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Question 1
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 2
Correct
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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: 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 3
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 4
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: Kimmelstiel–Wilson lesions
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 5
Correct
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A 23-year-old pregnant woman presents with glycosuria. What is the most likely mechanism?
Your Answer: Reduced renal reabsorption
Explanation:Throughout pregnancy the tubular reabsorption of glucose is less effective than in the non-pregnant state, this leads to glycosuria.
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This question is part of the following fields:
- Nephrology
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Question 6
Correct
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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: 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 7
Incorrect
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Which is the most severe form among the following?
Your Answer: Class VI: sclerosing glomerulonephritis
Correct Answer: Class IV: diffuse proliferative glomerulonephritis
Explanation:The classes refer to the WHO classification of glomerulonephritis in SLE patients.
class I: normal kidney
class II: mesangial glomerulonephritis
class III: focal (and segmental) proliferative glomerulonephritis
class IV: diffuse proliferative glomerulonephritis
class V: diffuse membranous glomerulonephritis
class VI: sclerosing glomerulonephritisClass IV: diffuse proliferative glomerulonephritis is the most common and the most severe form, where more than 50% of the glomeruli are involved.
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This question is part of the following fields:
- Nephrology
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Question 8
Correct
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A 58-year-old gentleman with a long history of gout presents with loin pain. Other past history of note includes an ileostomy after bowel surgery. There is no history of weight loss from malabsorption syndrome after his bowel surgery. Excretion urography reveals evidence of bilateral renal stones. What is the most likely composition of his renal stones?
Your Answer: Uric acid stones
Explanation:Uric acid stones will most likely be found in this case because of the patient’s long history of gout. Additionally, studies have shown that ileostomy patients have an increased risk for the development of uric acid stones.
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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 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: Commence erythropoetin
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 10
Correct
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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: 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 11
Incorrect
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A 3-year old boy presents with an abdominal mass. Which of the following is associated with Wilm’s tumour (nephroblastoma)?
Your Answer: Tuberose sclerosis
Correct Answer: Beckwith-Wiedemann syndrome
Explanation:Beckwith-Wiedemann syndrome is a inherited condition associated with organomegaly, macroglossia, abdominal wall defects, Wilm’s tumour and neonatal hypoglycaemia. Wilm’s tumour is a kidney cancer that usually occurs in children. The causes are unknown, however, risk factors include race and family history. Of note, Wilm’s tumour can occur as part of the following syndromes: WAGR syndrome, Denys-Drash syndrome, and Beckwith-Wiedmann syndrome and not the other listed options in this question.
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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 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 13
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 14
Incorrect
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Of the following disorders, which one causes acute tubular damage?
Your Answer: Berger's disease
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 15
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 16
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 17
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 18
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 19
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 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 20-year-old woman presents with weakness and is found to have a serum potassium of 2.2 mmol/l and pH 7.1. Which of the following would be LEAST useful in differentiating between renal tubular acidosis Types 1 and 2?
Your Answer:
Correct Answer: Osteomalacia
Explanation:Osteomalacia is a marked softening of the bones that can present in both type I and type II Renal Tubular Acidosis (RTA) and will thus not differentiate the two types in any case. The other measures will allow differentiation of the two types.
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This question is part of the following fields:
- Nephrology
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Question 22
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 23
Incorrect
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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:
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.
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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 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:
Correct 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 25
Incorrect
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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:
Correct 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 26
Incorrect
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A 15-year-old girl is referred to the paediatric unit with reduced urine output and lethargy. She has been passing bloody diarrhoea for the past four days. On admission she appears dehydrated. Bloods show the following: Na+ 142 mmol/L, K+ 4.8 mmol/L, Bicarbonate 22 mmol/L, Urea 10.1 mmol/L, Creatinine 176 µmol/L, Hb 10.4 g/dL, MCV 90 fl Plt 91 * 109/L, WBC 14.4 * 109/L, Given the likely diagnosis, which one of the following organisms is the most likely cause?
Your Answer:
Correct Answer: E. coli
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.
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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 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:
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 28
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:
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 29
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:
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 30
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 31
Incorrect
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A 28 year old female presents to her GP with joint pain , fever, a butterfly rash and fatigue. She has marked peripheral oedema. She is found to be hypertensive, in acute renal failure, low albumin levels and proteinuria. A renal biopsy is performed and reveals focal glomerulonephritis with subendothelial and mesangial immune deposits. What is the most likely diagnosis?
Your Answer:
Correct Answer: Lupus nephritis Class III
Explanation:This case presents with characteristic symptoms of SLE and with her renal biopsy results of focal glomerulonephritis, this is clearly Class III SLE.
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This question is part of the following fields:
- Nephrology
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Question 32
Incorrect
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Which of the following is most helpful in differentiating chronic from acute renal failure?
Your Answer:
Correct Answer: Kidney size at ultrasound scan
Explanation:The size of the kidneys on ultrasound would differentiate chronic from acute renal failures. Chronic renal failure is more associated with small-sized kidneys.
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This question is part of the following fields:
- Nephrology
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Question 33
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:
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 34
Incorrect
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A 25-year-old woman was admitted to hospital with a 3 day history of feeling generally unwell, with fatigue, arthralgia and pruritis. She had recently finished a 5 day course of antibiotics for a urinary tract infection but there was no other significant past medical history. She had no significant findings on clinical examination except for a widespread erythematous rash. Investigation results are below: Haemoglobin (Hb) 12.6 g/dL, White cell count (WCC) 13.0 × 109/l (eosinophilia) Platelets 390 × 109/L, Creatinine 720 μmol/L, Na+ 135 mmol/L, K+ 5.2 mmol/L, Urea 22.0 mmol/L, Urinalysis Protein ++ blood + What is the most important investigation to establish the diagnosis?
Your Answer:
Correct Answer: Renal biopsy
Explanation:There is a strong suspicion of drug-induced acute tubulo-interstitial nephritis with the classic triad of symptoms of rash, joint pain and eosinophils in the blood, associated with non-specific symptoms of fever and fatigue. This can be confirmed with renal biopsy showing interstitial oedema with a heavy infiltrate of inflammatory cells and variable tubular necrosis.
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This question is part of the following fields:
- Nephrology
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Question 35
Incorrect
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A 41-year-old gentleman required high doses of intravenous diuretics after his renal transplant for the purposes of fluid management. Soon after administration he developed hearing loss, tinnitus, and vertigo. Which diuretic is most likely to have caused this?
Your Answer:
Correct Answer: Furosemide
Explanation:Furosemide is a loop diuretic that is known to have significant ototoxicity side-effects although the mechanism is not fully known.
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This question is part of the following fields:
- Nephrology
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Question 36
Incorrect
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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:
Correct 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 37
Incorrect
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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:
Correct 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 38
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 39
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 40
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 41
Incorrect
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A 72-year-old woman is admitted with general deterioration and ‘off-legs’. On examination in the emergency department, she looks dry and uremic. Investigations reveal:
- K+ 7.2 mmol/L
- Na+ 145 mmol/L
- Creatinine 512 μmol/L
- Urea 36.8 mmol/L
Your Answer:
Correct Answer: ECG & IV Calcium gluconate bolus
Explanation:First and foremost, the patient should be put on ECG monitoring to identify the cardiac state, and because of the markedly raised serum potassium, a calcium gluconate bolus will have the immediate effect of moderating the nerve and muscle performance.
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This question is part of the following fields:
- Nephrology
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Question 42
Incorrect
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A 20-year-old woman presents to casualty with flank pain and a 48 hour history of dysuria. Her past medical history includes polycystic ovarian syndrome. She is not in a steady relationship at present. There is haematuria and proteinuria on urine dipstick testing. Examination reveals a pyrexia of 38.1 °C and flank pain. What diagnosis fits best with this clinical picture?
Your Answer:
Correct Answer: Pyelonephritis
Explanation:The patient presents with flank pain and fever with haematuria and proteinuria associated with a social history of not being in a steady relationship. This patient is a young presumably sexually active female, so the diagnosis is most likely pyelonephritis which has an increased incidence in young sexually active women or men of >50 years of age.
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This question is part of the following fields:
- Nephrology
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Question 43
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 44
Incorrect
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A 63-year-old woman visits the diabetes clinic for review. She has had type-2 diabetes for 9 years and is now on insulin therapy. She has diabetic nephropathy, as exemplified by hypertension and proteinuria (urinary PCR 155); a recent creatinine level was 205 μmol/l and eGFR 24 ml/min. Which of the following options best fits her prognosis or management?
Your Answer:
Correct Answer: Treatment with ARB or ACE-I may slow further deterioration in renal function
Explanation:Treatment with ARB or ACE-I may slow further deterioration in renal function in this patient, as studies have shown that blocking of the RAS in type 2 diabetic patients improve renal function.
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This question is part of the following fields:
- Nephrology
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Question 45
Incorrect
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In idiopathic hypercalciuria, what management should be initiated if there is renal stone disease or bone demineralization?
Your Answer:
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.
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This question is part of the following fields:
- Nephrology
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Question 46
Incorrect
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A 61-year-old gentleman presents with heart failure and pedal oedema. The oedema occurs due to:
Your Answer:
Correct Answer: Increased release of renin
Explanation:The oedema is an effect of the a decreased cardiac output that increases renin release which leads to vasoconstriction and sodium and water retention.
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This question is part of the following fields:
- Nephrology
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Question 47
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:
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 48
Incorrect
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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:
Correct 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 49
Incorrect
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A 26-year-old patient, previously fit and well, is admitted with fluctuating confusion and frank haematuria. He has recently been complaining of generalised malaise and joint pains. Examination reveals jaundice, splenomegaly, and petechiae. His blood pressure is 155/84 mmHg, temperature 37.9oC. Initial investigations reveal: Haemoglobin 9.5 g/dL, White cell count 12 × 109/L, Platelets 40 × 109/L, Creatinine 142 μmol/L, Sodium 139 mmol/L, Potassium 4.5 mmol/L, Urea 9.2 mmol/L, Lactate dehydrogenase 495 U/l (10–250) Urinalysis Protein ++, blood +++ Blood film shows schistocytes What treatment should NOT be given to this patient?
Your Answer:
Correct Answer: Platelet transfusion
Explanation:There is a strong suspicion of Thrombotic Thrombocytopenic Purpura (TTP) in this patient as he presents with neurological changes (from confusion to convulsions and coma), fever, haemolysis, thrombocytopenia, and renal failure. Additionally, TTP cases may present with jaundice, splenomegaly, and hypertension as seen in this patient. With a diagnosis of TTP, recent studies have shown that platelet transfusion is not recommended in this case because it has been shown to increase the risk for arterial thrombosis and mortality possibly due to increased aggregations.
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This question is part of the following fields:
- Nephrology
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Question 50
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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SESSION STATS - PERFORMANCE PER SPECIALTY
