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Question 1
Incorrect
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A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC.
Initial investigations reveal:
Haemoglobin 9.5 g/dl
White cell count 12 × 109/l
Platelets 40 × 109/l
Creatinine 142 μmol/l
Sodium 139 mmol/l
Potassium 4.5 mmol/l
Urea 9.2 mmol/l
Lactate dehydrogenase 495 U/l (10-250)
Urinalysis Protein ++, blood +++
Blood film shows schistocytes
What treatment should NOT be given to this patient?Your Answer: Antiplatet agents
Correct Answer: Platelet transfusion
Explanation:There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.
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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 patient presents to the nephrologist with proteinuria ++. Which medication would most likely result in the prevention of progression of this disease?
Your 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 3
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.
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 4
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: Urethral catheter
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 5
Correct
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Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?
Your 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 6
Correct
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A 65-year-old gentleman with a history of chronic renal failure due to diabetes comes to the clinic for review. He has reported increasing bone and muscle aches over the past few weeks.
Medications include ramipril, amlodipine and indapamide for blood pressure control, atorvastatin for lipid management, and insulin for control of his blood sugar. On examination his BP is 148/80 mmHg, his pulse is 79 and regular. His BMI is 28.
Investigations show:
Haemoglobin 10.7 g/dl (13.5-17.7)
White cell count 8.2 x 10(9)/l (4-11)
Platelets 202 x 10(9)/l (150-400)
Serum sodium 140 mmol/l (135-146)
Serum potassium 5.0 mmol/l (3.5-5)
Creatinine 192 μmol/l (79-118)
Calcium 2.18 mmol/l (2.2-2.67)
Phosphate 1.9 mmol/l (0.7-1.5)
He has tried following a low phosphate diet.
Which of the following would be the next most appropriate step in controlling his phosphate levels?Your Answer: Sevelamer
Explanation:Sevelamer is a phosphate-binding drug that can lower raised serum phosphate levels in chronic kidney disease. Because of its aluminium-related side-effects, aluminium hydroxide is no longer the drug of choice.
The other options are calcium-containing salts that may increase risks of tissue calcification. -
This question is part of the following fields:
- Renal System
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Question 7
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: Macrophages
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 8
Incorrect
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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: 24 hour urinary protein estimation
Correct 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 9
Correct
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A 3-year-old boy presents with facial puffiness, frothy urine, lethargy and oliguria for two weeks. Urine analysis reveals proteinuria. Which of the following is the most appropriate treatment for this child?
Your Answer: Prednisolone
Explanation:The presentation is suggestive of nephrotic syndrome. A trial of corticosteroids is the first step in treatment of idiopathic nephrotic syndrome. Diuretics are useful in managing symptomatic oedema. Cyclosporin and cyclophosphamide are indicated in frequently relapsing and steroid dependant disease.
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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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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 11
Incorrect
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A 68-year-old gentleman has been receiving dialysis for 6 years. His PTH is elevated at 345 pg/ml (NR 25-65), phosphate 2.13 mmol/l and corrected calcium 2.01 mmol/l.
Of the following, which is most likely responsible for renal osteodystrophy?Your Answer:
Correct Answer: Diminished activity of renal 1-?-hydroxylase
Explanation:Renal osteodystrophy is a metabolic bone disease often affecting long-term dialysis patients. The kidneys are no longer able to maintain the calcium levels in the blood, thus the PTH increases as the body attempts to raise blood calcium levels. Osteomalacia in these cases is most likely caused by the diminished activity of renal 1-a-hydroxylase that is important for hydroxylation of Calciferol to calcitriol (Vitamin D). This bioactive form of Vitamin D is responsible for increasing intestinal absorption of calcium.
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This question is part of the following fields:
- Renal System
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Question 12
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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Question 13
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 14
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 15
Incorrect
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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:
Correct 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 16
Incorrect
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A 37-year-old male patient presented with bilateral kidney stones. He gave a history of sarcoidosis. What is the most probable cause for renal stones?
Your Answer:
Correct Answer: Hyper calcaemic
Explanation:Sarcoidosis is a multisystem granulomatous disorder which may involve the kidneys to a variable degree. Renal calculi have been reported to occur in about 10% of patients with chronic sarcoidosis. Hypercalcaemia due to marked hyperabsorption of dietary calcium, bone resorption and renal tubular calcium reabsorption causes hypercalciuria. Both hypercalcemia and hypercalciuria contribute to nephrolithiasis.
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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 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:
Correct 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 18
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:
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 19
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 20
Incorrect
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A 34-year-old diabetic male is undergoing contrast radiography. What should you do to make sure that renal damage due to the contrast dye is prevented?
Your Answer:
Correct Answer: Plenty of fluids
Explanation:The risk of kidney damage during this procedure is greatly increased for a diabetic patient. It is therefore important that plenty of fluids are given to prevent dehydration and therefore damage to the kidneys.
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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 19-year-old girl suffers from a hereditary disease and presents at her GP with a renal colic. She claims that her mother had this problem too. What type of renal calculus is most likely responsible for the renal colic?
Your Answer:
Correct Answer: Cystine
Explanation:The patient seems to have inherited cystinuria which is an autosomal recessive disease. Typical for the disease is the abnormally high concentration of cysteine in the urine, finally causing cystinuria. In a person with cystinuria, the high concentrations of cysteine in the kidney results in the formation of stones with frequent colic pains and complications. If the genotype is partially expressed, then the phenotype might be even asymptomatic, thus the disease has a high variability.
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This question is part of the following fields:
- Renal System
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Question 22
Incorrect
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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.
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).
What is the most likely diagnosis?Your Answer:
Correct 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 23
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 24
Incorrect
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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:
Correct 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 25
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 26
Incorrect
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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:
Correct 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 27
Incorrect
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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:
Correct 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 28
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 29
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 30
Incorrect
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A 40-year-old female patient with a history of rheumatoid arthritis is diagnosed with type 1 renal tubular acidosis. What is the most probable sequela of this condition?
Your Answer:
Correct Answer: Nephrocalcinosis
Explanation:Distal renal tubular acidosis is due to defective proton secretion from the alpha intercalated cells of the distal tubule caused by dysfunction of the H+/K+ antiporter on the apical membrane. This leads to failure of H+ excretion thereby causing systemic acidosis and potassium depletion. Inability to lower the urine pH below 5.3 in the presence of systemic acidosis is the diagnostic hallmark of type I or distal renal tubular acidosis. Hypercalciuria, hypocitraturia and elevated urinary pH observed in distal renal tubular acidosis can lead to nephrocalcinosis and may cause renal calculi, obstructive uropathy and renal failure necessitating surgical or endoscopic stone extraction.
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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
