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  • Question 1 - A 64-year-old woman presents with malaise, ankle swelling and shortness of breath. Her...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Renal System
      78.4
      Seconds

  • Question 2 - A 63-year-old woman visits the diabetes clinic for review. She has had type-2...

    Correct

    • A 63-year-old woman visits the diabetes clinic for review. She has had type-2 diabetes for 9 years and is now on insulin therapy. She has diabetic nephropathy, as exemplified by hypertension and proteinuria (urinary PCR 155); a recent creatinine level was 205 μmol/l and eGFR 24 ml/min.
       
      Which of the following options best fits her prognosis or management?

      Your Answer: 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.

    • This question is part of the following fields:

      • Renal System
      35.9
      Seconds

  • Question 3 - A gentleman arrives at the renal clinic for review. He has long standing...

    Correct

    • 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.

    • This question is part of the following fields:

      • Renal System
      54.8
      Seconds

  • Question 4 - A 30-year-old woman is hypertensive and complains of painless haematuria. Other examination results...

    Correct

    • A 30-year-old woman is hypertensive and complains of painless haematuria. Other examination results are unremarkable. What is the most likely diagnosis?

      Your Answer: Polycystic kidneys

      Explanation:

      Renal ultrasound is utilized to confirm this condition. Although at a younger age, hypertension and haematuria that is not painful is already suggestive to the disease.

    • This question is part of the following fields:

      • Renal System
      39.6
      Seconds

  • Question 5 - A 30-year-old female presents with polyuria and is passing 4 litres of urine...

    Incorrect

    • 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: Glibenclamide

      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.

    • This question is part of the following fields:

      • Renal System
      80.3
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  • Question 6 - A 57-year-old man, who suffers from biventricular cardiac failure, comes to his doctor...

    Correct

    • 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.

    • This question is part of the following fields:

      • Renal System
      24.8
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  • Question 7 - A 50-year-old gentleman with renal cell carcinoma has a haemoglobin of 19 g/dl....

    Correct

    • 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.

    • This question is part of the following fields:

      • Renal System
      11.6
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  • Question 8 - A patient has an autosomal recessive disorder, which causes lysine, arginine, ornithine and...

    Incorrect

    • 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: Calcium oxylate

      Correct Answer: Cystine

      Explanation:

      The presence in the urine of cystine, orthinine, arginine and lysine indicate a tubular reabsorption defect. This condition is a hereditary one, and stone formation is more common in homozygotes. The patient has no other abnormalities that could indicate stone formation.

    • This question is part of the following fields:

      • Renal System
      68.8
      Seconds

  • Question 9 - A 28-year-old male has presented to his doctor with hypertension. Upon examination, he...

    Correct

    • A 28-year-old male has presented to his doctor with hypertension. Upon examination, he is found to have palpable kidneys. An abdominal ultrasound shows enlarged cystic kidneys on both sides. From the list of options, choose the most likely condition present in this patient.

      Your Answer: Polycythaemia

      Explanation:

      The most likely diagnosis for this patient is adult polycystic kidneys. This disease is associated with the following: valvular heart abnormalities, incompetence, and aneurysms of the cerebral circulation. It can also be associated with excessive erythropoietin production and polycythaemia. There is an increased incidence of aortic incompetence, and mitral valve prolapse occurs in 25 per cent of patients. Hepatic cysts can also occur, and present in 70 per cent of patients – these can also involve the pancreas in 10 per cent of patients and the spleen. Cerebral berry aneurysms are present in around 5-8 per cent of patients, but familial clustering is also observed. That is if there is a family history, over 20 per cent of patients will also have an aneurysm. Diverticular disease is also thought to be increased in patients with polycystic kidney disease.

    • This question is part of the following fields:

      • Renal System
      20.9
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  • Question 10 - A 26 year-old gentleman presented with complaints of multiple bruises over his body...

    Correct

    • A 26 year-old gentleman presented with complaints of multiple bruises over his body and reddish urine after a road traffic accident. Labs showed deranged renal function. The best management step would be?

      Your Answer: IV normal saline

      Explanation:

      Rhabdomyolysis occurs after severe muscles injury and the patient presents with myoglobinuria and deranged RFTS. The best initial step in management is fluid resuscitation with normal saline. If initial management fails to treat the patient, we can go to haemodialysis.

    • This question is part of the following fields:

      • Renal System
      48.4
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  • Question 11 - A 15-year-old boy presented to a urologist with a complaint of blood in...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Renal System
      45.1
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  • Question 12 - What is the site of action of antidiuretic hormone? ...

    Correct

    • 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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      • Renal System
      8.3
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  • Question 13 - A 7-year-old child presented to the paediatric clinic with a swollen face, hands...

    Correct

    • 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.

    • This question is part of the following fields:

      • Renal System
      12.8
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  • Question 14 - A 28-year-old female presents to her GP with joint pain , fever, a...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Renal System
      35.9
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  • Question 15 - A 68-year-old gentleman has been receiving dialysis for 6 years. His PTH is...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 16 - A 53-year-old diabetic man presents to the emergency with pain in left loin...

    Incorrect

    • 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 17 - A 63-year-old gentleman with chronic kidney disease secondary to diabetes mellitus is reviewed....

    Incorrect

    • 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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      • Renal System
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  • Question 18 - A 41-year-old female is referred to medical assessment unit by her physician for...

    Incorrect

    • A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline.

      What is the underlying pathophysiology of TTP?

      Your Answer:

      Correct Answer: Failure to cleave von Willebrand factor normally

      Explanation:

      Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.

    • This question is part of the following fields:

      • Renal System
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  • Question 19 - A 3-year-old girl is brought to the clinic by her mother due to...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 20 - A 53-year-old gentleman presents with several months' history of generalised swelling, fatigue, dyspnoea...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 21 - A patient is told to consult a pathologist regarding the stone that was...

    Incorrect

    • 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:

      Correct 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 22 - A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted...

    Incorrect

    • A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted after slipping on ice and falling over. Some routine blood tests are performed:


      Na+ 141 mmol/l
      K+ 2.9 mmol/l
      Chloride 114 mmol/l
      Bicarbonate 16 mmol/l
      Urea 5.2 mmol/l
      Creatinine 75 µmol/l

      Which one of the following is most likely to explain these results?

      Your Answer:

      Correct Answer: Renal tubular acidosis (type 1)

      Explanation:

      The patient’s underlying arthritis has most likely led to Renal tubular acidosis RTA type 1, which presents with the following symptoms consistent with the presentation of the patient: Normal anion gap metabolic acidosis/acidaemia, hypokalaemia and hyperchloremia. Comparatively, the other conditions are ruled out because Aspirin and diabetic ketoacidosis is associated with a raised anion gap, Conn’s syndrome explains hypokalaemia but not the metabolic acidosis, and RTA type 4 is associated with hyperkalaemia.

    • This question is part of the following fields:

      • Renal System
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  • Question 23 - In diabetes, what is the most common finding on renal biopsy? ...

    Incorrect

    • In diabetes, what is the most common finding on renal biopsy?

      Your Answer:

      Correct Answer: Glomerulosclerosis

      Explanation:

      Glomerulosclerosis is the scarring and hardening of the glomeruli known as diabetic glomerulosclerosis occurring in long-standing diabetes.

    • This question is part of the following fields:

      • Renal System
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  • Question 24 - Which complication of chronic renal failure is most likely associated with the accumulation...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 25 - A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs...

    Incorrect

    • A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:

      Your Answer:

      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.

    • This question is part of the following fields:

      • Renal System
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  • Question 26 - Following a road traffic accident, a gentleman is brought to A&E. He is...

    Incorrect

    • 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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      • Renal System
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  • Question 27 - A 20-year-old woman presents to casualty with flank pain and a 48 hour...

    Incorrect

    • 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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      • Renal System
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  • Question 28 - A 70-year-old man underwent emergency surgery for an acute abdomen. Following surgery, he...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 29 - A 65-year-old gentleman gives a two week history of progressive lethargy and weakness....

    Incorrect

    • 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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      • Renal System
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  • Question 30 - A 21-year-old woman presents with lethargy and confusion. On examination, you note a...

    Incorrect

    • 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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      • Renal System
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  • Question 31 - A 3-year-old boy presents with recurrent urinary tract infections. What is the most...

    Incorrect

    • 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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      • Renal System
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  • Question 32 - A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Renal System
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  • Question 33 - A 58-year-old gentleman with a long history of gout presents with loin pain....

    Incorrect

    • 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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      • Renal System
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  • Question 34 - Which of the following is most helpful in differentiating chronic from acute renal...

    Incorrect

    • Which of the following is most helpful in differentiating chronic from acute renal failure?

      Your Answer:

      Correct Answer: Kidney size at ultrasound scan

      Explanation:

      The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.

    • This question is part of the following fields:

      • Renal System
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  • Question 35 - A 3-year old boy presents with an abdominal mass. Which of the following...

    Incorrect

    • A 3-year old boy presents with an abdominal mass. Which of the following is associated with Wilms tumour (nephroblastoma)?

      Your Answer:

      Correct Answer: Beckwith-Wiedemann syndrome

      Explanation:

      Beckwith-Wiedemann syndrome is a inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia. Wilm’s tumour is a kidney cancer that usually occurs in children. The causes are unknown, however, risk factors include race and family history. Of note, Wilm’s tumour can occur as part of the following syndromes: WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome and not the other listed options in this question.

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  • Question 36 - Which one of the following statements regarding minimal change glomerulonephritis is incorrect? ...

    Incorrect

    • Which one of the following statements regarding minimal change glomerulonephritis is incorrect?

      Your Answer:

      Correct Answer: Hypertension is found in approximately 25% of patients

      Explanation:

      Hypertension and haematuria are not common presentations in minimal change glomerulonephritis, all other statements are correct.

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  • Question 37 - Which one of the following statements is true regarding autosomal recessive polycystic kidney...

    Incorrect

    • 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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  • Question 38 - Which is the most severe form among the following? ...

    Incorrect

    • Which is the most severe form among the following?

      Your Answer:

      Correct Answer: Class IV: diffuse proliferative glomerulonephritis

      Explanation:

      The classes refer to the WHO classification of glomerulonephritis in SLE patients.
      class I: normal kidney
      class II: mesangial glomerulonephritis
      class III: focal (and segmental) proliferative glomerulonephritis
      class IV: diffuse proliferative glomerulonephritis
      class V: diffuse membranous glomerulonephritis
      class VI: sclerosing glomerulonephritis

      Class IV: diffuse proliferative glomerulonephritis is the most common and the most severe form, where more than 50% of the glomeruli are involved.

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  • Question 39 - A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the...

    Incorrect

    • A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the most common problem that can arise in this case?

      Your Answer:

      Correct Answer: Protein-calorie malnutrition

      Explanation:

      Protein-calorie malnutrition is observed in almost 50% of dialysis patients, contributing to increased morbidity and mortality. All the other complications listed can usually be prevented thanks to modern-day dialysis techniques.

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  • Question 40 - A patient presents to the nephrologist with proteinuria ++. Which medication would most...

    Incorrect

    • 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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  • Question 41 - An 8-year-old boy is admitted to the ward with renal colic. Family history...

    Incorrect

    • 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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  • Question 42 - A 38-year-old patient with hypertension presented with facial puffiness, ankle oedema, haematuria and...

    Incorrect

    • 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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  • Question 43 - In end stage renal disease, deficiency of erythropoietin can lead to which of...

    Incorrect

    • 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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  • Question 44 - A 76-year-old man complains of painful microscopic haematuria and urgency. On examination of...

    Incorrect

    • 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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  • Question 45 - A 40-year-old man presents with periorbital and pedal oedema. 24h urine shows 9g...

    Incorrect

    • 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:

      Correct Answer: Membranous glomerulonephropathy

      Explanation:

      Membranous glomerulonephritis . However some authors believe FSGS a more commoner cause of nephrotic syndrome.

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  • Question 46 - A 75-year-old man was admitted with urinary dribbling and incontinence. Upon examination, there...

    Incorrect

    • 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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  • Question 47 - A 3-year-old boy presents with facial puffiness, frothy urine, lethargy and oliguria for...

    Incorrect

    • 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:

      Correct 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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  • Question 48 - In renal patients, bone reabsorption and fractures are significant due to high level...

    Incorrect

    • 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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  • Question 49 - A 33-year-old Afro-Caribbean gentleman with a 5 year history of HIV infection presents...

    Incorrect

    • A 33-year-old Afro-Caribbean gentleman with a 5 year history of HIV infection presents with swollen ankles. He has been treated with highly active antiretroviral therapy (HAART) for 2 years, with partial response.

      His plasma creatinine concentration is 358 μmol/l, albumin is 12 g/dl, CD4 count is 35/μl and 24 hour urine protein excretion rate is 6.8 g. Renal ultrasound shows echogenic kidneys 13.5 cm in length.

      What would a renal biopsy show?

      Your Answer:

      Correct Answer: Microcystic tubular dilatation and collapsing FSGS

      Explanation:

      HIV-associated nephropathy (HIVAN) show typical findings of scarring called focal segmental glomerulosclerosis (FSGS) and microcystic tubular dilatation, prominent podocytes, and collapsing capillary loops.

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  • Question 50 - You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma...

    Incorrect

    • 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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  • Question 51 - A 50-year-old male presented with pain in the left lumbar region. His abdominal...

    Incorrect

    • A 50-year-old male presented with pain in the left lumbar region. His abdominal X-ray revealed stones in his left kidney. Analysis of one of the stones that he passed in the urine showed that it was composed of uric acid. Which of the following is the most likely cause of this type of renal stone?

      Your Answer:

      Correct Answer: Thiazide diuretics

      Explanation:

      Like all diuretics, thiazide diuretics decrease the amount of body fluid. This leads to an increase in the concentration of uric acid in the body; hence the chances of forming uric acid stones.
      Allopurinol is actually a drug used to treat gout, reducing uric acid levels in the body. Therefore, allopurinol would rather decrease the chances of having uric acid stones.
      Primary hyperparathyroidism is not concerned with uric acid stones. It is related to calcium metabolism and hence, calcium stones.

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  • Question 52 - A 41-year-old gentleman underwent kidney transplantation for end-stage renal disease. Now, 2 months...

    Incorrect

    • 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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  • Question 53 - A 48-year-old patient with type 1 diabetes and chronic kidney disease attends for...

    Incorrect

    • 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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  • Question 54 - A 2-month-old infant was brought to the paediatrics ward by her mother with...

    Incorrect

    • 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:

      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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  • Question 55 - In idiopathic hypercalciuria, what management should be initiated if there is renal stone...

    Incorrect

    • In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?

      Your Answer:

      Correct Answer: Dietary modification and thiazide diuretics

      Explanation:

      Idiopathic hypercalciuria presents with excess calcium in the urine without an apparent cause. Dietary modification is the first step in addressing this condition, however, because hypercalciuria increases the risk of developing renal stones and bone demineralisation, thiazide diuretics should be prescribed to increase calcium reabsorption when these symptoms are also present.

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  • Question 56 - A woman with severe renal failure undergoes a kidney transplant. However, after a...

    Incorrect

    • 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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  • Question 57 - A 61-year-old male presented to the emergency with renal colicky pain and a...

    Incorrect

    • 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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  • Question 58 - A 19-year-old girl suffers from a hereditary disease and presents at her GP...

    Incorrect

    • 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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  • Question 59 - A 60-year-old gentleman is found dead in his apartment. He was known to...

    Incorrect

    • 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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  • Question 60 - A 30-year-old female presented with sudden onset severe right sided abdominal pain for...

    Incorrect

    • 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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