The Approach to the Patient with Kidney Disease

Abstract

In practice, patients with kidney disease are first identified by primary care practitioners, emergency physicians, internists and other specialty doctors, as well as by allied health professionals such as nurses and physician associates, before being referred to a nephrologist. Patients may present with specific urinary symptoms, with systemic features, or be otherwise asymptomatic, with blood and urine test abnormalities. The identification of the pathology and its cause by the nephrologist requires a careful history and physical examination, which will help direct tailored investigations.

Questions

• 1. A 22 year old black female presented with weakness, tiredness. On examination her pulse was 82/min, blood pressure was 165/80 mmHg and she had a red rash over her face. Urine examination showed blood and protein. Blood test showed low haemoglobin and creatinine was 187 μmol/L.

  What is most likely diagnosis

  • A. Henoch Schulein purpura

  • B. Systemic amyloidosis

  • C. Systemic lupus erythematosus

  • D. Essential cyroglobinimia

  • E. Systemic vasculitis

  Correct answer: young woman with low haemoglobin, haemo-proteinura and rash is most likely to be lupus.

• 2. A 45 year old black man presented with tiredness and frothy urine. On examination his pulse was 89/min, blood pressure was 130/82 mmHg. He had a white deposit over his tongue and inner side of his cheek. His urine protein:creatinine ratio was 300 mg/mol (Normal < 15). His kidney ultrasound showed bilateral normal size bright echogenic kidneys.

  What is the likely cause of his nephrotic syndrome?

  • A. Amyloidosis

  • B. Type 2 diabetes

  • C. Hypertension

  • D. HIV associated nephropathy

  • E. Systemic lupus nephritis

• 3. A 23 year old female with lupus nephritis, end stage kidney failure on haemodialysis presented with fever and lethargy. She denied Joint pain, dysuria, cough, diarrhoea or rash. On examination pulse was 100/min, temperature 38 °C, blood pressure 110/60 mmHg. The exit site of her tunneled catheter was clean. Blood cultures were sent. Her white cell and CRP were raised.

  What is next best plan of management?

  • A. Investigations for lupus nephritis.

  • B. Investigations for lymphoma

  • C. Start antibiotics for catheter related bacteremia

  • D. Start oral steroids

  • E. Start intravenous cyclophosphamide

  Correct answer: C mostly cause of fever is catheter related bacteremia and lupus id less likely.

• 4. A 55 year old asymptomatic man was admitted to hospital from the transplant clinic with rising creatine 15 days post kidney transplant from 150 to 230 μmol/L. He was on mycophenolate 250 mg bd and tacrolimus 2 mg bd. His tacrolimus level was 5 ng/mL (target 10–15). His pulse was 78/min, blood pressure 130/60 mmHg. His urine had no blood pr protein. Ultrasound of the transplanted kidney was normal.

  What is the likely cause of his AKI

  • A. Acute rejection

  • B. Acute intestinal nephritis

  • C. Tacrolimus toxicity

  • D. Thrombotic microangiopathy related to tacrolimus

  • E. Urinary tract infection

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