RENAL

POST STREPTOCOCCAL GLOMERULONEPHRITIS

A 35-year-old women presents with swelling around her eyes, shortness of breath and leg
swelling for two days. On examination, her blood pressure is 160/100 mmHg. Blood
investigations reveal reduced GFR< and increased blood levels of urea and creatinine.
Urinalysis shows oliguria, proteinuria and haematuria. Renal biopsy findings are consistent
with post-streptococcal glomerulonephritis (PSGN). The patient is prescribed a loop diuretic
to reduce her oedema and her blood pressure.
a. Explain how the reduced GFR results in oedema in this patient (4)
The mechanism of oedema induced by reduced GFR is the activation of renin-angiotensin
aldosterone system. The decrease in GFR in this patient causes a decrease in sodium
reabsorption at the macula densa cells of DCT. This will lead to stimulation of
juxtaglomerular cells of JGA to release renin. Renin converts angiotensinogen into
angiotensin I, then angiotensin converting enzyme (ACE) converts angiotensin 1 into
angiotensin II. Angiotensin II stimulates aldosterone release from the adrenal cortex,
resulting in salt and water retention, causing oedema.
b. State one loop diuretic that could be prescribed for this patient, and describe the
mechanism by which the diuretic prescribed helps to reduce her oedema (3)
A loop diuretic that can be prescribed to this patient includes Furosemide/bumetanide/
ethacrynic acid/ torsemide. The site of action of Loop diuretics is the thick ascending loop of
Henle. The co-transporter it inhibits is Na+/K+/2Cl- co-transporter, which lead to an increase
in the excretion of sodium and water, and hence helps in reducing the oedema.
c. State two important microbiological characteristics of the causative organism which is
responsible for the disease in this patient. (2)
Streptococcus pyogenes produces beta-hemolytic colonies on blood agar and is known to be
catalase negative. In addition, its colonies are sensitive to bacitracin and is Gram-positive
cocci in chains under microscopy
d. State the gold standard serological test that is employed in the diagnosis of the
infection in this patient (1)
The gold standard serological test that is employed in the diagnosis of post-streptococcal
glomerulonephritis (PSGN) is antibodies against streptococcal antigens (ASOT). However,
other tests such as anti-streptolysin (ASO), streptozyme test, anti-hyaluronidase (AHase),
anti-streptokinase (ASKase), anti-nicotinamide-adenine dinucleotidase (anti-NAD) and anti-
DNase B antibodies may also be used.
ACUTE RENAL FAILURE
A 19-year-old man was involved in a gang fight and lost a massive amount of blood. He was
brought into Accident & Emergency by First Aiders in a state of impending shock. His blood
pressure was 60/ 40 mm Hg, and his pulse was rapid and thready. He was immediately
warded and his vital signs monitored. In the next few hours, his urine output fell and became
zero the next day. His kidneys had gone into failure. The young house officer was worried
about the poor urine output and wanted to give saline infusions. The senior doctor advised
against it and ordered a blood transfusion instead.
1. Explain the meaning of the following terms: (2 marks)
 Oliguria: urine output that is less than 1 mL/kg/h in infants, less than 0.5 mL/kg/h in
children, and less than 400 mL daily in adults (1 mark)
 Anuria: urine output that is less than 50 mililiters a day (1 mark)

1. Explain why the urine output fell in this young man. (2 marks)
Very low BP (0.5 mark) causing low hydrostatic pressure (0.5 mark); when Osmotic
pressure(OP) exceeds Hydrostatic pressure(HP), (0.5 mark) glomerular filtration stops (0.5
mark)

2. What type of renal failure has this patient developed and why?
Type of renal failure: Acute renal failure
Reason: Hypovolaemia (pre-renal cause)

3. Name the phase of acute renal failure following the phase that the patient is in. (1
mark)
Diuretic phase.

4. Indicate the expected laboratory findings for this case as per the table.
(3 marks)

Parameter Increased (I)/

unchanged(UC)/
Explanation
decreased(D)
(0.5 mark)
(0.5 mark)
Blood pH Decreased Decreased bicarbonate absorption from urine,
 decreased H+ excretion in urine
Plasma Decreased Decreased bicarbonate reabsorption from
bicarbonate urine, The bicarbonate originally presented in
the plasma is used to neutralize the increased
H+ in the plasma
pCO2 Increased As there is increased H+ in the plasma, more
HCO3- is used to neutralize H+, producing CO2
and H2O in the process.
D or UC

Increase in respiration causes CO2 wash-out

RENAL CALCULI
A 36 year old woman presents with severe intermittent colicky pain over her left flank for 3
weeks. On examination, she had left costovertebral angle tenderness. Her work exposes her to
heat and high humidity and she often forgets to drink enough water. Intravenous pyelography
(IVP) shows two small calculi in the left mid-ureter with mild dilatation of calyces. She is put
on an antispasmodic and potassium citrate

a. Explain why this patient suffers from tenderness in the left costovertebral angle.
The sympathetic nerves to the ureter come from T12-L2 segments of spinal cord. These
nerves are responsible for carrying visceral pain. The dermatome of predominant segments
(T11, T12) corresponds to the renal angle area. Hence commonly, the ureteric pain is referred
to this area. (4 marks)

b. Explain what could happen to the glomerular filtration rate (GFR) of the left kidney
when calyces become much dilated.
The GFR decreases due to rise in the hydrostatic pressure inside the Bowman’s capsule of the
nephrons as a consequence of the build up of back pressure behind the obstruction by the
calculi. (2 marks)

c. List FOUR (4) predisposing factors for the diagnosis

Answer :
i. Changes in concentration of the solute, that exceeds their solubility in urine
ii. Changes in urinary pH- alkaline urine
iii. Bacterial infection- especially Proteus vulgaris infection that makes urine pH alkaline
iv. Hyperuricemia- in gout, increased turnover of cells (eg. Leukemia)
DRUG INDUCED NEPHROPATHY
A 69-year-old man with well controlled hypertension of 3 years duration is on diclofenac for
3 weeks following low backache. He has been fasting for religious reasons for the past 2
weeks. He now presents with bilateral leg swelling and decreased urination. Laboratory
results showed elevated serum urea and creatinine with reduced eGFR. Urinalysis showed
ketonuria and proteinuria.

7A. Define eGFR and list FOUR (4) parameters that can be used to estimate it. (3
marks)

eGFR refers to estimated glomerular filtration rate (0.5 mark). It is the most accurate
way to assess renal function (0.5 mark).

It is calculated using a formula that incorporates age, creatinine level, gender and ethnic
group (0.5 mark each).

7B. List TWO factors that contribute to the reduction of GFR in this patient. (2 marks)

Dehydration
Diclofenac induced

7C. The disturbance of a physiological mechanism is responsible for the reduction of

GFR in this patient. Explain. (2 marks)

Vasoconstriction in the afferent arteriole and vasodilation in the efferent arteriole will
decrease GFR in this patient.

7D. Describe the mechanism of nephropathy induced by the drug in this patient. (3
marks)

(any 3)
Inhibits prostaglandin synthesis by blocking COX1 & COX2 enzymes. This
reduces blood flow in the kidney by preventing prostaglandin-mediated
vasodilation.
This is enhanced in dehydrated patients.
CHRONIC KIDNEY DISEASE WITH DIABETIC NEPHROPATHY
A 52-year-old man known to be suffering from poorly controlled diabetes mellitus for the
past 7 years presents with bone pains, bilateral leg swelling and abdominal distension. On
examination, pitting pedal oedema and ascites are noted. Fundoscopic examination shows
the presence of soft exudates and new vessels in the retina. Urine examination reveals
proteinuria of more than 3.5 g over 24 hours. Renal function profile: Serum urea 24 mmol/L
(normal range 3.6 to 7.2 mmol/L) and serum creatinine is 875 mmol/L (normal range less
than 115 mmol/L). Estimated GFR is 10 ml/minute (normal range above 120 ml/minute). A
renal biopsy is done.
7A. What is the most likely clinical diagnosis? (2 marks)
Chronic kidney disease with diabetic retinopathy/diabetic nephropathy secondary to diabetes
mellitus
7B. Describe the pathophysiology of oedema in this patient. (3 marks)
Primary retention of sodium and water secondary to reduced GFR
Hypoalbuminemia resulting from loss of protein in the urine leading to failure of retention of
water in the intravascular compartment
Reduction in effective arterial blood volume as a result of the above leads to activation of the
renin angiotensin-aldosterone axis
7C. Describe the histopathological findings on renal biopsy in this patient. (2 marks)
Glomerular sclerosis as a result of basement membrane thickening and mesangial matrix
expansion eventually leading to nodular formation. (Kimmelstiel-Wilson lesion)
7D. Name the group of diuretics that can be prescribed to reduce the oedema in this patient
with TWO examples of a drug from this group. (3 marks)
Answer: (1 + 2 = 3 marks)
Group – Loop diuretic / high ceiling diuretic
Examples – Furosemide (Frusemide), bumetanide, torasemide (any other plausible answer).
CARCINOMA OF THE PROSTATE
An 82-year-old man presents with increasing back pain since 6 months. He also complains of
urinary hesitancy, frequency, and nocturia. Digital rectal examination is performed.
Transrectal prostatic biopsy shows small crowded glands lined by a single layer of dysplastic
epithelium. A bone scan shows increased areas of uptake in the thoracic, lumbar and sacral
vertebrae.
a. Describe the venous drainage of the lumbar vertebrae. State how they are connected
to the prostatic venous plexus. (2+1=3 marks)
Lumbar vertebrae are drained by internal and external vertebral venous plexuses.
Prostatic venous plexus is connected to the vertebral plexus by the deep pelvic veins.
b. Describe how urinary bladder sensations are carried to the central nervous system.
Sensations from the bladder are carried by pelvic nerves from the urinary bladder to sacral
plexus via pelvic nerves.
Some fibres may travel along sympathetic nerves as well. The main sensation arising from
the bladder is due to urine filling and stretching the bladder wall.
c. State the reason for hesitancy in this patient. (3+1=4 marks)
Due to the obstruction to the urethra by the growth, the patient needs to strain in order
to overcome the resistance, hence it takes some time before urine flows.
d. State the useful tumour marker in this patient. (1 mark)
Useful tumour marker in this patient is serum PSA.
e. Describe the gross appearance of the possible prostatic pathology in this patient. (2
marks)
Possible gross prostate pathology in this patient
 Usually occurs in the peripheral zone of the prostate and is irregular
 Yellowish, sometimes grey white colour
 Gritty & stony-hard on palpation
EMQ
Glomerular nephropathies
15 yr old M presents with increase BP and ASOT. PMH: Sore throat 1 week ago.
=Post-streptococcal glomerulopathy
27yr old presents with hematuria after honeymoon. PE: normal. Renal biopsy shows
depositions of depositions of Ig.
=IgA nephropathy
2 yrs old presents with chronic cough, heamotypsis, cachexic, NO fever and
Lymphadenopathy. Urinalysis shows 4 + protein.
=Goodpasture syndrome
25 yrs old got into RTA [Road traffic accidents] presents with multiple failure and rupture of
spleen. U&E and blood test is done. GFR < 5 ml.
=Acute RENAL failure
34 yr old presents with ankle swelling with 5gm protein in urine. Thickened glomerulus is
shown on renal biopsy.
=Membranous Glomerulopathy