A 29-year-old woman at 32 weeks gestation presents to the obstetric assessment unit with headache and right upper quadrant pain. She has no significant past medical history. Blood pressure is 168/112 mmHg. Blood tests show: haemoglobin 102 g/L, platelets 88 × 10^9/L, ALT 245 U/L, AST 312 U/L, bilirubin 34 μmol/L, creatinine 145 μmol/L (booking creatinine was 68 μmol/L), LDH 680 U/L. Urinalysis shows protein 3+. Peripheral blood film shows schistocytes. What is the most appropriate immediate management?

Commence IV labetalol, IV magnesium sulphate, and arrange immediate delivery

Commence IV magnesium sulphate and plan delivery within 24-48 hours

Commence plasma exchange for thrombotic thrombocytopenic purpura

Commence high-dose corticosteroids for HELLP syndrome

Transfuse platelets and arrange delivery once platelets >100 × 10^9/L

A 38-year-old man with chronic kidney disease stage 5 (eGFR 10 mL/min/1.73m²) secondary to focal segmental glomerulosclerosis is being prepared for renal replacement therapy. He has preserved urine output of approximately 1500 mL per day. He works full-time as a teacher and wishes to minimize time spent on dialysis. Blood tests show: haemoglobin 108 g/L, potassium 5.1 mmol/L, phosphate 1.72 mmol/L, albumin 36 g/L. He has good manual dexterity and lives with his partner. Which renal replacement modality would be most appropriate to offer first?

Automated peritoneal dialysis (APD)

Continuous ambulatory peritoneal dialysis (CAPD)

In-centre haemodialysis three times weekly

Pre-emptive renal transplantation

A 48-year-old woman with no significant past medical history presents to the emergency department with a 6-hour history of severe right loin pain. CT KUB confirms a 5 mm stone at the right pelviureteric junction with mild hydronephrosis. She is afebrile. Blood tests show: white cells 9.2 × 10^9/L, CRP 8 mg/L, creatinine 78 μmol/L. Urinalysis shows blood 3+, leucocytes 1+, nitrites negative. She has been given adequate analgesia with diclofenac and morphine. What is the most appropriate next step in her management?

Discharge with analgesia, alpha-blocker, and follow-up in stone clinic

Admit for IV antibiotics due to obstructive pyelonephritis

Arrange urgent ureteroscopy and stone extraction within 48 hours

Insert percutaneous nephrostomy for decompression

Arrange extracorporeal shock wave lithotripsy (ESWL) within one week

A 52-year-old woman presents to the emergency department with confusion and agitation. Her husband reports she has had watery diarrhoea for 5 days. She has a history of bipolar disorder treated with lithium for 15 years. Blood tests show: sodium 128 mmol/L, potassium 3.2 mmol/L, creatinine 245 μmol/L (baseline 85 μmol/L), lithium level 2.8 mmol/L (therapeutic range 0.6-1.0). ECG shows sinus tachycardia at 105 bpm. What is the most appropriate immediate management?

Stop lithium, give IV 0.9% saline, and arrange urgent haemodialysis

Stop lithium, give IV 0.9% saline, and recheck lithium level in 12 hours

Continue lithium, correct dehydration, and arrange gastroenterology review

Stop lithium, give hypertonic saline for hyponatraemia, then arrange dialysis

Stop lithium, give IV fluids, and start haemofiltration

A 67-year-old man with chronic kidney disease stage 3a (eGFR 52 mL/min/1.73m²) secondary to diabetic nephropathy attends for annual review. He takes metformin, gliclazide, ramipril, atorvastatin, and aspirin. Blood tests show: HbA1c 64 mmol/mol, creatinine 128 μmol/L (stable from previous), potassium 5.4 mmol/L, bicarbonate 19 mmol/L. Urine albumin:creatinine ratio is 45 mg/mmol. Blood pressure is 138/82 mmHg. What is the most appropriate modification to his management?

Add SGLT2 inhibitor for renoprotection

Increase ramipril dose to maximize renoprotection

Stop ramipril due to hyperkalaemia and worsening renal function

Add sodium bicarbonate supplementation for metabolic acidosis

Add spironolactone for additional proteinuria reduction

A 34-year-old previously healthy woman presents with oliguria and peripheral oedema. Blood tests show: creatinine 320 μmol/L (baseline 72 μmol/L two weeks ago), urea 22.4 mmol/L, albumin 28 g/L. Urinalysis shows protein 4+, blood 2+, and no leucocytes or nitrites. Urine protein:creatinine ratio is 520 mg/mmol. Renal biopsy shows crescentic glomerulonephritis. Serology shows: ANCA negative, anti-GBM negative, ANA 1:640 (speckled pattern), anti-dsDNA positive, C3 0.42 g/L (normal 0.75-1.65), C4 0.08 g/L (normal 0.14-0.54). What is the most likely diagnosis?

Anti-GBM disease (Goodpasture syndrome)

Post-streptococcal glomerulonephritis

A 56-year-old woman with chronic kidney disease stage 4 (eGFR 20 mL/min/1.73m²) secondary to IgA nephropathy presents for routine review. She reports increasing fatigue. Blood tests show: haemoglobin 95 g/L, ferritin 280 μg/L, transferrin saturation 28%, PTH 18.5 pmol/L (normal 1.6-6.9), corrected calcium 2.12 mmol/L, phosphate 1.85 mmol/L, 25-hydroxyvitamin D 32 nmol/L. What is the most appropriate initial management of her secondary hyperparathyroidism?

Start colecalciferol 20,000 units weekly

Start alfacalcidol 250 nanograms daily

Start calcium carbonate 1.25 g three times daily with meals

A 28-year-old man presents to the emergency department with sudden onset severe left-sided loin pain radiating to the groin. He has vomited twice and appears distressed. He has a history of inflammatory bowel disease (Crohn's disease) and has undergone two small bowel resections. CT KUB shows a 7 mm calculus at the left vesicoureteric junction with moderate hydronephrosis. Blood tests show: creatinine 88 μmol/L, calcium 2.35 mmol/L, uric acid 380 μmol/L. What is the most likely stone composition in this patient?

Struvite (magnesium ammonium phosphate)

Chronic kidney disease for UKMLA AKT: High-Yield Medicine (Core Systems) Lessons

Quick Overview

Chronic kidney disease (CKD) is defined as abnormalities of kidney structure/function present for >3 months with health implications. Affects ~7% of UK adults. Classification by GFR categories (G1-G5) and albuminuria stages (A1-A3) guides cardiovascular risk stratification and nephrology referral thresholds per NICE NG203.

Core Facts & Concepts

CKD Definition: ≥1 of the following for >3 months:

eGFR <60 mL/min/1.73m²
Albuminuria (ACR ≥3 mg/mmol)
Structural kidney abnormality

GFR Categories (CKD-EPI equation preferred):

Stage	eGFR (mL/min/1.73m²)	Description
G1	≥90	Normal (with other evidence of kidney damage)
G2	60-89	Mild reduction
G3a	45-59	Mild-moderate reduction
G3b	30-44	Moderate-severe reduction
G4	15-29	Severe reduction
G5	<15	Kidney failure

Albuminuria Stages:

A1: ACR <3 mg/mmol (normal-mildly increased)
A2: ACR 3-30 mg/mmol (moderately increased)
A3: ACR >30 mg/mmol (severely increased)

Figure 1: Ultrasound showing bilateral small echogenic kidneys with cortical thinning

📊 Monitoring Frequency (NICE NG203):

G3a + A1: Annually
G3b + A2: Every 6 months
G4-G5 or A3: Every 3-6 months

🚩 Nephrology Referral Thresholds:

eGFR <30 (G4-G5)
ACR ≥70 mg/mmol unless diabetes + appropriate treatment
Accelerated progression: eGFR decline ≥25% + ≥5 mL/min/1.73m² drop within 12 months
Uncontrolled hypertension despite ≥4 agents

Problem-Solving Approach

Step 1: Confirm CKD (repeat tests within 90 days)

Calculate eGFR using CKD-EPI equation
Measure ACR on early morning urine sample (not PCR alone)

Step 2: Cardiovascular Risk Stratification

Combine GFR + albuminuria categories into risk matrix
High risk: G3b-G5 with any A stage; any G stage with A3
Offer atorvastatin 20mg for primary prevention

Step 3: Blood Pressure Management

Target: <140/90 mmHg (<130/80 if ACR >70)
ACE-i/ARB first-line if diabetes or ACR ≥3 mg/mmol
Accept eGFR drop ≤25% within 2 weeks; stop if >25%

Figure 2: Blood film showing target cells and burr cells in uraemia

Step 4: Manage Complications

Anaemia (screen if eGFR <45):

Target Hb: 100-120 g/L
IV iron if ferritin <100 or TSAT <20%
Consider ESA if Hb <100 despite iron correction

Mineral Bone Disease (screen if eGFR <45):

Check calcium, phosphate, PTH, vitamin D
Phosphate binders if >1.7 mmol/L (G4-G5)
Maintain vitamin D 25-OH >75 nmol/L

Step 5: Identify Progression Risk

SGLT2 inhibitors (dapagliflozin 10mg) for diabetic + non-diabetic CKD with ACR ≥30
Dietary protein 0.8 g/kg/day (G4-G5)

Analysis Framework

Differential for Raised Creatinine:

Feature	Pre-renal	Renal	Post-renal
Urine Na	<20 mmol/L	>40 mmol/L	Variable
Urine osmolality	>500	<350	Variable
Response to fluids	Improves	No change	No change
Ultrasound	Normal	Small/scarred	Hydronephrosis

CKD vs AKI Discriminators:

CKD: Bilateral small kidneys (<9cm), anaemia, hyperparathyroidism, previous eGFR results
AKI: Rapid rise in creatinine, normal-sized kidneys, precipitant identified

Visual Aid

Cardiovascular Risk Matrix (simplified):

GFR/ACR	A1	A2	A3
G1-G2	Low	Moderate	High
G3a	Moderate	High	Very High
G3b-G5	High	Very High	Very High

Key Points Summary

✓ CKD = >3 months of eGFR <60 OR ACR ≥3 OR structural abnormality; confirm with repeat tests within 90 days

✓ Refer nephrology: eGFR <30 (G4-G5), ACR ≥70, progression ≥25% eGFR drop + ≥5 mL/min decline/year

✓ BP targets: <140/90 general; <130/80 if ACR >70; use ACE-i/ARB if diabetes or ACR ≥3

✓ SGLT2 inhibitors (dapagliflozin 10mg) for CKD with ACR ≥30 regardless of diabetes status (NICE NG203)

✓ Screen complications if eGFR <45: anaemia (Hb target 100-120), bone profile (phosphate binders if >1.7), PTH

✓ Monitoring frequency: G3a+A1 annually; G3b+A2 6-monthly; G4-G5/A3 every 3-6 months

✓ Progression red flags: eGFR drop ≥25% + ≥5 mL/min/year, uncontrolled HTN on ≥4 agents, ACR ≥70 despite treatment

⚠️ Warning: Accept eGFR drop ≤25% within 2 weeks of starting ACE-i/ARB; stop if >25% or hyperkalaemia >6 mmol/L

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