-
Question 1
Correct
-
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: 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.
-
This question is part of the following fields:
- Renal System
-
-
Question 2
Incorrect
-
A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?
Your Answer: Possible presentations include recurrent urinary tract infection
Correct Answer: Goserelin is licensed for refractory cases
Explanation:Goserelin (Zoladex) is usually prescribed to treat hormone-sensitive cancers of the breast and prostate not for BPH. All other statements are correct.
-
This question is part of the following fields:
- Renal System
-
-
Question 3
Incorrect
-
In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?
Your Answer: Dietary modification
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 4
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: Minimal change disease
Correct Answer: Membranous glomerulonephropathy
Explanation:Membranous glomerulonephritis . However some authors believe FSGS a more commoner cause of nephrotic syndrome.
-
This question is part of the following fields:
- Renal System
-
-
Question 5
Correct
-
A 7-year-old female presented with complaints of haematuria and fatigue. She had a history of bloody diarrhoea starting 7 days previously. On investigation, her serum urea and creatinine were raised and proteinuria was present. Which of the following is the most suitable diagnosis for her?
Your Answer: Haemolytic-uremic syndrome (HUS)
Explanation:HUS syndrome occurs mostly in children after some days of bloody diarrhoea. Damaged red blood cells also damage the kidney filtering unit and lead to sudden renal failure.
-
This question is part of the following fields:
- Renal System
-
-
Question 6
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
-
-
Question 7
Correct
-
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 8
Correct
-
A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl.
On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure.
Which of the following represents the best treatment option for this patient?Your Answer: Urgent haemodialysis
Explanation:This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.
-
This question is part of the following fields:
- Renal System
-
-
Question 9
Incorrect
-
A 40-year-old female patient with a history of rheumatoid arthritis is diagnosed with type 1 renal tubular acidosis. What is the most probable sequela of this condition?
Your Answer: Hyperkalaemia
Correct Answer: Nephrocalcinosis
Explanation:Distal renal tubular acidosis is due to defective proton secretion from the alpha intercalated cells of the distal tubule caused by dysfunction of the H+/K+ antiporter on the apical membrane. This leads to failure of H+ excretion thereby causing systemic acidosis and potassium depletion. Inability to lower the urine pH below 5.3 in the presence of systemic acidosis is the diagnostic hallmark of type I or distal renal tubular acidosis. Hypercalciuria, hypocitraturia and elevated urinary pH observed in distal renal tubular acidosis can lead to nephrocalcinosis and may cause renal calculi, obstructive uropathy and renal failure necessitating surgical or endoscopic stone extraction.
-
This question is part of the following fields:
- Renal System
-
-
Question 10
Correct
-
A 60 year-old patient known with stable angina was advised to have a contrast coronary angiography. Before the procedure, what will be the most appropriate step to take?
Your Answer: IV 0.9% Saline
Explanation:Contrast material poses a greater threat for contrast induced nephropathy. In order to decrease the chance of contrast nephropathy, IV 0.9% saline is considered as the best fluid to maintain blood pressure. Normal Saline helps to expand intravascular volume and decrease the renin angiotensin system activity.
-
This question is part of the following fields:
- Renal System
-
-
Question 11
Correct
-
A 46-year-old gentleman diagnosed with type 2 diabetes, hypertension, and proteinuria is started on Ramipril to prevent development of renal disease. He reports to his GP that he has developed a troublesome cough since starting the medication. He has no symptoms of lip swelling, wheeze and has no history of underlying respiratory disease.
What increased chemical is thought to be the cause of his cough?Your Answer: Bradykinin
Explanation:Ramipril is an ACE inhibitor that blocks the conversion of angiotensin I to angiotensin II as well as preventing the breakdown of bradykinin, leading to blood vessel dilatation and decreased blood pressure. However, bradykinin also causes smooth muscles in the lungs to contract, so the build-up of bradykinin is thought to cause the dry cough that is a common side-effect in patients that are on ACE inhibitors.
-
This question is part of the following fields:
- Renal System
-
-
Question 12
Incorrect
-
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 13
Incorrect
-
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: Vitamin D supplementation
Correct Answer: Sevelamer
Explanation:Sevelamer is a phosphate-binding drug that can lower raised serum phosphate levels in chronic kidney disease. Because of its aluminium-related side-effects, aluminium hydroxide is no longer the drug of choice.
The other options are calcium-containing salts that may increase risks of tissue calcification. -
This question is part of the following fields:
- Renal System
-
-
Question 14
Correct
-
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: 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 .
-
This question is part of the following fields:
- Renal System
-
-
Question 15
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: stop the furosemide
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 16
Incorrect
-
A 35-year-old gentleman is investigated for recurrent renal stones. He has been hospitalised on multiple occasions and has required lithotripsy three times. Investigations show the following:
Calcium 2.08 mmol/l
Phosphate 0.85 mmol/l
Parathyroid hormone 4.1 pmol/L (normal range = 0.8 - 8.5)
24 hour urinary calcium 521 mg/24 hours (normal range < 300)
Which one of the following treatments will most likely reduce the incidence of renal stones?Your Answer: Bicarbonate supplements
Correct Answer: Indapamide
Explanation:Indapamide is a mild thiazide-like diuretic with hypotensive effect, and compared to other thiazides, it is reported to also have less metabolic derangements. However, it may have beneficial hypo-calciuric effects that are often associated with thiazides, thus, in this case, we would recommend prescribing this to the patient.
-
This question is part of the following fields:
- Renal System
-
-
Question 17
Incorrect
-
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: Intensive glucose control will not affect prognosis
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 18
Correct
-
In diabetes, what is the most common finding on renal biopsy?
Your 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
-
-
Question 19
Incorrect
-
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 20
Incorrect
-
What is the site of action of antidiuretic hormone?
Your Answer: Distal convoluted tubule
Correct 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.
-
This question is part of the following fields:
- Renal System
-
-
Question 21
Incorrect
-
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: Antimyeloperoxidase antibodies
Correct 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.
-
This question is part of the following fields:
- Renal System
-
-
Question 22
Correct
-
A 3-year-old girl is brought to the clinic by her mother due to burning micturition, frequency and urgency. She is also experiencing some suprapubic tenderness. Which of the following investigations should be done initially?
Your Answer: Clean catch of urine for Culture &Sensitivity
Explanation:Urine culture and sensitivity is used to diagnose a urinary tract infection (UTI). A mid-stream clean catch urine sample is the most common type of sample collected. It is important to follow the clean catch process to have accurate results from an uncontaminated sample. Urine cultures can also check for infections of the bladder or kidney.
-
This question is part of the following fields:
- Renal System
-
-
Question 23
Incorrect
-
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: Allopurinol pre-chemotherapy
Correct 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
-
This question is part of the following fields:
- Renal System
-
-
Question 24
Correct
-
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: 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.
-
This question is part of the following fields:
- Renal System
-
-
Question 25
Correct
-
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: 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.
-
This question is part of the following fields:
- Renal System
-
-
Question 26
Correct
-
Which complication of chronic renal failure is most likely associated with the accumulation of aluminium?
Your 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
-
-
Question 27
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: Posterior urethral valves
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 28
Correct
-
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 29
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: Cystine
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.
-
This question is part of the following fields:
- Renal System
-
-
Question 30
Incorrect
-
A 75-year-old lady is referred to hospital from her GP. She has been treated for essential hypertension, with Bendroflumethiazide 2.5 mg once daily and triamterene 150 mg once daily.
Routine investigations show:
Serum sodium 134 mmol/L (137-144)
Serum potassium 5.9 mmol/L (3.5-4.9)
Serum urea 7.0 mmol/L (2.5-7.5)
Serum creatinine 100 μmol/L (60-110)
Her blood pressure is measured at 134/86 mmHg. Her electrocardiogram is normal. The GP has stopped the triamterene today.
Which of these is the most appropriate action?Your Answer:
Correct Answer: Repeat urea and electrolytes in one week
Explanation:Triamterene is a potassium-sparing diuretic that can cause hyperkalaemia, therefore, it was stopped in this patient. With all other lab results returning normal values and a normal ECG, management will simply require repeating the U & E after one week since the Triamterene has already be stopped.
-
This question is part of the following fields:
- Renal System
-
SESSION STATS - PERFORMANCE PER SPECIALTY
