General

Question 1

Add on agent for resistant hypertension

Answer 1

Spironolactone

3 agents at max tolerable dose including a diuretic

Question 2

“Normal” drop in GFR in diabetic nephropathy

Answer 2

4-10ml/min/year

Question 3

Stable adrenal lesion over 6 months. Anymore investigations?

Answer 3

No

Question 4

Which cells are most likely to infiltrate a kidney graft in acute rejection?

Answer 4

T cells
- Both effector and helper cells

(blue dots in transplant biopsy)

Question 5

Metoprolol is avoided as the 1st antihypertensive in patietns with pheo because it antagonises the effects of which adrenoceptor?

Answer 5

Beta 2
Beta 1 cardiac specific and blockade helps to lower BP
Beta 2 found in vascular SM and causes vasodilation - helpful in pheo and if blocked

But need alpha blockade first, if not, can make hypertension worse

Question 6

Type 4 RTA is a classic complication of

Answer 6

Diabetic nephropathy

HyperK+, acidosis

Caused by reduced ammonium excretion in prox tubule
Reduced conversion from pro-renin to renin –> reduced aldosterone

Question 7

Tenofovir affects which part of the kidney?

Answer 7

Proximal tubule
Proteinuria
Glycosuria
Phosphaturia

Question 8

What is the cause of dialysis disequilibrium syndrome?

Answer 8

Problem of cerebral oedema
Urea and lots of molecules accumulate in dialysis patients –> slowly diffuse into brain tissue –> chronically increased osmolality in the brain –> dialyse these molecules from the blood –> shift of water from blood to brain –> cerebral oedema

We start with slow, poor quality dialysis to not remove too much… and slowly increase to avoid this

Question 9

Which drug is associated with scleroderma renal crisis?

Answer 9

Steroid

Question 10

Which ab is most commonly associated with primary membranous nephorpathy?

Answer 10

70% M-type phospholipase A2 (PLA2R)

10% Thrombospondin type 1 domain containing 7A

Question 11

Medical management of eclampsia

Answer 11

Magnesium sulphate infusion
Until they deliver

Downside
Too much = renal failure, respiratory depression (monitor reflexes)

Question 12

Most common complication of nephrotic syndrome

Answer 12

VTE

Risk factors
Serum albumin <20
Urine protein >8g/day

Think about anticoagulation

Question 13

Where is metformin excreted in the tubules?

Answer 13

PCT

Most solutes and drugs are reabsorbed and secreted in the PCT. Distal to this mostly does water and Na.

Question 14

PKD and sudden onset headache

Dx

Answer 14

SAH

Question 15

Extrarenal manifestations PKD

Answer 15

Hepatic cysts
AAA
Valvular abnormalities
LVH
HTN
Diverticular hernias
Bronchiectasis 
Pain
Intracranial aneurysm/Berry aneurysms

Question 16

BP and proteinuria treatment goals for IgA nephropathy

Answer 16

BP <130/80

Proteinuria <1g/d

Question 17

Alport syndrome presentation

Answer 17

X-linked most common, but also AD, AR
Mutation in COL4A5 gene

FHx  kidney disease
Sensorineural deafness 
Proteinuria
Haematuria
Ocular changes
ESKD

Question 18

When to do CRRT over haemodialysis

Answer 18

CRRT is a slower, more gentle version

Done in ICU when there is haemodynamic instability

Question 19

How do you send PLA2R?

Answer 19

In blood and kidney biopsy

Question 20

eGFR most accurate in patients with

Answer 20

eGFR <60

STABLE disease so stable CKD

Question 21

Urine proteus or klebsiella infection is associated with what kind of stones?

Answer 21

Struvite stones

SO treat aggressively

Question 22

Common causes of high osmolar gap metabolic acidosis

Answer 22

Mannitol
Methanol
Ethylene glycol
Sorbitol
Polyethylene glycol (IV lorazepam)
Prophylene glycol (IV lorazepam, diazepam, phenytoin)
Glycine (TURP syndrome)
Maltose (IVIG)

Question 23

FGF23 in CKD

What does it do?

Answer 23

CKD –> increased phosphate retention –> increased FGF23 –> increased excretion of phosphate
Predominantly responds to phosphate

Also reduce 1,25 vitamin D, PTH and calcium

Question 24

Where is potassium excreted?

Answer 24

90% kidneys (collecting duct)

10% Gut

Question 25

Why do we get hypokalaemia in vomiting?

Answer 25

Vomiting --> volume depletion --> hyperaldosteronism --> increase Na+ reabsorption, increased potassium secretion (collecting tubule) Also get metabolic alkalosis --> reduced availability of tubular H+ ions --> increased potassium secretion Get excess HCO3- --> potassium is secreted with it

Question 26

Iodine contrast induced kidney injury in CKD | Mechanism

Answer 26

Intra-renal vasoconstriction

Question 27

What's renal cortical dysplasia?

Answer 27

Kidneys present Development abnormal Usually asymptomatic If unilateral, consequences similar to having single functioning kidney - HTN, proteinuria, CKD If bilateral, much more severe with ESKD in childhood

Question 28

What is Medullary cystic kidney?

Answer 28

AD Abnormal MUC1 gene Both kidneys affected

Question 29

2 main causes of unilateral renal artery stenosis

Answer 29

Atherosclerosis mainly men >45 FMD mainly women <50

Question 30

What's reflux nephropathy? | Difference in male and female presentation?

Answer 30

Abnormal retrograde flow of urine from the bladder into one or both ureters, due to incompetent or mislocated ureterovesical valves, leads to stunted renal growth and fibrosis Often asymptomatic Quite common In adult males = HTN, proteinuria, progressive renal failure In adult females = recurrent UTI, more favourable outcome

Question 31

Most common EM finding in GN?

Answer 31

Podocyte foot process effacement and flattening

Question 32

Rx scleroderma crisis

Answer 32

ACEI - captopril preferred

Question 33

``` 35F 3/12 post renal transplant Fevers and rigors On MMF, tac, pred, bactrim, vagan What is the most likely cause of her presentation? A) BK virus B) Ecoli C) Nocardia D) listeria E) CMV ```

Answer 33

A) BK virus - Asymptomatic usually - Get a nephropathy - Occasionally can get a haemorrhagic cystitis with haematuria, dysuria, not usually fevers and rigors B) Ecoli - correct - UTIs most common bacterial infection post renal transplant - Ecoli most common uropathogen - Common 2-6/12 post transplant - still decent immunosuppression on board and have stopped a lot of the prophylactic abx by now C) Nocardia - Pulmonary symptoms D) listeria - GI symptoms E) CMV - doesn't usually cause fevers, rigors - Commonly affects gut, but also lung, liver

Question 34

Treatment of BK nephropathy

Answer 34

Reduce immunosuppression

Question 35

Which cell initiates rejection in kidney transplant?

Answer 35

Dendritic cell! (either from host or recipient) Presents antigen to T cells --> then get T cell mediated rejection or antibody mediated rejection

Question 36

Is it better to get a kidney from your parent or unrelated spouse?

Answer 36

Unrelated spouse provided the recipient has not been pregnant (increased sensitisation) and good HLA match Kidneys from younger people are healthier and better long-term outcome

Question 37

When considering the long-term outcome of renal transplant, other than rejection, which of the following has the greatest adverse effect on graft survival? ``` A) diabetes in the recipient B) donor age >65 C) recipient age >65 D) Polycystic kidney disease in the recipient E) Post transplant HTN ```

Answer 37

Donor age >65