Acute Kidney Injury and Glomerular Diseases — WACS Viva & Clinical Scenarios (Nephrology)

Exam-style acute kidney injury and glomerular diseases viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: A 34-year-old male presents to the emergency department with a 5-day history of high-grade fever, chills, jaundice, and marked oliguria following untreated Plasmodium falciparum malaria and ingestion of traditional herbal concoctions. Clinical examination reveals blood pressure of 90/60 mmHg, heart rate of 118 beats per minute, respiratory rate of 28 breaths per minute, dry mucous membranes, and bilateral flank fullness without palpable bladder enlargement. Laboratory investigations show serum creatinine of 580 µmol/L (baseline presumed normal), blood urea nitrogen of 32 mmol/L, serum potassiu
• SCENARIO 2: A 28-year-old female presents with progressive generalized body swelling, facial puffiness, and frothy urine over 6 weeks. Physical examination confirms anasarca, blood pressure of 145/90 mmHg, and absence of jugular venous distension. Laboratory workup reveals 24-hour urinary protein excretion of 6.8 g, serum albumin of 18 g/L, total serum cholesterol of 9.2 mmol/L, and serum creatinine of 88 µmol/L. Serology is reactive for Hepatitis B surface antigen (HBsAg) with high viral load, while HIV and HCV screening tests are negative.
• SCENARIO 3: A 42-year-old woman presents with macroscopic haematuria, exertional breathlessness, cough with mild haemoptysis, and declining urine output over two weeks. Examination reveals blood pressure of 165/100 mmHg, bilateral basal crackles, and purpuric cutaneous lesions over both lower limbs. Urinalysis reveals 3+ blood and 2+ protein; urine microscopy demonstrates dysmorphic red blood cells (acanthocytes) and red cell casts. Serum creatinine has risen from 140 µmol/L on admission to 380 µmol/L over 72 hours.
• SCENARIO 4: A 24-year-old female known to have Systemic Lupus Erythematosus (SLE) presents with worsening pedal oedema, malar rash, and active inflammatory synovitis. Laboratory evaluation shows serum creatinine of 210 µmol/L, 24-hour urine protein of 3.8 g, active urinary sediment with red cell casts, markedly reduced complement C3 and C4 levels, and highly elevated anti-dsDNA titres. A percutaneous renal biopsy demonstrates diffuse endocapillary and extracapillary proliferation involving 70% of glomeruli with extensive subendothelial immune deposits and cellular crescents.
• SCENARIO 5: A 19-year-old male with sickle cell anaemia (HbSS) experiences a severe vaso-occlusive and haemolytic crisis following an acute febrile illness. Within 48 hours, he develops profound dark brown (coca-cola coloured) urine, muscular tenderness, and oliguria. Urinalysis dipstick is strongly positive for blood/haemoglobin, but centrifuged urine sediment reveals fewer than 2 red blood cells per high-power field. Serum creatine kinase is 28,000 U/L, total bilirubin is 120 µmol/L (predominantly unconjugated), serum potassium is 6.2 mmol/L, and serum creatinine is 420 µmol/L.