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Question 1
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:
- Nephrology
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Question 2
Incorrect
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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: Renal failure
Correct Answer: Cardiac involvement
Explanation:Primary amyloidosis is characterised by abnormal protein build-up in the tissues and organ such as the heart, liver, spleen, kidneys, skin, ligaments, and nerves. However, the most common cause of death in patients with primary amyloidosis is heart failure.
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This question is part of the following fields:
- Nephrology
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Question 3
Correct
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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: 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:
- Nephrology
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Question 4
Correct
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A 68-year-old gentleman has been receiving dialysis for 6 years. His PTH is elevated at 345 pg/ml (NR 25-65), phosphate 2.13 mmol/l and corrected calcium 2.01 mmol/l. Of the following, which is most likely responsible for renal osteodystrophy?
Your Answer: Diminished activity of renal 1-α-hydroxylase
Explanation:Renal osteodystrophy is a metabolic bone disease often affecting long-term dialysis patients. The kidneys are no longer able to maintain the calcium levels in the blood, thus the PTH increases as the body attempts to raise blood calcium levels. Osteomalacia in these cases is most likely caused by the diminished activity of renal 1-a-hydroxylase that is important for hydroxylation of Calciferol to calcitriol (Vitamin D). This bioactive form of Vitamin D is responsible for increasing intestinal absorption of calcium.
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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 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 enalapril and furosemide
Explanation:The patient presents with worsened renal condition from the last consultation when he was started on enalapril (an ACE inhibitor) so this medication should be stopped. Because there is also no fluid overload; furosemide, a diuretic, should also be stopped.
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This question is part of the following fields:
- Nephrology
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Question 6
Correct
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A 70-year-old complains of lower urinary tract symptoms. Which one of the following statements regarding benign prostatic hyperplasia is incorrect?
Your 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.
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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 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: Antiglomerular basement membrane 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.
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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 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: Cystinosis
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 9
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:
- Nephrology
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Question 10
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: Focal necrotising crescentic nephritis
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 11
Correct
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Which of the following is most helpful in differentiating chronic from acute renal failure?
Your 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:
- Nephrology
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Question 12
Correct
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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: 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 13
Incorrect
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A 52-year-old woman with polycystic kidney disease and a slowly rising creatinine, which was 320 μmol/L at her last clinic visit 3 weeks ago, is brought into the Emergency Department having been found collapsed at home by her partner. She is now fully conscious but complains of a headache. What is the most likely diagnosis?
Your Answer: Uraemic encephalopathy
Correct Answer: Subarachnoid haemorrhage
Explanation:One of the most important complications in patients with PKD is being affected by berry aneurysms that may burst, causing a subarachnoid haemorrhage, which seems to be the case in this patient.
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This question is part of the following fields:
- Nephrology
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Question 14
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 15
Incorrect
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A 66-year-old gentleman is seen in the Emergency Department complaining of muscle weakness and lethargy. Admission bloods show the following: Na+ 138 mmol/L, K+ 6.6 mmol/L, Bicarbonate 15 mmol/L, Urea 9.2 mmol/L, Creatinine 110 µmol/L, An ECG is done which shows no acute changes. What is the most appropriate initial treatment to lower the serum potassium level?
Your Answer: Intravenous calcium gluconate
Correct Answer: Insulin/dextrose infusion
Explanation:Insulin/dextrose infusion will increase the activity of the sodium-potassium pump in the cells, which will in turn decrease serum potassium levels.
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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 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: Serum bicarbonate 8 mmol/l
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:
- Nephrology
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Question 17
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:
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:
- Nephrology
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Question 18
Incorrect
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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:
Correct 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 19
Incorrect
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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:
Correct 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 20
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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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 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 23
Incorrect
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A 11-year-old boy has a history of tonsillitis followed by haematuria and hypertension about 10 days later. What would be the characteristic blood test finding in this condition?
Your Answer:
Correct Answer: Depressed CH 50 level
Explanation:Because the medical history included tonsillitis followed by haematuria and hypertension, there is a strong suspicion of a case of post-streptococcal glomerulonephritis (PSGN). Patients with PSGN usually have serological findings showing depressed serum haemolytic component CH50 and serum concentrations of C3. Sometimes depressed C4 levels are also apparent, but not always, therefore, the answer to this question is: depressed CH50 level.
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This question is part of the following fields:
- Nephrology
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Question 24
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:
- Nephrology
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Question 25
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 26
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:
- Nephrology
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Question 27
Incorrect
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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:
Correct 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:
- Nephrology
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Question 28
Incorrect
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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.
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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 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 30
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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SESSION STATS - PERFORMANCE PER SPECIALTY
