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Question 1
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 2
Incorrect
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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: Mycobacterium tuberculosis
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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This question is part of the following fields:
- Renal System
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Question 3
Correct
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Reduced renal reabsorption
Explanation:Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.
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This question is part of the following fields:
- Renal System
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Question 4
Correct
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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: 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 5
Correct
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A 71-year-old woman with a medical history of a blood transfusion in the early 1980s presents with a 10 month history of malaise and is noted to have impaired renal function. Her urine sediment reveals red cell casts.
The results of immunological investigations are as follows: serum IgG 6.5 g/L (normal range 6-13), IgA 1.5 g/L (normal range 0.8-4.0), IgM 5.7 g/L (normal range 0.4-2.0), serum electrophoresis shows a faint band in the gamma region, complement C3 1.02 g/L (normal range 0.75-1.65), complement C4 <0.02 g/L (normal range 0.20-0.65), and rheumatoid factor 894 IU/L (normal range <40).
Which of the following investigations is likely to be most important in making a definitive diagnosis?Your Answer: Cryoglobulins
Explanation:The patient’s history of a blood transfusion and lab results showing a markedly low C4 (with normal C3), elevated rheumatoid factor, and elevated serum IgM is highly suggestive of hepatitis C-associated cryoglobulinaemic vasculitis. Testing for Cryoglobulins will confirm this suspicion.
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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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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 7
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 8
Incorrect
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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:
Correct 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.
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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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A 70-year-old male patient was started on gentamicin after developing a pseudomonas aeruginosa infection. Which of the following is associated with aminoglycoside nephrotoxicity?
Your Answer:
Correct Answer: Frequency of aminoglycoside dosing
Explanation:Aminoglycosides can induce acute kidney injury by damaging the cells of the proximal tubule which is its site of reabsorption after glomerular filtration. When the aminoglycoside is administered less frequently, the kidney has more time to recover by eliminating the drug and preventing its accumulation and possible toxic effects.
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This question is part of the following fields:
- Renal System
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Question 10
Incorrect
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A 3-year-old boy presents with recurrent urinary tract infections. What is the most common cause for this problem in a child of this age?
Your Answer:
Correct Answer: Vesicoureteric reflux
Explanation:Vesicoureteral reflux is the condition when the urine flows backwards from the bladder into the kidneys, which is the most common cause of UTI in patients this age.
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This question is part of the following fields:
- Renal System
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Question 11
Incorrect
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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.
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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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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 13
Incorrect
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A 38-year-old patient with hypertension presented with facial puffiness, ankle oedema, haematuria and frothy urine. Which of the following is a definitive diagnostic test?
Your Answer:
Correct Answer: Renal biopsy
Explanation:The history is suggestive of nephritic syndrome. Renal biopsy is the definitive diagnostic test which shows the glomerular pathology.
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This question is part of the following fields:
- Renal System
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Question 14
Incorrect
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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.
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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 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:
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 16
Incorrect
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A 70-year-old male patient with hypertension complains of acute urinary retention. He provides a history of urinary frequency for the past 18 months and has been taking Nifedipine and Propranolol for blood pressure control. Which of the following is the most probable cause for his acute presentation?
Your Answer:
Correct Answer: Drug induced
Explanation:Calcium channel blockers decrease smooth-muscle contractility in the bladder and this can cause urinary retention.
An enlarged prostate gland could be the reason if he gave a history of obstructive symptoms.
Diabetes presents with polyuria.
Bladder cancer commonly presents with painless haematuria. -
This question is part of the following fields:
- Renal System
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Question 17
Incorrect
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A 2-month-old infant was brought to the paediatrics ward by her mother with a complaint of excessive crying during urination. The urine culture of the infant revealed E.coli. Which of the following investigations should be done next?
Your Answer:
Correct Answer: US
Explanation:Urine culture confirms a diagnosis of a UTI. A kidney ultrasound will be the next best investigation because it will help us to visualise the bladder, kidneys, and ureters to rule out any congenital obstruction in the urinary tract that might be the actual cause of infection in this 2-month old girl.
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This question is part of the following fields:
- Renal System
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Question 18
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 19
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 20
Incorrect
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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:
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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This question is part of the following fields:
- Renal System
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Question 21
Incorrect
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A 10-year-old boy presents with generalized swelling. This includes puffiness in the face and swollen ankles - these symptoms have been present for 4 days. The swelling began just a few days after he suffered from a mild cold with a runny nose. His only past medical history is that of eczema. His urine analysis showed the following: haematuria; proteinuria (10g/24h); creat 60 umol/l; and albumin of 15g/l. From the list of options, what is the single most likely diagnosis for this patient?
Your Answer:
Correct Answer: IgA nephropathy
Explanation:A 10 year old child, with a history of URTI and haematuria, presents a picture consistent with a diagnosis of IgA nephropathy. This condition can present with proteinuria and generalized swelling. However, an important differentiating point from rapidly progressive GN is the duration. IgA nephropathy is usually <10 days (commonly 4-5 day history of infection).
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This question is part of the following fields:
- Renal System
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Question 22
Incorrect
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A 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:
Correct Answer: Treatment with ARB or ACE-I may slow further deterioration in renal function
Explanation:Treatment with ARB or ACE-I may slow further deterioration in renal function in this patient, as studies have shown that blocking of the RAS in type 2 diabetic patients improve renal function.
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This question is part of the following fields:
- Renal System
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Question 23
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:
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 24
Incorrect
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A 30-year-old woman who underwent a live related renal transplant for end-stage renal failure secondary to chronic pyelonephritis, 12 weeks previously, attends the clinic for routine follow up. She is taking tacrolimus and mycophenolate mofetil (MMF).
Her urea and electrolytes are below:
Na+ 136 mmol/l
K+ 3.7 mmol/l
Urea 7.2 mmol/l
Creatinine 146 μmol/l
She was last seen in clinic 2 weeks previously when her urea was 4.2 mmol/l and creatinine 98 μmol/l. She is clinically well and asymptomatic.
On examination she was apyrexial and normotensive. Her transplant site was non-tender with no swelling and there were no other signs to be found.
Which THREE initial investigations are the most important to perform?Your Answer:
Correct Answer: Urine and blood cultures
Explanation:After renal transplant, asymptomatic patients can still have graft dysfunction as an early complication, with rising serum creatinine; therefore, urine and blood cultures should be ordered first. This should be followed by measuring the Tacrolimus levels, as this drug can be directly nephrotoxic. Next, a Doppler ultrasound of the transplant site should be ordered, to check for any obstructions or occlusions.
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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 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 26
Incorrect
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A 60-year-old gentleman presents with symptoms of nocturia and difficulty in passing urine. He is not known to have any previous prostatic problems and denies any dysuria. Following a digital rectal examination, he is started on Finasteride and Tamsulosin. Three months later he presents to the emergency department with urinary retention and is catheterized, and a craggy mass is felt on rectal examination. He is referred to a urologist, and a prostatic ultrasound and needle biopsy are arranged, and prostate serum antigen (PSA) is requested.
Which of the following factors is most likely to give a false negative PSA?Your Answer:
Correct Answer: Finasteride
Explanation:Finasteride is often prescribed for patients with Benign Prostatic Hyperplasia (BPH) or enlarged prostate. However, it has been known to cause a decrease in Prostatic Specific Antigen (PSA) levels in patients with BPH, which may lead to false negatives in a case like this, where a palpable mass has been detected and malignancy is suspected.
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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 40-year-old male presented with sudden onset chest pain and difficulty in breathing for the past 2 hours. On examination he had bilateral ankle swelling. Investigations revealed proteinuria of 6g/d. Which of the following is the most likely explanation for this presentation?
Your Answer:
Correct Answer: Reduced antithrombin III activity
Explanation:This patient has presented with a thromboembolic event most probably secondary to nephrotic syndrome (nephrotic-range proteinuria). Hypercoagulability is due to urinary loss of anticoagulant proteins, such as antithrombin III and plasminogen and an increase in clotting factors, especially factors I, VII, VIII, and X.
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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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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 29
Incorrect
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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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This question is part of the following fields:
- Renal System
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Question 30
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:
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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SESSION STATS - PERFORMANCE PER SPECIALTY
