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Question 1
Incorrect
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A 75-year-old lady is referred to hospital from her GP. She has been treated for essential hypertension, with Bendroflumethiazide 2.5 mg once daily and triamterene 150 mg once daily.
Routine investigations show:
Serum sodium 134 mmol/L (137-144)
Serum potassium 5.9 mmol/L (3.5-4.9)
Serum urea 7.0 mmol/L (2.5-7.5)
Serum creatinine 100 μmol/L (60-110)
Her blood pressure is measured at 134/86 mmHg. Her electrocardiogram is normal. The GP has stopped the triamterene today.
Which of these is the most appropriate action?Your Answer: Stop bendroflumethiazide
Correct Answer: Repeat urea and electrolytes in one week
Explanation:Triamterene is a potassium-sparing diuretic that can cause hyperkalaemia, therefore, it was stopped in this patient. With all other lab results returning normal values and a normal ECG, management will simply require repeating the U & E after one week since the Triamterene has already be stopped.
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This question is part of the following fields:
- Renal System
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Question 2
Correct
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Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?
Your Answer: Cystine stones
Explanation:Only cystine stones are semi-opaque because they contain sulphur. All the other stones will appear either radio-lucent or radio-opaque.
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This question is part of the following fields:
- Renal System
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Question 3
Incorrect
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A 19-year-old girl suffers from a hereditary disease and presents at her GP with a renal colic. She claims that her mother had this problem too. What type of renal calculus is most likely responsible for the renal colic?
Your Answer: Calcium oxylate
Correct Answer: Cystine
Explanation:The patient seems to have inherited cystinuria which is an autosomal recessive disease. Typical for the disease is the abnormally high concentration of cysteine in the urine, finally causing cystinuria. In a person with cystinuria, the high concentrations of cysteine in the kidney results in the formation of stones with frequent colic pains and complications. If the genotype is partially expressed, then the phenotype might be even asymptomatic, thus the disease has a high variability.
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This question is part of the following fields:
- Renal System
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Question 4
Correct
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A 65-year-old gentleman with a history of chronic renal failure due to diabetes comes to the clinic for review. He has reported increasing bone and muscle aches over the past few weeks.
Medications include ramipril, amlodipine and indapamide for blood pressure control, atorvastatin for lipid management, and insulin for control of his blood sugar. On examination his BP is 148/80 mmHg, his pulse is 79 and regular. His BMI is 28.
Investigations show:
Haemoglobin 10.7 g/dl (13.5-17.7)
White cell count 8.2 x 10(9)/l (4-11)
Platelets 202 x 10(9)/l (150-400)
Serum sodium 140 mmol/l (135-146)
Serum potassium 5.0 mmol/l (3.5-5)
Creatinine 192 μmol/l (79-118)
Calcium 2.18 mmol/l (2.2-2.67)
Phosphate 1.9 mmol/l (0.7-1.5)
He has tried following a low phosphate diet.
Which of the following would be the next most appropriate step in controlling his phosphate levels?Your Answer: Sevelamer
Explanation:Sevelamer is a phosphate-binding drug that can lower raised serum phosphate levels in chronic kidney disease. Because of its aluminium-related side-effects, aluminium hydroxide is no longer the drug of choice.
The other options are calcium-containing salts that may increase risks of tissue calcification. -
This question is part of the following fields:
- Renal System
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Question 5
Incorrect
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Which one of the following statements regarding minimal change glomerulonephritis is incorrect?
Your Answer: The majority of cases are steroid responsive
Correct Answer: Hypertension is found in approximately 25% of patients
Explanation:Hypertension and haematuria are not common presentations in minimal change glomerulonephritis, all other statements are correct.
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This question is part of the following fields:
- Renal System
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Question 6
Correct
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In end stage renal disease, deficiency of erythropoietin can lead to which of the following conditions?
Your Answer: Anaemia
Explanation:Erythropoietin is necessary for normal Hb levels. Reduced levels of erythropoietin in renal failure leads to anaemia in these patients.
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This question is part of the following fields:
- Renal System
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Question 7
Incorrect
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A 63-year-old gentleman with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?
Your Answer: Gender
Correct Answer: Serum urea
Explanation:A formula for estimating glomerular filtration rate (eGFR) is the Modification Diet of Renal Disease (MDRD) equation which takes into account the following variables: serum creatinine, age, gender, and ethnicity. Thus, serum urea is not required in this formula.
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This question is part of the following fields:
- Renal System
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Question 8
Incorrect
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A 28-year-old male has presented to his doctor with hypertension. Upon examination, he is found to have palpable kidneys. An abdominal ultrasound shows enlarged cystic kidneys on both sides. From the list of options, choose the most likely condition present in this patient.
Your Answer: Mitral stenosis
Correct Answer: Polycythaemia
Explanation:The most likely diagnosis for this patient is adult polycystic kidneys. This disease is associated with the following: valvular heart abnormalities, incompetence, and aneurysms of the cerebral circulation. It can also be associated with excessive erythropoietin production and polycythaemia. There is an increased incidence of aortic incompetence, and mitral valve prolapse occurs in 25 per cent of patients. Hepatic cysts can also occur, and present in 70 per cent of patients – these can also involve the pancreas in 10 per cent of patients and the spleen. Cerebral berry aneurysms are present in around 5-8 per cent of patients, but familial clustering is also observed. That is if there is a family history, over 20 per cent of patients will also have an aneurysm. Diverticular disease is also thought to be increased in patients with polycystic kidney disease.
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This question is part of the following fields:
- Renal System
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Question 9
Incorrect
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A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy.
Investigations showed:
Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6)
Serum alkaline phosphatase 1100 IU/L
Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion.
Which of the following is the most appropriate next step?Your Answer: Intravenous 0.9% saline infusion over four hours
Correct Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Renal System
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Question 10
Correct
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In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?
Your Answer: Dietary modification and thiazide diuretics
Explanation:Idiopathic hypercalciuria presents with excess calcium in the urine without an apparent cause. Dietary modification is the first step in addressing this condition, however, because hypercalciuria increases the risk of developing renal stones and bone demineralisation, thiazide diuretics should be prescribed to increase calcium reabsorption when these symptoms are also present.
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This question is part of the following fields:
- Renal System
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Question 11
Correct
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A 38-year-old patient with hypertension presented with facial puffiness, ankle oedema, haematuria and frothy urine. Which of the following is a definitive diagnostic test?
Your Answer: Renal biopsy
Explanation:The history is suggestive of nephritic syndrome. Renal biopsy is the definitive diagnostic test which shows the glomerular pathology.
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This question is part of the following fields:
- Renal System
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Question 12
Incorrect
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A 63-year-old woman visits the diabetes clinic for review. She has had type-2 diabetes for 9 years and is now on insulin therapy. She has diabetic nephropathy, as exemplified by hypertension and proteinuria (urinary PCR 155); a recent creatinine level was 205 μmol/l and eGFR 24 ml/min.
Which of the following options best fits her prognosis or management?Your Answer: Non-dihydropyridine calcium antagonists have no effect on proteinuria
Correct Answer: Treatment with ARB or ACE-I may slow further deterioration in renal function
Explanation:Treatment with ARB or ACE-I may slow further deterioration in renal function in this patient, as studies have shown that blocking of the RAS in type 2 diabetic patients improve renal function.
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This question is part of the following fields:
- Renal System
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Question 13
Incorrect
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Which of the following is most helpful in differentiating chronic from acute renal failure?
Your Answer: Elevated parathyroid hormone
Correct Answer: Kidney size at ultrasound scan
Explanation:The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.
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This question is part of the following fields:
- Renal System
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Question 14
Incorrect
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A 53-year-old diabetic man presents to the emergency with pain in left loin and haematuria that was sudden in onset. Investigations revealed an 8mm stone in the left lower ureter. Supportive therapy was initiated with nifedipine and steroids. The patients returned to the emergency with vomiting and worsening pain and passage of two stones. Renal function tests are significant for an impending ARF. Which of the following steps would be employed in the management of this patient?
Your Answer: Percutaneous nephrolithotomy
Correct Answer: Percutaneous nephrostomy
Explanation:Nephrolithiasis encompasses the formation of all types of urinary calculi in the kidney, which may deposit along the entire urogenital tract from the renal pelvis to the urethra. Nephrolithiasis manifests as sudden onset colicky flank pain that may radiate to the groin, testes, or labia (renal/ureteric colic) and is usually associated with haematuria.
Risk factors include low fluid intake, high-sodium, high-purine, and low-potassium diets, which can raise the calcium, uric acid, and oxalate levels in the urine and thereby promote stone formation.
Diagnostics include noncontrast spiral CT of the abdomen and pelvis or ultrasound to detect the stone, as well as urinalysis to assess for concomitant urinary tract infection and serum BUN/creatinine to evaluate kidney function. Urinary stones are most commonly composed of calcium oxalate. Less common stones are made up of uric acid, struvite (due to infection with urease-producing bacteria), calcium phosphate, or cystine.
Small uncomplicated stones without concurrent infection or severe dilation of the urinary tract may be managed conservatively with hydration and analgesics to promote spontaneous stone passage. When the spontaneous passage appears unlikely or fails due to the stone’s size or location, first-line urological interventions include shock wave lithotripsy, ureterorenoscopy, and, in case of large kidney stones, percutaneous nephrolithotomy. The most important preventive measure is adequate hydration.
Collected stones should be sent for chemical analysis because in many cases specific lifestyle guidance, diet changes, and/or initiation of medical treatment (e.g., thiazide diuretics, urine alkalinisation) can prevent future stone formation. -
This question is part of the following fields:
- Renal System
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Question 15
Incorrect
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A 30-year-old woman is hypertensive and complains of painless haematuria. Other examination results are unremarkable. What is the most likely diagnosis?
Your Answer:
Correct Answer: Polycystic kidneys
Explanation:Renal ultrasound is utilized to confirm this condition. Although at a younger age, hypertension and haematuria that is not painful is already suggestive to the disease.
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This question is part of the following fields:
- Renal System
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Question 16
Incorrect
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A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline.
What is the underlying pathophysiology of TTP?Your Answer:
Correct Answer: Failure to cleave von Willebrand factor normally
Explanation:Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.
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This question is part of the following fields:
- Renal System
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Question 17
Incorrect
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A 38-year-old woman has been reviewed in the hypertension clinic. Abdominal ultrasound scanning reveals that her left kidney is much smaller than her right kidney.
You suspect renal artery stenosis, as her GP noticed a deteriorating serum creatinine concentration within 1 month of starting ACE inhibitor therapy.
What is the most appropriate next investigation?Your Answer:
Correct Answer: Magnetic resonance angiography
Explanation:MRA is next appropriate management for this case. It is non-invasive and has been shown to correlate with angiographic appearance. Although Renal arteriography is considered gold standard, it is invasive, so a non-invasive option is preferred as first line of investigation in this case.
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This question is part of the following fields:
- Renal System
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Question 18
Incorrect
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A 69-year-old male with a history of Hepatitis C liver cirrhosis presented with spontaneous bacterial peritonitis. He had no symptoms of hypovolaemia. Choose the best treatment option to prevent the patient from developing hepatorenal syndrome.
Your Answer:
Correct Answer: Intravenous albumin administration
Explanation:In randomised controlled trials, the administration of albumin has been shown to lower the risk of the hepatorenal syndrome – this is thought to be due to its positive effect on circulatory systems. Diuretics can aid in the prevention of renal failure, but this patient is not showing signs of hypovolaemia. Synthetic disaccharide lactulose is primarily used for the prevention of hepatic encephalopathy, which has no function in preventing hepatorenal syndrome. Limited evidence is available for the use of Neomycin as a treatment for hepatic encephalopathy, but is associated with nephrotoxicity and ototoxicity.
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This question is part of the following fields:
- Renal System
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Question 19
Incorrect
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A 67-year-old female with end-stage renal failure, presented to her doctor with confusion and a flapping tremor. She has not travelled abroad, has not changed her medication, and does not consume alcohol. Which of the following options would explain her symptoms?
Your Answer:
Correct Answer: Uraemic encephalopathy
Explanation:Uremic encephalopathy is most often associated with a flapping tremor (as observed in this patient) due to the accumulation of urea. A similar kind of ‘flap’ can be observed in decompensated liver disease due to high levels of ammonia, too.
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This question is part of the following fields:
- Renal System
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Question 20
Incorrect
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A 60-year-old gentleman presents with symptoms of nocturia and difficulty in passing urine. He is not known to have any previous prostatic problems and denies any dysuria. Following a digital rectal examination, he is started on Finasteride and Tamsulosin. Three months later he presents to the emergency department with urinary retention and is catheterized, and a craggy mass is felt on rectal examination. He is referred to a urologist, and a prostatic ultrasound and needle biopsy are arranged, and prostate serum antigen (PSA) is requested.
Which of the following factors is most likely to give a false negative PSA?Your Answer:
Correct Answer: Finasteride
Explanation:Finasteride is often prescribed for patients with Benign Prostatic Hyperplasia (BPH) or enlarged prostate. However, it has been known to cause a decrease in Prostatic Specific Antigen (PSA) levels in patients with BPH, which may lead to false negatives in a case like this, where a palpable mass has been detected and malignancy is suspected.
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This question is part of the following fields:
- Renal System
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Question 21
Incorrect
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A 33-year-old Afro-Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response.
His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length.
What would a renal biopsy show?Your Answer:
Correct Answer: Microcystic tubular dilatation and collapsing FSGS
Explanation:HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.
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This question is part of the following fields:
- Renal System
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Question 22
Incorrect
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A patient has an autosomal recessive disorder, which causes lysine, arginine, ornithine and cystine to appear in his urine. The treatment proposed is the combination of urinary alkalinisation with penicillamine. Choose the most likely type of renal calculus present.
Your Answer:
Correct Answer: Cystine
Explanation:The presence in the urine of cystine, orthinine, arginine and lysine indicate a tubular reabsorption defect. This condition is a hereditary one, and stone formation is more common in homozygotes. The patient has no other abnormalities that could indicate stone formation.
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This question is part of the following fields:
- Renal System
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Question 23
Incorrect
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A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?
Your Answer:
Correct Answer: Goserelin is licensed for refractory cases
Explanation:Goserelin (Zoladex) is usually prescribed to treat hormone-sensitive cancers of the breast and prostate not for BPH. All other statements are correct.
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This question is part of the following fields:
- Renal System
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Question 24
Incorrect
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A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started on Ramipril to prevent development of renal disease. He reports to his GP that he has developed a troublesome cough since starting the medication. He has no symptoms of lip swelling, wheeze and has no history of underlying respiratory disease.
What increased chemical is thought to be the cause of his cough?Your Answer:
Correct Answer: Bradykinin
Explanation:Ramipril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II as well as preventing the breakdown of bradykinin, leading to blood vessel dilatation and decreased blood pressure. However, bradykinin also causes smooth muscles in the lungs to contract, so the build-up of bradykinin is thought to cause the dry cough that is a common side-effect in patients that are on ACE inhibitors.
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This question is part of the following fields:
- Renal System
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Question 25
Incorrect
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A 68-year-old gentleman has been receiving dialysis for 6 years. His PTH is elevated at 345 pg/ml (NR 25-65), phosphate 2.13 mmol/l and corrected calcium 2.01 mmol/l.
Of the following, which is most likely responsible for renal osteodystrophy?Your Answer:
Correct Answer: Diminished activity of renal 1-?-hydroxylase
Explanation:Renal osteodystrophy is a metabolic bone disease often affecting long-term dialysis patients. The kidneys are no longer able to maintain the calcium levels in the blood, thus the PTH increases as the body attempts to raise blood calcium levels. Osteomalacia in these cases is most likely caused by the diminished activity of renal 1-a-hydroxylase that is important for hydroxylation of Calciferol to calcitriol (Vitamin D). This bioactive form of Vitamin D is responsible for increasing intestinal absorption of calcium.
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This question is part of the following fields:
- Renal System
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Question 26
Incorrect
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A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor for a review. His symptoms are currently well controlled; he is taking Ramipril 10mg, Spironolactone 25mg, Bisoprolol 10mg, and Furosemide 40mg. His main complaint is of painful gynaecomastia that he says has developed over the past 6 months. Physical exam reveals a blood pressure of 125/80 mmHg and no residual signs of cardiac failure. Renal function is unchanged from 6 months earlier, with stable creatinine at 125 µmol/l.
Which of the following is the most appropriate next step?Your Answer:
Correct Answer: Change the spironolactone to eplerenone
Explanation:Spironolactone is an aldosterone antagonist diuretic that is well-known to cause gynaecomastia because it increases testosterone clearance and oestradiol production. The patient’s primary complaint of gynaecomastia should immediately prompt discontinuation of spironolactone and replacement with Eplerenone, which lacks the antiandrogenic effects, and thus there is less risk of gynaecomastia.
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This question is part of the following fields:
- Renal System
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Question 27
Incorrect
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A 67-year-old male presents to the emergency complaining of frank haematuria. There are no associated symptoms. Which of the following would be the most helpful in pointing towards a diagnosis?
Your Answer:
Correct Answer: Cystoscopy
Explanation:Diagnostic indications for cystoscopy include the following: evaluation of patients with voiding symptoms (storage or obstructive), gross or microscopic haematuria, urologic fistulas, urethral or bladder diverticula and congenital anomalies in paediatric population.
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This question is part of the following fields:
- Renal System
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Question 28
Incorrect
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Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your Answer:
Correct Answer: Dialysis dementia
Explanation:Dialysis dementia is a unique neurological syndrome associated with chronic dialysis. Aluminium toxicity is probably the major factor in the pathogenesis of the dementia, which is due to aluminium-containing compounds in the dialysis fluid. Patients with dialysis dementia present with progressive dementia, dysarthria and seizures.
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This question is part of the following fields:
- Renal System
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Question 29
Incorrect
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A 22-year-old gentleman presents to A&E for the third time with recurrent urinary stones. There appear to be no predisposing factors, and he is otherwise well; urine culture is unremarkable. The urine stones turn out to be cystine stones.
What is the most likely diagnosis in this case?Your Answer:
Correct Answer: Cystinuria
Explanation:Cystinuria is strongly suspected because of the recurrent passing of cystine stones and otherwise non-remarkable medical history of this young adult patient. Like Cystinuria, all the conditions listed are also inherited disorders, however, the other differentials usually present in the early years of childhood, usually with failure to thrive.
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This question is part of the following fields:
- Renal System
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Question 30
Incorrect
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A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted after slipping on ice and falling over. Some routine blood tests are performed:
Na+ 141 mmol/l
K+ 2.9 mmol/l
Chloride 114 mmol/l
Bicarbonate 16 mmol/l
Urea 5.2 mmol/l
Creatinine 75 µmol/l
Which one of the following is most likely to explain these results?Your Answer:
Correct Answer: Renal tubular acidosis (type 1)
Explanation:The patient’s underlying arthritis has most likely led to Renal tubular acidosis RTA type 1, which presents with the following symptoms consistent with the presentation of the patient: Normal anion gap metabolic acidosis/acidaemia, hypokalaemia and hyperchloremia. Comparatively, the other conditions are ruled out because Aspirin and diabetic ketoacidosis is associated with a raised anion gap, Conn’s syndrome explains hypokalaemia but not the metabolic acidosis, and RTA type 4 is associated with hyperkalaemia.
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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
