Renal System

Question 1

Where do suprarenal veins drain into? What do they drain?

Answer 1

Right drains into IVC, Left drains into Left renal vein.
Suprarenal veins drain the suprarenal glands/adrenal glands.

Question 2

What is the blood flow in the kidney? (Arteries, capillaries, veins)

Answer 2

Mneumonic: Rough Sports Is Always Great Exercise
Renal artery, segmental artery, interlobar artery, arcuate artery, interlobular a, afferent a, glomerular a, capillary, vasa recta (where most secretion takes place), interlobular v, arcuate v, interlobar v, renal v

Question 3

What arteries, veins, nerves and lymph supply/drain the kidney? Where does pain refer?

Answer 3

Arteries: Renal artery:from abdominal aorta R(longer and posterior to IVC)
Veins: Renal veins –L (longer): drains left gonadal, testes, kidney; R: only drains R kidney–gonadal vein drains directly into IVC
Nerves: T12 least splanchnic nerves : pain refers to the lumbar T11-12 and the back
Lymphatics: para-aortic LN –> cisternae chyli

Question 4

What arteries, veins and nerves supply/drain the Ureters? Where does pain refer?

Answer 4

Arteries
Upper: Renal artery
Middle: Aorta, gonadal artery, common iliac
Lower: Internal iliac artery

Nerves:
GVA (SNS afferents) to T11-L2

LN:
Upper: Aortic nodes
Middle: LN associated with common iliac vessels
Lower: LN associated with external and internal iliac vessels

Question 5

What arteries, veins and nerves supply/drain the adrenal glands?

Answer 5

Arteries: Suprarenal arteries
Superior: from inferior phrenic artery
Middle: from abdominal aorta
Inferior: from renal artery

Veins: suprarenal arteries: L drains into left renal vein, R drains into IVC

Nerves: greater splanchnic nerves

Question 6

What arteries, veins and nerves supply/drain the bladder?

Answer 6

Arteries:
superior and inferior vesicle arteries: internal iliac a. and umbilical a

Veins:
Vesicular venous plexus drains to internal iliac veins

Nerves:
Detrusor muscle: PSNS, pelvic splanchnic S2-4
Internal sphincter: SNS hypogastric nerve T11-12, L1-2
External sphincter: Somatic, pudendal nerve S2-4

Lymph:
External and internal iliac LNs

Question 7

Select which of the following drug combinations is LEAST LIKELY to lead to electrolyte disturbances of
renal origin and lead to cardiovascular complications.
Select one:
a. furosemide and hydrochlorothiazide
b. spironolactone and ramipril
c. hydrochlorothiazide and spironolactone
d. ramipril and losartan

Answer 7

C

a/ furosemide=loop diuretic, hypokalemia + hydrochlorothiazide = thiazide hypokalemia
b/ k+ sparing diuretic–hyperkalemia + ACE inhibitor (increases aldosterone and K+) –> hyperkalemia
C: cancels out effect, k+ sparing given together to prevent hypokalemia
d/ ace inhibitor and arb –> K+ reabsorption –> hyperkalemia

Question 8

Select which of the following does NOT normally appear in the glomerular filtrate.
Select one:
a. Urea
b. Sodium
C. Plasma protein
d. Glucose

Answer 8

C
glucose is in filtrate but is reabsorbed and not excreted

Question 9

Fill in the blanks
1. Macula densa found on ______ arterioles in _____ : low GFR –> rise/fall in [NaCl] signals the release of ______ which vasodilates/vasoconstricts _____ arterioles to ____ GFR.

Answer 9

Afferent
DCT
Fall
Prostaglandins
Vasodilates
Afferent
Increase

Question 10

Fill in the blanks
1. Macula densa found on ______ arterioles in _____ : high GFR –> rise/fall in [NaCl] signals the release of ______ which vasodilates/vasoconstricts _____ arterioles to ____ GFR.

Answer 10

afferent, DCT
rise (increased flow past macula densa)
adenosine
vasoconstricts afferent
decrease

Question 11

What structures does a surgeon need to be especially careful of in hysterectomy (removal of
uterus)?

1. Pudendal nerve
2. Inferior epigastric vein
3. Ureter
4. Vas deferens
5. Femoral artery

Answer 11

c

Question 12

Where is ureteric pain referred, and what fibres carry them?
1. Ipsilateral flank only, PSNS afferents
2. Ipsilateral flank only, SNS afferents
3. Loin to groin, PSNS afferents
4. Loin to groin, SNS afferents

Answer 12

4

Question 13

Where renal stones most likely to get trapped in?
1. Minor calyx
2. Major calyx
3. Ureteropelvic junction
4. Where ureter crosses pelvic brim
5. Vesicoureteric junction

Answer 13

5

3-5 are all common constrictions of the ureters where stones are likely to be trapped in, but the vesicourteric junction is the most common one

Question 14

Which is true of vascular supply of suprarenal glands?
1. Right suprarenal vein drains into right renal vein.
2. Left superior suprarenal artery is supplied by the aorta.
3. Right inferior suprarenal artery is supplied by renal artery.
4. Left suprarenal vein drains into splenic vein.

Answer 14

3
Suprarenal arteries
Superior: from inferior phrenic artery
Middle: from abdominal aorta
Inferior: from renal artery

Suprarenal vein
Left from left renal vein
Right from IVC

Question 15

Which of the following about innervation is true?

a. Kidney - Greater splanchnic
b. Adrenal glands - lesser splanchnic
c. Kidney referred pain to T11-T12

Answer 15

C

F a. least splanchnic
F b. greater splanchnic
c: correct, least splanchnic T12

Question 16

True or false? Lateral arcuate ligament overlies the muscle medial to the transversus abdominis
muscle

Answer 16

True.

muscle medial to transversus abdominis is the quad. lamborum

Question 17

Are these true/false about the proximal convoluted tubule?

1. SGLT2 inhibitors work here to inhibit the sodium-phosphate cotransporter
2. Hydrochlorothiazide works here to inhibit the sodium chloride cotransporter
3. Acetazolamide works here by upregulating carbonic anhydrase and causing alkaline
   diuresis
4. Reabsorption here is isotonic

Answer 17

1. SGLT2 inhibitors work here to inhibit the sodium-phosphate cotransporter FALSE,
   sodium glucose linked transporter
2. Hydrochlorothiazide works here to inhibit the sodium chloride cotransporter FALSE,
   wrong location
3. Acetazolamide works here by upregulating carbonic anhydrase and causing alkaline
   diuresis FALSE, downregulate
4. Reabsorption here is isotonic TRUE, water reabsorbed as sodium reabsorbed by
   passive diffusion

Question 18

Where does frusemide work?

Answer 18

Loop diuretic: works on the thick ascending limb of the LOH in the nephron –blocks the NKCC cotransporter to decrease Na+ reabsorption

Question 19

T/F Amiloride upregulates the H/K pump of intercalated cells to maintain acid-base homeostasis of the body

Answer 19

FALSE, inhibits Na+ channels on principal cells to cause
diuresis

Question 20

T/F V2 aquaporins, signalled by ADH, are inserted on the luminal side of intercalated cells
to increase water reabsorption

Answer 20

FALSE, principal cells

Question 21

Alpha intercalated cells are involved when the body is alkalotic and needs to reabsorb acids and secrete bases

Answer 21

FALSE
remember that Alpha SECRETES Acid, Beta SECRETES
Base

Question 22

12 year old boy presents to the emergency department with abdominal pain, fruity breath and ketones in urine. What happens to his K+ levels?

Answer 22

HYPERKALEMIA in diabetic ketoacidosis (remember
insulin causes potassium to enter cells and therefore decreases potassium levels in
blood!) In DKA, no insulin thus build up of K+

Question 23

Are these statements true/false of renal osteodystrophy?
1. Happens mostly in acute kidney injury
2. High phosphate retention causes hypercalcemia in the early stages
3. Low calcitriol reduces Ca absorption in intestines, worsening osteodystrophy
4. Persistently high PTH in secondary hyperparathyroidism causes hypercalcemia in later
stages

Answer 23

1. Happens mostly in acute kidney injury FALSE, CKD
2. High phosphate retention causes hypercalcemia in the early stages FALSE,
   hypocalcemia
3. Low calcitriol reduces Ca absorption in intestines, worsening osteodystrophy TRUE
4. Persistently high PTH in secondary hyperparathyroidism causes hypercalcemia in later
   stages FALSE, tertiary hyperparathyroidism

Question 24

What are the symptoms of nephrotic syndrome?

Answer 24

Abnormal permeability of BM (podocytes) –> proteinuria
HELP
Hypoalbuminuria
Edema
Lipid abnormalities
Proteinura

Question 25

Symptoms of nephritic syndrome?

Answer 25

Inflammation of glomerular capillaries PHAROAH Proteinura, pruria Hematuria Azotemia (high uric acid and nitro waste) Red blood casts Oliguria Anti-strep titres Hypertension

Question 26

Patient present with headache for several months. She has blood pressure of 200/100 mmHg, and an ultrasound confirms the cause of her hypertension. Decreased perfusion of which structure causes renin release that leads to hypertension? 1. Adrenal medulla 2. DCT 3. Afferent arteriole 4. Efferent arteriole 5. Loop of henle 6. PCT

Answer 26

3 both 2/3 can cause, but since ultrasound confirms the cause of hypertension: *Cause of her hypertension is renal artery stenosis --> 3 is a better answer + jg apparatus releasing renin is in the afferent arteriole --> making it a better answer

Question 27

Nephrolithiasis can cause obstruction of urine and pain. Where is likely for stones to lodge in the urinary system? 1. Bladder 2. Penile urethra 3. Prostatic urethra 4. Renal calyx 5. Ureter over the iliac vessels

Answer 27

5

Question 28

As a result of countercurrent exchange, the fluid in the tubule is most hyperosmotic in the: 1. Proximal convoluted tubule 2. Distal convoluted tubule 3. Ascending limb 4. Descending limb 5. Loop of Henle

Answer 28

4 Countercurrent multiplication: Water diffuses out of the descending limb via osmosis --> hyperosmotic at the end of descending limb. Concentration of fluid in lumen is the highest at the tip of LOH (the more inward you go towards medulla). Ascending limb: impermeable to water, actively pumps out ions into interstitium, decreasing osmolarity in tubule (hypoosmotic)

Question 29

Mrs Tan is an 80 year old lady that comes into the GP and is prescribed a carbonic anhydrase inhibitor. Which of the following mechanisms explain how this drug works? 1. It causes an increased urinary acid excretion 2. It increases bicarbonate reclamation 3. It induces metabolic alkalosis to counter low pH levels 4. It decreases bicarbonate regeneration

Answer 29

4 Carbonic anhydrase inhibitors, such as acetazolamide, are drugs that work by inhibiting the activity of the enzyme carbonic anhydrase. This enzyme plays a crucial role in the production of bicarbonate ions (HCO3-) in the kidneys. Normally, carbonic anhydrase catalyzes the reaction between carbon dioxide (CO2) and water (H2O) to form carbonic acid (H2CO3). Carbonic acid then dissociates into bicarbonate ions (HCO3-) and hydrogen ions (H+). The bicarbonate ions are reabsorbed into the bloodstream, while the hydrogen ions are excreted into the urine. By inhibiting carbonic anhydrase, carbonic anhydrase inhibitors disrupt this process. As a result, the conversion of carbon dioxide and water into bicarbonate ions and hydrogen ions is reduced. This leads to a decrease in bicarbonate regeneration in the kidneys, as fewer bicarbonate ions are produced. Since bicarbonate is a major buffer in the body, a decrease in its regeneration leads to a decrease in the availability of bicarbonate to counteract acid in the body. This results in a mild metabolic acidosis, rather than metabolic alkalosis as mentioned in option 3.

Question 30

ADH secretion is increased by all of the following factors except: 1. Increase in plasma osmolality 2. Loss of blood 3. Pain 4. Vomiting 5. Alcohol

Answer 30

5 1/ activation of osmoreceptors --> increase ADH secretion 2/ decreased blood vol --> ADH inc 3/ pain --> stress response, increased CRH and ACTH --> increase ADH 4/ decreased blood vol 5. is a known diuretic, inhibiting ADH release

Question 31

T/F Damage at the level of sacral spinal cord causes urge incontinence

Answer 31

FALSE (Overflow incontinence)

Question 32

T/F Damage at the level of sacral spinal cord causes stress incontinence

Answer 32

TRUE (pudendal nerve)

Question 33

T/F Damage above sacral spinal cord level causes retention

Answer 33

FALSE (urge incontinence)

Question 34

How would renal cell cancer metastasize via a lymphovenous junction? 1. Via renal artery 2. Via renal vein 3. Via arcuate veins 4. Via interlobular veins

Answer 34

2 (Cancer spreads to lymph nodes present in proximity to renal vein)

Question 35

40yo man presents with hematuria, and sharp sudden colicky pain on lower back that radiates to his flanks. Noncontrast CT scan shows several stones in both ureters. What is the most likely cause of this? 1. BPH 2. Large stool in small bowel 3. Hyperparathyroidism 4. Hyperuricemia 5. Staphylococcal infection of the bladder

Answer 35

3 *Favours formation of calcium stones, most common type of kidney stone

Question 36

72yo man recently diagnosed with heart disease has sudden onset swelling of face and lips and mouth. He mentions he was put on medications for hypertension and that sometimes he gets rashes when taking antibiotics. The accumulation of what substance is likely causing his symptoms? 1. Bradykinin 2. Histamine 3. Prostacyclin 4. Prostaglandin E2 5. Serotonin

Answer 36

1 Bradykinin *ACEi prevent ACE from degrading bradykinin -> accumulation causes angioedema

Question 37

An 85 year old man with a history of lung cancer presents to the GP complaining of bloating and being unable to pass urine. On further investigations, he is found to have a low plasma osmolality, low sodium concentration and high urine osmolality. Which of the following options is most likely causing all of his symptoms? 1. His aldosterone levels are high 2. His reduced salt intake 3. He has an ADH secreting tumour 4. His ADH receptors are not responding

Answer 37

3 Given his history of lung cancer, you would be highly suspicious of an ADH secreting tumour. Low plasma osmolality and high urine osmolality points to ADH being the problem.