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Question 1
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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: 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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Question 2
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: Bicarbonate supplements
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 3
Incorrect
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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: Intravenous calcium gluconate
Correct 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 4
Correct
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A 35-year-old gentleman presents to the Emergency Department with abdominal pain. This started earlier on in the day and is getting progressively worse. The pain is located on his left flank and radiates down into his groin. He has no history of this pain or any other condition. Examination reveals a gentleman who is flushed and sweaty but is otherwise unremarkable. What is the most suitable initial management?
Your Answer: IM diclofenac 75 mg
Explanation:Because of the patient’s presentation with flank pain that radiates to the groin, we are suspecting renal colic. We should follow guidelines for acute renal management and prescribe IM diclofenac for immediate relief of pain.
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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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Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your Answer: Encephalopathy
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 6
Incorrect
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Increased renal secretion
Correct Answer: Reduced renal reabsorption
Explanation:Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.
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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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A 21-year-old woman presents with lethargy and confusion. On examination, you note a purpuric rash covering the abdominal wall and thighs, and a fever of 38C. Investigations reveal haemolytic anaemia, thrombocytopenia, and acute kidney injury.
Which feature of the presentation makes the diagnosis of thrombotic thrombocytopenic purpura more likely than haemolytic uremic syndrome?Your Answer: Confusion
Explanation:Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.
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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 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: Apple-green birefringence under polarised light
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 9
Correct
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A 40-year-old man presents with periorbital and pedal oedema. 24h urine shows 9g of protein/d and serum cholesterol of 7 mmol/L. What would be the most likely diagnosis?
Your Answer: Membranous glomerulonephropathy
Explanation:Membranous glomerulonephritis . However some authors believe FSGS a more commoner cause of nephrotic syndrome.
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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 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: Aluminium hydroxide
Correct 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 11
Correct
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A patient is told to consult a pathologist regarding the stone that was found in his urine. The pathologist describes the stone as laminated, with areas of black staining. Urinalysis indicates hypercalciuria. Which is the most likely type of renal calculus?
Your Answer: Calcium oxylate
Explanation:Hypercalciuria is the most common cause of kidney stone disease. It is an identifiable cause and can be primary (or idiopathic) or secondary. Secondary hypercalciuria might be due to hyperparathyroidism (2-3%), high levels of vitamin D, Cushing’s syndrome, sarcoidosis or milk-alkali syndrome. Hypercalciuria can also be idiopathic and is considered the commonest metabolic abnormality in people with stone disease. Factors favouring stone formation are: abnormal urine constituents, infection and stasis. In these cases, investigations fail to reveal any calcium metabolism disorders.
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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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Of the following disorders, which one causes acute tubular damage?
Your Answer: Dehydration
Correct 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 13
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.
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 14
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.
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.
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 15
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 16
Correct
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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: 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 17
Correct
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your 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 18
Incorrect
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A 15-year-old boy presented to a urologist with a complaint of blood in the urine and pain in his abdomen. On examination, abdominal swelling is present and blood pressure is elevated. Which of the following is the most appropriate investigation in this case?
Your Answer: CT
Correct Answer: Ultrasound
Explanation:Haematuria and abdominal swelling may indicate either polycystic kidney disease or a tumour. Because of the patient’s age, the likelihood of a tumorous growth is small, thus an ultrasound is the best choice for this case.
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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 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: 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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Question 20
Correct
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A 71-year-old female presents for investigation of fatigue and weight loss.
Investigations reveal:
Haemoglobin 9.0 g/dL (11.5-16.5)
White cell count 2.0 x109/L (4-11 x109)
Platelet count 250 x109/L (150-400 x109)
Total protein 74 g/L (61-76)
Albumin 28 g/L (37-49)
Urea 16 mmol/L (2.5-7.5)
Creatinine 250 mol/L (60-110)
Plasma glucose 6.5 mmol/L (3.0-6.0)
Urine dipstick analysis: Protein+ & blood+
Renal ultrasound: Normal
Which one of the following investigations would be most appropriate for this patient?Your Answer: Plasma protein electrophoresis
Explanation:This patient’s symptoms of anaemia, leukopenia, and elevated non-albumin protein concentration with fatigue and weight loss, point to myeloma. Thus plasma protein electrophoresis or Serum Protein Electrophoresis (SPE) is indicated when there is suspicion of myeloma.
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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 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 22
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 23
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: Stenosis of one or both main renal arteries
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 24
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: Mid-stream urine for culture
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 25
Incorrect
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A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl.
On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure.
Which of the following represents the best treatment option for this patient?Your Answer:
Correct Answer: Urgent haemodialysis
Explanation:This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.
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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 pain in his right flank and haematuria. A CT scan of the abdomen reveals a large 8 × 8 cm solid mass in the right kidney and a 3 × 3 cm solid mass occupying the upper pole of the left kidney.
What is the most appropriate treatment for this patient?Your Answer:
Correct Answer: Right radical nephrectomy and left partial nephrectomy
Explanation:This patient presents with the classic triad of renal carcinoma: haematuria, loin pain and a mass in the kidneys. Management will entail right radical nephrectomy because of the 8x8cm solid mass and a left partial nephrectomy of the 3x3cm solid mass.
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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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Which of the following types of renal stones are said to have a semi-opaque appearance on x-ray?
Your Answer:
Correct 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 28
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 29
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 30
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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SESSION STATS - PERFORMANCE PER SPECIALTY
