A 62-year-old man with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?
Correct Answer E: eGFR variables - CAGE - Creatinine, Age, Gender, Ethnicity.
Chronic kidney disease: eGFR and classification:
Serum creatinine may not provide an accurate estimate of renal function due to differences in muscle. For this reason formulas were develop to help estimate the glomerular filtration rate (estimated GFR or eGFR). The most commonly used formula is the Modification of Diet in Renal.
Disease (MDRD) equation, which uses the following variables:
Factors which may affect the result:
CKD may be classified according to GFR:
*i.e. normal U&Es and no proteinuria
Which one of the following may be useful in the prevention of calcium renal stones?
Correct Answer E: The fact that thiazide diuretics cause hypercalcaemia is sometimes confused with their role in preventing calcium renal stones - the hypercalcaemia seen is secondary to increased distal tubular calcium resorption and hence lower calcium concentration in the urine.
Renal stones: management:
Acute management of renal colic:
Diclofenac 75 mg by intramuscular injection is the analgesia of choice for renal colic*.
A second dose can be given after 30 minutes if necessary.
Prevention of renal stones:
Calcium stones:
Oxalate stones:
Uric acid stones:
A 45-year-old man is seen in the Emergency Department with nausea, pallor and lethargy. He has no past medical history of note. A cannula is inserted and bloods show the following:
What is the most appropriate initial management?
Correct Answer E: The first priority in this patient is to stabilize the myocardium with intravenous calcium gluconate.
Hyperkalaemia: management:
Untreated hyperkalaemia may cause life-threatening arrhythmias. Precipitating factors should be addressed (e.g. acute renal failure) and aggravating drugs stopped (e.g. ACE inhibitors). Management may be categorized by the aims of treatment.
Stabilization of the cardiac membrane:
Removal of potassium from the body:
You review a 42-year-old woman six weeks following a renal transplant for focal segmental glomerulosclerosis. Following the procedure she was discharged on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On examination her sclera are jaundiced and she has widespread lymphadenopathy with hepatomegaly.
What is the most likely diagnosis?
Correct Answer E: Cytomegalovirus is the most common and important viral infection in solid organ transplant recipients.
Ganciclovir is the treatment of choice in such patients.
Renal transplant: HLA typing and graft failure:
The human leucocyte antigen (HLA) system is the name given to the major histocompatibility complex (MHC) in humans. It is coded for on chromosome 6.
Some basic points on the HLA system:
Graft survival:
Post-op problems:
Hyperacute acute rejection (minutes to hours):
Acute graft failure (< 6 months):
Causes of chronic graft failure (> 6 months):
A 43-year-old man has a work-up for hypertension. He has found to have blood + on a urine dipstick of a freshly voided sample.
Which one of the following may account for this finding?
Correct Answer B:
Haematuria:
The management of patients with haematuria is often difficult due to the absence of widely followed guidelines. It is sometimes unclear whether patients are best managed in primary care, by urologists or by nephrologists.
The terminology surrounding haematuria is changing. Microscopic or dipstick positive haematuria is increasingly termed non-visible haematuria whilst macroscopic haematuria is termed visible haematuria.
Causes of transient or spurious non-visible haematuria:
Causes of persistent non-visible haematuria:
Management:
Current evidence does not support screening for haematuria. The incidence of non-visible haematuria is similar in patients taking aspirin/warfarin to the general population hence these patients should also be investigated.
Testing:
NICE urgent cancer referral guidelines:
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