Renal & Urology — MCQs
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A 31-year-old woman with HIV infection (CD4 count 180 cells/μL) presents with fever, dysuria, and right loin pain. She appears unwell with temperature 39.2°C, pulse 118/min, BP 102/68 mmHg. Urine dipstick shows blood 3+, leucocytes 3+, nitrites positive. What is the most appropriate initial antibiotic choice?
A 78-year-old man with diabetes and CKD stage 3a presents with acute confusion. Blood tests show: sodium 118 mmol/L, potassium 3.8 mmol/L, glucose 6.2 mmol/L, serum osmolality 250 mOsm/kg, urine osmolality 420 mOsm/kg, urine sodium 65 mmol/L. He takes metformin, ramipril, and bendroflumethiazide. What is the most likely cause of his hyponatraemia?
A 65-year-old man with CKD stage 4 (eGFR 24 mL/min/1.73m²) presents for routine review. Blood tests show: haemoglobin 92 g/L, MCV 88 fL, ferritin 180 μg/L, transferrin saturation 22%, vitamin B12 and folate normal. He has no evidence of bleeding. What is the most appropriate next step in management of his anaemia?
A 43-year-old man presents to the emergency department with a 6-hour history of severe left loin-to-groin pain. Non-contrast CT KUB shows a 7mm calculus at the left vesicoureteric junction with moderate hydronephrosis. He is apyrexial. Creatinine is 110 μmol/L. Pain is controlled with analgesia. What is the most appropriate definitive management?
A 36-year-old woman presents with severe nausea and vomiting for 5 days following gastroenteritis. Blood tests show: sodium 142 mmol/L, potassium 2.1 mmol/L, chloride 88 mmol/L, bicarbonate 36 mmol/L, urea 8.2 mmol/L, creatinine 95 μmol/L. Arterial blood gas: pH 7.54, pCO2 6.1 kPa, HCO3- 35 mmol/L. What is the most appropriate initial management?
A 51-year-old man with end-stage renal failure on peritoneal dialysis for 3 years presents with abdominal pain and cloudy dialysate effluent. Dialysate white cell count is 450 cells/μL with 75% neutrophils. Gram stain shows no organisms. Cultures are pending. What is the most appropriate initial antibiotic regimen?
A 24-year-old woman presents to her GP with a 24-hour history of dysuria and urinary frequency. She is otherwise well, not pregnant, and has no past medical history. Temperature is 37.1°C. Urinalysis shows leucocytes 2+, nitrites positive, no blood. What is the most appropriate management?
A 59-year-old man with chronic hepatitis C and compensated cirrhosis presents to the emergency department with oliguria. He has been taking NSAIDs for back pain. Blood results show: urea 32 mmol/L, creatinine 380 μmol/L (baseline 85 μmol/L), sodium 128 mmol/L, potassium 5.8 mmol/L. Urinalysis shows no blood or protein. Urinary sodium is 8 mmol/L. What is the most likely diagnosis?
A 47-year-old woman with newly diagnosed IgA nephropathy is found to have persistent haematuria and an albumin:creatinine ratio of 95 mg/mmol despite 4 months of maximal tolerated ACE inhibitor therapy and blood pressure control <130/80 mmHg. eGFR is 52 mL/min/1.73m². What is the most appropriate next step in management?
A 33-year-old woman presents with fever, dysuria, and right-sided loin pain. She is 8 weeks pregnant with her first child. Temperature is 38.7°C, pulse 105/min, BP 118/72 mmHg. Urinalysis shows leucocytes 3+, nitrites positive, protein 1+. What is the most appropriate initial antibiotic treatment?
Renal & Urology UK Medical PG Practice Questions and MCQs
Question 31: A 31-year-old woman with HIV infection (CD4 count 180 cells/μL) presents with fever, dysuria, and right loin pain. She appears unwell with temperature 39.2°C, pulse 118/min, BP 102/68 mmHg. Urine dipstick shows blood 3+, leucocytes 3+, nitrites positive. What is the most appropriate initial antibiotic choice?
- A. Oral nitrofurantoin 100 mg four times daily for 7 days
- B. Intravenous co-amoxiclav 1.2g three times daily
- C. Intravenous gentamicin 5 mg/kg once daily plus oral co-trimoxazole (Correct Answer)
- D. Intravenous ceftriaxone 2g once daily
- E. Oral ciprofloxacin 500 mg twice daily for 14 days
Explanation: ***Intravenous gentamicin 5 mg/kg once daily plus oral co-trimoxazole*** - This patient presents with **acute pyelonephritis** and signs of **sepsis** in the setting of advanced **HIV infection** (CD4 count 180 cells/μL). This combination therapy provides broad-spectrum coverage against common uropathogens and addresses the patient's severe clinical picture. - **Gentamicin** offers potent, rapid bactericidal action against Gram-negative bacteria, which are common causes of pyelonephritis. **Co-trimoxazole** (trimethoprim/sulfamethoxazole) is crucial not only for treating urinary pathogens but also for **Pneumocystis jirovecii pneumonia (PCP) prophylaxis**, which is indicated for HIV patients with CD4 counts below 200 cells/μL. *Oral nitrofurantoin 100 mg four times daily for 7 days* - **Nitrofurantoin** is primarily effective for **uncomplicated cystitis** as it concentrates in the urine and does not achieve adequate therapeutic levels in the renal parenchyma, making it ineffective for **pyelonephritis**. - Oral therapy is unsuitable for a patient presenting with **sepsis** and severe symptoms; **intravenous antibiotics** are required for initial stabilization and better drug delivery. *Intravenous co-amoxiclav 1.2g three times daily* - While an intravenous antibiotic, **co-amoxiclav** has higher rates of **resistance** among common uropathogens, particularly *E. coli*, which is the most frequent cause of pyelonephritis, making it a less reliable empiric choice in severe infections. - This regimen lacks the crucial component of **PCP prophylaxis** provided by co-trimoxazole, which is mandatory for this HIV-positive patient with a low CD4 count. *Intravenous ceftriaxone 2g once daily* - **Ceftriaxone** is a strong intravenous antibiotic and a reasonable choice for complicated pyelonephritis, offering good Gram-negative coverage. However, similar to co-amoxiclav, it does not provide **PCP prophylaxis**. - In immunocompromised patients with a low CD4 count, it is critical to ensure coverage for opportunistic infections like **PCP**, which is addressed by the inclusion of **co-trimoxazole**. *Oral ciprofloxacin 500 mg twice daily for 14 days* - **Ciprofloxacin** is a fluoroquinolone effective against many urinary pathogens, but **oral administration** is inappropriate for a patient presenting with **sepsis** and signs of systemic illness requiring intravenous therapy. - There are increasing concerns about **antibiotic resistance** to fluoroquinolones among uropathogens, and like other monotherapies, it does not address the vital need for **PCP prophylaxis** in this immunocompromised patient.
Question 32: A 78-year-old man with diabetes and CKD stage 3a presents with acute confusion. Blood tests show: sodium 118 mmol/L, potassium 3.8 mmol/L, glucose 6.2 mmol/L, serum osmolality 250 mOsm/kg, urine osmolality 420 mOsm/kg, urine sodium 65 mmol/L. He takes metformin, ramipril, and bendroflumethiazide. What is the most likely cause of his hyponatraemia?
- A. Syndrome of inappropriate ADH secretion
- B. Thiazide diuretic-induced hyponatraemia (Correct Answer)
- C. Hyperglycaemia causing pseudohyponatraemia
- D. Primary polydipsia
- E. Cerebral salt wasting syndrome
Explanation: ***Thiazide diuretic-induced hyponatraemia*** - **Thiazide diuretics** like **bendroflumethiazide** are a common cause of hyponatraemia in elderly patients, impairing free water excretion by inhibiting sodium reabsorption in the **distal convoluted tubule**. - This mechanism, combined with potential mild **volume depletion** stimulating **ADH secretion**, leads to hypotonic hyponatraemia with elevated urine osmolality and urine sodium, as observed in this patient (Na 118, serum osmolality 250, urine osmolality 420, urine Na 65). *Syndrome of inappropriate ADH secretion* - **SIADH** presents with similar biochemical features of **hypotonic hyponatraemia** (low serum sodium and osmolality) with inappropriately concentrated urine and high urine sodium. - However, **SIADH is a diagnosis of exclusion**, and the patient's use of **bendroflumethiazide**, a medication known to cause hyponatraemia, makes a drug-induced cause much more likely as the primary etiology. *Hyperglycaemia causing pseudohyponatraemia* - **Pseudohyponatraemia** due to **hyperglycaemia** occurs when high glucose draws water into the extracellular space, diluting serum sodium, but the patient's **blood glucose (6.2 mmol/L) is normal**. - The **serum osmolality of 250 mOsm/kg** confirms this is true **hypotonic hyponatraemia**, not an artifact from elevated plasma osmolytes. *Primary polydipsia* - **Primary polydipsia** is characterized by excessive water intake that suppresses **ADH** secretion, leading to the excretion of maximally **dilute urine** (typically urine osmolality <100 mOsm/kg). - This patient's **urine osmolality is high (420 mOsm/kg)**, indicating that ADH is active and the kidneys are concentrating urine, which rules out primary polydipsia. *Cerebral salt wasting syndrome* - **Cerebral salt wasting (CSW)** involves **hyponatraemia**, volume depletion, and high urinary sodium excretion, usually occurring in the context of **intracranial pathology** (e.g., subarachnoid hemorrhage, brain injury). - This patient lacks any history of **neurological insults** or conditions typically associated with CSW, making a drug-induced cause a more plausible explanation for his presentation.
Question 33: A 65-year-old man with CKD stage 4 (eGFR 24 mL/min/1.73m²) presents for routine review. Blood tests show: haemoglobin 92 g/L, MCV 88 fL, ferritin 180 μg/L, transferrin saturation 22%, vitamin B12 and folate normal. He has no evidence of bleeding. What is the most appropriate next step in management of his anaemia?
- A. Commence erythropoiesis-stimulating agent (ESA) therapy
- B. Prescribe oral iron supplementation
- C. Arrange blood transfusion
- D. Prescribe intravenous iron therapy (Correct Answer)
- E. Arrange bone marrow biopsy
Explanation: ***Prescribe intravenous iron therapy*** - In **CKD Stage 4**, iron stores must be optimized before starting erythropoiesis-stimulating agents (ESAs); **intravenous iron** is preferred as it bypasses **hepcidin-mediated** poor oral absorption. - Although ferritin is 180 μg/L, a **transferrin saturation (TSAT)** of 22% indicates **functional iron deficiency**, requiring replenishment to support erythropoiesis. *Commence erythropoiesis-stimulating agent (ESA) therapy* - ESAs should not be started until **iron stores are fully optimized**, as initiating them in iron-deficient states leads to poor treatment response and can worsen **functional iron deficiency**. - Starting an ESA without adequate available iron (target TSAT often >25-30%) often results in **ESA resistance**, necessitating higher and potentially riskier ESA doses. *Prescribe oral iron supplementation* - **Oral iron** is often poorly tolerated and largely ineffective in advanced CKD due to high **hepcidin levels** which block intestinal iron absorption and utilization. - Clinical guidelines often recommend **intravenous iron** as the first-line iron supplementation strategy for patients with CKD Stage 3-5D (eGFR <45 mL/min/1.73m²) and iron deficiency. *Arrange blood transfusion* - **Blood transfusions** are generally reserved for patients with severe, symptomatic anaemia (e.g., Hb <70 g/L or significant symptoms) or acute bleeding, not for stable, asymptomatic anaemia of CKD at this Hb level (92 g/L). - Transfusion carries risks such as **iron overload**, **allergic reactions**, infection, and **HLA sensitisation**, which can complicate future possibilities for renal transplantation. *Arrange bone marrow biopsy* - A **bone marrow biopsy** is an invasive procedure and is not indicated when the cause of anaemia (anaemia of chronic kidney disease with functional iron deficiency) is already clearly established by clinical context and routine blood tests. - This patient’s **normocytic anaemia**, CKD history, and iron panel abnormalities provide sufficient diagnostic information without needing histological confirmation of marrow function or iron stores.
Question 34: A 43-year-old man presents to the emergency department with a 6-hour history of severe left loin-to-groin pain. Non-contrast CT KUB shows a 7mm calculus at the left vesicoureteric junction with moderate hydronephrosis. He is apyrexial. Creatinine is 110 μmol/L. Pain is controlled with analgesia. What is the most appropriate definitive management?
- A. Urgent (within 48 hours) ureteroscopy and stone extraction
- B. Medical expulsive therapy with tamsulosin and review in 2-4 weeks (Correct Answer)
- C. Immediate percutaneous nephrostomy
- D. Extracorporeal shock wave lithotripsy (ESWL)
- E. Immediate open ureterolithotomy
Explanation: ***Medical expulsive therapy with tamsulosin and review in 2-4 weeks*** - For ureteric stones **<10mm** in a stable patient without evidence of infection or renal failure, **conservative management** with medical expulsive therapy (MET) is the preferred initial step. - Alpha-blockers like **tamsulosin** relax the smooth muscle of the distal ureter, increasing the passage rate of stones, particularly those at the **vesicoureteric junction**. *Urgent (within 48 hours) ureteroscopy and stone extraction* - Urgent surgical intervention is reserved for patients with **uncontrolled pain**, **sepsis**, or evidence of **acute kidney injury**, none of which are present here. - Routine ureteroscopy is usually planned only if the stone fails to pass after a **trial of conservative management** for several weeks. *Immediate percutaneous nephrostomy* - This procedure is indicated for emergent **decompression** of an **obstructed and infected** collecting system (pyonephrosis). - As the patient is **apyrexial** and hemodynamically stable, invasive decompression is not currently necessary. *Extracorporeal shock wave lithotripsy (ESWL)* - While ESWL is a management option, it is generally less effective than MET for **distal ureteric stones** located at the **vesicoureteric junction** due to bony interference from the pelvis. - Conservative management with MET is less invasive and has a high success rate for stones of this size (**7mm**) in this location. *Immediate open ureterolithotomy* - **Open surgery** is rarely performed in modern practice due to the high success rates of **minimally invasive** endoscopic and lithotripsy techniques. - It is only considered if all other endourological interventions fail or are contraindicated, and it is never the **first-line** choice for a simple 7mm stone.
Question 35: A 36-year-old woman presents with severe nausea and vomiting for 5 days following gastroenteritis. Blood tests show: sodium 142 mmol/L, potassium 2.1 mmol/L, chloride 88 mmol/L, bicarbonate 36 mmol/L, urea 8.2 mmol/L, creatinine 95 μmol/L. Arterial blood gas: pH 7.54, pCO2 6.1 kPa, HCO3- 35 mmol/L. What is the most appropriate initial management?
- A. Intravenous 0.9% sodium chloride with added potassium chloride (Correct Answer)
- B. Intravenous acetazolamide to correct the alkalosis
- C. Oral potassium supplementation alone
- D. Intravenous calcium gluconate for cardiac protection
- E. Intravenous sodium bicarbonate
Explanation: ***Intravenous 0.9% sodium chloride with added potassium chloride***- The patient presents with **hypochloremic, hypokalemic metabolic alkalosis** due to persistent vomiting; **0.9% saline** is essential to restore volume and provide chloride, which allows the kidneys to excrete bicarbonate.- Severe **hypokalemia (2.1 mmol/L)** requires urgent intravenous replacement, as oral intake is insufficient and likely intolerable due to ongoing vomiting.*Intravenous acetazolamide to correct the alkalosis*- **Acetazolamide** inhibits carbonic anhydrase to increase bicarbonate excretion but significantly increases **urinary potassium loss**, which would be dangerous in this patient.- It is generally reserved for metabolic alkalosis in patients with **fluid overload** (e.g., heart failure) rather than volume-depleted patients.*Oral potassium supplementation alone*- Oral replacement is inappropriate for **severe hypokalemia (<2.5 mmol/L)** and is likely to fail in a patient with active **nausea and vomiting**.- It fails to address the underlying **volume depletion** and chloride deficiency necessary to reverse the metabolic alkalosis.*Intravenous calcium gluconate for cardiac protection*- **Calcium gluconate** is indicated for the emergency treatment of **hyperkalemia** with ECG changes to stabilize the myocardium.- It has no role in treating **hypokalemia** and will not correct the patient's electrolyte or acid-base derangements.*Intravenous sodium bicarbonate*- Administering **sodium bicarbonate** would exacerbate the existing **metabolic alkalosis** (pH 7.54) and further increase bircarbonate levels.- This intervention is contraindicated in this scenario as it would worsen the patient's clinical condition.
Question 36: A 51-year-old man with end-stage renal failure on peritoneal dialysis for 3 years presents with abdominal pain and cloudy dialysate effluent. Dialysate white cell count is 450 cells/μL with 75% neutrophils. Gram stain shows no organisms. Cultures are pending. What is the most appropriate initial antibiotic regimen?
- A. Intraperitoneal vancomycin and gentamicin
- B. Oral ciprofloxacin
- C. Intravenous ceftriaxone
- D. Intraperitoneal cefazolin and ceftazidime (Correct Answer)
- E. Intravenous meropenem
Explanation: ***Intraperitoneal cefazolin and ceftazidime*** - This patient meets the criteria for **peritoneal dialysis-associated peritonitis** (abdominal pain, cloudy dialysate, high WBC count with neutrophilic predominance). The **intraperitoneal (IP) route** is the preferred delivery method to achieve high local drug concentrations at the site of infection. - Empiric therapy must cover both **Gram-positive** (e.g., coagulase-negative staphylococci, S. aureus) and **Gram-negative** (e.g., Pseudomonas aeruginosa, Enterobacteriaceae) organisms. **Cefazolin** provides Gram-positive coverage, and **ceftazidime** covers Gram-negative organisms, making this a preferred non-toxic combination. *Intraperitoneal vancomycin and gentamicin* - While this combination offers broad-spectrum coverage, **vancomycin** is generally reserved for patients with a known history of **MRSA infection** or significant cephalosporin allergy, which is not indicated in this case. - **Gentamicin** carries a higher risk of **ototoxicity** and **nephrotoxicity** compared to third-generation cephalosporins, especially in patients with some residual renal function. *Oral ciprofloxacin* - **Oral administration** is inappropriate for initial empiric therapy in acute PD peritonitis as it does not reliably achieve the required **bactericidal concentrations** in the peritoneal fluid quickly enough to effectively manage the acute infection. - **Ciprofloxacin** alone does not provide sufficient broad-spectrum coverage for both common Gram-positive and Gram-negative organisms typically implicated in PD peritonitis. *Intravenous ceftriaxone* - The **intravenous route** is less effective than **intraperitoneal administration** for localized peritonitis because it delivers lower drug concentrations directly to the peritoneal cavity, which is the primary site of infection. - Single-agent therapy with **ceftriaxone** does not provide adequate coverage for all potential **Gram-negative pathogens**, particularly *Pseudomonas aeruginosa*, which is a significant concern in PD peritonitis. *Intravenous meropenem* - Using an **ultra-broad spectrum** carbapenem like meropenem intravenously as initial empiric therapy is typically reserved for very severe cases, those with signs of sepsis, or when multi-drug resistant organisms are highly suspected, to avoid promoting **antibiotic resistance**. - Similar to other IV options, it fails to provide the superior **local bioavailability** achieved through **intraperitoneal administration**, which is critical for effective treatment of peritoneal infection.
Question 37: A 24-year-old woman presents to her GP with a 24-hour history of dysuria and urinary frequency. She is otherwise well, not pregnant, and has no past medical history. Temperature is 37.1°C. Urinalysis shows leucocytes 2+, nitrites positive, no blood. What is the most appropriate management?
- A. Urine culture then start empirical antibiotics
- B. Immediate empirical antibiotic treatment without urine culture (Correct Answer)
- C. Urine culture and withhold antibiotics pending results
- D. Arrange urgent ultrasound of renal tract
- E. Advise increased fluid intake and symptomatic treatment only
Explanation: ***Immediate empirical antibiotic treatment without urine culture***- In **non-pregnant women** with simple **uncomplicated urinary tract infections**, the diagnosis can be made based on typical symptoms like **dysuria** and **frequency** combined with **positive nitrites** on dipstick.- National guidelines (NICE) recommend starting immediate antibiotics (e.g., nitrofurantoin or trimethoprim) without the need for a **urine culture**, as it is unlikely to change the initial management.*Urine culture then start empirical antibiotics*- A **urine culture** is not routinely indicated for **uncomplicated cystitis** in a healthy, non-pregnant female where symptoms and dipstick are definitive.- Performing a culture in this scenario is considered unnecessary and is generally reserved for **recurrent UTIs** or cases where **empirical treatment fails**.*Urine culture and withhold antibiotics pending results*- Withholding treatment while waiting for culture results is inappropriate as it causes unnecessary suffering and increases the risk of the infection ascending to the **upper urinary tract**.- Most cases of cystitis are caused by **E. coli**, which is reliably treated with **first-line empirical antibiotics**.*Arrange urgent ultrasound of renal tract*- A **renal ultrasound** is not indicated for a first presentation of an uncomplicated lower UTI with no features of **pyelonephritis** (e.g., loin pain or high fever).- Imaging is typically reserved for patients with **recurrent infections**, suspected **renal stones**, or structural abnormalities.*Advise increased fluid intake and symptomatic treatment only*- While hydration and **analgesia** are helpful adjuncts, they are not a substitute for antibiotic therapy in a patient with a **confirmed bacterial UTI** (nitrite positive).- Delayed treatment can lead to prolonged morbidity and a higher risk of developing **pyelonephritis**.
Question 38: A 59-year-old man with chronic hepatitis C and compensated cirrhosis presents to the emergency department with oliguria. He has been taking NSAIDs for back pain. Blood results show: urea 32 mmol/L, creatinine 380 μmol/L (baseline 85 μmol/L), sodium 128 mmol/L, potassium 5.8 mmol/L. Urinalysis shows no blood or protein. Urinary sodium is 8 mmol/L. What is the most likely diagnosis?
- A. Acute tubular necrosis
- B. Hepatorenal syndrome (Correct Answer)
- C. Prerenal acute kidney injury
- D. Acute interstitial nephritis
- E. Rapidly progressive glomerulonephritis
Explanation: ***Hepatorenal syndrome*** - Characterized by **functional renal failure** in patients with **cirrhosis**, often precipitated by factors like **NSAIDs** (which inhibit renal vasodilatory prostaglandins) leading to intense renal vasoconstriction. - Key diagnostic features include **oliguria**, significant increase in **creatinine** (from 85 to 380 μmol/L), **hyponatremia** (128 mmol/L), **hyperkalemia** (5.8 mmol/L), and a **very low urinary sodium (< 10 mmol/L)** (8 mmol/L in this case), indicating avid sodium retention with a **bland urinalysis**. *Acute tubular necrosis* - Typically presents with a **urinary sodium > 40 mmol/L** and often low urine osmolality, as the tubules lose their ability to reabsorb sodium and concentrate urine. - **Urinalysis** would classically reveal **muddy brown granular casts** and renal tubular epithelial cells, which are absent in this patient's bland sediment. *Prerenal acute kidney injury* - While sharing features like **low urinary sodium (< 20 mmol/L)** and **oliguria**, it usually improves rapidly with **volume expansion**. - The context of **cirrhosis** and sustained kidney injury despite initial volume status suggests a more severe vasoconstrictive process like HRS, where the effective circulating volume is severely diminished due to splanchnic vasodilation. *Acute interstitial nephritis* - Often drug-induced (including NSAIDs) but typically presents with **sterile pyuria**, white blood cell casts, and sometimes **eosinophiluria**. - Clinical features such as fever, rash, and arthralgia are frequently present, and the urinalysis here does not support this diagnosis. *Rapidly progressive glomerulonephritis* - Characterized by an **active urinary sediment** containing **dysmorphic red blood cells** and **red cell casts**, indicative of glomerular inflammation. - It also typically involves significant **proteinuria and hematuria**, both of which are explicitly stated as absent in this patient's urinalysis.
Question 39: A 47-year-old woman with newly diagnosed IgA nephropathy is found to have persistent haematuria and an albumin:creatinine ratio of 95 mg/mmol despite 4 months of maximal tolerated ACE inhibitor therapy and blood pressure control <130/80 mmHg. eGFR is 52 mL/min/1.73m². What is the most appropriate next step in management?
- A. Add a systemic corticosteroid such as oral prednisolone (Correct Answer)
- B. Commence mycophenolate mofetil
- C. Add a sodium-glucose co-transporter-2 inhibitor
- D. Perform a repeat renal biopsy to assess disease activity
- E. Refer for plasma exchange therapy
Explanation: ***Add a systemic corticosteroid such as oral prednisolone*** - Per **KDIGO 2021 guidelines**, patients with **IgA nephropathy** and persistent **proteinuria >0.75-1 g/day** (ACR 95 mg/mmol) despite 90 days of optimized supportive care should be considered for **corticosteroid therapy**. - This patient has a preserved **eGFR (>30 mL/min/1.73m²)**, making her a candidate for a 6-month course of steroids to reduce the risk of progressive renal decline. *Commence mycophenolate mofetil* - **Mycophenolate mofetil (MMF)** is generally not recommended as first-line immunosuppression in the general IgA nephropathy population due to inconsistent trial data. - It is sometimes considered as a **steroid-sparing agent** in specific populations (e.g., Chinese patients), but **systemic corticosteroids** remain the standard evidence-based next step. *Add a sodium-glucose co-transporter-2 inhibitor* - While **SGLT2 inhibitors** provide cardiovascular and renal protection in chronic kidney disease, they are typically integrated into **supportive care** rather than replacing indicated immunosuppression for high-risk IgA disease. - The priority here is addressing the high inflammatory risk and **proteinuria** that has failed maximal **ACE inhibitor** therapy. *Perform a repeat renal biopsy to assess disease activity* - A **repeat renal biopsy** is not routinely indicated as the initial diagnosis of IgA nephropathy is already established and clinical markers (**ACR** and **eGFR**) guide treatment. - Biopsy may be revisited only if there is an unexpectedly rapid decline in renal function suggesting a **crescentic transformation** or a secondary pathology. *Refer for plasma exchange therapy* - **Plasma exchange** has no established role in the routine management of **IgA nephropathy**. - It is reserved for severe small-vessel vasculitis conditions like **ANCA-associated vasculitis** or **anti-GBM disease**, particularly when involving pulmonary hemorrhage.
Question 40: A 33-year-old woman presents with fever, dysuria, and right-sided loin pain. She is 8 weeks pregnant with her first child. Temperature is 38.7°C, pulse 105/min, BP 118/72 mmHg. Urinalysis shows leucocytes 3+, nitrites positive, protein 1+. What is the most appropriate initial antibiotic treatment?
- A. Oral nitrofurantoin 100 mg twice daily for 7 days
- B. Intravenous cefuroxime 750 mg three times daily (Correct Answer)
- C. Oral trimethoprim 200 mg twice daily for 7 days
- D. Oral ciprofloxacin 500 mg twice daily for 7 days
- E. Intramuscular gentamicin 5 mg/kg once daily
Explanation: ***Intravenous cefuroxime 750 mg three times daily***- This patient presents with **acute pyelonephritis** in pregnancy, evidenced by fever, **loin pain**, and systemic symptoms, which necessitates hospital admission and initial **intravenous antibiotic** therapy.- **Cefuroxime**, a second-generation cephalosporin, is considered safe in all trimesters of pregnancy and effectively covers common **Gram-negative uropathogens** like E. coli.*Oral nitrofurantoin 100 mg twice daily for 7 days*- **Nitrofurantoin** is primarily used for uncomplicated cystitis and does not achieve adequate therapeutic concentrations in the **renal parenchyma** to treat pyelonephritis.- While generally safe in early pregnancy, it should be avoided near **term** due to the risk of neonatal **haemolysis**, particularly in infants with G6PD deficiency.*Oral trimethoprim 200 mg twice daily for 7 days*- **Trimethoprim** is an anti-folate drug and is **contraindicated** in the **first trimester** of pregnancy due to its association with an increased risk of **neural tube defects**.- Oral therapy is insufficient for a febrile patient with systemic signs of **upper urinary tract infection** requiring inpatient management.*Oral ciprofloxacin 500 mg twice daily for 7 days*- **Quinolones** like ciprofloxacin are generally **contraindicated in pregnancy** due to concerns regarding potential **arthropathy** and adverse effects on **fetal cartilage development**.- Oral administration is not the appropriate initial route for managing **febrile pyelonephritis** and associated systemic illness.*Intramuscular gentamicin 5 mg/kg once daily*- While effective against Gram-negative bacteria, **aminoglycosides** such as gentamicin carry a significant risk of **fetal ototoxicity** and **nephrotoxicity**.- **Cephalosporins** are preferred first-line agents in pregnant patients with pyelonephritis; gentamicin is typically reserved for severe infections or documented resistant organisms.
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