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Question 1
Correct
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A 74-year-old widow is undergoing haemodialysis for chronic renal failure. What is the most common problem that can arise in this case?
Your Answer: Protein–calorie malnutrition
Explanation:Protein-calorie malnutrition is observed in almost 50% of dialysis patients, contributing to increased morbidity and mortality. All the other complications listed can usually be prevented thanks to modern-day dialysis techniques.
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This question is part of the following fields:
- Nephrology
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Question 2
Correct
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A 58-year-old lady was admitted to hospital with increasing thirst and generalised abdominal pain. She was diagnosed with breast carcinoma three years previously and treated with a radical mastectomy. Investigations showed: Serum corrected calcium 3.5 mmol/L (NR 2.2-2.6) Serum alkaline phosphatase 1100 IU/L Her serum calcium was still elevated following 4 litres of 0.9% saline intravenous infusion. Which of the following is the most appropriate next step?
Your Answer: Pamidronate 60 mg intravenously
Explanation:This case has hypercalcaemia most likely associated with the bony metastases from her pre-existing breast carcinoma. The most appropriate next step is to give Pamidronate 60mg intravenously, a bisphosphonate, to immediately inhibit bone resorption and formation.
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This question is part of the following fields:
- Nephrology
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Question 3
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 4
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 5
Correct
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A 16-year-old boy suffers recurrent episodes of haematuria following a flu-like illness. He is otherwise well. Physical examination is normal. Urinalysis reveals no proteinuria, blood ++, and 2–3 white blood cells/mm3. What is the most probable diagnosis?
Your Answer: IgA nephropathy
Explanation:IgA nephropathy’s characteristic presentation is haematuria following a non-specific upper respiratory infection as was evident in this case. IgA nephropathy also usually occurs in children and young males, like this patient.
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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 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: 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 7
Correct
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A 11-year-old boy is admitted to the hospital with diarrhoea and lethargy. There is a known local outbreak of E coli 0157:H7, and his initial bloods show evidence of acute renal failure. Given the likely diagnosis, which one of the following investigation results would be expected?
Your Answer: Fragmented red blood cells
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. The laboratory results will usually include fragmented RBCs, decreased serum haptoglobin, reduced platelet count, nonspecific WBC changes, and normal coagulation tests (PTT included).
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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 40-year-old woman presents to her GP with malaise, anorexia, and weight loss. Screening blood samples reveals urea of 50.1 mmol/l and serum creatinine of 690 μmol/l. Her past history includes frequent headaches, but nothing else of note. She has, however, failed to attend her routine ‘well-woman’ appointments. Ultrasound reveals bilateral hydronephrosis and a suspicion of a central pelvic mass. What diagnosis is most likely to be responsible for this woman’s hydronephrosis?
Your Answer: Ovarian carcinoma
Correct Answer: Cervical carcinoma
Explanation:The patient’s history of recent weight loss and malaise, paired with enlarged kidneys and renal failure, as well as a suspected central pelvic mass on ultrasound, gives a suspicion of cervical carcinoma.
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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 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 aetiological cause?
Your 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:
- Nephrology
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Question 10
Correct
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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: 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 11
Correct
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A 41-year-old female is referred to medical assessment unit by her physician for querying thrombotic thrombocytopenic purpura (TTP) after she presented with a temperature of 38.9C. Her subsequent urea and electrolytes showed deteriorating renal function with a creatinine 3 times greater than her baseline. What is the underlying pathophysiology of TTP?
Your Answer: Failure to cleave von Willebrand factor normally
Explanation:Thrombotic thrombocytopenic purpura (TTP) is characterised by the von Willebrand factor (vWF) microthrombi within the vessels of multiple organs. In this condition, the ADAMTS13 metalloprotease enzyme which is responsible for the breakdown of vWF multimer, is deficient, causing its build-up and leading to platelet clots that then decreases the circulating platelets, leading to bleeding in the patient.
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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 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: 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 13
Correct
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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: 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 14
Correct
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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: 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 15
Correct
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A 61-year-old woman with a history of hypothyroidism and inflammatory arthritis is admitted after slipping on ice and falling over. Some routine blood tests are performed: Na+ 141 mmol/L, K+ 2.9 mmol/L, Chloride 114 mmol/L, Bicarbonate 16 mmol/L, Urea 5.2 mmol/L, Creatinine 75 µmol/L, Which one of the following is most likely to explain these results?
Your Answer: Renal tubular acidosis (type 1)
Explanation:The patient’s underlying arthritis has most likely led to Renal tubular acidosis RTA type 1, which presents with the following symptoms consistent with the presentation of the patient: Normal anion gap metabolic acidosis/acidaemia, hypokalaemia and hyperchloremia. Comparatively, the other conditions are ruled out because Aspirin and diabetic ketoacidosis is associated with a raised anion gap, Conn’s syndrome explains hypokalaemia but not the metabolic acidosis, and RTA type 4 is associated with hyperkalaemia.
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This question is part of the following fields:
- Nephrology
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Question 16
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:
- Nephrology
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Question 17
Correct
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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: 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 18
Correct
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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: 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 19
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:
- Nephrology
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Question 20
Correct
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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: 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 21
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: Parathyroidectomy
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 22
Correct
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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: 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 23
Incorrect
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Which one of the following statements is true regarding autosomal recessive polycystic kidney disease?
Your Answer: Is due to a defect on chromosome 16
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:
- Nephrology
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Question 24
Incorrect
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Of the following disorders, which one causes acute tubular damage?
Your Answer: Alport’s syndrome
Correct Answer: Myoglobinuria
Explanation:Myoglobinuria is the condition when there is degeneration of necrosed muscle that it is excreted in the urine. This condition would then cause acute tubular damage leading to renal failure.
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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 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Increased renal secretion
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 26
Incorrect
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In diabetes, what is the most common finding on renal biopsy?
Your Answer: Mesangial proliferation
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 27
Incorrect
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Which one of the following is a recognised cause of hypokalaemia associated with hypertension:
Your Answer: Gitelman syndrome
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 28
Correct
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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: 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:
- Nephrology
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Question 29
Correct
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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: 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 30
Incorrect
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer: Increased proximal tubular sodium reabsorption
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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SESSION STATS - PERFORMANCE PER SPECIALTY
