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Question 1
Correct
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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: 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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A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache.
What is the most likely diagnosis?Your Answer: Subarachnoid haemorrhage
Explanation:One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.
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This question is part of the following fields:
- Renal System
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Question 3
Correct
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A 30-year-old female presented with sudden onset severe right sided abdominal pain for the past 30 minutes. The pain radiated to the groin. She vomited once. Her abdomen was non tender. Which of the following is the most probable diagnosis?
Your Answer: Ureteric colic
Explanation:Characteristic colicky pain and non tender abdomen is characteristic of ureteric colic. Some patients present with urinary symptoms such as haematuria and dysuria, Vomiting is due to activation of sympathetic nervous system due to pain.
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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 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: 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 5
Incorrect
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A 40-year-old male presented with sudden onset chest pain and difficulty in breathing for the past 2 hours. On examination he had bilateral ankle swelling. Investigations revealed proteinuria of 6g/d. Which of the following is the most likely explanation for this presentation?
Your Answer: Reduced factor VIII
Correct Answer: Reduced antithrombin III activity
Explanation:This patient has presented with a thromboembolic event most probably secondary to nephrotic syndrome (nephrotic-range proteinuria). Hypercoagulability is due to urinary loss of anticoagulant proteins, such as antithrombin III and plasminogen and an increase in clotting factors, especially factors I, VII, VIII, and X.
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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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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: 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 7
Correct
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In diabetes, what is the most common finding on renal biopsy?
Your Answer: Glomerulosclerosis
Explanation:Glomerulosclerosis is the scarring and hardening of the glomeruli known as diabetic glomerulosclerosis occurring in long-standing diabetes.
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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 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo.
Which diuretic is most likely to have caused this?Your Answer: Bendroflumethiazide
Correct Answer: Furosemide
Explanation:Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.
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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 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 10
Incorrect
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A patient presents to the nephrologist with proteinuria ++. Which medication would most likely result in the prevention of progression of this disease?
Your Answer:
Correct Answer: ACE inhibitors
Explanation:Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) reduce intraglomerular pressure by inhibiting angiotensin II ̶ mediated efferent arteriolar vasoconstriction. These drugs also have a proteinuria-reducing effect that is independent of their antihypertensive effect.
In addition, ACE inhibitors have renoprotective properties, which may be partially due to the other hemodynamic and nonhemodynamic effects of these drugs. ACE inhibitors reduce the breakdown of bradykinin (an efferent arteriolar vasodilator); restore the size and charge selectivity to the glomerular cell wall; and reduce the production of cytokines, such as transforming growth factor-beta (TGF-beta), that promote glomerulosclerosis and fibrosis.
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This question is part of the following fields:
- Renal System
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Question 11
Incorrect
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A 58-year-old gentleman with a long history of gout presents with loin pain. Other past history of note includes an ileostomy after bowel surgery. There is no history of weight loss from malabsorption syndrome after his bowel surgery. Excretion urography reveals evidence of bilateral renal stones.
What is the most likely composition of his renal stones?Your Answer:
Correct Answer: Uric acid stones
Explanation:Uric acid stones will most likely be found in this case because of the patient’s long history of gout. Additionally, studies have shown that ileostomy patients have an increased risk for the development of uric acid stones.
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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 10-year-old boy presents with generalized swelling. This includes puffiness in the face and swollen ankles - these symptoms have been present for 4 days. The swelling began just a few days after he suffered from a mild cold with a runny nose. His only past medical history is that of eczema. His urine analysis showed the following: haematuria; proteinuria (10g/24h); creat 60 umol/l; and albumin of 15g/l. From the list of options, what is the single most likely diagnosis for this patient?
Your Answer:
Correct Answer: IgA nephropathy
Explanation:A 10 year old child, with a history of URTI and haematuria, presents a picture consistent with a diagnosis of IgA nephropathy. This condition can present with proteinuria and generalized swelling. However, an important differentiating point from rapidly progressive GN is the duration. IgA nephropathy is usually <10 days (commonly 4-5 day history of infection).
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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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A 3-year-old boy presents with recurrent urinary tract infections. What is the most common cause for this problem in a child of this age?
Your Answer:
Correct Answer: Vesicoureteric reflux
Explanation:Vesicoureteral reflux is the condition when the urine flows backwards from the bladder into the kidneys, which is the most common cause of UTI in patients this age.
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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 48-year-old patient with type 1 diabetes and chronic kidney disease attends for review. His blood tests show:
Haemoglobin 11.2 g/dl (13.0 - 18.0 g/dL)
MCV 87 fl (80 - 96 fL)
Sodium 133 mmol/l (137 - 144 mmol/L)
Potassium 4.3 mmol/l (3.5 - 4.9 mmol/L)
Urea 19.1 mmol/l (2.5 - 7.5 mmol/L)
Creatinine 267 μmol/l (60 - 110 μmol/L)
Ferritin 150 μg/l (15 - 300 μg/L)
C reactive protein <5 mg/l (< 10 mg/L)
What is the most appropriate management of his anaemia?Your Answer:
Correct Answer: Monitor haemoglobin, no treatment required at present
Explanation:Because the patient has chronic kidney disease, we need to consider the associated adverse effects of trying to maintain normal haemoglobin levels (14-18g/dl in this patient) and instead only instigate therapy when the level falls below 11 g/dl. Thus, in this case we should just monitor the haemoglobin levels and not initiate therapy just yet.
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This question is part of the following fields:
- Renal System
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Question 15
Incorrect
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Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?
Your Answer:
Correct Answer: May be diagnosed on prenatal ultrasound
Explanation:Autosomal recessive polycystic kidney disease (ARPKD) is less common than ADPKD (dominant form) but can already present with symptoms and be diagnosed on prenatal ultrasound.
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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 71-year-old woman with a medical history of a blood transfusion in the early 1980s presents with a 10 month history of malaise and is noted to have impaired renal function. Her urine sediment reveals red cell casts.
The results of immunological investigations are as follows: serum IgG 6.5 g/L (normal range 6-13), IgA 1.5 g/L (normal range 0.8-4.0), IgM 5.7 g/L (normal range 0.4-2.0), serum electrophoresis shows a faint band in the gamma region, complement C3 1.02 g/L (normal range 0.75-1.65), complement C4 <0.02 g/L (normal range 0.20-0.65), and rheumatoid factor 894 IU/L (normal range <40).
Which of the following investigations is likely to be most important in making a definitive diagnosis?Your Answer:
Correct Answer: Cryoglobulins
Explanation:The patient’s history of a blood transfusion and lab results showing a markedly low C4 (with normal C3), elevated rheumatoid factor, and elevated serum IgM is highly suggestive of hepatitis C-associated cryoglobulinaemic vasculitis. Testing for Cryoglobulins will confirm this suspicion.
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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 male presented with multiple bruises and fractured pelvis after a road traffic accident. He is also complaining of anuria for the past 4 hours. The next management step would be?
Your Answer:
Correct Answer: Suprapubic catheter
Explanation:Stress and urge urinary incontinence has been observed in patients who have sustained pelvic fractures due to trauma. The best treatment option would be to pass suprapubic catheter. If there is still no urine output, then ureteral damage might be the cause, which needs to be managed.
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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 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 19
Incorrect
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A gentleman arrives at the renal clinic for review. He has long standing chronic renal failure and is unfortunately suffering from metabolic bone disease. His GP has asked for an explanation of the causes and features of metabolic bone disease.
Which of the following best describes the biochemical changes involved?Your Answer:
Correct Answer: Phosphate excretion is decreased, parathyroid hormone levels are increased and 1,25-OH vitamin D levels are decreased
Explanation:The patient’s chronic renal failure causes decreased renal hydroxylation of vitamin D which leads to decreased calcium absorption in the gut. Simultaneously, there is also decreased renal excretion of phosphate, and this combination of factors results in increased PTH levels.
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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 53-year-old gentleman presents with several months' history of generalised swelling, fatigue, dyspnoea and several episodes of haemoptysis. There is no significant past medical history and he did not take any regular medication. He smokes 20 cigarettes per day and drinks 14 units of alcohol per week.
On examination, he is grossly oedematous and has ascites. Cardiorespiratory examination is unremarkable and there are no neurological signs or rashes.
Investigation results are below:
Haemoglobin (Hb) 10.2 g/dl
White cell count (WCC) 6.0 × 109/l
Platelets 380 × 109/l
Mean corpuscular volume (MCV) 90fl
Na+ 145 mmol/l
K+ 3.7 mmol/l
Urea 8.2 mmol/l
Bilirubin 16 μmol/l
Creatinine 180 μmol/l
Albumin 22 g/l
Aspartate transaminase 32 iu/l
Alkaline phosphatase 120 iu/l
Urinalysis: Protein +++
24 h urinary protein excretion: 5g
Chest radiograph: Enlarged right hilum
Echocardiogram: Mild left ventricular impairment, no valve lesion
Abdominal ultrasound scan: Normal-sized kidneys, no abnormality seen
A renal biopsy was performed. What is it most likely to show?Your Answer:
Correct Answer: Thickened glomerular basement membrane with deposits of IgG and C3
Explanation:Renal biopsy in this patient will most likely show thickened glomerular basement membrane with deposits of IgG and C3 as a result of membranous glomerulonephritis that has caused the nephrotic syndrome in this patient. Membranous glomerulonephritis in this case is most likely associated with an underlying bronchial carcinoma, consistent with the patient’s smoking history and physical presentation.
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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 45-year-old male suffers multiple injuries in a road traffic accident. He complains of inability to urinate for the past 4 hours. Radiological examination reveals a fractured pelvis. Which of the following will be the most appropriate step in the management of this patient?
Your Answer:
Correct Answer: Suprapubic catheter
Explanation:When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopaedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm. Initial emergent treatment remains controversial, but mainstays of therapy include drainage of the urinary bladder, often with placement of a suprapubic catheter (SPT) and primary endoscopic realignment of the urethra if possible.
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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 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:
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 23
Incorrect
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In end stage renal disease, deficiency of erythropoietin can lead to which of the following conditions?
Your Answer:
Correct 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 24
Incorrect
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A 76-year-old man complains of painful microscopic haematuria and urgency. On examination of the abdomen, there is suprapubic tenderness but no palpable abnormality. He is apyrexial, inflammatory markers and PSA in the blood are normal. Which is the most likely diagnosis?
Your Answer:
Correct Answer: Bladder calculi
Explanation:Painful haematuria suggests trauma, infection or calculi, whereas painless haematuria suggests a possible occult malignancy. This man is apyrexial with normal WCC and CRP which should effectively exclude infection as a cause for his symptoms. There is no history of trauma in this scenario (often catheter-associated) which makes this cause unlikely. It is worth noting that haematuria associated with injury tends to be macroscopic. Therefore, bladder calculi are the most likely source of his symptoms. Imaging will help to determine the presence of calculi.
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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 28-year-old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria.
A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits.
What is the most likely diagnosis?Your Answer:
Correct Answer: Lupus nephritis Class III
Explanation:This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.
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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 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:
Correct 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 27
Incorrect
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Following a road traffic accident, a gentleman is brought to A&E. He is found to have oliguria and diagnosed with acute renal tubular necrosis.
What is the most common complication and cause of death in this condition?Your Answer:
Correct Answer: Infection
Explanation:In patients with acute renal tubular necrosis, infection in the form of gram-negative septicaemia is the most common cause of death, especially while the patient is awaiting spontaneous recovery of their renal function.
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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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A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her blood pressure is 215/140 mmHg, she has +2 peripheral oedema and the skin over her fingers appears very tight. Fundoscopy discloses bilateral papilledema.
Plasma creatinine concentration is 370 μmol/l, potassium is 4.9 mmol/l, haemoglobin is 8.9 g/dl and her platelet count is 90 x 109 /ml.
What is the pathological hallmark of this condition?Your Answer:
Correct Answer: Mucoid intimal thickening of vascular endothelium
Explanation:The history is suggestive of scleroderma renal crisis, where we would expect thrombotic microangiopathy process with vascular endothelium involvement manifesting as mucoid intimal thickening or onion skin effect.
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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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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 30
Incorrect
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A 61-year-old male presented to the emergency with renal colicky pain and a subsequent passage of stone the next day. Radiological examination, however, revealed no signs of calculi. The renal calculus was most likely composed of which of the following?
Your Answer:
Correct Answer: Uric acid
Explanation:Calcium-containing stones are relatively radio dense, and they can often be detected by a traditional radiograph of the abdomen that includes the kidneys, ureters, and bladder (KUB film). Some 60% of all renal stones are radiopaque. In general, calcium phosphate stones have the greatest density, followed by calcium oxalate and magnesium ammonium phosphate stones. Cystine calculi are only faintly radio dense, while uric acid stones are usually entirely radiolucent.
Uric acid is the relatively water-insoluble end product of purine nucleotide metabolism. It poses a special problem because of its limited solubility, particularly in the acidic environment of the distal nephron of the kidney. It is problematic because humans do not possess the enzyme uricase, which converts uric acid into the more soluble compound allantoin. Three forms of kidney disease have been attributed to excess uric acid: acute uric acid nephropathy, chronic urate nephropathy, and uric acid nephrolithiasis. These disorders share the common element of excess uric acid or urate deposition, although the clinical features vary.
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This question is part of the following fields:
- Renal System
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Question 31
Incorrect
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A 75-year-old man was admitted with urinary dribbling and incontinence. Upon examination, there is a palpable mass up to the umbilicus. His clothes smell of ammonia and he is known to be a chronic alcoholic. What is the next most appropriate step?
Your Answer:
Correct Answer: Urethral catheter
Explanation:It is obvious in this case that chronic alcohol use has contributed to the patient’s urinary incontinence which requires a urethral catheter. Suprapubic catheters are usually preferred in cases of acute urinary retention while condom catheters are indicated in less severe cases of urinary incontinence. We would administer antibiotics if we suspected a urinary infection causing the urinary incontinence, but in this case the cause is obvious.
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This question is part of the following fields:
- Renal System
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Question 32
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 33
Incorrect
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A 60 year-old patient known with stable angina was advised to have a contrast coronary angiography. Before the procedure, what will be the most appropriate step to take?
Your Answer:
Correct Answer: IV 0.9% Saline
Explanation:Contrast material poses a greater threat for contrast induced nephropathy. In order to decrease the chance of contrast nephropathy, IV 0.9% saline is considered as the best fluid to maintain blood pressure. Normal Saline helps to expand intravascular volume and decrease the renin angiotensin system activity.
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This question is part of the following fields:
- Renal System
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Question 34
Incorrect
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A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months after the operation, he has developed fever and features suggestive of bilateral diffuse interstitial pneumonia.
What is the most likely etiological cause?Your Answer:
Correct Answer: Cytomegalovirus
Explanation:After renal transplantation, cytomegalovirus has been identified to affect 1/4 of the post-op patients. It is the most common viral infection causing morbidity and mortality in post-op patients in the first 3 months.
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This question is part of the following fields:
- Renal System
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Question 35
Incorrect
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A 20-year-old woman presents to casualty with flank pain and a 48 hour history of dysuria. Her past medical history includes polycystic ovarian syndrome. She is not in a steady relationship at present. There is haematuria and proteinuria on urine dipstick testing.
Examination reveals a pyrexia of 38.1 °C and flank pain.
What diagnosis fits best with this clinical picture?Your Answer:
Correct Answer: Pyelonephritis
Explanation:The patient presents with flank pain and fever with haematuria and proteinuria associated with a social history of not being in a steady relationship. This patient is a young presumably sexually active female, so the diagnosis is most likely pyelonephritis which has an increased incidence in young sexually active women or men of >50 years of age.
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This question is part of the following fields:
- Renal System
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Question 36
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:
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 37
Incorrect
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A 30-year-old previously well male was found to have a blood pressure of 140/90 mmHg. Investigations revealed microalbuminuria. FBS and HbA1c were normal. Which of the following is the most appropriate management for this patient?
Your Answer:
Correct Answer: Renal scan
Explanation:A renal scan is important in the diagnosis of early renal damage, acute or chronic nephropathies and nephrovascular disease. Renal resistive index (RRI) which is measured by Doppler sonography, is proved to be a marker of renal disease onset and progression. Young hypertension with microalbuminuria is an indication for a renal scan to identify the possible aetiology.
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This question is part of the following fields:
- Renal System
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Question 38
Incorrect
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A 65-year-old woman with type 2 diabetes mellitus is feeling more fatigued than usual. She has not attended the previous three annual check-ups and her blood glucose control has been poor. She has not been compliant with his medications. Blood pressure is 170/90 mmHg. Urinalysis shows microalbuminuria. A blood test reveals her glomerular filtration rate (GFR) is 26 mL/min.
If a renal biopsy was to be performed in this patient, what would be the expected findings?Your Answer:
Correct Answer: Nodular glomerulosclerosis and hyaline arteriosclerosis
Explanation:This patient has a poorly controlled T2DM with an underlying diabetic nephropathy. The histological findings are Kimmelstiel-Wilson lesions (nodular glomerulosclerosis) and hyaline arteriosclerosis. This is due to nonenzymatic glycosylation.
Diabetic nephropathy is the chronic loss of kidney function occurring in those with diabetes mellitus. Protein loss in the urine due to damage to the glomeruli may become massive, and cause a low serum albumin with resulting generalized body swelling (edema) and result in the nephrotic syndrome. Likewise, the estimated glomerular filtration rate (eGFR) may progressively fall from a normal of over 90 ml/min/1.73m2 to less than 15, at which point the patient is said to have end-stage kidney disease (ESKD). It usually is slowly progressive over years.
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This question is part of the following fields:
- Renal System
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Question 39
Incorrect
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In renal patients, bone reabsorption and fractures are significant due to high level of parathyroid hormone. Which one of the following is a major culprit for this high level of parathyroid hormones?
Your Answer:
Correct Answer: Hyperphosphataemia
Explanation:Hyperphosphatemia is the cause known to enhance the production of PTH through parathyroid glands in renal patients. Hypercalcaemia and Hypophosphatemia decrease PTH production. Phosphate binders also reduce PTH level. Serum ALP is an indicator of rapid bone turnover.
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This question is part of the following fields:
- Renal System
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Question 40
Incorrect
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A 70-year-old male patient with hypertension complains of acute urinary retention. He provides a history of urinary frequency for the past 18 months and has been taking Nifedipine and Propranolol for blood pressure control. Which of the following is the most probable cause for his acute presentation?
Your Answer:
Correct Answer: Drug induced
Explanation:Calcium channel blockers decrease smooth-muscle contractility in the bladder and this can cause urinary retention.
An enlarged prostate gland could be the reason if he gave a history of obstructive symptoms.
Diabetes presents with polyuria.
Bladder cancer commonly presents with painless haematuria. -
This question is part of the following fields:
- Renal System
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Question 41
Incorrect
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A 60-year-old gentleman is found dead in his apartment. He was known to be suffering from primary systemic amyloidosis. What is the most probable cause for his death?
Your Answer:
Correct Answer: Cardiac involvement
Explanation:Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.
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This question is part of the following fields:
- Renal System
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Question 42
Incorrect
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A 30-year-old woman who underwent a live related renal transplant for end-stage renal failure secondary to chronic pyelonephritis, 12 weeks previously, attends the clinic for routine follow up. She is taking tacrolimus and mycophenolate mofetil (MMF).
Her urea and electrolytes are below:
Na+ 136 mmol/l
K+ 3.7 mmol/l
Urea 7.2 mmol/l
Creatinine 146 μmol/l
She was last seen in clinic 2 weeks previously when her urea was 4.2 mmol/l and creatinine 98 μmol/l. She is clinically well and asymptomatic.
On examination she was apyrexial and normotensive. Her transplant site was non-tender with no swelling and there were no other signs to be found.
Which THREE initial investigations are the most important to perform?Your Answer:
Correct Answer: Urine and blood cultures
Explanation:After renal transplant, asymptomatic patients can still have graft dysfunction as an early complication, with rising serum creatinine; therefore, urine and blood cultures should be ordered first. This should be followed by measuring the Tacrolimus levels, as this drug can be directly nephrotoxic. Next, a Doppler ultrasound of the transplant site should be ordered, to check for any obstructions or occlusions.
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This question is part of the following fields:
- Renal System
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Question 43
Incorrect
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A woman with severe renal failure undergoes a kidney transplant. However, after a few hours, she develops fever and anuria. The doctors are suspecting hyperacute organ rejection. Which are the cells primarily responsible for hyperacute organ rejection?
Your Answer:
Correct Answer: B Cells
Explanation:Hyperacute rejection appears in the first minutes following transplantation and occurs only in vascularized grafts. This very fast rejection is characterized by vessel thrombosis leading to graft necrosis. Hyperacute rejection is caused by the presence of antidonor antibodies existing in the recipient before transplantation. These antibodies induce both complement activation and stimulation of endothelial cells to secrete Von Willebrand procoagulant factor, resulting in platelet adhesion and aggregation. The result of these series of reactions is the generation of intravascular thrombosis leading to lesion formation and ultimately to graft loss. Today, this type of rejection is avoided in most cases by checking for ABO compatibility and by excluding the presence of antidonor human leukocyte antigen (HLA) antibodies by cross-match techniques between donor graft cells and recipient sera. This type of rejection is also observed in models of xenotransplantation of vascularized organs between phylogenetically distant species when no immunosuppressive treatment is given to the recipients.
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This question is part of the following fields:
- Renal System
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Question 44
Incorrect
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A 70-year-old man underwent emergency surgery for an acute abdomen. Following surgery, he was noted to be oliguric. Investigations revealed the following: Sodium 121 mmol/L (137-144) Potassium 6.6 mmol/L (3.5-4.9) Chloride 92 mmol/L (95-107) Urea 17.2 mmol/L (2.5-7.5) Creatinine 250 µmol/L (60-110) pH 7.16 (7.36-7.44) Standard bicarbonate 15.6 mmol/L (20-28). What is the calculated anion gap for this patient?
Your Answer:
Correct Answer: 20 mmol/L
Explanation:Anion gap is calculated as (Na + K) − (Cl + HCO3). Therefore in this patient, the calculated value is 20 mmol/L. The normal anion gap is between 8-16 mmol/l. The excessive value here reflects the presence of other acidic anions, and in this case with the metabolic acidosis, the constituents may be lactate, etc.
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This question is part of the following fields:
- Renal System
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Question 45
Incorrect
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A 30-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication.
Results show:
Serum sodium 144 mmol/L (137-144)
Plasma osmolality 299 mosmol/L (275-290)
Urine osmolality 210 mosmol/L (350-1000)
Which of the following drugs was prescribed?Your Answer:
Correct Answer: Lithium
Explanation:The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.
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This question is part of the following fields:
- Renal System
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Question 46
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:
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 47
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 48
Incorrect
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A 35-year-old gentleman is investigated for recurrent renal stones. He has been hospitalised on multiple occasions and has required lithotripsy three times. Investigations show the following:
Calcium 2.08 mmol/l
Phosphate 0.85 mmol/l
Parathyroid hormone 4.1 pmol/L (normal range = 0.8 - 8.5)
24 hour urinary calcium 521 mg/24 hours (normal range < 300)
Which one of the following treatments will most likely reduce the incidence of renal stones?Your Answer:
Correct Answer: Indapamide
Explanation:Indapamide is a mild thiazide-like diuretic with hypotensive effect, and compared to other thiazides, it is reported to also have less metabolic derangements. However, it may have beneficial hypo-calciuric effects that are often associated with thiazides, thus, in this case, we would recommend prescribing this to the patient.
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This question is part of the following fields:
- Renal System
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Question 49
Incorrect
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A 60-year-old patient with type 2 diabetes mellitus is advised to start taking an ACE-inhibitor in order to control his hypertension. However, he also needs to monitor his renal function. Keeping in mind that he just started an ACE-inhibitor, how long should he wait until he undergoes a blood test to check creatinine and potassium levels?
Your Answer:
Correct Answer: One to two weeks after starting the medication
Explanation:ACE inhibitors effectively reduce systemic vascular resistance in patients with hypertension, heart failure or chronic renal disease. This antihypertensive efficacy probably accounts for an important part of their long term renoprotective effects in patients with diabetic and non-diabetic renal disease. Systemic and renal haemodynamic effects of ACE inhibition, both beneficial and adverse, are potentiated by sodium depletion. Consequently, sodium repletion contributes to the restoration of renal function in patients with ACE inhibitor-induced acute renal failure. On the other hand, co-treatment with diuretics and sodium restriction can improve therapeutic efficacy in patients in whom the therapeutic response of blood pressure or proteinuria is insufficient. Patients at the greatest risk for renal adverse effects (those with heart failure, diabetes mellitus and/or chronic renal failure) also can expect the greatest benefit. Therefore, ACE inhibitors should not be withheld in these patients, but dosages should be carefully titrated, with monitoring of renal function and serum potassium levels. The optimum period to check this is one to two weeks after starting the medication.
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This question is part of the following fields:
- Renal System
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Question 50
Incorrect
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A 3-year-old girl is brought to the clinic by her mother due to burning micturition, frequency and urgency. She is also experiencing some suprapubic tenderness. Which of the following investigations should be done initially?
Your Answer:
Correct Answer: Clean catch of urine for Culture &Sensitivity
Explanation:Urine culture and sensitivity is used to diagnose a urinary tract infection (UTI). A mid-stream clean catch urine sample is the most common type of sample collected. It is important to follow the clean catch process to have accurate results from an uncontaminated sample. Urine cultures can also check for infections of the bladder or kidney.
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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
