2. Your next patient is a woman in her mid 30’s. She complains of patient in her lower back, radiating to her right flank and down into the groin. What else would you like to know?

3. DDx’s.

4. How will you proceed.

5. The patient asks what the stone is made of and why she got the stone.

6. From her bloods you see that her calcium is quite high. You wonder why this is.

7. Upon ultrasound the ureter is dilated, but no stone is found. Looking at the kidney there is an obvious mass, that is clearly not cystic.

8. The patient asks if it could be cancer. What tumours are found in the kidney?

9. A CT-guided biopsy is undertaken. You take the sample up to the pathologist.

11. What is her prognosis? How does this compare to the prognosis of the other RCCs?

12. The patient asks you if any of her 8 children will be at risk of cancer. Are they? What about the other types of RCC?

13. Your patient then tells you that she was considering donating a kidney to her mother who has ESRD.

14. Stage 1: kidney damage with normal or high GFR (>90) Mild CKD 6.5% prevalence Asymptomatic Stage 2: kidney damage and GFR 60-89 Stage 3: 3A – GFR 45-59 3B – GFR 30-44 Moderate CKD 4.5% prevalence Usually asymptomatic, anaemia in some patients at 3B, most are non-progressive or progress very slowly Stage 4: GFR 15-29 Severe CKD Prevalence 0.4% First symptoms often at GFR < 20. Electrolyte problems likely as GFR falls Stage 5: GFR < 15, or on dialysis Kidney failure Significant symptoms and complications usually present. Dialysis initiation varies but usually at GFR < 10

15. What are the options available to the patients mother?

16. Absolute Active malignancy – at least 2 yrs of complete remission for most tumours Active vasculitis or recent anti-GBM disease Severe heart disease Severe occlusive aorto-iliac vascular disease Relative Age – not routinely offered to 75 yo High risk of disease recurrence in the transplant kidney Disease of the lower urinary tract Significant comorbidity

18. Your patient mutters something about her mother having hyperparathyroidism and being anaemic. Explain how hyperparathyroidism can be caused by CKD. How would you manage the hyperparathyroidism. Why is she anaemic? How would you manage the anaemia.

19. CVD Acidosis Fluid and electrolyte balance Cellular and humoral immunity are impaired in CKD Infections are the 2 nd most common cause of death in dialysis patients after CVD Increased bleeding tendency – cutaneous ecchymoses, mucosal bleeds Generalised myopathy –poor nutrition, hyperparathyroidism, vit D deficiency, disorders of electrolyte metabolism Restless leg syndrome Both sexes – loss of libido, sexual function -> hyperprolactinaemia GIT – anorexia, nausea, vomiting, higher incidence of peptic ulcer disease Depression also an issue

20. Your patient mentions that her mother is diabetic. What are the other common causes of CKD. Congenital and inherited (5%) – polycystic kidney etc Renal artery stenosis (5%) Hypertension (5-20%) Glomerular diseases (10-20%) – IgA nephropathy is the most common Interstitial disease (20-30%) Systemic inflammatory disease (5-10%) – SLE, vasculitis Diabetes mellitus (20-40%) Unknown (5-20%)

21. What are the mechanisms behind diabetic nephropathy? Mesangial explansion, thickening of the GBM, glomerular scleroris (intraglomerular hypertension).

22. The mother comes in the next day in a coma. What other symptoms are associated with ESRD?

23. Pathology image recognition time