Nephrology

Question 1

goserelin - action & other name?

Answer 1

GnRH agonist
zoladex
locally advanced prostate cancer

Question 2

spike and dome appearance on EM - what dx?

Answer 2

membranous GN

Question 3

anti-phospholipase a2 antibodies what dx?

Answer 3

membranous GN

Question 4

why is nephrotic syndrome hypercoagulable

Answer 4

loss of antithrombin 3 from kidneys

Question 5

why does ckd cause anaemia

Answer 5

due to reduced levels of EP

Question 6

whats most common cause of peritonitis 2o to peritoneal dialysis

Answer 6

coag negative staph eg epidermis, capitis

2nd most common: staph aureus (coag +ve)

Question 7

sterile pyuria and white cell casts with rash + fever

Answer 7

Acute interstitial nephritis
- Commonly due to abx

Features

- Fever, rash, arthralgia
- Eosinophilia
- Mild renal impairment
- HTN

Histo: marked interstitial oedema + interstitial infiltrate in connective tissue between renal tubules

Question 8

+ve congo-red stain - when polarised light shone, it appears apple green

Answer 8

amyloidosis

Question 9

tx for AD PKD?

Answer 9

tolvaptan = vasopressin rec 2 antag

Question 10

GNs that present with nephritic syn

Answer 10

Rapidly progressive GN
- goodpasture’s, anca positive vasculitis/wegener’s

IgA nephropathy/berger’s/mesangioproliferative GN

Alport syndrome

Question 11

what presents with a mixed nephritic/nephrotic pic

Answer 11

Diffuse proliferative GN

- Post-strep GN in child
- Nephritic syn/AKI
- Most common form of renal disease in SLE

Membranoproliferative GN (mesangiocapillary)
- Type 1: cryoglobinaemia, hep C
Type 2: partial lipodystrophy

Question 12

what presents w nephrotic syndrome

Answer 12

Minimal change disease

- Child w nephrotic syn
- Causes: hodgkin's, NSAIDs
- Good response to steroids

Membranous GN

- Proteinuria/nephrotic syn/CKD
- Causes infections, rheumatoid drugs, cancer
- 1/3 resolve, 1/3 respond to cytotoxics, 1/3 ckd

FSGS
- idiopathic, or due to HIV/heroin
Proteinuria/nephrotic syn/ckd

Question 13

young women who dev AKI after starting ACEi

Answer 13

Fibromuscular dysplasia: consider in young women who dev AKI after starting ACEi
Renal artery stenosis: old = atherosclerosis. Young F = FMD

Question 14

upper resp tract signs (recurrent sinusitis), nosebleeds, saddle-shaped nose, vasculitic rash

Answer 14

granulomatosis w polyangiitis

Question 15

haemoptysis

Answer 15

Goodpasture’s: haemoptysis

Crescentic GN

Question 16

lower resp symptoms EG recent dx asthma, eosinophilia on bloods

Answer 16

Eosinophilic granulomatosis w polyangiitis

Question 17

young pt w macroscpoic haematuria just after an acute upper rest infection

Answer 17

IgA nephropathy

Question 18

enlarged and hypercellular glomeruli w starry sky (granular)

Answer 18

Post-strep GN:

Question 19

Microscopic haematuria, bilateral SN deafness, progressive renal failure, longitudinal splitting of lamina densa of GBM on EM (basket weave appearance)

Answer 19

Alport’s:
• X-linked dominant
• Defect in gene for type IV collagen > abnormal GBM
• Failing renal transplant – anti-GBM Abs&raquo_space; goodpasture’s picture
• Microscopic haematuria, bilateral SN deafness, progressive renal failure, longitudinal splitting of lamina densa of GBM on EM (basket weave appearance)
• More severe in M (women rarely get renal failure)

Question 20

stag horn calculi - made of?

Answer 20

Stag horn calculi: struvite
(ammonium, magnesium, phosphate; triple phosphate)
form in alkaline urine
- so ammonia producing bacteria eg ureaplasma and proteus predispose to it

Question 21

tx of BPH?

Answer 21

1. if mod-severe voiding symptoms = alpha-1 antags (tamsulosin, alfuzosin)
   • SE: dizzy, postural hypotension, dry mouth, depressed
   • If persistent can add in tolterodine, darifenacin (anticholingeric/antimuscarinic)
2. if sig enlarged prostate and at high risk of progression: finasteride (5 alpha reductase inhibitor) - takes 6 months to work but slows disease progression
   - SE: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

If both – use both together
Or: TURP

Question 22

how does chemotx cause kidney disease

Answer 22

hyperuricaemia

Question 23

what effect does alcohol binge drinking have on the kidneys

Answer 23

Alcohol binge drinking can > ADH suppression in posterior pit gland > polyuria
• Hypernatraemia, raised serum osm, low urine osm

Question 24

Bicalutamide

Answer 24

Bicalutamide: androgen receptor blocker. Used in prostate cancer

Question 25

bladder problems in M - mainly voiding syms: - mixed voiding and storage? - mainly overactive bladder?

Answer 25

Mainly voiding syms in M: conservative. If mod: a-blocker. If big prostate/high risk: 5-a reductase inhibitor. If both: have both drugs • If mixed voiding and storage not responding to a-blocker, add antimuscarinic Mainly overactive bladder in M: conservative. If persist: antimusc (oxybutynin, tolterodine, darifenacin) if fail: mirabegron

Question 26

GN & low complement (4)

Answer 26

- Post strep GN - Subacute bacterial endocarditis - SLE mesangiocapillary GN

Question 27

most common histo pattern in lupus nephritis

Answer 27

diffuse proliferative GN

Question 28

causes of cranial DI | & tx

Answer 28

Cranial: desmopressin ``` Causes of cranial DI • idiopathic • post head injury • pituitary surgery • craniopharyngiomas • histiocytosis X • DIDMOAD/wolfram's syndrome - Haemochromatosis ```

Question 29

nephrogenic DI causes tx

Answer 29

Causes of nephrogenic DI • genetic: ADH rec (more common),aquaporin 2 channel • electrolytes: high calcium, low K • lithium • demeclocycline tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis nephrogenic: thiazides, low salt/protein diet

Question 30

``` alport's syndrome - inheritence gene defect features renal biopsy ft ```

Question 30

``` alport's syndrome - inheritence gene defect features renal biopsy ft ```

Answer 30

ost: x-linked dominant · defect in the gene which codes for type IV collagen >> abnormal GDM · More severe in M (females rarely get renal failure) NB renal transplants often fail: due to anti-GBM Abs > goodpasture's like pic ``` Usually presents in children • microscopic haematuria • progressive renal failure • bilateral SN deadness • lenticonus: protrusion of the lens surface into the anterior chamber • retinitis pigmentosa ``` EM: basket-weave (longitudinal splitting of lamina densa of GBM) DETAILS Diagnosis • molecular genetic testing • renal biopsy NB 10-15% autosomal recessive

Question 31

HOW TO TELL ATN FROM AIN ON URINE DIP

Answer 31

Urine dip can differentiate ATN from acute interstitial nephritis: - AIN: inflam process = more white cells in urine (can be caused by penicillin abx) - ATN: not inflam - no white cells - If protein is present = rules out pre or post renal cause

Question 32

stages of diabetic nephropathy

Answer 32

Stage 1 • hyperfiltration: increase in GFR • may be reversible ``` Stage 2 (silent or latent phase) • most patients do not develop microalbuminuria for 10 years • GFR remains elevated ``` ``` Stage 3 (incipient nephropathy) • microalbuminuria (albumin excretion of 30 - 300 mg/day, dipstick negative) ``` Stage 4 (overt nephropathy) • persistent proteinuria (albumin excretion > 300 mg/day, dipstick positive) • hypertension is present in most patients • histology shows diffuse glomerulosclerosis and focal glomerulosclerosis (Kimmelstiel-Wilson nodules) Stage 5 • end-stage renal disease, GFR typically < 10ml/min • renal replacement therapy needed The timeline given here is for type 1 diabetics. T2DM progress through similar stages but in a different timescale - some T2DM patients may progress quickly to the later stages

Question 33

how does alcohol cause polyuria

Answer 33

Alcohol binge > ADH suppression in posterior pituitary gland > polyuria

Question 34

renal stones - radiolucent (2) - semi opaque (1) opaque (4)

Answer 34

radiolucent: urate, xanthine stones semi opaque: cystine opaque: calcium oxalate, calcium phosphate, triple phosphate/struvite, mixed ca oxalate/phosphate stones

Question 35

membranoproliferative GN - mx? - types and their causes/fts

Answer 35

· may present as nephrotic syndrome, haematuria or proteinuria · poor prognosis Management: steroids may be effective ``` Type 1 (90%) · cause: cryoglobulinaemia, hep C · EM: subendothelial + mesangium immune deposits of electron-dense material = 'tram-track' appearance ``` Type 2 - 'dense deposit disease' · causes: partial lipodystrophy (loss of SC tissue from face), factor H deficiency · caused by persistent activation of alternative complement pathway · low circulating levels of C3 · C3b nephritic factor in 70% ○ an antibody to alternative-pathway C3 convertase (C3bBb) ○ stabilizes C3 convertase · renal biopsy ○ EM: intramembranous immune complex deposits with 'dense deposits' Type 3 causes: hepatitis B and C

Question 36

metabolic acidosis - anion gap eqn - normal range for anion gap - normal anion gap MA causes (5) - raised causes (4)

Answer 36

Classified according to the anion gap - calculated by: (Na+ + K+) - (Cl- + HCO-3) - If a question supplies the chloride level then this is often a clue that the anion gap should be calculated - normal range = 10-18 mmol/L Normal anion gap ( = hyperchloraemic metabolic acidosis) • GI bicarb loss: diarrhoea, ureterosigmoidostomy, fistula • renal tubular acidosis • drugs: e.g. acetazolamide • ammonium chloride injection • Addison's disease ``` Raised anion gap • lactate: shock, sepsis, hypoxia • ketones: diabetic ketoacidosis, alcohol • urate: renal failure • acid poisoning: salicylates, methanol ``` Metabolic acidosis secondary to high lactate levels may be subdivided into two types: • lactic acidosis type A: sepsis, shock, hypoxia, burns • lactic acidosis type B: metformin

Question 37

ATN v prerenal uraemia

Answer 37

Prerenal uraemia - kidneys hold on to sodium to preserve volume - Fractional sodium excretion <1%, urine sodium <20

Question 38

High calcium in urine & kidney stones

Answer 38

thiazide diuretics

Question 39

plasma exchange indications (7) comps (5)

Answer 39

Indications for plasma exchange (also known as plasmapheresis) • GBS • myasthenia gravis • Goodpasture's • ANCA positive vasculitis if rapidly progressive renal failure or pulmonary haemorrhage • TTP/HUS • cryoglobulinaemia • hyperviscosity syndrome e.g. secondary to myeloma ``` Complications of plasma exchange • Low calcium • metabolic alkalosis • removal of systemic medications • coagulation factor depletion immunoglobulin depletion ```