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Question 1
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A 58-year-old gentleman with a long history of gout presents with loin pain. Other past history of note includes an ileostomy after bowel surgery. There is no history of weight loss from malabsorption syndrome after his bowel surgery. Excretion urography reveals evidence of bilateral renal stones.
What is the most likely composition of his renal stones?Your Answer: Uric acid stones
Explanation:Uric acid stones will most likely be found in this case because of the patient’s long history of gout. Additionally, studies have shown that ileostomy patients have an increased risk for the development of uric acid stones.
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This question is part of the following fields:
- Renal System
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Question 2
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: Interleukin-2 and interferon-?
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 3
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 4
Incorrect
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A 53-year-old diabetic man presents to the emergency with pain in left loin and haematuria that was sudden in onset. Investigations revealed an 8mm stone in the left lower ureter. Supportive therapy was initiated with nifedipine and steroids. The patients returned to the emergency with vomiting and worsening pain and passage of two stones. Renal function tests are significant for an impending ARF. Which of the following steps would be employed in the management of this patient?
Your Answer: Percutaneous nephrolithotomy
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 5
Incorrect
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A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo.
Which diuretic is most likely to have caused this?Your Answer: Acetazolamide
Correct Answer: Furosemide
Explanation:Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.
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This question is part of the following fields:
- Renal System
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Question 6
Correct
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A 23-year-old student commences chemotherapy for B-type acute lymphoblastic leukaemia. She suffers from vomiting, but 36 hours later her condition worsens and her bloods reveal a corrected calcium of 2.0 mmol/l and serum potassium of 6.7 mmol/l.
Which of the following options is the best way to avoid this problem from occurring?Your Answer: Hydration and allopurinol pre-chemotherapy
Explanation:This case is most likely tumour lysis syndrome, often occurring immediately after starting chemotherapy because the tumour cells are killed and their contents are released into the bloodstream. After treating lymphomas or leukaemia, there is a sudden hypocalcaemia, hyperphosphatemia, and hyperkalaemia
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This question is part of the following fields:
- Renal System
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Question 7
Correct
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In 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 8
Incorrect
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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: Aspirin overdose
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.
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This question is part of the following fields:
- Renal System
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Question 9
Incorrect
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Which is the most severe form among the following?
Your Answer: Class VI: sclerosing glomerulonephritis
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 glomerulonephritisClass 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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This question is part of the following fields:
- Renal System
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Question 10
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 11
Correct
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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: Renal biopsy
Explanation:The history is suggestive of nephritic syndrome. Renal biopsy is the definitive diagnostic test which shows the glomerular pathology.
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This question is part of the following fields:
- Renal System
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Question 12
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 13
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 14
Correct
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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: 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 15
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 16
Correct
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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: 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 17
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 18
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 19
Correct
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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: 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 20
Correct
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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: 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. -
This question is part of the following fields:
- Renal System
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Question 21
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 22
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 23
Incorrect
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A 7-year-old child presented to the paediatric clinic with a swollen face, hands and feet. She gained 2 kilograms over the last month despite poor feeding. What is the investigation of choice in this case?
Your Answer: Serum urea &creatinine
Correct Answer: Urinary albumin
Explanation:This is a case of nephrotic syndrome that can be confirmed by the presence of urinary albumin. It should be further investigated by a tissue sample to confirm the diagnosis.
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This question is part of the following fields:
- Renal System
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Question 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 45-year-old male suffers multiple injuries in a road traffic accident. He complains of inability to urinate for the past 4 hours. Radiological examination reveals a fractured pelvis. Which of the following will be the most appropriate step in the management of this patient?
Your Answer: IV furosemide
Correct Answer: Suprapubic catheter
Explanation:When faced with urethral trauma, initial management decisions must be made in the context of other injuries and patient stability. These patients often have multiple injuries, and management must be coordinated with other specialists, usually trauma, critical care, and orthopaedic specialists. Life-threatening injuries must be corrected first in any trauma algorithm. Initial emergent treatment remains controversial, but mainstays of therapy include drainage of the urinary bladder, often with placement of a suprapubic catheter (SPT) and primary endoscopic realignment of the urethra if possible.
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This question is part of the following fields:
- Renal System
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Question 26
Incorrect
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A 48-year-old patient with type 1 diabetes and chronic kidney disease attends for review. His blood tests show:
Haemoglobin 11.2 g/dl (13.0 - 18.0 g/dL)
MCV 87 fl (80 - 96 fL)
Sodium 133 mmol/l (137 - 144 mmol/L)
Potassium 4.3 mmol/l (3.5 - 4.9 mmol/L)
Urea 19.1 mmol/l (2.5 - 7.5 mmol/L)
Creatinine 267 μmol/l (60 - 110 μmol/L)
Ferritin 150 μg/l (15 - 300 μg/L)
C reactive protein <5 mg/l (< 10 mg/L)
What is the most appropriate management of his anaemia?Your Answer: Blood transfusion
Correct Answer: Monitor haemoglobin, no treatment required at present
Explanation:Because the patient has chronic kidney disease, we need to consider the associated adverse effects of trying to maintain normal haemoglobin levels (14-18g/dl in this patient) and instead only instigate therapy when the level falls below 11 g/dl. Thus, in this case we should just monitor the haemoglobin levels and not initiate therapy just yet.
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This question is part of the following fields:
- Renal System
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Question 27
Incorrect
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A 63-year-old gentleman with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?
Your Answer:
Correct Answer: Serum urea
Explanation:A formula for estimating glomerular filtration rate (eGFR) is the Modification Diet of Renal Disease (MDRD) equation which takes into account the following variables: serum creatinine, age, gender, and ethnicity. Thus, serum urea is not required in this formula.
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This question is part of the following fields:
- Renal System
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Question 28
Incorrect
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A 20-year-old woman presents with weakness and is found to have a serum potassium of 2.2 mmol/l and pH 7.1.
Which of the following would be LEAST useful in differentiating between renal tubular acidosis Types 1 and 2?Your Answer:
Correct Answer: Osteomalacia
Explanation:Osteomalacia is a marked softening of the bones that can present in both type I and type II Renal Tubular Acidosis (RTA) and will thus not differentiate the two types in any case. The other measures will allow differentiation of the two types.
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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 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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This question is part of the following fields:
- Renal System
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Question 30
Incorrect
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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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This question is part of the following fields:
- Renal System
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SESSION STATS - PERFORMANCE PER SPECIALTY
