Renal (from MCQBank)

Question 1

Urinalysis findings of UTI

Answer 1

Nitrites (due to presence of nitrate reductase which convert nitrate to nitrite) - PPV 96% (ie if patient has UTI, the test will be positive)
Leucocyte - suggesting pyuria
Leucocyte esterase (can only be detected with relatively high WBC count in urine - so low test sensitivity).

Question 2

PHIMOSIS vs PARAPHIMOSIS

What is phimosis?

Answer 2

PARAPHIMOSIS: cannot move the retracted foreskin bact to cover the penis tip

PHIMOSIS: cannot retract the foreskin from the penis tip

Inability to retract the foreskin due to narrow preputial ring.
If cannot clean under the foreskin, increase risk of stones forming and leading to cancer of penis.

Causes: primary/physiological (without scarring), secondary (due to scarring from conditions such as recurrent balanitis, traumatic retraction of foreskin, balanitis xerotica et obliterans)

Treatment (depends on cause!)
If primary/physiological (ie foreskin is retractable): conservative tx. topical steroids can be applied.
If pathological/secondary: circumcision, short course of topical steroids can be beneficial in mild scarring

Question 3

Common organisms of UTI

Answer 3

E.coli (80%)
Staph saprophyticus (4%) in sexually active young women
Klebsiella pneumoniae (4%)
Proteus mirabilis (4%)
Enterobacter
Candida
Enterococci

If there are abnormalities of urinary tract- pseudomonas aeruginosa OR staph epidermidis

Question 4

Complicated VS Uncomplicated UTI - what are the criteria?

Answer 4

Complicated: increase risk of complications such as persistent infection, treatment failure or recurrent infection. Associated with >=1 risk factor:
- abnormal urinary tract anatomy (eg calculus, vesicoureteric reflux, indwelling catheter, obstruction etc)
- virulent organism (eg Staph. aureus)
- immunosuppression (eg poorly controlled diabetes)
- impaired renal function

Uncomplicated: typical organisms, normal urinary tract and kidney function, no predisposing/comorbidities

Question 5

What is recurrent UTI?

Answer 5

> =2 in 6 months OR >=3 in 12 months

Question 6

Treatment of UTI

Answer 6

Women:
1st line:
- nitrofurantoin for 3 days (if eGFR>=45. cannot be used for G6PD deficiency or acute prophyria).
- Trimethoprim for 3 days (cannot use for blood dyscrasias)
2nd line:
- Nitrofurantoin for 3 days (if this is not used).
- Pivmecillinam for 3 days.
- Fosfomycin single dose sachet.

Pregnant:
- Nitrofurantoin for 7 days (avoid at term due to risk of neonatal haemolysis).
2nd choice:
- amoxicillin (if cultures support this) for 7 days or cefalexin for 7 days.
- AVOID TRIMETHOPRIM DUE TO FOLATE ANTAGONIST.

Men:
Trimethoprim or nitrofurantoin for 7 days

Question 7

What is cryptoorchidism?

Answer 7

undescended testis
Greek kryptos (hidden), orchis (testicle)

Question 8

Hallmark of genitourinary TB?

Answer 8

Sterile pyuria

Question 9

Which side is more likely to be affected in testicular torsion?

Answer 9

Left side

Question 10

What disease would mean that pain be relieved when elevated the scrotum?

Answer 10

Epididymitis
This is called the Prehn’s sign

Question 11

What is priapism?

Answer 11

disorder in which the penis maintains a prolonged, rigid erection in the absence of appropriate stimulation.

Question 12

Causes of high PSA

Answer 12

Old Age
Acute retention
Urinary catheter
Prostatitis
Prostate cancer
TURP
BPH

Before PSA test, make sure that they dont have active UTI, ejaculated in the last 48 hours, exercised vigorously in the last 48 hours, have a prostate biopsy in the last 6 weeks. CONTROVERSIAL: delay PSA test by 1 week post PR examination.

Question 13

Reference range of PSA

Answer 13

50-59y/o: >=3ng/ml
60-69y/o: >=4ng/ml
>=70y/o: >5ng/ml

Question 14

Cause of bacterial vaginosis

Answer 14

Gardnerella vaginalis (MOST COMMON)
Prevotella spp
Mycoplasma hominis
Mobiluncus spp

(they replace lactobacilli and cause increase in pH)

Question 15

Classification of testicular cancer

Answer 15

Germ cell tumours: 45%seminomas, 50%non-seminomas (ie teratoma)
Non-germ cell tumour: Leydig cell, Sertoli, sarcomas
Extragonadal tumours

Question 16

Risk factor of testicular cancer

Answer 16

cryptoorchidism
malignancy in contralateral testis
Klinefelter’s syndrome
FHx
Male infertility
Low birth weight
Young maternal age
Young paternal age
Multiparity
Breech delivery
Infantile hernia
Testicular microlithiasis (small intratesticular calcification seen on USS)

Question 17

Most common type of ureteric stone

Answer 17

Calcium oxalate

Question 18

Hallmark investigative finding for diabetes insipidus

Answer 18

urine specific gravity 1.005 or less
urine osmolality less than 200mOsm/kg
random plasma osmolality is usually >287mOsm/kg

Question 19

Treatment of diabetes insipidus

Answer 19

Desmopressin (ADH analogue)
Thiazide diuretic - inhibit reabsorption of NaCl in the distal renal tubule
NSAIDs (eg indamethacin)
Sodium restriction

Question 20

invasive treatment options for urge incontinence (aka detrusor overactivity / detrusor instability)

Answer 20

Botulinum toxin A - 1st line
Sacral nerve stimulation
Surgery - only indicated for intractable and severe detrusor overactivity

Question 21

Examples of drugs causing infertility for women

Answer 21

NSAIDs (?reversible inhibit ovulation)
Cyclo-oxygenase inhibitors (negative local effect on ovulation)
Spironolactone (menstrual irregularities)
Cytotoxic drugs (induce ovarian failure)
Neuroleptic drugs (amenorrhoea)
Marijuana/Coccaine (impaired ovulation and tubal function)

Question 22

Bacterial causes of epididymo-orchitis
- Less than 35y/o
- More than 35y/o

Answer 22

<35y/o - chlamydia trachomatis & neisseria gonorrhoea
>35y/o - non-sexual Gram negative organism such as E.coli & pseudomonas

Question 23

Treatment of epididymo-orchitis

Answer 23

Uncomplicated gonorrhoea: cefiximine / ciprofloxacin

Uncomplicated genital chlamydia, non-gonorrhoeal urethritis & non-specific genital infection: doxycycline / azithromycin

if urine dip positive - treat as complicated UTI - trimethoprim or ofloxacin for 14 days

Question 24

Urethral injuries - how many types?

Answer 24

2 types:
- Posterior (membranous and prostatic part) - due to major blunt trauma ie RTA & pelvic fractures
- Anterior (distal to the membranous part - ie bulbar and penile urethra) - due to blunt trauma to perineum

Question 25

Apart from smoking, other exposures that increases risk of bladder cancer?

Answer 25

Aromatic amines in dyes, paints, solvents, leather dust, inks, combustion products, rubber & textiles

Arsenic contaminated wells

Radiation to pelvis

Cyclophosphamide

Chronic infection - HIV, Herpes simplex

Coffee (by 20%? but disputed by some papers)

?artificial sweeteners

Question 26

Radiological investigation for colovesical fistula

Answer 26

CT-AP

Question 27

Minimally invasive procedures for BPH

Answer 27

TUMT (transurethral microwave thermotherapy)
TUNA (transurethral needle ablation)

Invasive: TURP (transurethral resection of prostate)

Question 28

Classification of CKD
- GFR category
- ACR category

Answer 28

GFR category (1-5)
ACR category (1-3): <3, 3-30, >30

Question 29

Ethnic risk factors for progression of CKD?

Answer 29

Black / Asian

Question 30

Findings from cystoscopy for interstitial cystitis (bladder pain syndrome)

Answer 30

Diffuse erythematous bladder epithelium & ulcerative patches (Hunner’s ulcers) surrounded by mucosal congestion

end-stage fibrotic bladder as cannot fill more than 300ml of urine

after over-distension, there may be glomerulations (discrete tiny raspberry-like lesions appearing as miniscule mucosal tears and haemorrhages)

Question 31

Complex invasive treatment for interstitial cystitis (bladder pain syndrome)

Answer 31

pelvic floor trigger point injections
pelvic floor botox injections
surgery: bladder augmentation, cystectomy with urinary diversion

Question 32

Tx nephrogenic diabetes insipidua

Answer 32

Chlorothiazide

Question 33

common kidney transplant post-op problems

Answer 33

Post-op problems
ATN of graft
vascular thrombosis
urine leakage
UTI

Hyperacute rejection (minutes to hours)
due to pre-existing antibodies against ABO or HLA antigens
an example of a type II hypersensitivity reaction
leads to widespread thrombosis of graft vessels → ischaemia and necrosis of the transplanted organ
no treatment is possible and the graft must be removed

Acute graft failure (< 6 months)
usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
other causes include cytomegalovirus infection
may be reversible with steroids and immunosuppressants

Causes of chronic graft failure (> 6 months)
both antibody and cell-mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy)
recurrence of original renal disease (MCGN > IgA > FSGS

Question 34

causes of minimal change glomerulonephritis

Answer 34

idiopathic majority
10-20% :
- drugs: NSAIDs, rifampicin
- Hodgkin’s lymphoma, thyomoma
- infectious mononucleosis

Question 35

difference between pre-renal uraemia and acute tubular necrosis in terms of:
- urine sodium
- urine osmolality
- fractional sodium excretion
- response to fluid challenge

Answer 35

CHECK PPT slides!

Question 36

what electrolyte changes can you see in a patient with rhabdomyolysis?

Answer 36

high creatine kinase

hypocalcaemia (calcium typically binds to myoglobin released from damaged muscle)

hyperphosphataemia (phosphate is released during necrosis and destruction of myocytes)

hyperuricaemia (due to cellular breakdown and leakage of cellular contents into circulation)

hyperkalaemia: develop before renal failure

myoglobinuris - dark/reddish brown colour

metabolic acidosis

Question 37

what are the acceptable changes in renal function when you start ACEi?

Answer 37

decrease in eGFR by 25%
increase of creatinine by 30%

Question 38

IgA vs post-streptococcal GN

Answer 38

IgA: visible haematuria following a recent URTI. AKA Berger’s disease. Presents in young maes and onset is very acute.

Post-strep: occurs 2 weeks post URTI/LRTI. main symptom is proteinuria. there is low complement levels. tx: ACEi or immunosuppression with corticosteroids

Question 39

why do you get metabolic acidosis in a patient with chronic kidney disease?

Answer 39

fixed acids (lactic acid, phosphoric acid, sulphuric acid, acetoacetic acid and beta-hydroxybutyric acid) will be produced from protein catabolism.

they require alkali to buffer and be excreted.

this alkali is usually NH4+ & produced by the kidneys.

in CKD, the kidneys are not producing this -> hence metabolic acidosis.
> reduce HCO3-
>respiratory compensation (reduced pCO2)

Question 40

membranous nephropathy is associated with what..?

Answer 40

stomach cancer
SLE
HepB/C

PS: drugs: captoril, gold, lithium, NSAIDs causes minimal change GN.

Question 41

Fanconi syndrome

Answer 41

Generalised inherited or acquired disturbance of renal tubular transport.

Leads to aminoaciduria, glycosuria, phsophaturia, renal tubular acidosis type 2 (proximal) and hypopgosphataemic rickets (children) or osteomalacia (adults)

Autosomal dominant (chromosome 15) but can also be recessive or x-link.

Tax: replacement if substance lost in urine and specific treatment for underlying cause

Question 42

Advise to reduce renal stone formation - what to take and what to avoid?

Answer 42

to consume less oxalate by reducing tea, chocolate, nuts, strawberries, rhubarb, spinach, beans & beetroot.

to drink plenty of fluids especially in the summer.

Question 43

Treatment of nephrogenic diabetes insipidus

Answer 43

Desmopressin - Large doses (ADH analogue)
Thiazide diuretic
NSAIDS
Sodium retention

Question 44

Balkan nephropathy - what is it?

Answer 44

Found in small communities along the Danube River.

Only in adults.

Lack of high blood pressure, xanthochromia on palms and soles (tanchev’s sign), early anaemia of hypochromous type, slow progressive renal failure

Due to chronic dietary exposure to aristolochic acid which grows as a weed in the wheat fields

Question 45

What to do with the dose of these drugs in renal impairment?
Phenytoin
Cefuroxime
Furosemide

Answer 45

Phenytoin is metabolised in lover - so no change in dose for retail impairment,

Cefuroxime is a cephalosporin and this is excreted unchanged by the kidney. So, reduce dose frequency in renal impairment.

Furosemide acts on Na/K/Cl co-transporter. Higher doses needed if number of functioning nephrons are reduced.

Question 46

Churn Strauss -what are the components?

Answer 46

Asthma
Eosinophilia
Vasculitis
P-ANCA

Question 47

Difference in examination for :
- hydrocele
- varicocele
- epididymal cyst
- cancer

Answer 47

Hydrocele : firm lump in scrotum, testis cannot be felt as the hydrocele is located superior & anterior to testis, lump is transilluminable

Varicocele: scrotal swelling, like ‘bag of worms’ when standing

Epididymal cyst : transilluminable lump in scrotum, distinct from testis (palpable separately from testis)

Tumour : lump in scrotum, cannot palpate separately to testis

Spermatocele: located superior and posterior to testis

Question 48

Incontinence - what is this:
- true incontinence
- overactive incontinence
- overflow incontinence
- functional incontinence

Answer 48

True: due to fistulous tract between the vagina and either ureter, bladder or urethra

Overactive: detrusor overactivity. can associate with dryness or incontinence.

Overflow: incomplete bladder emptying due to detrusor contractility or bladder outlet obstruction

Functional: when patients have mental or physical disabilities that keeps them from urinating normally although the urinary tract is intact.

Question 49

Examples of drugs causing infertility in men

Answer 49

Sulfasalazine (reduce sperm count)
Androgens and anabolic steroids (reduce testicular volume and oligospermia/azoospermia)
Cytotoxic drugs (may cause permanent azoospermia)
Coccaine/Marjuana - affect quality of semen
Herbal remedies ie root extracts of Tripterygium wilfordii (reduce testicular volume and azoospermia/oligospermia)