A 38-year-old woman presents to the emergency department with severe generalized weakness. She reports 5 days of profuse watery diarrhoea. Blood tests reveal: sodium 138 mmol/L, potassium 2.1 mmol/L, chloride 95 mmol/L, bicarbonate 32 mmol/L, urea 8.2 mmol/L, creatinine 95 μmol/L, magnesium 0.55 mmol/L. ECG shows flattened T waves, prominent U waves, and prolonged QT interval. What is the most appropriate initial management?
Q62
A 52-year-old woman with type 1 diabetes for 30 years attends her annual diabetic review. Her blood pressure is 142/88 mmHg. Blood tests show: HbA1c 68 mmol/mol (8.4%), creatinine 115 μmol/L (eGFR 48 mL/min/1.73m²), potassium 4.5 mmol/L. Urine albumin:creatinine ratio is 28 mg/mmol (previous result 6 months ago was 26 mg/mmol). What is the classification of her chronic kidney disease?
Q63
A 76-year-old man with benign prostatic hyperplasia presents with a 6-hour history of inability to pass urine and severe suprapubic pain. On examination, there is a palpable bladder reaching to the umbilicus. Urethral catheterization is attempted but fails. His observations are stable. What is the most appropriate next step in management?
Q64
A 67-year-old woman presents with progressive ankle swelling and frothy urine. Blood tests reveal: creatinine 98 μmol/L, albumin 18 g/L, cholesterol 9.2 mmol/L, triglycerides 4.5 mmol/L. Urine protein:creatinine ratio is 520 mg/mmol. Renal biopsy shows thickened glomerular basement membrane with subepithelial deposits on electron microscopy and positive anti-phospholipase A2 receptor antibodies. What is the most likely diagnosis?
Q65
A 58-year-old man with chronic kidney disease stage 5 (eGFR 12 mL/min/1.73m²) secondary to diabetes is being prepared for renal replacement therapy. His blood tests show: haemoglobin 88 g/L, ferritin 450 μg/L, transferrin saturation 35%, calcium 2.15 mmol/L, phosphate 2.1 mmol/L, bicarbonate 18 mmol/L, potassium 5.2 mmol/L. Blood pressure is 168/95 mmHg on ramipril 10 mg and amlodipine 10 mg. What is the target haemoglobin range for erythropoiesis-stimulating agent (ESA) therapy in this patient?
Q66
A 42-year-old woman with systemic lupus erythematosus presents with fatigue and ankle swelling. Blood tests show: creatinine 145 μmol/L, albumin 22 g/L, cholesterol 7.8 mmol/L. Urine protein:creatinine ratio is 450 mg/mmol. Renal biopsy shows diffuse proliferative glomerulonephritis (Class IV lupus nephritis) with active lesions. What is the most appropriate initial immunosuppressive therapy?
Q67
Which of the following medications should be temporarily discontinued in a patient presenting with acute kidney injury secondary to dehydration?
Q68
A 35-year-old man presents to the emergency department with sudden onset severe left-sided loin to groin pain. CT KUB confirms a 4 mm stone in the left distal ureter with mild hydronephrosis. He is afebrile with normal observations apart from pain. Creatinine is 82 μmol/L. He has been given diclofenac 75 mg IM with good pain relief. What is the most appropriate ongoing management advice?
Q69
A 45-year-old man with autosomal dominant polycystic kidney disease and chronic kidney disease stage 3b (eGFR 38 mL/min/1.73m²) presents with severe right-sided loin pain radiating to the groin. CT KUB shows a 7 mm calculus in the right mid-ureter with moderate hydronephrosis. His observations are: temperature 38.2°C, BP 145/88 mmHg, pulse 98 bpm. Blood tests show: WCC 15.2 × 10⁹/L, neutrophils 12.8 × 10⁹/L, CRP 145 mg/L, creatinine 195 μmol/L (baseline 155 μmol/L). What is the most appropriate management?
Q70
A 28-year-old woman presents to her GP with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She is otherwise well with no fever or loin pain. She is not pregnant and has no significant past medical history. Urine dipstick shows: leucocytes ++, nitrites +, blood +, protein trace. What is the most appropriate management according to current UK guidelines?
Renal & Urology UK Medical PG Practice Questions and MCQs
Question 61: A 38-year-old woman presents to the emergency department with severe generalized weakness. She reports 5 days of profuse watery diarrhoea. Blood tests reveal: sodium 138 mmol/L, potassium 2.1 mmol/L, chloride 95 mmol/L, bicarbonate 32 mmol/L, urea 8.2 mmol/L, creatinine 95 μmol/L, magnesium 0.55 mmol/L. ECG shows flattened T waves, prominent U waves, and prolonged QT interval. What is the most appropriate initial management?
A. Oral potassium supplementation 24 mmol three times daily
B. Intravenous calcium gluconate followed by potassium replacement
C. Intravenous potassium chloride infusion without magnesium supplementation
D. Immediate haemodialysis
E. Intravenous potassium chloride infusion with cardiac monitoring, and intravenous magnesium replacement (Correct Answer)
Explanation: ***Intravenous potassium chloride infusion with cardiac monitoring, and intravenous magnesium replacement*** - The patient has **severe hypokalaemia** (2.1 mmol/L) with **cardiac manifestations** (flattened T waves, prominent U waves, prolonged QT interval), necessitating urgent **intravenous replacement** and continuous **ECG monitoring** due to the high risk of arrhythmias. - Concurrent **hypomagnesaemia** (0.55 mmol/L) must be corrected simultaneously, as magnesium is a necessary cofactor for **renal potassium reabsorption**; without it, potassium wasting continues and hypokalaemia becomes **refractory to treatment**.*Oral potassium supplementation 24 mmol three times daily* - **Oral replacement** is inadequate and too slow for **severe hypokalaemia** (<2.5 mmol/L) or when **ECG changes** are present, as it does not raise serum levels rapidly enough to mitigate life-threatening arrhythmia risk. - This approach also fails to address the significant **magnesium deficiency**, which is crucial for effective potassium repletion and preventing ongoing renal potassium losses.*Intravenous calcium gluconate followed by potassium replacement* - **Calcium gluconate** is indicated for immediate myocardial stabilization in **hyperkalaemia**, not hypokalaemia, and has no role in treating low potassium or magnesium levels. - While potassium replacement is needed, starting with calcium gluconate is inappropriate and could potentially worsen certain cardiac rhythms in a hypokalaemic state.*Intravenous potassium chloride infusion without magnesium supplementation* - Administering potassium alone in the presence of **hypomagnesaemia** is often **ineffective** because magnesium deficiency leads to increased **renal potassium excretion** via the ROMK channels in the distal tubule. - Failure to correct magnesium simultaneously increases the risk of **persistent hypokalaemia**, ongoing cardiac arrhythmias, and makes the potassium repletion attempt inefficient.*Immediate haemodialysis* - **Haemodialysis** is an emergent treatment for severe **hyperkalaemia**, refractory fluid overload, or acute renal failure, where the goal is to remove substances from the blood. - In this case, the patient is experiencing electrolyte *deficits* (hypokalaemia, hypomagnesaemia) due to severe diarrhoea, requiring **replacement** rather than removal.
Question 62: A 52-year-old woman with type 1 diabetes for 30 years attends her annual diabetic review. Her blood pressure is 142/88 mmHg. Blood tests show: HbA1c 68 mmol/mol (8.4%), creatinine 115 μmol/L (eGFR 48 mL/min/1.73m²), potassium 4.5 mmol/L. Urine albumin:creatinine ratio is 28 mg/mmol (previous result 6 months ago was 26 mg/mmol). What is the classification of her chronic kidney disease?
A. CKD G3bA3
B. CKD G3aA3 (Correct Answer)
C. CKD G3aA2
D. CKD G2A2
E. CKD G3aA1
Explanation: ***CKD G3aA2*** (Note: The provided answer key in the source prompt suggests G3aA3, but technically 26-28 mg/mmol falls under category A2). - The patient's **eGFR is 48 mL/min/1.73m²**, which falls specifically into the **G3a category** (45–59 mL/min/1.73m²). - Her persistent **Urine Albumin:Creatinine Ratio (ACR)** of 28 mg/mmol is within the 3–30 mg/mmol range, defined as **category A2** (moderately increased albuminuria). *CKD G3bA3* - Category **G3b** requires an eGFR between 30–44 mL/min/1.73m², which is lower than this patient's calculated value. - Category **A3** (severely increased albuminuria) is defined by an ACR of **>30 mg/mmol**. *CKD G3aA3* - While the GFR category is correct, the patient's ACR of 28 mg/mmol does not meet the **A3 threshold** of >30 mg/mmol. - This stage would signify a higher risk of **progression to end-stage renal disease** than what her current labs indicate. *CKD G2A2* - Category **G2** is defined by an eGFR of 60–89 mL/min/1.73m², which indicates much better renal function than her eGFR of 48. - This classification would underestimate the severity of her **diabetic nephropathy**. *CKD G3aA1* - Category **A1** is defined as an ACR of **<3 mg/mmol**, representing normal to mildly increased albuminuria. - With an ACR of 28 mg/mmol, she has significant **microalbuminuria**, placing her well above the A1 cutoff.
Question 63: A 76-year-old man with benign prostatic hyperplasia presents with a 6-hour history of inability to pass urine and severe suprapubic pain. On examination, there is a palpable bladder reaching to the umbilicus. Urethral catheterization is attempted but fails. His observations are stable. What is the most appropriate next step in management?
A. Intravenous furosemide to promote diuresis
B. Repeated attempts at urethral catheterization with different sized catheters
C. Suprapubic catheter insertion (Correct Answer)
D. Urgent transurethral resection of prostate
E. Trial of tamsulosin and wait for spontaneous voiding
Explanation: ***Suprapubic catheter insertion***- When **urethral catheterization fails** in a patient with **acute urinary retention**, a suprapubic catheter is the gold standard for immediate **bladder decompression**.- This procedure provides rapid symptomatic relief and prevents complications like **obstructive uropathy** or bladder wall ischemia without further traumatizing the urethra.*Intravenous furosemide to promote diuresis*- Administering a **loop diuretic** is contraindicated here as it would increase urine production and worsen the **suprapubic pain** and bladder distension.- It does nothing to resolve the **anatomical or functional obstruction** caused by the benign prostatic hyperplasia.*Repeated attempts at urethral catheterization with different sized catheters*- Multiple failed attempts increase the risk of **urethral trauma**, significant bleeding, and the creation of a **false passage**.- Persistence is discouraged after initial failure by an experienced clinician; alternative drainage methods must be sought to avoid permanent **urethral strictures**.*Urgent transurethral resection of prostate*- **TURP** is a definitive surgical treatment for BPH but is not performed as an **emergency procedure** during a state of acute retention.- The primary goal in the acute setting is **bladder drainage** and patient stabilization, with surgery considered only after a formal workup.*Trial of tamsulosin and wait for spontaneous voiding*- **Alpha-blockers** like tamsulosin take time to work and are used to facilitate a **Trial Without Catheter (TWOC)** only after the bladder has been successfully drained.- Leaving a patient in acute retention while waiting for medication to take effect is inappropriate and risks **renal failure** and severe distress.
Question 64: A 67-year-old woman presents with progressive ankle swelling and frothy urine. Blood tests reveal: creatinine 98 μmol/L, albumin 18 g/L, cholesterol 9.2 mmol/L, triglycerides 4.5 mmol/L. Urine protein:creatinine ratio is 520 mg/mmol. Renal biopsy shows thickened glomerular basement membrane with subepithelial deposits on electron microscopy and positive anti-phospholipase A2 receptor antibodies. What is the most likely diagnosis?
A. Primary membranous nephropathy (Correct Answer)
B. Minimal change disease
C. Focal segmental glomerulosclerosis
D. IgA nephropathy
E. Membranoproliferative glomerulonephritis
Explanation: ***Primary membranous nephropathy*** - The presence of **anti-phospholipase A2 receptor (PLA2R) antibodies** is highly specific for the primary form of this disease and is a definitive diagnostic marker. - Histology showing **thickened glomerular basement membrane** and **subepithelial deposits** on electron microscopy confirms this diagnosis in the context of nephrotic syndrome. *Minimal change disease* - This condition typically shows **normal light microscopy** and only displays **podocyte foot process effacement** on electron microscopy. - It is the most common cause of nephrotic syndrome in **children**, whereas this patient is an older adult. *Focal segmental glomerulosclerosis* - Biopsy would reveal **segmental sclerosis** (scarring) in some, but not all, glomeruli rather than uniform membrane thickening. - It is not associated with **anti-PLA2R antibodies**, which are the hallmark of primary membranous disease. *IgA nephropathy* - Typically presents with **synpharyngitic macroscopic haematuria** (nephritic syndrome) rather than full-blown nephrotic syndrome with massive proteinuria. - Diagnosis requires **immunofluorescence** showing **IgA deposits** in the mesangium, not subepithelial deposits. *Membranoproliferative glomerulonephritis* - Characterized by **mesangial hypercellularity** and a **"tram-track" appearance** due to duplication of the glomerular basement membrane. - It often presents with a mixed **nephritic/nephrotic picture** and is frequently associated with low complement levels or chronic infections like Hepatitis C.
Question 65: A 58-year-old man with chronic kidney disease stage 5 (eGFR 12 mL/min/1.73m²) secondary to diabetes is being prepared for renal replacement therapy. His blood tests show: haemoglobin 88 g/L, ferritin 450 μg/L, transferrin saturation 35%, calcium 2.15 mmol/L, phosphate 2.1 mmol/L, bicarbonate 18 mmol/L, potassium 5.2 mmol/L. Blood pressure is 168/95 mmHg on ramipril 10 mg and amlodipine 10 mg. What is the target haemoglobin range for erythropoiesis-stimulating agent (ESA) therapy in this patient?
A. 100-120 g/L (Correct Answer)
B. 110-130 g/L
C. 120-140 g/L
D. 90-110 g/L
E. 130-150 g/L
Explanation: ***100-120 g/L***- According to **NICE** and **KDIGO** guidelines, the target haemoglobin for patients with **Chronic Kidney Disease (CKD)** on ESA therapy is **100-120 g/L**.- This range balances the improvement of **quality of life** and symptoms while minimizing the risk of **cardiovascular complications** like stroke or thrombosis.*110-130 g/L*- This range is too high; clinical trials like **CHOIR** and **CREATE** showed that targeting these levels increases the risk of **hypertension** and **vascular access thrombosis**.- Targets above 120 g/L do not provide additional survival benefits and may correlate with a higher **mortality rate** in CKD patients.*120-140 g/L*- Aiming for near-normal haemoglobin levels in renal failure is discouraged as it significantly increases the risk of **malignancy progression** and **stroke**.- Large trials like **TREAT** demonstrated that targets in this range lead to a higher incidence of **cardiovascular events** in diabetic CKD patients.*90-110 g/L*- While the lower limit of 100 g/L is acceptable for initiation, a target range including 90 g/L is generally too low and may leave the patient with **hypoxic symptoms** and **reduced exercise tolerance**.- ESA therapy is typically initiated when haemoglobin falls below **100 g/L** to prevent the need for **blood transfusions**, but the target range for maintenance is higher to optimize patient well-being.*130-150 g/L*- This represents a **normal physiological range** for healthy adults but is dangerously high for patients with CKD receiving **ESA therapy**.- Attempting to reach these levels can cause blood **hyperviscosity**, making the patient highly susceptible to **thromboembolic events** and **increased mortality**.
Question 66: A 42-year-old woman with systemic lupus erythematosus presents with fatigue and ankle swelling. Blood tests show: creatinine 145 μmol/L, albumin 22 g/L, cholesterol 7.8 mmol/L. Urine protein:creatinine ratio is 450 mg/mmol. Renal biopsy shows diffuse proliferative glomerulonephritis (Class IV lupus nephritis) with active lesions. What is the most appropriate initial immunosuppressive therapy?
A. Intravenous cyclophosphamide or mycophenolate mofetil plus corticosteroids (Correct Answer)
B. Rituximab monotherapy
C. Oral prednisolone alone at high dose
D. Azathioprine plus low-dose corticosteroids
E. Ciclosporin plus hydroxychloroquine
Explanation: ***Intravenous cyclophosphamide or mycophenolate mofetil plus corticosteroids***
- The patient's presentation with **Class IV lupus nephritis** with **active lesions**, significant **proteinuria**, and signs of **nephrotic syndrome** (low albumin, high cholesterol, ankle swelling) indicates severe renal involvement requiring aggressive induction therapy.
- Current guidelines (EULAR/ERA-EDTA, KDIGO) recommend **high-dose corticosteroids** combined with either **intravenous cyclophosphamide** or **mycophenolate mofetil (MMF)** as first-line induction agents for such severe disease to induce remission and preserve renal function.
*Rituximab monotherapy*
- **Rituximab** is generally reserved for **refractory lupus nephritis** or as an **add-on therapy** for patients who do not respond adequately to standard induction regimens, rather than as initial monotherapy.
- Evidence does not support **rituximab monotherapy** as a superior initial induction strategy for severe **Class IV lupus nephritis** compared to established regimens.
*Oral prednisolone alone at high dose*
- While **corticosteroids** are essential for reducing inflammation in lupus nephritis, **high-dose prednisolone alone** is insufficient to achieve remission in aggressive **diffuse proliferative (Class IV)** disease.
- Relying solely on **steroid monotherapy** for severe lupus nephritis significantly increases the risk of **treatment failure**, progressive renal damage, and steroid-related side effects without adequate disease control.
*Azathioprine plus low-dose corticosteroids*
- **Azathioprine** is a less potent immunosuppressant compared to cyclophosphamide or MMF and is primarily used as **maintenance therapy** for lupus nephritis after remission has been achieved.
- It is **inadequate for initial induction therapy** in patients with active, severe **Class IV lupus nephritis** due to its slower onset of action and lower efficacy in controlling acute inflammation.
*Ciclosporin plus hydroxychloroquine*
- **Ciclosporin**, a calcineurin inhibitor, is often used for **Class V (membranous)** lupus nephritis, especially for proteinuria, or as an alternative in Class III/IV patients intolerant to other agents; it's not a primary choice for active proliferative lesions.
- **Hydroxychloroquine** is a fundamental long-term medication for all SLE patients for disease control but is **not potent enough** to induce remission in severe **active Class IV lupus nephritis**.
Question 67: Which of the following medications should be temporarily discontinued in a patient presenting with acute kidney injury secondary to dehydration?
A. Ramipril, metformin, and ibuprofen (Correct Answer)
B. Bisoprolol, clopidogrel, and omeprazole
C. Levothyroxine, sertraline, and paracetamol
D. Amlodipine, atorvastatin, and aspirin
E. Warfarin, digoxin, and furosemide
Explanation: ***Ramipril, metformin, and ibuprofen***
- **ACE inhibitors** (Ramipril) and **NSAIDs** (Ibuprofen) worsen AKI by disrupting renal autoregulation: Ramipril reduces efferent arteriolar tone, decreasing **glomerular filtration pressure**, while Ibuprofen inhibits vasodilatory **prostaglandins**, leading to afferent arteriolar constriction and reduced renal blood flow.
- **Metformin** is primarily renally cleared; in AKI, its accumulation significantly increases the risk of **lactic acidosis**, a severe metabolic complication, necessitating temporary discontinuation.
*Bisoprolol, clopidogrel, and omeprazole*
- **Beta-blockers** like Bisoprolol are generally not nephrotoxic and can be continued in AKI unless the patient is severely **hypotensive** or bradycardic.
- **Clopidogrel** (antiplatelet) and **Omeprazole** (proton pump inhibitor) do not directly affect renal hemodynamics or function and are typically not withheld in AKI.
*Levothyroxine, sertraline, and paracetamol*
- **Levothyroxine** and **Sertraline** are not known to be nephrotoxic and do not exacerbate AKI secondary to dehydration, so their continuation is usually safe.
- **Paracetamol** (acetaminophen) is a safe analgesic choice in patients with renal impairment as it does not impair renal prostaglandin synthesis like NSAIDs.
*Amlodipine, atorvastatin, and aspirin*
- **Calcium channel blockers** (Amlodipine) and **Statins** (Atorvastatin) are generally not harmful to the kidneys and do not require discontinuation in dehydration-induced AKI.
- Low-dose **cardioprotective aspirin** is typically continued in AKI, as its systemic anti-inflammatory effects are minimal and do not significantly compromise renal function, unlike high-dose NSAIDs.
*Warfarin, digoxin, and furosemide*
- **Warfarin** does not cause AKI, but its monitoring may need adjustment; **Digoxin** requires dose reduction in AKI due to renal excretion but is not always discontinued.
- While **furosemide** (a diuretic) should be stopped in dehydration to prevent further volume depletion, this option is less comprehensive than the 'sick day rules' medications (ACEI, NSAIDs, Metformin) in the correct option.
Question 68: A 35-year-old man presents to the emergency department with sudden onset severe left-sided loin to groin pain. CT KUB confirms a 4 mm stone in the left distal ureter with mild hydronephrosis. He is afebrile with normal observations apart from pain. Creatinine is 82 μmol/L. He has been given diclofenac 75 mg IM with good pain relief. What is the most appropriate ongoing management advice?
A. Medical expulsive therapy with tamsulosin 400 micrograms once daily (Correct Answer)
B. Urgent ureteroscopy within 48 hours
C. Extracorporeal shockwave lithotripsy within 1 week
D. Admit for intravenous antibiotics and observation
E. Percutaneous nephrolithotomy within 2 weeks
Explanation: ***Medical expulsive therapy with tamsulosin 400 micrograms once daily*** - In patients with an uncomplicated **distal ureteric stone <5 mm** and no signs of infection or acute renal failure, **medical expulsive therapy (MET)** with an alpha-blocker is the most appropriate first-line management.- **Tamsulosin**, an alpha-blocker, works by relaxing the smooth muscle in the distal ureter, thereby facilitating **spontaneous stone passage** and reducing pain. *Urgent ureteroscopy within 48 hours* - **Ureteroscopy** is an invasive procedure typically reserved for larger stones (generally **>10 mm**), stones resistant to MET, or cases with complications like severe hydronephrosis, infection, or uncontrolled pain.- This patient has a **small 4 mm stone** and is clinically stable with good pain control, making urgent ureteroscopy an overaggressive initial approach. *Extracorporeal shockwave lithotripsy within 1 week* - **Extracorporeal shockwave lithotripsy (ESWL)** is a non-invasive procedure used for certain kidney and ureteric stones, but it is typically not the **initial management** for a small, uncomplicated distal ureteric stone.- For a 4 mm stone, the probability of spontaneous passage with MET is high, making conservative treatment preferable before considering ESWL. *Admit for intravenous antibiotics and observation* - **Admission for intravenous antibiotics** is primarily indicated in cases of **obstructed pyelonephritis** or **urosepsis**, evidenced by fever, leukocytosis, or other signs of infection along with obstruction.- This patient is **afebrile** with normal observations and a normal creatinine, indicating no acute infection or renal compromise requiring hospital admission or IV antibiotics. *Percutaneous nephrolithotomy within 2 weeks* - **Percutaneous nephrolithotomy (PCNL)** is a major surgical intervention reserved for very **large renal stones** (typically **>20 mm**) or complex **staghorn calculi**.- It is an inappropriate and overly invasive procedure for a **4 mm distal ureteric stone** which has a high chance of spontaneous passage or management with less invasive methods.
Question 69: A 45-year-old man with autosomal dominant polycystic kidney disease and chronic kidney disease stage 3b (eGFR 38 mL/min/1.73m²) presents with severe right-sided loin pain radiating to the groin. CT KUB shows a 7 mm calculus in the right mid-ureter with moderate hydronephrosis. His observations are: temperature 38.2°C, BP 145/88 mmHg, pulse 98 bpm. Blood tests show: WCC 15.2 × 10⁹/L, neutrophils 12.8 × 10⁹/L, CRP 145 mg/L, creatinine 195 μmol/L (baseline 155 μmol/L). What is the most appropriate management?
A. Urgent urological referral for nephrostomy or ureteric stenting within 24 hours (Correct Answer)
B. Analgesia and medical expulsive therapy with tamsulosin
C. Immediate emergency ureteroscopy and stone extraction
D. Intravenous antibiotics and elective stone treatment in 2-4 weeks
E. Extracorporeal shockwave lithotripsy (ESWL) within 48 hours
Explanation: ***Urgent urological referral for nephrostomy or ureteric stenting within 24 hours***- This patient presents with an **obstructed infected kidney** (obstructive pyelonephritis), evidenced by a stone, **fever (38.2°C)**, high CRP/WCC, and worsening renal function.- This is a **urological emergency** that requires urgent **surgical decompression** via nephrostomy or stenting to prevent sepsis and irreversible kidney damage.*Analgesia and medical expulsive therapy with tamsulosin*- Conservative management is only suitable for small, **uncomplicated stones** in patients who are hemodynamically stable and without infection.- Medical expulsive therapy is contraindicated here due to the presence of **systemic infection** and acute kidney injury.*Immediate emergency ureteroscopy and stone extraction*- Performing primary ureteroscopy in the presence of active infection is dangerous as it can trigger **life-threatening sepsis** by pushing bacteria into the bloodstream.- The priority is **drainage** first; definitive stone removal should only be performed once the patient is stable and the infection has cleared.*Intravenous antibiotics and elective stone treatment in 2-4 weeks*- Antibiotics alone cannot penetrate an **obstructed system** effectively and will fail to resolve the underlying source of infection.- Delaying decompression in the setting of **obstructive pyelonephritis** significantly increases the risk of mortality and severe renal failure.*Extracorporeal shockwave lithotripsy (ESWL) within 48 hours*- ESWL is contraindicated in the presence of an **active urinary tract infection** and is not the treatment of choice for an obstructing ureteric stone with sepsis.- In patients with **ADPKD**, ESWL carries additional risks such as the potential rupture of renal cysts and perinephric hematoma.
Question 70: A 28-year-old woman presents to her GP with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She is otherwise well with no fever or loin pain. She is not pregnant and has no significant past medical history. Urine dipstick shows: leucocytes ++, nitrites +, blood +, protein trace. What is the most appropriate management according to current UK guidelines?
A. Send urine for microscopy, culture and sensitivity before treatment
B. Prescribe trimethoprim 200 mg twice daily for 3 days
C. Prescribe nitrofurantoin 100 mg modified-release twice daily for 3 days (Correct Answer)
D. Prescribe ciprofloxacin 500 mg twice daily for 7 days
E. Advise increased fluid intake and simple analgesia only
Explanation: ***Prescribe nitrofurantoin 100 mg modified-release twice daily for 3 days***
- In the UK, **nitrofurantoin** is the recommended first-line empirical treatment for **uncomplicated lower urinary tract infections (UTI)** in non-pregnant women due to low resistance rates of E. coli.
- A **3-day course** is sufficient for acute cystitis in women, providing a balance between clinical cure and minimizing potential side effects.
*Send urine for microscopy, culture and sensitivity before treatment*
- Routine **urine culture** is not indicated for non-pregnant women with **uncomplicated cystitis** and a positive dipstick; it is reserved for treatment failure, pregnancy, or suspected pyelonephritis.
- Management can be initiated based on **symptoms and dipstick** (positive nitrites and leucocytes) to avoid unnecessary delays and costs.
*Prescribe trimethoprim 200 mg twice daily for 3 days*
- While previously a first-line option, **trimethoprim** is now generally considered second-line or an alternative if there is a **low risk of resistance** (e.g., previous culture indicates sensitivity).
- High rates of **bacterial resistance** to trimethoprim in many UK regions make nitrofurantoin the preferred choice for empirical therapy.
*Prescribe ciprofloxacin 500 mg twice daily for 7 days*
- **Fluoroquinolones** like ciprofloxacin should be avoided in uncomplicated UTIs due to significant **side effects** (tendonitis/aortic aneurysm) and antimicrobial stewardship concerns.
- This agent is reserved for **complicated UTIs**, acute **pyelonephritis**, or cases where other antibiotics are not suitable.
*Advise increased fluid intake and simple analgesia only*
- Although **self-care advice** is a helpful adjunct, antibiotics are indicated here because the patient is symptomatic with a **positive dipstick** (leucocytes and nitrites).
- Delayed prescribing may be considered for mild symptoms, but standard practice for clear acute **cystitis** is a short-course antibiotic to reduce morbidity.
