers: CRP * Biopsy: Crescenteric glomerular deposits * Serology (antibodies): * Anti-GBM (type IV collagen) * ANCA – Granulomatosis with polyangiitis; Churg-Strauss Syndrome; Microscopic polyangiitis * Anti-dsDNA = Systemic Lupus Erythematosus Anti-GBM (type IV collagen) antibodies suggest an autoimmune disease against the basement membrane in alveoli (lung involvement) and glomerulus (renal involvement). Additionally, haematuria is observed with proteinuria due to nephritic syndrome progressing to nephrotic signs. Biopsy showed crescentic glomerular deposits. DDx: Rapidly Progressing Glomerulonephritis as part of Goodpasture's Syndrome ? ``` Management: • Corticosteroids: Prednisolone 40mg + Bisphosphonates + Calcium/Vitamin D3 • Cyclophosphamide • Plasmapheresis • RRT: Dialysis/Transplant ```

Question 96

Describe membranoproliferative glomerulonephritis. What type of hypersensitivity reaction is it?

Answer 96

Glomerular disease caused by immune complex (type III hypersensitivity) deposits in the kidney glomerular mesangium and basement membrane which results in both basement membrane and mesangium thickening Type III hypersensitivity reaction.

Question 97

State the key features of membranoproliferative glomerulonephritis. Is this a nephritic or nephrotic syndrome?

Answer 97

Features: Nephrotic Syndrome * Slow * Haematuria * Proteinuria * No pain

Question 98

What is Berger's Disease? Is this a nephritic or nephrotic syndrome?

Answer 98

Glomerulonephritis caused by IgA deposition in the mesangium of the glomerulus which results in mesangial proliferation Features: Nephritic Syndrome • Pain • Haematuria • Oliguria/Anuria

Question 99

What is Proliferative Glomerulonephritis? Outline the key features.

Answer 99

glomerular disease involving immune complex deposition (antibody against tissue antigen in type III hypersensitivity) resulting in complement fixation and pro-inflammatory reactions which mediates proliferation of endothelial cells and mesangial cells resulting in damage to the basement membrane and nephritic syndrome. Nephritic Syndrome • Haematuria • Pain • Oliguria/Anuria

Question 100

Describe Goodpasture Syndrome.

Answer 100

autoimmune disease with anti-GBM antibodies attacking glomerulus in kidney and alveoli in lungs which cause haemoptysis and haematuria with a relatively rapid onset classed as a type II hypersensitivity reaction.

Question 101

Outline the pathophysiology of Goodpasture Syndrome.

Answer 101

• Anti-GBM antibody-mediated (type II hypersensitivity) with a3-type IV collagen antigens in plasma and IgM/IgG deposited in glomerular membrane + alveolar membrane  complement generating cytokines and C3a/C5a complement fixing with MAC creating disruption in BM ≈ leakage of plasma proteins + passage of inflammatory cells into Bowman space ≈ formation of fibbing clot + proliferation of cells (macrophages, fibroblasts, neutrophils, epithelial cells) ≈ crescent moon formation ≈ compression of glomerulus ≈ renal dysfunction

Question 102

List the symptoms and signs of Goodpasture Syndrome. Is this a Nephrotic or Nephritic Syndrome?

Answer 102

Nephritic Syndrome (pain, haematuria, oliguria, little/no proteinuria) ``` Signs and Symptoms: • Haemoptysis • Pain • Fatigue • Fever • Nausea ``` * Anuria/Oliguria * Haematuria * Crackles on lung examination * Proteinuria * Oedema * Hypertension

Question 103

Outline 3 investigations you would want to conduct in a queried Goodpasture Syndrome patient. For each of the investigations, suggest what may be seen.

Answer 103

* Renal function: Creatinine (high)/Urea (high)/ GFR (low) * Renal biopsy: anti-GBM immunofluorescence – crescentic glomerulonephritis * Serology: Anti-GBM/anti-ANCA/Serum complement C3 * Hepatitis screen: exclude HBV/HCV * Anti-streptolysin O titre: Rule out post-streptococcal glomerulonephritis * Clotting screen: Rule out coagulopathy prior to biopsy

Question 104

For a patient known to have Goodpasture Syndrome, outline the management.

Answer 104

* Oral corticosteroid * Plasmapheresis * Cyclophosphamide • Supportive care (irreversible renal disease)

Question 105

Describe membranous nephropathy.

Answer 105

slow progressive glomerular disease which is primary (idiopathic) or secondary (autoimmune, infections, drugs, inorganic salts, tumours) whereby immune complexes (antibodies bound to antigens in type III hypersensitivity) in glomerular basement membrane resulting in thickened glomerular basement membrane (hyperplasia).

Question 106

Outline the pathophysiology of membranous nephropathy.

Answer 106

• Primary (idiopathic) or Secondary (autoimmune/infection/drugs/inorganic salts/tumours) result in immune complexes (type III hypersensitivity) adhere to glomerular basement membrane resulting in glomerular basement membrane hyperplasia

Question 107

Give 3 risk factors for a patient to develop Membranous Nephropathy.

Answer 107

* M * > 40 Years * FHx of autoimmune * Hepatitis B/C * Syphilis * Medications: NSAIDs/Penicillamine/Lithium/Captopril

Question 108

List the signs and symptoms of Membranous Nephropathy.

Answer 108

Signs and Symptoms: Nephrotic Syndrome • Oedema: Peri-orbital + Lower extremities • Slow onset * Hypertension * Proteinuria * Xanthelasma * Foamy urine

Question 109

Mrs Smith, a 44 year old Waitress presents with peri-orbital oedema and oedema at the lower extremities. She has Hepatitis B and previously had Syphilis which has been treated with penicillin. Her family have a history of cardiovascular disease and autoimmune diseases such as Goodpasture Syndrome on her mother's side and Vasculitis/SLE on her father's side. O/E you notice she has a blood pressure of 155/94, peripheral oedema and peri-orbital oedema. Additionally xanthelasma is present as well as xanthomas on the elbows and knees. What stage of Hypertension does Mrs Smith have? What is the difference between xanthelasma and xanthomas? What investigations would you order. For each investigation, what might you expect to see? Give a DDx and outline a management plan.

Answer 109

Stage of Hypertension 1 (140-159/90-99 mmHg) Xanthelasma is present on the eyelids whereas Xanthoma is present anywhere on the body. * Urinalysis: Proteinuria/Lipiduria/Bland sediment * UACR: > 3.5 = nephrotic syndrome * Serum urea: Normal/Elevated * Serum creatinine: Normal/ Elevated * eGFR: Normal/Decreased * Serum albumin: Hypoalbuminemia (<3g/dL) * Lipid profile: Hyperlipidemia/Normal DDx: Membranous Nephropathy * Lifestyle change: Low salt + Protein diet (if HTN) * ACEi/ARB: Ramipril/Losartan (if Hyperlipidemia) * Statin: Atorvastatin/Simvastatin (if Oedema) * Loop diuretic: Furosemide * Corticosteroid: Prednisolone

Question 110

Describe minimal change disease. What type of hypersensitivity reaction is it?

Answer 110

glomerular disease which results in nephrotic syndrome due to idiopathic T-cell mediated damage (type IV hypersensitivity) of altering the glomerular basement membrane, particularly podocytes, altering permeability so increased serum proteins and albumin enter Bowman’s space, resulting in Nephrotic syndrome.

Question 111

Outline the pathophysiology of Minimal Change Disease.

Answer 111

• Primary (kidney) or Secondary (HBV, HCV, Lymphoma, Measles) causing T-cell mediated (type IV hypersensitivity) damage of glomerular basement membrane causing effacement of podocytes with increased permeability allowing protein extrusion into Bowman’s Space

Question 112

List 3 risk factors for Minimal Change Disease.

Answer 112

* Age < 18 years * Viral infection * Cancer (lymphoma)

Question 113

Is Minimal Change Disease a nephritic or nephrotic syndrome? State the features of a nephrotic syndrome.

Answer 113

``` Signs and Symptoms: Nephrotic Syndrome • History of recent viral illness • Oedema • Normal BP • Absence of haematuria ```

Question 114

A 16 year old boy presents with oedema in the peripheries and around his eyes. He recently visited his local GP with viral infection symptoms which is being managed supportively. He also adds that there have been no changes to his bowel function but he has noticed his urine is foamy and 'thicker'. You take a comprehensive sexual history and elucidate that he is a heterosexual man who has one sexual partner, has not travelled to any high-risk places, exhibits low-risk behaviours and is not an IVDU with no tattoos. O/E you identify a blood pressure of 126/85mmHg, a heart rate of 76bpm. What investigations would you order? Give an anticipated find for each. Suggest a DDx and outline a management plan.

Answer 114

Investigations: • Urinalysis: Hyaline casts/Oval bodies/Proteinuria/No significant haematuria • UPCR: > 2 = 2g/24 hours • Serum albumin levels: < 3g/dL • Serum lipid profile: hyper-TG, Hyper-Cl • U+E: Hyperuremia; Hyponatremia • GFR: Normal • US-Abdomen: Normal; May be echogenic and loss of corticomedullary differentiation if severe oedema DDx: Minimal Change Disease Management: • Corticosteroids: Prednisolone 40mg for 6/52. 60mg PE on Day 1 • Low salt and protein diet • Loop diuretic: Furosemide 1-2mg/kg IV every 6-12 hours

Question 115

Outline the pathophysiology of Focal Segmental Glomerulosclerosis. What type of hypersensitivity reaction is this?

Answer 115

Primary (idiopathic) or Secondary (viruses, toxins, autoimmune) cause T-cell mediated (Type IV hypersensitivity)  damage podocytes = detach from glomerular basement membrane  expose glomerular basement membrane + parietal epithelial cells which stimulates proliferation of endothelial, epithelial and mesangial cells and fibrosis with sclerosis in a segment of glomerulus (segmental)  Podocytes and Epithelial cells die with protein leaking across membrane and cholesterol levels rise due to hepatic synthesis and loss of fat-binding proteins in serum (proteinuria depletes them).

Question 116

A 45 year old male presents with weight gain over a few months. He has a family history of a kidney disease which has a slow progression but he cannot remember the name of it. He is an obese gentleman with a history of heroin abuse which lead to him having chronic viral infection - Hepatitis B Virus. He says he takes no over the counter drugs apart from Entecavir. He says he has no bowel changes but has noticed a change in his urine, it is thicker and foamy. O/E you notice peripheral oedema, a blood pressure of 167/98mmHg, xanthelasma and Muehrcke's Lines. i) Why is he taking Entecavir? ii) Why may his urine be foam? Give two reasons. iii) What stage of hypertension does he have? iv) What do Muehrcke's Lines suggest? Outline the investigations you would conduct and the anticipated findings Give a DDx. . Outline the management plan for this patient.

Answer 116

i) Antiviral drug for his HBV - Entecavir ii) a) Proteinuria from his Nephrotic syndrome b) Pyuria from a UTI iii) Stage 2 hypertension (160-179/99-109mmHg) iv) Banding on nails suggesting hypoalbuminemia * Serum Urea: Elevated * Creatinine: Elevated * eGFR (MDRD): Decreased * Urinalysis: Proteinuria/Fatty casts/Oval fat bodies * UPCR: * UPCR < 1 = asymptomatic * UPCR > 3 = symptomatic ≈ 3g/24 hours * Serum albumin: Hypoalbuminemia (nephrotic syndrome) * Renal biopsy: Focal segmental areas of mesangial collapse and sclerosis DDx: Focal Segmental Glomerulosclerosis * Corticosteroid: Prednisolone 1mg/kg PO OD ≈ 40mg * ACEi/ARB: Lisinopril 2.5 mg PO OD * Dietary modification: Reduce sodium + Protein intake * Statin: Atorvastatin/Simvastatin/Risovustatin/Pravastatin * Loop diuretics: Furosemide

Question 117

Describe Vasculitis.

Answer 117

c-ANCA or p-ANCA antibodies bind to neutrophils adhered to endothelium of vessels restricting flow and causing inflammation of vessels

Question 118

State the 3 categories of Vasculitis. Give an example for each.

Answer 118

Categories: 1) Large-vessel vasculitis • Takayasu’s arteritis • Giant cell arteritis 2) Medium-vessel vasculitis • Polyarteritis nodosa • Kawasaki’s disease 3) Small-vessel vasculitis • ANCA-associated vasculitis (granulomatosis with polyangiitis; microscopic polyangiitis; eosinophilic granulomatosis • Henoch-Schonlein Purpura • Leukocytoclastic angiitis

Question 119

Outline the pathophysiology of Vasculitis.

Answer 119

• Idiopathic (unknown cause) with antigen exposure leading to immune response  immune-complexes mediate damage of the blood vessel wall = fibrinoid necrosis of vessel wall with karyorrhexis (nuclear fragmentation and chromatin break-up) with red blood cell extravasation

Question 120

State 5 signs and 3 symptoms of Vasculitis.

Answer 120

* Arthralgia * Myalgia * Malaise • Headache (GCA) * Amaurosis fugax (= painless vision loss) (large vessel vasculitis) * Upper extremity/jaw claudication (large vessel) * Asymmetric pulses (large vessel) * Bruits (SCA and AA) (large vessel) * Abdominal pain (medium-vessel) * Foot/Wrist drop (medium-vessel) * Cutaneous levers (medium-vessel) • Vasculitic rash: Purpura/Petechial * Haematuria (small-vessel) * Otorrhoea (small-vessel) * Wheeze (small-vessel; eosinophilic granulomatosis with polyangiitis)

Question 121

A 51 year old caucasian female presents with headache, myalgia, malaise and fever. She mentions she has experienced some vision loss in her right eye but there is no pain. She also mentions that she has been experiencing some tightness in her jaw. She has a PMHx of diabetes mellitus, coronary artery disease and Coeliac Disease. She has a family history of autoimmune diseases which include Glomerulonephritis, SLE, Vasculitis and Ankylosing Spondylitis. O/E you notice asymmetric pulses, bruits in her Subclavian Artery and Aortic Artery. You also identify a vasculitis rash which is approximately 15cm by 18cm present on the anterior leg that is a confluent patch with purpura. The rash is non-blanching. Additionally you notice foot drop, compensated by her gait. i) What is a bruit? ii) What is the term for a skin manifestation of vasculitis? iii) What nerve is affected in foot drop? Give the three main muscles innervated by this nerve. iv) What type of gait is compensating for the foot drop? What Investigations would you run and what may you anticipate? Give a DDx and outline the management plan.

Answer 121

i) Turbulent blood flow heard on auscultation over an artery ii) Cutaneous vasculitis iii) Deep peroneal/fibular nerve (L4-S1) Anterior leg compartment: Extensor digitorum, Tibialis Anterior, Extensor Hallucis Longus iv) High-stepping gait Investigations: • ESR: > 100mm/hour • CPR: Elevated • ANCA: • Positive cANCA against proteinase-3 = granulomatosis with polyangiitis • pANCA against myeloperoxidase = microscopic polyangiitis/eosinophilic granulomatosis with polyangiitis • Serum urea + creatinine: Elevated (Small-vessel vasculitis -> GN) • Urinalysis (small-vessel): Haematuria/Proteinuria/RBC casts • Biopsy: Fibrinoid necrosis/Karyorrhexis/Red blood cell extravasation DDx: Vasculitis (Large-vessel)? ``` Management: • Corticosteroids + • Bisphosphonates: Alendronic acid 5mg PO OD + • Vitamin D3/Calcium ``` • Cyclophosphamide: 1.5-2mg/kg PO OD for 2/12-6/12

Question 122

Give the alternate, eponymous name for Thrombotic Thrombocytic Purpura (TTP). Describe TTP.

Answer 122

(Moschcowitz Syndrome) = Thrombotic microangiopathy whereby microthrombi comprising of platelets form in glomerular endothelium causing occlusion to microvasculature 


Question 123

Outline the pathophysiology of Moschcowitz Syndrome.

Answer 123

• ADAMTS-13 deficient/inactive = large vWF multimers in circulation interacting with platelet membranes --> platelet aggregation at sites of high intravascular shear stress --> thrombi causing TTP pentad: microangiopathic haemolytic anaemia; thrombocytopenic purpura; neurological dysfunction; renal dysfunction; fever

Question 124

An overweight African, American Female patient presents with fever, fatigue and pallor. She also reports experiencing a seizure which reduced her movement. She has no other medical conditions but notes that her father had similar symptoms which went undiagnosed. O/E you notice conjunctival pallor, a purpuric rash on her abdomen. i) What type of seizure could lead to reduced movement? Be specific and give the area of brain that may be affected. Suggest the investigations you would wish to order. List the anticipated finds for each investigation. Suggest a DDx. Outline the Management plan for this patient.

Answer 124

i) Jacksonian Seizure: Motor cortex of the cerebrum ``` Investigations: • Platelet count: Thrombocytopenia • Haemoglobin: Low (anaemia) • Haptoglobin: Decreased • Peripheral blood smear: Schistocytes • Reticulocytes: Raised • Urinalysis: Proteinuria • Urea and creatinine: Uremia/Hypercreatinemia ``` DDx: Thrombotic Thrombocytic Purpura (Moschcowitz Syndrome) • Plasma exchange • Corticosteroids: Prednisolone 1mg/kg/day PO • Caplacizumab: 10mg IV 1st day then 10mg SC OD for 30 days --> Caplacizumab mAB against vWF • Aspirin • Folic acid: 3-5mg PO OD

Question 125

List the risk factors for Thrombotic Thrombocytic Purpura.

Answer 125

* Female * Obesity * Pregnancy * Black * Cancer Tx

Question 126

Describe Tubulointerstitial Nephritis.

Answer 126

Acute or Chronic condition whereby immune-mediated infiltration of kidney interstitium by inflammatory cells may progress to fibrosis

Question 127

Give 3 RFs for Tubulointerstitial Nephritis.

Answer 127

* Older age * Chronic inflammatory disease * Drugs: ABX; NSAIDs; Diuretics; PPIs; H2As; Immunotherapy

Question 128

Outline the pathophysiology of Tubulointerstitial Nephritis.

Answer 128

• ABX/PPIs/Immunotherapy agents/Diuretics/H2a/Allopurinol/ Warfarin/Infection/Systemic Diseases/Malignancies/Idiopathic --> antigen-initiated cell-mediated injury ≈ inflammatory cell infiltrate in renal interstitium and tubules ≈ reduced GFR

Question 129

List the signs and symptoms of Tubulointerstitial Nephritis.

Answer 129

* Fever * Arthralgia * Flank pain * Headache * Oedema * Rash * Costovertebral Angle Tenderness

Question 130

A 76 year old Male with a history of chronic inflammatory disease presents with fever, arthralgia and flank pain. The pain is localised to the Right Hypochondrium. The patient is currently on the following drugs: Warfarin, Allopurinol, Bendroflumethiazide. O/E you notice a rash which is 20cm x 15cm on the central upper back of the patient. It is a confluent maculopapular rash with erythema and no secondary characteristics. Additionally, you notice oedema and abdominal distension (enlarged kidney). i) What risk factors are present for your DDx? Outline the investigations you would order for this patient. State any anticipated changes with each investigation. Give your DDx. Outline the management.

Answer 130

``` Investigations: • Urea + Creatinine: Uremia/Hypercreatinemia • FBC: Eosinophilia • Urinalysis: Sterile pyuria/Low-grade proteinuria/WBC casts • Discontinue offending medication • US-Kidney: Large, echogenic kidneys • Serology: - ANCA (vasculitis) - ANA (SLE) - dsDNA (SLE) ``` DDx: Tubulointerstitial Nephritis Management: • Discontinue offending medication • Supportive care: Fluids, electrolytes, urea, creatinine • Diuretic: Furosemide 40-100mg IV 8-12 hours (maximum 600mg/day) • Corticosteroid: Prednisolone 40-60mg PO OD for 2/52 then 2-3/§1 • Dialysis

Question 131

What is renal papillary necrosis?

Answer 131

nephropathy involving necrosis of renal papilla (collects urine from nephron) due to ischaemia from diminished renal flow

Question 132

List the causes of Renal Papillary Necrosis. Give the aide-memoire/Mnemonic for remembering this.

Answer 132

``` Causes: POSTCARDS • Pyelonephritis • Obstruction • Sickle Cell Disease • Tuberculosis • Cirrhosis • Analgesics (NSAIDs) • Rejection (renal transplant) • Diabetes Mellitus • Systemic Vasculitis ```

Question 133

Outline the pathophysiology of renal papillary necrosis.

Answer 133

• (POSTCARDS: Pyelonephritis/Obstruction/Sickle Cell Disease/Tuberculosis/Cirrhosis/Analgesics/Renal transplant rejection/Diabetes Mellitus/Systemic Vasculitis) causing ischaemia resulting in necrosis and papilla sloughing. Sloughed papillae then obstruct ureters and sclerosis may occur.

Question 134

List the signs and symptoms of Renal Papillary Necrosis.

Answer 134

• Flank/colicky pain * Oliguria/Anuria * Fever * Albuminuria (proteinuria)

Question 135

Outline the investigations you would order in a patient with suspected Renal Papillary Necrosis.

Answer 135

* Urinalysis: Proteinuria/Haematuria/ WBC Casts/Sterile pyuria * U+E: Uremia/Low bicarbonate/alkalosis * FBC: Anaemia * US-Kidney: Obstruction and hydronephrosis (sloughing off papillae)

Question 136

Describe Nephrolithiasis.

Answer 136

formation of stones (calculi; composed of calcium oxalate/calcium phosphate/ uric acid/cysteine/struvite) present in the kidneys (nephrolithiasis) or ureters (ureterolithiasis) causing renal colic (colicky pain) due to dilation, stretching and spasm due to acute ureteral obstruction

Question 137

List the 5 main types of Renal Calculi.

Answer 137

* Calcium oxalate: Low urine volume/ hypercalciuria/ hypocitraturia * Calcium phosphate: Low urine volume/ hypercalciuria/ hypocitraturia/ high urine pH * Uric acid stones * Cystine stones (inborn metabolic errors -> cysteinuria) * Struvite stones (Magnesium, ammonium phosphate)

Question 138

Outline the pathophysiology of Nephrolithiasis.

Answer 138

• Renal papillary plaques of calcium phosphate/apatite deposits erode through uroepithelium as adhesion site for stones; OR intra-tubular stones form  obstruction of collecting system with intraluminal pressure increased + stretching giving afferent sensory input generating pain (renal colic)

Question 139

List the signs and symptoms of a patient with Nephrolithiasis.

Answer 139

* Renal colic: Severe, acute, loin-to-groin radiation * Testicular pain * Obesity * Hx nephrolithiasis * Urinary urgency * Haematuria * Abdominal distension (hydronephrosis)

Question 140

Mrs Horin, a 43 year old patient presents with severe, acute pain. She says it is in her upper right abdomen, on the side. She says it comes on randomly, the type of pain is sharp and it radiates from her flank to her groin. It is made to feel much worse with urinary urgency and she fears enuresis which would be devastating as she is a primary school teacher. Her diet is balanced but she says she likes a meat platter with Red Wine and cheese every evening to relax. O/E you notice abdominal distension, guarding on palpation and the kidneys are heavy when balloting on an Abdomen exam. What investigations would you order? State the anticipated finds for each investigation. Give your DDx and outline a management plan for Mrs. Horin.

Answer 140

• Urinalysis: Leukocytosis/Haematuria/Nitrates • FBC: Leukocytosis/Variable • Serum U+E and creatinine: Variable • Urine pregnancy test: Negative • CT-KUB (non-contrast): Calcification, hydronephrosis, perinephric stranding - Uric Acid Stones are radiolucent --> not visible on CT • Stone analysis: Stone composition DDx: Nephrolithiasis --> Suspected Uric Acid Stone Management: • Conservative management: Hydration/Pain control/Anti-emetics (metoclopramide) • ABX: Nitrofurantoin 100mg PO BD 1-2/52 • Medical Expulsive Therapy (MET): Tamsulosin 0.4mg OD • Surgical removal: Percutaneous nephrostolithotomy

Question 141

State the most common type of renal calculi. What are these caused by? What do these appear like?

Answer 141

Calcium oxalate ≈ 75% - Hypercalciuria - Hyperoxaluria - Hypocitraturia - Low urine pH Appearance: Biconcave dumbbells/bipyramidal envelopes

Question 142

What is the appearance of calcium oxalate stones? A. Coffin-lid appearance B. Rounded rhomboids/needle-shaped C. Biconcave dumbbells/bipyramidal envelopes D. Hexagon-shaped

Answer 142

C. Biconcave dumbbells/bipyramidal envelopes

Question 143

What is the appearance of uric acid stones? A. Coffin-lid appearance B. Rounded rhomboids/needle-shaped C. Biconcave dumbbells/bipyramidal envelopes D. Hexagon-shaped

Answer 143

B. Rounded rhomboids/needle-shaped

Question 144

What is the appearance of struvite stones? A. Coffin-lid appearance B. Rounded rhomboids/needle-shaped C. Biconcave dumbbells/bipyramidal envelopes D. Hexagon-shaped

Answer 144

A. Coffin-lid appearance

Question 145

What is the appearance of cystine stones? A. Coffin-lid appearance B. Rounded rhomboids/needle-shaped C. Biconcave dumbbells/bipyramidal envelopes D. Hexagon-shaped

Answer 145

D. Hexagon-shaped

Question 146

What is the appearance of calcium phosphate stones? What is the cause of calcium phosphate stones? A. Wedge-shaped crystals B. Rounded rhomboids/needle-shaped C. Biconcave dumbbells/bipyramidal envelopes D. Hexagon-shaped

Answer 146

A. Wedge-shaped crystals Causes: - Hyperparathyiridism - Type 1 renal tubular acidosis

Question 147

What type of renal calculi may not be seen on a CT-KUB and why?

Answer 147

Uric Acid stones are radiolucent thus may not be seen on a CT-KUB

Question 148

What is the cause of uric acid stones?

Answer 148

Low urine pH Gout Hyperuricemia Hyperuricosuria

Question 149

What is the cause of struvite stones? State the crystal appearance of these stones

Answer 149

- UTI with urease-producing bacteria Rectangular prisms (Coffin-lid appearance)

Question 150

Describe Pyelonephritis.

Answer 150

inflammation of the kidney due to a bacterial infection

Question 151

State 3 risk factors for pyelonephritis.

Answer 151

* Acute pyelonephritis * Vesicoureteral reflux * Obstruction * Renal calculi * Diabetes Mellitus

Question 152

Outline the pathophysiology for Pyelonephritis.

Answer 152

Chronic inflammatory process (failure to treat acute pyelonephritis; infection with E. coli, Klebsiella, Proteus spp.) --> thinning of renal cortex with deep, segmental, coarse cortical scarring --> Club-shaped deformity of renal calyces occur at papilla which retract into scars.

Question 153

Give two types of Pyelonephritis. Outline the key difference.

Answer 153

• Xanthogranulomatous pyelonephritis (XGP): severe, atypical rare form of chronic pyelonephritis - Unilateral - Causative pathogen mainly Proteus • Emphysematous pyelonephritis (EPN): severe, life-threatening infection of renal parenchyma - main pathogens: E. coli, Proteus, Klebsiella - Occurs mainly in patients with poorly controlled diabetes

Question 154

List the signs and symptoms of pyelonephritis.

Answer 154

* Nausea * Fever * Flank pain: Severe, loin-to-groin * Fish-smelling urine * Dysuria * Hypertension * Hx of acute pyelonephritis * Hx of renal obstruction * Pyuria * Leukocyturia

Question 155

A 53 year old male painter presents with nausea, fever and flank pain. He describes the pain as a 9/10 which is present on his right flank and moves towards his genitals. He also says that he has notices a foul-smelling, fish smell to his urine as well as it being painful when urinating. He has a history of gout and nephrolithiasis/ The latter of which was left undiagnosed as the renal calculi could not be seen on the CT-KUB. O/E you notice a blood pressure of 185/113mmHg. Additionally, you notice abdominal distension on his right hypochondrium which the patient displays signs of guarding on palpation. What stage of hypertension does this patient have? Outline the investigations you may order and state the anticipated finds for each. Give a DDx and outline the management plan.

Answer 155

Stage 3 Hypertension Investigations: • Urinalysis: Haematuria/Proteinuria/Leukocytes/WBCs • Renal function: Hypercreatinemia/Reduced eGFR • Urine culture: Positive or sterile • Electrolyte panel: Hyponatremia/Hyperkalemia/Acidosis (low bicarbonate) • FBC: Anaemia/Leukocytosis • US-renal: small, irregular, scarred kidneys; echogenic parenchyma; hydronephrosis; renal stones; peri-renal fluid collections • XR-KUB: Renal calculi/kidney size DDx. Nephrolithiasis and Pyelonephritis Management: • Treat underlying cause XGP • Ceftriaxone: 1g/24 hours IV • Nephrectomy EPN • Percutaneous drainage + ABX + Supportive therapy: Ceftriaxone 1g/24 hours IV • Nephrectomy

Question 156

Describe hydronephrosis.

Answer 156

kidney enlargement due to water accumulation as a result of improper urine excretion from the kidney to the bladder secondary to another disease e.g. nephrolithiasis, CAKUT, vesicoureteral reflux, urethral stricture and stenosis

Question 157

Outline the pathophysiology of hydronephrosis.

Answer 157

• Obstructive condition intrinsic or extrinsic reducing urinary flow --> reduced renal blood flow, reduced GFR and up-regulation of RAAS causing atrophy and apoptosis in tubules and interstitial fibrosis with macrophage infiltration of interstitial spaces

Question 158

List the signs and symptoms of hydronephrosis.

Answer 158

* Flank pain: Severe, local, loin-to-groin * Fever * Urinary urgency/Enuresis * Reduced force of stream * Incomplete emptying * Distended/palpable bladder * Anuria/dysuria * Enlarged nodular prostate on PR * Costovertebral angle tenderness

Question 159

A 37 year old women, Mrs James, presents with a fever and extreme flank pain. She describes the pain as 8/10, at the site of her right flank and it moves to her groin. She says she has had issues with urinary continence (enuresis). She has a PMHx of varicose veins, fibromyalgia, anxiety and gout. O/E you observe a distended and palpable bladder with costovertebral angle tenderness. What investigations would you order? Give the anticipated find for each. State your DDx. Outline your management.

Answer 159

Investigations: • Urinalysis: Leukocytes/Nitrites/Haematuria ---> Rule out Pregnancy with ß-hCG test urinary (preferably blood) ≈ Ectopic pregnancy • US-Renal: Hydronephrosis • Urea + Creatinine: Normal/elevated • FBC: Leukocytosis/Anaemia • CT-Pyelogram: nephrolithiasis/ureterolithiasis • IV-Pyelogram: Delayed nephrogram/Delayed obstruction Hydronephrosis secondary to potential nephrolithiasis (uric acid stone?) Management: • Passage with analgesia and rehydration: Ketorolac 30mg IM • Alpha-blockers: Tamsulosin 0.4mg PO OD • Active stone removal: Percutaneous nephrolithotomy

Question 160

A 3 year old boy presents with abdominal distention, abdominal pain and nausea and vomiting. He was born with a congenital syndrome but had the omphalocoele surgically corrected. His parents cannot remember the name of the condition. O/E you notice early onset obesity, brachydactyly, hypogonadism, macroglossia but his growth is normal as checked by the growth chart. What investigations would you order and state any anticipated finds you may expect. What is your suspicion for the DDx of the syndrome this child may have? State the DDx of the presenting condition. Outline the management plan. Outline the pathophysiology of the presenting condition.

Answer 160

``` Investigations: • FBC: Anaemia <110g/L • Renal function: Reduced eGFR • Hypercreatinemia • Urinalysis: Haematuria/Proteinuria • Serum protein: Hypoalbuminemia • US-Abdomen: Echogenic/Heterogeneous/Solid mass • CT/MRI: Renal mass with heterogeneous enhancement ``` DDx: Wilm's Tumour Prader-Willi Syndrome Management: • Surgery: Radical nephrectomy • Post-operative chemotherapy: Dactinomycin + Vincristine Pathophysiology: WT1 TS gene ∆ in children with oncology referral (surgery, radio + chemo)

Question 161

What is the most common type of kidney cancer?

Answer 161

Renal Cell Carcinoma | = most common type of kidney cancer originating in the lining of the proximal convoluted tubule

Question 162

List 3 risk factors for renal cell carcinoma.

Answer 162

* Smoking * Male * Age: 55-84 years * Developed countries * Obesity * Hypertension

Question 163

Outline the pathogenesis of renal cell carcinoma.

Answer 163

• VHL protein∆ --> elevated HIF ≈ transcription promotion of VEGF, PDGF, EGFR and MMPs (aiding oncogenesis and tumour invasion) --> tumorigenesis and invasion

Question 164

Mr. James, a 76 year old gentleman from America presents with flank pain, weight loss, fever and malaise. He says the pain has only recently come on but he notices its in the same location (right flank) as where he has had a lump for quite some time. He says he didn't want to bother the busy doctors with his lump which he noticed 3 years ago. He has coronary artery disease, has had two strokes, has gastritis. He doesn't drink alcohol since quitting but still smokes 10 cigarettes a day with 40 pack years. O/E you notice a palpable mass in the abdomen and a blood pressure of 187/117mmHg. i) What stage of hypertension does Mr James have? ii) What are the red flags in Mr. James' history? What investigations would you order? State the anticipated findings for each. Outline the management plan for your DDx.

Answer 164

i) Stage 3 ii) - Age (> 50 years old) - Weight loss - Lump - Malaise - Smoking - Alcoholic (previously) Investigations: • FBC: Reduced Hb (Anaemia); RBC elevated (erythrocytosis) • LDH: Elevated > 1.5x • LFTs: AST elevation/ALT elevation • Urinalysis: Haematuria/Proteinuria • US-Pelvis: Abnormal renal cyst/mass • CT-Abdomen: Renal mass/Regional lymphadenopathy/Visceral bone metastases DDx: Renal cell carcinoma Management: Stage-dependent 1-3 • Surgery: Surgical resection • Local ablation therapy: Radiofrequency ablation (RFA) 4 • Surgery • Chemotherapy/Radiotherapy • Clinical trials

Question 165

A 65 year old female, Mrs Jin, presents with painful urination (dysuria), urinary urgency and polyuria. Additionally, though she is concerned, she is pleased she has lost 2 stone in the last month without exercise. She also suggests flank pain. She has previously had Breast cancer which was cured with surgery and chemotherapy. She is retired after previously working in a industrial factory which was closed due to fears of chemical carcinogens and radiation exposure. She has no other medical conditions other than GORD and gastritis. O/E you notice abdominal distension and a painless palpable mass in the suprapubic region. i) What are the red flags in Mrs. Jin's history? What investigations would you order? State the anticipated find for each. Give your DDx. Outline a management plan for Mrs. Jin.

Answer 165

i) - Age (> 55 years) - Weight loss - PMHx Ca - Occupational radiation exposure - Chemical carcinogen exposure - Mass - painless ``` Investigations: • Urinalysis: Haematuria/Pyuria/RBC casts • FBC: Normal/mild anaemia • US-renal and US-bladder: Obstruction • CT-urogram: Bladder tumours ``` DDx: Urothelial Bladder Cancer Management: Non-invasive • Transurethral resection • Intravesical chemotherapy Locally invasive tumours • Radical/partial cystectomy with pelvic lymph node dissection • Preoperative + postoperative chemotherapy Metastatic Disease • Chemotherapy • Surgery/Radiotherapy • Immunotherapy

Question 166

Define CKD.

Answer 166

Abnormality of kidney structure or function for ≥ 3 months as determined by eGFR or urinary Albumin

Question 167

State the three categories of CKD in relation to the anatomy. Give an example of a disease for each.

Answer 167

a) Pre-Renal • Atherosclerosis • Real hypoplasia • Bilateral renal agenesis (Potters Syndrome) ``` b) Renal • Glomerulonephritis • Focal Segmental Glomerulosclerosis • Membranous Nephropathy • Renal papillary necrosis • Minimal Change Disease • Rapidly Progressive Glomerulonephritis • Diabetes Mellitus • Hypertension • Polycystic Kidney Disease ``` c) Post-renal • Obstruction

Question 168

State the different stages of CKD and the eGFR values for each.

Answer 168

``` G1: > 90 G2: 60-89 G3a: 45-59 G3b: 30-44 G4: 15-29 G: < 15 ```

Question 169

State the different stages of CKD and the different Urinary Albumin Creatinine Ratios for each.

Answer 169

A1: < 30 A2: 30 to 300 A3: > 300

Question 170

List 5 goals for prevention of CKD.

Answer 170

``` • BP management - 140/90 (< 80 years old) - 150/80 (<80 years old and HBPM/ABPM) - 130/80 (proteinuria present) • Reduce proteinuria • Cessation of smoking • Diabetes control • Reduce BMI ```

Question 171

List 2 complications of CKD. State how each occurs.

Answer 171

1) Anaemia • Reduced EPO • Increased hepcidin • Reduced RBC lifespan (uremic environment) • Increased bleeding risk (uremic environment) 2) Hyperparathyroidism i) Vitamin D: • 7-dehydrocholesterol + UVB -> Cholecalciferol (pre-VitD) -> WAT (storage) or Liver (activation) • Cholecalciferol + 25alpha-hydroxylase (CYP2R1) -> 25-hydroxycholecalciferol (Liver) • 25-hydroxycholecalciferol + 1alpha-hydroxylase (CYP27B1) -> Calcitriol (Kidneys) • Calcitriol ≈ increased Calcium resorption + inhibits PTH secretion ii) PTH: Physiological [Ca++] of 1.1-1.3mM PTH at 50% basal secretion which changes if CaSR detects large deviations e.g. reduced calcium causes increased PTH • Net reabsorption from bone thus increased serum [Ca2+] and Pi from HA of bone • Increased calcium reabsorption across DCT of nephron • Reduced Pi reabsorption across the tubules

Question 172

Outline the complete pathway of vitamin D synthesis.

Answer 172

Vitamin D: • 7-dehydrocholesterol + UVB -> Cholecalciferol (pre-VitD) -> WAT (storage) or Liver (activation) • Cholecalciferol + 25alpha-hydroxylase (CYP2R1) -> 25-hydroxycholecalciferol (Liver) • 25-hydroxycholecalciferol + 1alpha-hydroxylase (CYP27B1) -> Calcitriol (Kidneys) • Calcitriol ≈ increased Calcium resorption + inhibits PTH secretion

Question 173

What is dialysis? When is it used?

Answer 173

Type of renal replacement therapy based on diffusion of molecules across semipermeable membrane separating blood on one side and dialysate. * eGFR = 7mL * Prepare patient when eGFR < 20mL * Education * Options: Hemodialysis, Peritoneal Dialysis, Transplantation

Question 174

Explain the differences between the two types of dialysis. Give the benefits and drawbacks of each.

Answer 174

1) Haemodialysis: circulating blood through disposable dialyser with selectively permeable material of large SA. • Dialysate produced by continuous combination of concentrate with highly treated tap water which has contralateral flow to blood • Contains low concentration of factors to be removed and high concentration of bicarbonate allowing diffusion in blood and correct of acidosis. • Removal of accumulated fluid achieved via pressure gradient across dialysis membrane resulting in controlled ultrafiltration. • Heparin used to prevent clotting and treatment performed x3 per week. • Adequate control of biochemistry, fluid overload, acidosis and uraemic symptoms in most patients 
 + Site of access + Established technique: Arteriovenous fistula (arterialised vein thus flow through vein prevents collapse) + Less isolating - 3x per week - Done in hospital 2) Peritoneal dialysis: peritoneum used as dialysis membrane with pre-packaged fluid instilled into peritoneal space for exchange of products between blood and peritoneal fluid. • Dialysate contains factors that do not need to be removed at similar levels to plasma • Acidosis corrected by diffusion of buffer from fluid into blood and ultrafiltration occurs down oncotic gradient as fluid has higher osmolality than plasma due to high concentration of glucose in the instilled fluid. + Younger patients preferred + Less restrictions - Complications due to high-glucose fluid e.g. Peritonitis 
 - Placement of tube 
 - Requires a virgin abdomen 
- Requires 3-5 exchanges of fluid per day every day

Question 175

Compare and contrast the benefits and drawbacks of renal transplants.

Answer 175

+ No dialysis 
 + Better QoL 
 + Better Survival (new kidneys) 
+ Cost (17,000 per year cf 38,000 per year with dialysis) ``` 

- Optional extra (reasons below) 
 - Cardiac disease 
- Respiratory disease 
 - Malignancy 
- Severe PVD 
- BMI > 35: Delayed Graft Function + Post-operative complications 
- Age? 
 ```

Question 176

Which of the following is the gold standard investigation for upper tract calculi? A) XR-KUB B) CT-KUB - no contrast C) CT Urogram with contrast D) USSKUB

Answer 176

B) CT-KUB - no contrast

Question 177

Upper tract calculi least commonly presents with... A) Pain B) Urinary retention C) Sepsis D) Haematuria

Answer 177

B) Urinary retention

Question 178

In someone with proven ureteric stones, which symptom would be most concerning? A) Haematuria B) Nausea C) Pain D) Fever

Answer 178

D) Fever

Question 179

Which is not a recognised risk factor for the development of urolithiasis? A) Dehydration B) High salt intake C) High Red Meat Intake D) Smoking

Answer 179

D) Smoking

Question 180

Which of the following bacteria is most commonly associated with stag horn calculi? A) S. Aureus B) E. coli C) Proteus D) N. gonorrhoea

Answer 180

C) Proteus

Question 181

Outline what must be done if sepsis is suspected secondary to nephrolithiasis/ureterolithiasis.

Answer 181

Sepsis 6: BUFALO Give 3, Take 3 ``` Bloods (take) Urine culture (take) Fluids (give) ABX (give) Lactate (take) Oxygen (give) ```

Question 182

What feature of ureteric calculi primarily determines its management?

Answer 182

Size - 1cm (10mm) is the key number ESWL if <1cm PCNL > 1cm

Question 183

What percentage of adults have a BP of above 140/90? A. 40% B. 50% C. 60% D. 70%

Answer 183

A. 40%

Question 184

If a patient has a BP of 158/95 in your clinic (2 readings 2mins apart) should you? A. Start treatment immediately B. Organise ambulatory or home blood pressure monitoring C. Repeat blood pressure in 6 months

Answer 184

B. Organise ambulatory or home blood pressure monitoring

Question 185

Name 4 lifestyle changes that can reduce blood pressure

Answer 185

Salt reduction Weight loss Alcohol reduction Increased exercise Relaxation - mindfulness/bibliotherapy/meditation

Question 186

Lifestyle changes can lower BP by the same as a single anti-hypertensive drug - true or false?

Answer 186

True

Question 187

What are the guidelines for a sphygmomanometer cuff?

Answer 187

Bladder width should be 40% arm circumference, bladder length should be 80% arm circumference

Question 188

Does a cuff that is too small underestimate or overestimate the BP?

Answer 188

overestimates

Question 189

What is the definition of white coat hypertension?

Answer 189

Hypertension present in surgery but not home readings

Question 190

Name 2 things that should be done as part of the initial assessment of a patient with hypertension

Answer 190

Check height/weight Check ECG Check urinalysis Check U+Es Lipid panel

Question 191

You have a patient with a BP of 223/120 in your clinic – do you.. a. start treatment immediately b. work out his 10 year risk of cardiovascular disease and then decide c. give lifestyle advice and repeat BP in 4-6 months

Answer 191

a. start treatment immediately

Question 192

Which BP treatment should not be given in a patient with a history of gout?

Answer 192

Diuretics (esp thiazides)

Question 193

Which BP treatment is contra-indicated in asthma?

Answer 193

Beta-blockers

Question 194

Which BP treatment requires u+es checking 7-14 days after starting?

Answer 194

ACE inhibitors

Question 195

What would be the significance of a doubling of creatinine after starting this treatment (ACEi)?

Answer 195

Would point to a renal cause of hypertension esp renal artery stenosis

Question 196

Which BP treatment is first line in Afro-Caribbean patients?

Answer 196

Calcium channel blockers

Question 197

What is the level of increased cardiovascular risk in Afro-Caribbean patients with hypertension?

Answer 197

3.5x

Question 198

How long should you give lifestyle measures to work?

Answer 198

4-6 months

Question 199

You have a patient with a BP of 164/95 who has AF with a rate of 112 (no other medical problems). What type of BP treatment might be particularly effective?

Answer 199

Beta-blocker (might accept rate limiting calcium channel blocker)

Question 200

You have a 65 year old patient who needs to commence BP treatment. What would be your first choice?

Answer 200

Calcium channel blocker

Question 201

At which stage of CKD would you refer a patient to secondary care?

Answer 201

When they hit stage 4 (eGFR <30)

Question 202

What are the parameters for Stage 3a (G3a) CKD?

Answer 202

eGFR 45-59

Question 203

What level of ACR is relevant for the management of a diabetic patient?

Answer 203

A2 (3-30)

Question 204

How would you manage a diabetic patient with an ACR at this level (A2 = 3-30)?

Answer 204

Prescribe ACE inhibitor (or ARB)

Question 205

Symptoms of CKD are common in patients with CKD3 – true or false?

Answer 205

FALSE – usually asymptomatic

Question 206

Is a single eGFR of 55ml/min/1.73m² diagnostic of CKD3? Justify your answer. (2 points)

Answer 206

No – requires 2 readings 2 months apart Could be acute - AKI?

Question 207

What is the correction factor applied to eGFR for Afro-Caribbean patients?

Answer 207

X 1.159

Question 208

What is an alternative treatment when ace inhibitors are required, but not tolerated?

Answer 208

ARB

Question 209

What BP treatment commonly causes swollen ankles?

Answer 209

Calcium channel blockers

Question 210

At which level of ACR in a hypertensive (non-diabetic) patient would specific treatment be recommended?

Answer 210

A3 (ACR ≥ 30)

Question 211

At which level of ACR in a normotensive, non – diabetic patient would specific treatment be recommended?

Answer 211

ACR ≥70

Question 212

What 2 types of treatment might be recommended in the above scenarios? (2 points)

Answer 212

ACE inhibitor or ARB

Question 213

What is superior for testing microscopic haematuria – dipstix or miscoscopy?

Answer 213

DIPSTIX (red cells may haemolyse in transport)

Question 214

What should you do with a patient of 65 who has isolated persistent microscopic haematuria and dysuria and no evidence of UTI?

Answer 214

Refer as cancer referral to urology

Question 215

Name one common side effect of ACE inhibitors

Answer 215

cough

Question 216

ACE inhibitors lower potassium – true or false

Answer 216

False, they tend to raise potassium

Question 217

ARBs can raise potassium – true or false?

Answer 217

true

Question 218

Furosemide lowers potassium – true or false

Answer 218

true

Question 219

What percentage of patients with stage 4 CKD have anaemia?

Answer 219

33%

Question 220

What is the ideal Hb target level in a patient with CKD?

Answer 220

10-12g/dl (increased thrombotic risk if higher)

Question 221

What does ESA stand for in the context of CKD related anaemia?

Answer 221

Erythropoietin stimulating Agents

Question 222

What derangement of calcium occurs in patients with advanced CKD and outline why?

Answer 222

Failure to convert vit D to active form Failure to convert a25-hyroxyvitamin-D to a1,25-hydroxyvitamin D in the kidney

Question 223

What rate of decline in eGFR should prompt a nephrology referral?

Answer 223

Decrease of 25% and change in stage or drop of 15ml or more in 1 year