Disease

Question 1

What are the features of nephrotic syndrome?

Answer 1

presence of proteinuria (>3.5 g/24 hours), hypoalbuminaemia (<30 g/L), and peripheral oedema. Hyperlipidaemia and thrombotic disease are also frequently seen. Despite heavy proteinuria and lipiduria, the urine contains few cells or casts.

Question 2

What are the differentials for nephrotic syndrome?

Answer 2

Minimal change disease 
Focal Segmental Glomerulosclerosis 
Membranous Nephropathy
Diabetic Nephropathy 
Multiple myeloma-associated ALL amyloidosis
IgA nephropathy

Question 3

What are the features of minimal change disease?

Answer 3

common in children (occasionally found in adults), can be secondary to Hodgkin’s lymphoma

Question 4

What are the signs of minimal change disease?

Answer 4

typically not hypertensive, otherwise physical examination is non-specific

Question 5

What investigations would you consider for minimal change disease?

Answer 5

serial creatinine and estimated GFR: typically normal

renal biopsy: normal by light microscopy, but podocyte effacement on electron microscopy

Question 6

What are the symptoms of focal segmental glomerulosclerosis (FSGS)

Answer 6

asymptomatic, or may have oedema and other symptoms of renal dysfunction, hx HIV, reflux nephropathy, morbid obesity, chronic glomerular hyperfiltration from a solitary kidney, or any other cause of extensive nephron loss (e.g., renal obstruction, prior glomerulonephritis), or hx of drug use (e.g., pamidronate, heroin)

Question 7

What are the signs of FSGS?

Answer 7

may be hypertensive, otherwise physical examination is non-specific

Question 8

What first line investigations would you consider for FSGS?

Answer 8

serial creatinine and estimated GFR: may be abnormal

renal biopsy: focal and segmental sclerosis of the glomeruli

Question 9

What other investigations would you consider for FSGS?

Answer 9

HIV test: positive

Question 10

What are the symptoms of membranous nephropathy?

Answer 10

may be primary or secondary (associated with malignancy, hepatitis, lupus, certain drugs)

Question 11

What are the signs of membranous nephropathy?

Answer 11

physical examination is non-specific

Question 12

What first line investigations would you consider for membranous nephropathy?

Answer 12

renal biopsy: characteristic thickening of basement membranes seen on biopsy, as well as subepithelial electron-dense deposits

Question 13

What other investigations would you consider for membranous nephropathy?

Answer 13

CXR or chest CT for lung cancer: mass consistent with lung tumour
occult blood in stool: haem-positive stool
hepatitis serologies: positive
rapid plasma reagin (RPR) syphilis test: positive

Question 14

What are the symptoms of diabetic nephropathy?

Answer 14

long-standing history of diabetes often in conjunction with symptoms suggestive of diabetic retinopathy (impaired vision) or slowly progressive renal dysfunction (e.g., fatigue, swelling of the extremities)

Question 15

What are the signs of diabetic nephropathy?

Answer 15

diabetic retinopathy (microaneurysms, hard and soft exudates, microinfarcts, macular oedema, increased tortuosity of veins, and neovascularisation) seen on funduscopic examination

Question 16

What first line investigations would you consider for diabetic nephropathy?

Answer 16

HbA1c: often elevated

renal biopsy: diagnostic

Question 17

What other investigations would you consider for diabetic nephropathy?

Answer 17

urinalysis: may show microscopic haematuria

Question 18

What are the symptoms of IgA nephropathy?

Answer 18

episodes of dark urine that often occur along with pharyngitis; may be a history of liver disease, seronegative arthropathy, coeliac disease, Henoch-Schonlein purpura (especially in children), purpuric skin lesions, melaena, or bright red blood per rectum

Question 19

What are the signs of IgA nephropathy?

Answer 19

rarely presents with oedema, otherwise physical examination is non-specific

Question 20

What first line investigation would you consider for diabetic nephropathy?

Answer 20

renal biopsy: IgA deposits seen on immunofluorescent examination of renal biopsy

Question 21

What are the differentials for dysuria?

Answer 21

cystitis 
urethritis 
pyelonephritis 
vulvovaginitis
balanitis 
acute prostatitis

Question 22

What are the features of cystitis?

Answer 22

rapid onset, history of previous UTI, sexual activity/spermicide/diaphragm use (higher risk in women), post-menopausal status (women), history of BPH (men), instrumentation, urinary frequency/urgency, cloudy or malodorous urine, haematuria

suprapubic discomfort, absence of costovertebral tenderness

Question 23

How would you approach cystitis?

Answer 23

urine dipstick: leukocyte esterase-positive; positive for RBCs; occasionally positive for nitrites
urine microscopy: leukocytes and/or bacteria
urine culture: >10^5 colony forming units (cfu)/mL
pregnancy test: positive or negative
renal ultrasound: abnormalities such as dilation of the renal pelvis or ureters, or distension of thick-walled bladder; renal abscess: area of radiolucency to the renal parenchyma with local hypoperfusion on colour Doppler; perinephric abscess: hypoechoic fluid

Question 24

What are the features of urethritis?

Answer 24

gradual onset (over days), most common in young patients, sexual activity, urinary frequency/urgency, urethral discharge (common in men, rare in women), post-coital or intermenstrual bleeding

variable (watery or thick) discharge, suprapubic discomfort (may be present if associated with pelvic inflammatory disease in women)

Question 25

How would you approach someone with urethritis?

Answer 25

urine dipstick: leukocyte esterase-positive; positive for RBCs
nucleic acid amplification test: positive for Chlamydia trachomatis or Neisseria gonorrhoeae
urethral or vaginal culture: positive for C trachomatis or N gonorrhoeae
serum rapid plasma reagent or VDRL: excludes syphilis
HIV serology: excludes HIV in high-risk groups

Question 26

What are the features of pyelonephritis?

Answer 26

fever, rigors, myalgia, headache, nausea, vomiting, flank pain, urinary frequency/urgency, diabetes, immunosuppression, history of anatomical abnormality

fever, costovertebral angle tenderness, deep right or left upper quadrant tenderness

Question 27

How would you approach someone with pyelonephritis?

Answer 27

urine dipstick: nitrite- and/or leukocyte esterase-positive; positive for RBCs
urine microscopy: leukocytes and/or bacteria
urine culture: >10^5 colony forming units/mL
renal ultrasound: abnormalities such as dilation of the renal pelvis or ureters, or distension of thick-walled bladder; renal abscess: area of radiolucency to the renal parenchyma with local hypoperfusion on colour Doppler; perinephric abscess: hypoechoic fluid
CT renal tract: excludes hydronephrosis, abscess, and renal calculi

Question 28

What are the differentials of visible haematuria?

Answer 28

Benign prostatic hyperplasia
UTI
Acute pyelonephritis
Bladder cancer
prostate cancer 
kidney stone 
instrumentation of the urinary tract menstruation

Question 29

What are the differentials of non-visible haematuria?

Answer 29

Menstruation 
Cystitis 
Pyelonephritis 
Acute prostatitis 
Benign prostatic hyperplasia 
nephrolithiasis (flank or groin pain, non-specific or may find flank tenderness, helical CT of urinary tract without contrast: visible stone present, IV urography: filling defect)
Trauma

Question 30

What are the features of good pasture’s disease (antiglomerular basement membrane disease)?

Answer 30

reduced urine output 
haemoptysis
oedema 
male sex 
20-30yrs old or 60-70yrs 
recent URTI
SOB cough, fever, nausea, crackles on lung examination

Question 31

What are the features of nephritic syndrome?

Answer 31

presence of acute kidney injury (renal dysfunction), hypertension, and an active urinary sediment (red cells and red cell casts).