Specialist & Consultant Nephrology oral assessment prep

Knowledge: This is life-threatening hyperkalaemia with ECG changes and bradycardia, and he is at immediate risk of cardiac arrest. Calcium protects the myocardium within minutes but does not lower potassium. Insulin with glucose and nebulised salbutamol shift potassium into cells for a few hours. Only dialysis removes potassium definitively in an anuric patient, so the 5-hour delay is unsafe. Missed dialysis also brings fluid overload, acidosis and uraemia. Sodium bicarbonate has a limited role unless he has severe acidosis. Newer potassium binders such as sodium zirconium cyclosilicate act too slowly to replace dialysis.

Management: I would place him on continuous cardiac monitoring with defibrillator pads attached. I would give 30 mL of 10% calcium gluconate intravenously over 10 minutes and repeat the ECG, repeating the dose if changes persist. I would give 10 units of soluble insulin with 25 g of glucose intravenously and monitor glucose closely for at least 6 hours. I would add salbutamol 10 to 20 mg by nebuliser if there is no tachyarrhythmia. I would speak to the on-call nephrology consultant and dialysis unit directly to obtain emergency dialysis within the hour. If bradycardia worsens, I would treat it with atropine or pacing support. I would recheck potassium after treatment and after dialysis for rebound. Before discharge, I would review his diet, binders and dialysis schedule.

Ethics and communication: I would avoid blaming him and explore why sessions were missed, including work pressure and transport. With his consent, I would involve the social worker and, if needed, write to his employer about his medical needs. I would not disclose his diagnosis to the employer without his agreement. I would document the advice and the agreed schedule.

Reference: UK Kidney Association Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults; Comprehensive Clinical Nephrology, 7th edition

Knowledge: This is MPO-ANCA associated vasculitis with rapidly progressive glomerulonephritis and probable diffuse alveolar haemorrhage. Both organs are in danger, and the lung haemorrhage is the more immediate threat to life. Anti-GBM disease is excluded by serology, but double-positive disease and infection should still be considered. A kidney biopsy confirms the diagnosis and shows chronicity, but treatment should not wait for it. KDIGO 2024 recommends glucocorticoids with either rituximab or cyclophosphamide for induction. Plasma exchange is not routine, but it should be considered with creatinine above 300 micromol/L, dialysis need, a rapidly rising creatinine or alveolar haemorrhage with hypoxaemia. A reduced-dose glucocorticoid regimen lowers infection risk without reducing efficacy.

Management: I would admit him to a high-dependency or intensive care setting with respiratory monitoring. I would start pulsed intravenous methylprednisolone, for example 500 mg daily for 3 days, after blood and sputum cultures. I would then use a reduced-dose oral prednisolone taper. I would start rituximab or intravenous cyclophosphamide, choosing based on age, fertility and prior exposure. Given his creatinine and hypoxaemia, I would discuss plasma exchange with the team and the patient. I would arrange a kidney biopsy once safe and screen for hepatitis B, hepatitis C, HIV and latent tuberculosis. I would start Pneumocystis prophylaxis and gastric protection, and monitor for dialysis need. Later, I would plan maintenance with rituximab.

Ethics and communication: I would explain the seriousness and the uncertain kidney outcome honestly. Consent for immunosuppression must cover infection, infertility and malignancy risks. I would record the shared decision about plasma exchange, since the evidence is mixed. If he needs dialysis, I would explain that kidney recovery is possible but not guaranteed.

Reference: KDIGO 2024 Clinical Practice Guideline for the Management of Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis; Comprehensive Clinical Nephrology, 7th edition

Knowledge: Rising creatinine, new proteinuria, low tacrolimus levels and a new donor-specific antibody strongly suggest active antibody-mediated rejection. T-cell mediated rejection, BK virus nephropathy, calcineurin inhibitor toxicity, obstruction and recurrent disease are differentials. A kidney biopsy, read using the Banff classification, confirms the diagnosis. Non-adherence is a leading cause of late antibody-mediated rejection. DQ antibodies are commonly linked with chronic antibody-mediated damage. Treatment evidence for antibody-mediated rejection is limited, and outcomes depend on early treatment and restored immunosuppression. De novo donor-specific antibodies after a period of under-immunosuppression predict poorer long-term graft survival.

Management: I would arrange an urgent ultrasound and a transplant biopsy. I would check BK virus PCR, urine culture, repeat drug levels and look for drug interactions or diarrhoea affecting absorption. I would hold off escalating immunosuppression until the biopsy result is known, unless he deteriorates rapidly. If active antibody-mediated rejection is confirmed, I would give pulsed methylprednisolone and start plasma exchange with intravenous immunoglobulin. I would discuss rituximab, while noting the weak evidence. I would raise tacrolimus to target and consider a once-daily formulation that suits his shifts. I would involve a transplant pharmacist and arrange reminder tools. I would monitor creatinine, levels and donor-specific antibodies regularly. I would also plan long-term follow-up for infection and cancer risk.

Ethics and communication: I would discuss adherence without blame, recognising that shift work and cost are real barriers. I would explain the risk to the graft honestly. I would not share his adherence with his brother without his consent, even though the brother was the donor. Cost barriers may need help from the social worker or insurer, and I would advocate for him. I would document the discussion and treatment consent.

Reference: KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients, 2009; Banff Classification of Allograft Pathology

Knowledge: The picture favours a lupus nephritis flare: low complement, rising anti-dsDNA, red cell casts and rising proteinuria. A low sFlt-1/PlGF ratio makes pre-eclampsia unlikely in the short term, although the two can coexist and need different treatment. Pre-eclampsia is uncommon before 20 weeks and does not usually cause red cell casts or falling complement. A kidney biopsy is reasonable before about 28 weeks if the result would change treatment. Mycophenolate, cyclophosphamide and ACE inhibitors or ARBs are unsafe in pregnancy. Azathioprine, hydroxychloroquine, tacrolimus and glucocorticoids are compatible with pregnancy. Active nephritis raises the risks of fetal loss, preterm birth, growth restriction and superimposed pre-eclampsia.

Management: I would admit her for assessment under a joint team of nephrology, rheumatology and maternal-fetal medicine. I would control blood pressure with labetalol or nifedipine, aiming for a target around 135/85 mmHg. I would continue hydroxychloroquine, azathioprine and low-dose aspirin. I would discuss a kidney biopsy now, while it is still technically safe, if the diagnosis remains unclear. If a flare is confirmed, I would give pulsed methylprednisolone, then oral prednisolone tapered to the lowest effective dose. I would add tacrolimus if proteinuria does not respond, with regular trough levels. If she becomes nephrotic, I would add prophylactic low molecular weight heparin. I would arrange regular fetal growth scans, repeat sFlt-1/PlGF testing, and plan delivery timing with the obstetric team.

Ethics and communication: I would explain the risks to her and her baby honestly, including uncertainty about the biopsy and treatment. Drug safety in pregnancy is a common worry, so I would give clear information and written material. If she wishes, I would involve her husband in discussions, but the consent is hers. Decisions about delivery belong to her, guided by the team. I would document each consent and the multidisciplinary plan.

Reference: KDIGO 2024 Clinical Practice Guideline for the Management of Lupus Nephritis; EULAR Recommendations for Women's Health and the Management of Family Planning, Assisted Reproduction, Pregnancy and Menopause in Patients with SLE and/or APS, 2017

Knowledge: This is metformin-associated lactic acidosis, with acute kidney injury from dehydration stopping metformin clearance and allowing it to accumulate. Sepsis, mesenteric ischaemia, hepatic failure and toxic alcohols must still be excluded as causes of high-lactate acidosis. Severe acidosis with shock carries a high mortality. The EXTRIP workgroup recommends extracorporeal treatment for pH at or below 7.0, lactate above 20 mmol/L, shock, decreased consciousness or failure of supportive care. She meets several of these criteria. Intermittent haemodialysis is preferred because it removes metformin and corrects acidosis quickly, and continuous therapy is an alternative if she is too unstable. Bicarbonate alone does not remove the drug and can worsen fluid overload.

Management: I would stop metformin and transfer her to intensive care for resuscitation. I would give balanced fluids and start noradrenaline if hypotension persists, after taking blood cultures and a stool culture. I would request a CT if abdominal pain suggests ischaemia. I would place a dialysis catheter and start urgent haemodialysis, or continuous therapy if she cannot tolerate it. I would continue it until lactate is below about 3 mmol/L and pH above 7.35. Metformin redistributes from tissues, so I would recheck lactate after each session for rebound. I would review all her medications, including ACE inhibitors, diuretics and NSAIDs. Before discharge, I would give written sick-day advice about pausing these drugs during vomiting or diarrhoea.

Ethics and communication: I would explain to her and her family what happened and why. I would check whether sick-day advice was ever given, and if not, I would say so honestly and report it as a learning event. I would inform her general practitioner so that her prescriptions are reviewed. I would document the advice given at discharge.

Reference: EXTRIP Workgroup: Extracorporeal Treatment for Metformin Poisoning, Systematic Review and Recommendations, 2015; Comprehensive Clinical Nephrology, 7th edition

Knowledge: A request to stop dialysis needs careful assessment of capacity, mood and reasons, because depression is common in dialysis patients and treatable. Pain, poor sleep, itch, breathlessness and dialysis-related fatigue may also be driving his view. His prognosis on dialysis is poor given his heart failure, amputations and repeated admissions. Without dialysis, survival is usually days to a few weeks, depending on residual function. Conservative kidney care, with palliative support, focuses on symptom control and quality of life. End-of-life decisions in the UAE must follow the medical liability law, its executive regulation and facility policy, and I would not assume the legal position from other countries.

Management: I would meet him privately, assess capacity formally and explore his reasons, fears and goals. I would screen for depression and treat any symptoms that might change his view. I would offer alternatives, such as shorter or less frequent sessions, as a time-limited trial. With his consent, I would hold a family meeting to share his wishes and hear the sons' concerns. I would involve palliative care early. Before any change in treatment, I would seek advice from the hospital ethics committee and legal team, in line with UAE law and facility policy. I would agree a written plan covering symptoms, place of care and resuscitation status. I would review the decision regularly, as he may change his mind.

Ethics and communication: A competent adult has the right to be fully informed and to refuse treatment, and I would respect his wishes within the law. I would avoid pressuring him either way. I would support the sons, acknowledge their grief, and explain gently that the decision is his. I would document capacity, the discussions and the agreed plan carefully.

Reference: Renal Physicians Association Clinical Practice Guideline: Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, 2nd edition, 2010; Federal Decree-Law No. 4 of 2016 on Medical Liability