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Question 1
Incorrect
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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: Histamine
Correct 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.
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This question is part of the following fields:
- Nephrology
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Question 2
Correct
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A 63-year-old gentleman is admitted to the Emergency Department, with a past history of chronic renal failure, who complains of increasing shortness of breath. Bloods reveal a creatinine of 570 μmol/l, urea of 48 mmol/l. He is also anaemic with a haemoglobin (Hb) of 8.9 g/dl. On examination he has a pericardial rub and there are bibasal crackles consistent with heart failure. Which of the following represents the best treatment option for this patient?
Your Answer: Urgent haemodialysis
Explanation:This case presents with symptoms and lab results suggestive of uremic pericarditis, which is an indication for immediate haemodialysis. Uremic pericarditis is caused by inflammation of the membranes of the pericardial sac, which usually resolves after a period of intensive dialysis.
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This question is part of the following fields:
- Nephrology
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Question 3
Correct
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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: 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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This question is part of the following fields:
- Nephrology
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Question 4
Correct
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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.
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This question is part of the following fields:
- Nephrology
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Question 5
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:
- Nephrology
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Question 6
Incorrect
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer: Left heart failure
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:
- Nephrology
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Question 7
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: Minimal-change disease
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:
- Nephrology
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Question 8
Incorrect
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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:
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.
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This question is part of the following fields:
- Nephrology
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Question 9
Incorrect
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A patient with chronic renal failure, treated with regular haemodialysis, attends the renal clinic. He has been treated for six months with oral ferrous sulphate, 200 mg three times a day. His haemoglobin at this clinic attendance is 7.6. His previous result was 10.6 six months ago. Which of the following is the most appropriate treatment?
Your Answer:
Correct Answer: IV iron and subcutaneous erythropoietin
Explanation:The patient should be prescribed IV iron and subcutaneous erythropoietin to enhance erythropoiesis to address the dropped haemoglobin.
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This question is part of the following fields:
- Nephrology
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Question 10
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:
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:
- Nephrology
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Question 11
Incorrect
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You are reviewing a 70-year-old gentleman who has been suffering from multiple myeloma for the past 3 years. He presents with lethargy, muscle aches and pain in his lower back. Arterial blood sampling reveals a metabolic acidosis. Serum potassium is 3.1 mmol/l (3.5–4.9), and urine pH is 5.1 (> 5.3). What is the most likely diagnosis?
Your Answer:
Correct Answer: Renal tubular acidosis-type II
Explanation:This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .
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This question is part of the following fields:
- Nephrology
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Question 12
Incorrect
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A 21-year-old gentleman presents with facial and ankle swelling. This has slowly been developing over the past week. During the review of systems, he describes passing ‘frothy’ urine. A urine dipstick shows protein +++. What is the most likely cause of this presentation?
Your Answer:
Correct Answer: Minimal change disease
Explanation:Minimal change glomerulonephritis usually presents as nephrotic syndrome wherein the patient (usually a young adult) will present with proteinuria, oedema, and impaired kidney function, which were evident in this patient.
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This question is part of the following fields:
- Nephrology
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Question 13
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:
- Nephrology
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Question 14
Incorrect
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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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This question is part of the following fields:
- Nephrology
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Question 15
Incorrect
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A 22-year-old gentleman presents to A&E for the third time with recurrent urinary stones. There appear to be no predisposing factors, and he is otherwise well; urine culture is unremarkable. The urine stones turn out to be cystine stones. What is the most likely diagnosis in this case?
Your Answer:
Correct Answer: Cystinuria
Explanation:Cystinuria is strongly suspected because of the recurrent passing of cystine stones and otherwise non-remarkable medical history of this young adult patient. Like Cystinuria, all the conditions listed are also inherited disorders, however, the other differentials usually present in the early years of childhood, usually with failure to thrive.
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This question is part of the following fields:
- Nephrology
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Question 16
Incorrect
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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:
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:
- Nephrology
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Question 17
Incorrect
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A 38-year-old woman has been reviewed in the hypertension clinic. Abdominal ultrasound scanning reveals that her left kidney is much smaller than her right kidney. You suspect renal artery stenosis, as her GP noticed a deteriorating serum creatinine concentration within 1 month of starting ACE inhibitor therapy. What is the most appropriate next investigation?
Your Answer:
Correct Answer: Magnetic resonance angiography
Explanation:MRA is next appropriate management for this case. It is non-invasive and has been shown to correlate with angiographic appearance. Although Renal arteriography is considered gold standard, it is invasive, so a non-invasive option is preferred as first line of investigation in this case.
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This question is part of the following fields:
- Nephrology
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Question 18
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:
- Nephrology
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Question 19
Incorrect
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A 15-year-old boy presents with hypertension and acute renal failure after an episode of diarrhoea. What is the most likely diagnosis?
Your Answer:
Correct Answer: Haemolytic–uraemic syndrome
Explanation:The likely diagnosis in this case is Haemolytic Uremic Syndrome (HUS), which is generally seen in young children presenting with a triad of symptoms, namely: acute renal failure, microangiopathic haemolytic anaemia, and thrombocytopenia. The typical cause of HUS is ingestion of a strain of Escherichia coli causing diarrhoea in these cases as well.
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This question is part of the following fields:
- Nephrology
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Question 20
Incorrect
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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:
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
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This question is part of the following fields:
- Nephrology
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Question 21
Incorrect
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A 25-year-old gentleman presents to the hospital feeling unwell and breathless. History reveals that he has chronic renal failure, for which he receives haemodialysis three times per week. Since one week prior to consultation, he has been on vacation and has missed two dialysis sessions. Examination reveals pulmonary oedema. His ECG shows no P waves, broad QRS complexes and peaked T waves. What should you do?
Your Answer:
Correct Answer: Give 10 ml of 10% calcium gluconate intravenously
Explanation:The patient is most likely complaining of the effects of hyperkalaemia, due to missing his dialysis sessions. Additionally, because the patient presents with a risk of cardiac arrest (based on pulmonary oedema and ECG findings), the best intervention is to give calcium gluconate that will address the hyperkalaemia as well as improve the cardiac condition.
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This question is part of the following fields:
- Nephrology
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Question 22
Incorrect
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer:
Correct 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:
- Nephrology
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Question 23
Incorrect
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Which one of the following is a recognised cause of hypokalaemia associated with hypertension:
Your Answer:
Correct Answer: Liddle's syndrome
Explanation:Liddle’s Syndrome is an autosomal dominant disorder that presents with hypertension usually in young patients, that do not respond to anti-hypertensive therapy and is later associated with hypokalaemia, low renin plasma, and low aldosterone levels as well. The other conditions listed do not present with hypertension and associated hypokalaemia.
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This question is part of the following fields:
- Nephrology
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Question 24
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:
- Nephrology
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Question 25
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:
- Nephrology
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Question 26
Incorrect
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A 21-year-old woman presents with lethargy and confusion. On examination, you note a purpuric rash covering the abdominal wall and thighs, and a fever of 38C. Investigations reveal haemolytic anaemia, thrombocytopenia, and acute kidney injury. Which feature of the presentation makes the diagnosis of thrombotic thrombocytopenic purpura more likely than haemolytic uremic syndrome?
Your Answer:
Correct Answer: Confusion
Explanation:Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.
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This question is part of the following fields:
- Nephrology
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Question 27
Incorrect
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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:
Correct 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.
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This question is part of the following fields:
- Nephrology
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Question 28
Incorrect
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A 30-year-old female presents with polyuria and is passing 4 litres of urine per day. She was recently started on a new medication. Results show: Serum sodium 144 mmol/L (137-144) Plasma osmolality 299 mosmol/L (275-290) Urine osmolality 210 mosmol/L (350-1000) Which of the following drugs was prescribed?
Your Answer:
Correct Answer: Lithium
Explanation:The patient’s presentation is consistent with diabetes insipidus: eunatreaemia, high serum osmolality, and inappropriately dilute urine, which leads to the suspicion of lithium-induced diabetes insipidus.
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This question is part of the following fields:
- Nephrology
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Question 29
Incorrect
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A gentleman arrives at the renal clinic for review. He has longstanding 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:
- Nephrology
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Question 30
Incorrect
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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.
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This question is part of the following fields:
- Nephrology
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SESSION STATS - PERFORMANCE PER SPECIALTY
