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Question 1
Incorrect
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A 16-year-old boy suffers recurrent episodes of haematuria following a flu-like illness. He is otherwise well. Physical examination is normal. Urinalysis reveals no proteinuria, blood ++, and 2-3 white blood cells/mm3.
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What is the most probable diagnosis?Your Answer: Post-streptococcal glomerulonephritis
Correct Answer: IgA nephropathy
Explanation:IgA nephropathy’s characteristic presentation is haematuria following a non-specific upper respiratory infection as was evident in this case. IgA nephropathy also usually occurs in children and young males, like this patient.
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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 23-year-old man visited the OPD with a complaint of pain in the abdomen and dark urine. His blood pressure was found to be elevated. Which of the following should be done next to reach a diagnosis?
Your Answer: US
Explanation:Hypertension along with haematuria give an indication of cystic kidneys which can be diagnosed with an ultrasound.
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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 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.
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Which of the following options best fits her prognosis or management?Your 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 4
Correct
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You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma for the past 3 years. He presents with lethargy, muscle aches and pain in his lower back.
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Arterial blood sampling reveals a metabolic acidosis. Serum potassium is 3.1 mmol/l (3.5-4.9), and urine pH is 5.1 (> 5.3).
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What is the most likely diagnosis?Your Answer: Renal tubular acidosis-type II
Explanation:This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .
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This question is part of the following fields:
- Renal System
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Question 5
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 6
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: Posterior urethral valves
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 7
Correct
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What is the site of action of antidiuretic hormone?
Your Answer: Collecting ducts
Explanation:Vasopressin, also called antidiuretic hormone (ADH), regulates the tonicity of body fluids. It is released from the posterior pituitary in response to hypertonicity and promotes water reabsorption in the collecting ducts of the kidneys by the insertion of aquaporin-2 channels.. An incidental consequence of this renal reabsorption of water is concentrated urine and reduced urine volume. In high concentrations may also raise blood pressure by inducing moderate vasoconstriction.
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This question is part of the following fields:
- Renal System
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Question 8
Correct
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An 83-year-old gentleman presents to his GP with increasing oedema and ascites. He is hypertensive, for which he takes amlodipine. There is shortness of breath on exercise. His alcohol history is two cans of stout per day.
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ECG is normal, and CXR reveals normal heart size and no signs of cardiac failure. Serum albumin is 23 g/dl; urinary albumin excretion is 7 g/24 h, with no haematuria. He has mild anaemia with a normal MCV. Total cholesterol is elevated.
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What diagnosis fits best with this clinical picture?Your Answer: Nephrotic syndrome
Explanation:Nephrotic syndrome usually presents with the symptoms in this patient: low albumin, abnormal cholesterol, increased urinary albumin excretion, oedema, and as a consequence, hypertension as well.
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This question is part of the following fields:
- Renal System
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Question 9
Correct
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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: 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 10
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 11
Incorrect
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Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?
Your Answer: Is due to a defect on chromosome 16
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 12
Correct
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A 65-year-old gentleman gives a two week history of progressive lethargy and weakness. Eight weeks previously, he was treated for hypertensive heart failure with 120 mg furosemide and 5 mg enalapril daily. His haemoglobin at the time was 12.0, urea 14.2 mmol/l and creatinine 298 μmol/l. His blood pressure in clinic was 148/85 mmHg.
His blood results are shown below:
Hb 10.2g/dl
MCV 89.2 fl
WCC 4.9 x 109/l
Plats 175 x 109/l
Na+ 135
K+ 5.2 mmol/l
Urea 25.2 mmol/l
Creat 600 μmol/l
Assuming that he is not volume overloaded, what would be the most appropriate action?Your Answer: stop the enalapril and furosemide
Explanation:The patient presents with worsened renal condition from the last consultation when he was started on enalapril (an ACE inhibitor) so this medication should be stopped. Because there is also no fluid overload; furosemide, a diuretic, should also be stopped.
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This question is part of the following fields:
- Renal System
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Question 13
Correct
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A 70-year-old male patient was started on gentamicin after developing a pseudomonas aeruginosa infection. Which of the following is associated with aminoglycoside nephrotoxicity?
Your Answer: Frequency of aminoglycoside dosing
Explanation:Aminoglycosides can induce acute kidney injury by damaging the cells of the proximal tubule which is its site of reabsorption after glomerular filtration. When the aminoglycoside is administered less frequently, the kidney has more time to recover by eliminating the drug and preventing its accumulation and possible toxic effects.
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This question is part of the following fields:
- Renal System
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Question 14
Correct
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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: 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 15
Incorrect
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A patient with chronic renal failure, treated with regular haemodialysis, attends the renal clinic. He has been treated for six months with oral ferrous sulphate, 200 mg three times a day. His haemoglobin at this clinic attendance is 7.6. His previous result was 10.6 six months ago.
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Which of the following is the most appropriate treatment?Your Answer: Commence SC erythropoietin
Correct Answer: IV iron and subcutaneous erythropoietin
Explanation:The patient should be prescribed IV iron and subcutaneous erythropoietin to enhance erythropoiesis to address the dropped haemoglobin.
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This question is part of the following fields:
- Renal System
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Question 16
Correct
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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.
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What increased chemical is thought to be the cause of his cough?Your 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 17
Correct
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A 7-year-old child presented to the paediatric clinic with a swollen face, hands and feet. She gained 2 kilograms over the last month despite poor feeding. What is the investigation of choice in this case?
Your Answer: Urinary albumin
Explanation:This is a case of nephrotic syndrome that can be confirmed by the presence of urinary albumin. It should be further investigated by a tissue sample to confirm the diagnosis.
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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 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: Start ACE inhibitor
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 19
Correct
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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: 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 20
Correct
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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: 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 21
Correct
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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: 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 22
Incorrect
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A 25-year-old woman was admitted to hospital with a 3 day history of feeling generally unwell, with fatigue, arthralgia and pruritus. She had recently finished a 5 day course of antibiotics for a urinary tract infection but there was no other significant past medical history. She had no significant findings on clinical examination except for a widespread erythematous rash.
Investigation results are below:
Haemoglobin (Hb) 12.6 g/dl
White cell count (WCC) 13.0 × 109/l (eosinophilia)
Platelets 390 × 109/l
Creatinine 720 μmol/l
Na+ 135 mmol/l
K+ 5.2 mmol/l
Urea 22.0 mmol/l
Urinalysis Protein ++ blood +
What is the most important investigation to establish the diagnosis?Your Answer: Urine microscopy and culture
Correct Answer: Renal biopsy
Explanation:There is a strong suspicion of drug-induced acute tubulo-interstitial nephritis with the classic triad of symptoms of rash, joint pain and eosinophils in the blood, associated with non-specific symptoms of fever and fatigue. This can be confirmed with renal biopsy showing interstitial oedema with a heavy infiltrate of inflammatory cells and variable tubular necrosis.
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This question is part of the following fields:
- Renal System
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Question 23
Correct
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An 8-year-old boy is admitted to the ward with renal colic. Family history is significant for similar renal calculi in his mother. Which of the following is the most likely explanation for this recurrent colic in both mother and child?
Your Answer: Idiopathic hypercalciuria
Explanation:Idiopathic hypercalciuria (IH) is the commonest metabolic abnormality in patients with calcium kidney stones. It is characterized by normocalcemia, absence of diseases that cause increased urine calcium, and calcium excretion that is above 250 mg/day in women and 300 mg/day in men. Subjects with IH have a generalized increase in calcium turnover, which includes increased gut calcium absorption, decreased renal calcium reabsorption, and a tendency to lose calcium from bone. Despite the increase in intestinal calcium absorption, negative calcium balance is commonly seen in balance studies, especially on a low calcium diet. The mediator of decreased renal calcium reabsorption is not clear; it is not associated with either an increase in filtered load of calcium or altered PTH levels. There is an increased incidence of hypercalciuria in first-degree relatives of those with IH, but IH appears to be a complex polygenic trait with a large contribution from diet to expression of increased calcium excretion. Increased tissue vitamin D response may be responsible for the manifestations of IH in at least some patients.
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This question is part of the following fields:
- Renal System
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Question 24
Correct
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A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission bloods show the following:
Na+ 138 mmol/l
K+ 6.6 mmol/l
Bicarbonate 15 mmol/l
Urea 9.2 mmol/l
Creatinine 110 µmol/l
An ECG is done which shows no acute changes.
What is the most appropriate initial treatment to lower the serum potassium level?Your Answer: Insulin/dextrose infusion
Explanation:Insulin/dextrose infusion will increase the activity of the sodium-potassium pump in the cells, which will in turn decrease serum potassium levels.
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This question is part of the following fields:
- Renal System
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Question 25
Correct
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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: 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 26
Incorrect
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer: Increased proximal tubular sodium reabsorption
Correct Answer: Increased release of renin
Explanation:The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.
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This question is part of the following fields:
- Renal System
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Question 27
Correct
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A 50-year-old gentleman with renal cell carcinoma has a haemoglobin of 19 g/dl. Which investigation will conclusively prove that this patient has secondary polycythaemia?
Your Answer: Erythropoietin level
Explanation:Erythropoietin (EPO) is used to distinguish between primary and secondary polycythaemia. Secondary polycythaemia can be caused by tumours in the kidney that may secrete EPO or EPO-like proteins.
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This question is part of the following fields:
- Renal System
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Question 28
Correct
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Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your 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
Correct
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Of the following disorders, which one causes acute tubular damage?
Your Answer: Myoglobinuria
Explanation:Myoglobinuria is the condition when there is degeneration of necrosed muscle that it is excreted in the urine. This condition would then cause acute tubular damage leading to renal failure.
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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 2-month-old infant was brought to the paediatrics ward by her mother with a complaint of excessive crying during urination. The urine culture of the infant revealed E.coli. Which of the following investigations should be done next?
Your Answer: MCUG
Correct Answer: US
Explanation:Urine culture confirms a diagnosis of a UTI. A kidney ultrasound will be the next best investigation because it will help us to visualise the bladder, kidneys, and ureters to rule out any congenital obstruction in the urinary tract that might be the actual cause of infection in this 2-month old girl.
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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
