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)

Urinary tract infections for UKMLA AKT: High-Yield Medicine (Core Systems) Lessons

Quick Overview

Urinary tract infections (UTIs) are among the most common bacterial infections in primary and secondary care. Accurate differentiation between lower UTI (cystitis) and upper UTI (pyelonephritis) is critical for appropriate antibiotic selection and preventing complications. NICE NG109 provides evidence-based guidance on diagnosis, treatment thresholds, and management of recurrent infections.

Core Facts & Concepts

Lower UTI (Cystitis) vs Upper UTI (Pyelonephritis)

Feature	Lower UTI	Upper UTI
Symptoms	Dysuria, frequency, urgency, suprapubic pain	Fever >38°C, loin pain, nausea/vomiting
Systemic features	Absent	Present (rigors, malaise)
Examination	Suprapubic tenderness only	Loin/costovertebral angle tenderness
Severity	Mild-moderate	Moderate-severe, may require admission

Figure 1: Urine dipstick showing positive nitrites and leukocytes

When to Obtain Urine Culture (NICE NG109):

Suspected acute pyelonephritis or upper UTI
Symptoms not resolving or worsening with 48-72 hours of antibiotic treatment
Pregnant women with suspected UTI
Men with suspected UTI
Recurrent UTIs (≥2 in 6 months or ≥3 in 12 months)
Catheter-associated UTI (CA-UTI)
Atypical organisms suspected

Diagnostic Thresholds:

Significant bacteriuria: ≥10⁵ CFU/mL (midstream urine)
CA-UTI: ≥10³ CFU/mL with symptoms
Pyuria: ≥10 WBC/mm³ or positive leukocyte esterase

Problem-Solving Approach

Antibiotic Selection (NICE NG109):

1. Uncomplicated Lower UTI (Non-pregnant Women):

First-line: Nitrofurantoin 100mg MR BD for 3 days (avoid if eGFR <45)
Second-line: Trimethoprim 200mg BD for 3 days (if low local resistance)
Avoid quinolones unless culture-directed

2. Acute Pyelonephritis/Upper UTI:

Oral (if mild): Cefalexin 500mg TDS for 7-10 days OR Co-amoxiclav 500/125mg TDS for 7-10 days
IV (if severe): Cefuroxime 750mg-1.5g TDS OR Co-amoxiclav 1.2g TDS
Duration: 7-10 days total

Figure 2: CT scan showing perinephric stranding and renal enlargement

3. Catheter-Associated UTI (CA-UTI):

Only treat if symptomatic (fever, rigors, new confusion, loin pain)
Change/remove catheter before starting antibiotics
First-line: Nitrofurantoin 100mg MR BD for 7 days OR Trimethoprim 200mg BD for 7 days
Send culture before starting treatment

4. Recurrent UTI Management:

Investigate if ≥2 UTIs in 6 months or ≥3 in 12 months
Consider post-coital prophylaxis (single dose after intercourse)
Daily prophylaxis: Nitrofurantoin 50-100mg OD OR Trimethoprim 100mg OD for 6 months
Non-antibiotic options: Cranberry products, vaginal oestrogen (postmenopausal women)

🚩 Red Flags Requiring Admission:

Sepsis or severe systemic illness
Unable to take oral fluids/medications
Pregnancy with pyelonephritis
Significant comorbidities (diabetes, immunosuppression)

Analysis Framework

Differentiating UTI from Other Causes:

Condition	Key Discriminators
UTI	Dysuria + frequency + positive dipstick (nitrites/leukocytes)
Urethritis (STI)	Dysuria + discharge, negative nitrites, sexually active
Vaginitis	External dysuria, discharge, itch, negative dipstick
Interstitial cystitis	Chronic pain, negative cultures, sterile pyuria
Prostatitis (men)	Perineal pain, tender prostate on PR, fever

⭐ Clinical Pearl: Asymptomatic bacteriuria (positive culture without symptoms) should NOT be treated except in pregnancy or before urological procedures.

Visual Aid

Recurrent UTI Investigation Pathway:

Investigation	Indication
Urine culture	All recurrent UTIs
Post-void bladder scan	Suspected incomplete emptying
Renal USS	Recurrent pyelonephritis, haematuria, men
Cystoscopy	Haematuria, >60 years, refractory symptoms

Key Points Summary

✓ Lower UTI: Treat empirically for 3 days with nitrofurantoin 100mg MR BD (first-line per NICE NG109)

✓ Upper UTI/Pyelonephritis: Requires 7-10 days antibiotics; consider IV therapy if severe with cefalexin or co-amoxiclav

✓ Culture indications: Pyelonephritis, men, pregnant women, recurrent UTI (≥2/6 months), catheter-associated, treatment failure at 48-72h

✓ CA-UTI: Only treat if symptomatic; change catheter before antibiotics; use 7-day course

✓ Recurrent UTI prophylaxis: Consider after ≥2 UTIs in 6 months; nitrofurantoin 50-100mg OD or trimethoprim 100mg OD for 6 months

✓ Asymptomatic bacteriuria: Do NOT treat except in pregnancy or pre-urological procedures

✓ Avoid quinolones as first-line due to resistance and adverse effects; reserve for culture-directed therapy only

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