A 22 year-old man is referred to clinic with refractory hypertension.

Potassium 2.7mmol/l
Other U&E, FBC, calcium and LFTs are normal. Which would be the most
appropriate next investigation?
CT abdomen
MR angiography renal tract
24 hour urinary catecholamines
USS abdomen
Plasma renin and aldosterone levels
A: E
The differential for hypertension with low potassium includes Conn's, Cushing's,
renal artery stenosis and Liddle's. The first step in this case should be further
simple investigations. Quantifying the renin and angiotensin levels will help to
distinguish the cause here, before going on to more specialised tests.
Cushing's and Conn's would be associated with a high aldosterone and a low
renin, renal artery stenosis would be associated with a high renin and aldosterone,
Liddle's is associated with a low renin and aldosterone.
Hypokalaemia and hypertension
For exams it is useful to be able to classify the causes of hypokalaemia in to those
associated with hypertension, and those which are not
Hypokalaemia with hypertension
Cushing's syndrome
Conn's syndrome (primary hyperaldosteronism)
Liddle's syndrome
11-beta hydroxylase deficiency*
Carbenoxolone, an anti-ulcer drug, and liquorice excess can potentially
cause hypokalaemia associated with hypertension
Hypokalaemia without hypertension
diuretics
GI loss (e.g. Diarrhoea, vomiting)

renal tubular acidosis (type 1 and 2**)

Bartter's syndrome
Gitelman syndrome
*21-hydroxylase deficiency, which accounts for 90% of congenital adrenal
hyperplasia cases, is not associated with hypertension
**type 4 renal tubular acidosis is associated with hyperkalaemia
A 62-year-old man is seen in renal transplant clinic. He had a cadaveric kidney
transplant 1 years ago that was initially complicated by rejection and has required
high dose immunosuppression. He has good graft function with creatinine 121
umol/l and no proteinuria. He complains of 2 stone weight loss in 2 months and
feels tired.
There is a large painless lymph node in his right axilla and a palpable node in his
left inguinal region.
Hb 8.7 g/dl
Platelets 195 * 109/l
WBC 6.7 * 109/l
Which is the most useful virology test?
BK virus
Cytomegalovirus
Epstein Barr virus
Hepatitis B
HIV
A: C
This patient has post-transplantation lymphoproliferative disorder (PTLD)
indicated by:
weight loss
anaemia
lymphadenopathy
His high dose immunosuppression have precipitated infection with EBV and
subsequent B cell proliferation. PTLD incidence is highest in the first year post-

transplantation, which is the time when immunosuppression is the most intense.

Treatment involves reducing his current immunosuppression therapy and giving
additional chemotherapy.
CMV causes systemic symptoms, colitis, pneumonitis and graft dysfunction.
BK virus causes graft dysfunction and ureteric stenosis.
You receive a call from the Biochemistry Lab. A blood sample you have taken
from a patient is reported to have a potassium level of 6.4mmol/L. What is your
first step?
Repeat the blood sample
Perform an ECG
Commence a calcium gluconate infusion
Commence an insulin/dextrose infusion
Commence a salbutamol nebuliser
A: B
Although there is no universal definition of hyperkalaemia, a serum K+ of 5.5
mmol/L is widely accepted. It can be further classified as mild (5.5-5.9 mmol/L),
moderate (6.0-6.4 mmol/L) or severe ( 6.5 mmol/L). The Renal Association1
recommend all patients with a serum K+ of 6.0 or more to undergo an urgent
ECG.
ECG changes associated with hyperkalaemia include diminished P wave
amplitude, increased T wave amplitude, PR prolongation and widened QRS
complex.
Any such changes in association with hyperkalaemia necessitate immediate
stabilisation of the myocardium with calcium gluconate/calcium chloride
infusion. The next step will be to shift K+ into cells. This is most reliably done
with an insulin infusion, together with dextrose to avoid hypoglycaemia.
Additional therapy with salbutamol can further shift K+ into cells.
---------------------------A 55-year-old woman presents for review. Her mother has just been discharged
after suffering a hip fracture. She is concerned that she may have 'inherited'

osteoporosis and is asking what she should do. She has no significant past
medical history of note, takes no regular medication and has never sustained any
fractures. She smokes around 20 cigarettes per day and drinks about 3-4 units of
alcohol per day.
What is the most appropriate course of action?
Arrange bone mineral density measurement (DEXA scan)
Reassure her that assessment of fragility fracture risk does not need to be done
until 65 years
Refer her to the genetics team for a risk assessment
Start first-line bone protection (i.e. ensure calcium/vitamin D replete + oral
bisphosphonate)
Use the FRAX tool
A: E
This lady has a number of risk factors for developing osteoporosis:
positive family history
smoking
excess alcohol intake
She should therefore have an immediate FRAX assessment, rather than waiting
until 65 years as we would for women without any relevant risk factors
FRAX
- estimates the 10-year risk of fragility fracture
- valid for patients aged 40-90 years
- based on international data so use not limited to UK patients
- assesses the following factors: age, sex, weight, height, previous fracture,
parental fracture, current smoking, glucocorticoids, rheumatoid arthritis,
secondary osteoporosis, alcohol intake
- bone mineral density (BMD) is optional, but clearly improves the accuracy of
the results. NICE recommend arranging a DEXA scan if FRAX (without
BMD) shows an intermediate result
http://www.clinmed.rcpjournal.org/content/12/Suppl_6/s2.full.pdf