00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 67-year-old man presents to the hospital with acute chest pain. He reports...

    Incorrect

    • A 67-year-old man presents to the hospital with acute chest pain. He reports experiencing increasing shortness of breath on exertion, a widespread itchy rash, palpitations over the past few days, and ankle swelling. He has not seen his GP in many years due to a lack of trust in doctors. Upon examination, he has a pericardial rub and crackles at both lung bases. Blood tests reveal abnormalities in haemoglobin, white cell count, potassium, urea, creatinine, and CRP levels, as well as baseline troponin. A chest radiograph shows blunting of both costophrenic angles, and an ECG shows widespread ST elevation. What is the most likely cause of his chest pain?

      Your Answer: Myocardial infarction

      Correct Answer: Uraemic pericarditis

      Explanation:

      Diagnosis and Differential Diagnosis of a Patient with Severe Renal Impairment

      This patient has presented with severe renal impairment and a rash that is indicative of either uraemia or hyperphosphataemia, both of which are consequences of renal impairment. The patient’s low haemoglobin levels and long history suggest that this may be a chronic condition. The patient’s ECG changes and borderline troponin levels are consistent with pericarditis, which is likely to be uraemic pericarditis rather than viral myocarditis due to the patient’s high urea levels. While a myocardial infarction is possible, ECG changes are typically limited to one coronary territory. Pulmonary emboli could cause ECG changes, but usually present with sinus tachycardia or signs of right heart strain. An atypical pneumonia is unlikely to cause ECG changes or a rise in troponin, and the patient’s clinical presentation does not support this diagnosis.

    • This question is part of the following fields:

      • Nephrology
      33.6
      Seconds
  • Question 2 - A 30-year-old woman visits her doctor complaining of pharyngitis and is prescribed amoxicillin...

    Incorrect

    • A 30-year-old woman visits her doctor complaining of pharyngitis and is prescribed amoxicillin for a week. She also requests a refill of her oral contraceptive pill, bendroflumethiazide, lansoprazole, and naproxen, which she has been taking for the past nine months due to a skiing injury.

      After three weeks, she returns to the doctor with joint pains and a mild rash. Blood tests reveal a creatinine level of 356 µmol/L and an eosinophilia of 1.7 ×109/L (NR 0-0.4). The doctor refers her to renal services with a suspected diagnosis of tubulointerstitial nephritis.

      Which medication is the most likely cause of her symptoms?

      Your Answer: Bendroflumethiazide

      Correct Answer: Amoxicillin

      Explanation:

      The most likely cause of tubulointerstitial nephritis in this case is amoxicillin, which can cause acute inflammation of the tubules and interstitium of the kidney. TIN can also be caused by other drugs, infections, and autoimmune disorders. Treatment involves removing the causative agent and using oral steroids to dampen inflammation. Chronic TIN can lead to end stage renal failure. Drug-induced TIN is usually due to hypersensitivity reactions and is characterized by raised IgE levels and eosinophilia.

    • This question is part of the following fields:

      • Nephrology
      36.8
      Seconds
  • Question 3 - A 70-year-old patient receiving haemodialysis three times a week through a tunnelled internal...

    Correct

    • A 70-year-old patient receiving haemodialysis three times a week through a tunnelled internal jugular line arrives at the dialysis unit feeling well.

      However, 15 minutes after starting haemodialysis he develops a fever, his blood pressure drops rapidly and he becomes unwell. He is sweaty and appears confused.

      He still passes small volumes of urine and has a history of diverticular disease.

      What could be the possible reason for his symptoms?

      Your Answer: Haemodialysis line infection

      Explanation:

      Rapidly Unwell Patient on Haemodialysis: Consider Line Infection

      When a patient who was previously healthy becomes rapidly unwell after starting haemodialysis, it is crucial to consider the possibility of a line infection. Symptoms may include low blood pressure, sweating, and a fever. Although haemodialysis lines are silver-coated to reduce the risk of infection, line infection remains a significant problem. During haemodialysis, blood is returned to the patient through the infected line, causing a rapid bacteraemia and systemic inflammatory response that can lead to a sudden drop in blood pressure.

      While other conditions such as urinary tract or lower respiratory tract infections and perforated diverticulum are possible, they are less likely to present as rapidly as a line infection. Patients with end-stage renal failure are at higher risk of cardiovascular disease, including myocardial infarction, but chest pain that develops after a drop in blood pressure may indicate a secondary rather than primary cause. Although a fever is more suggestive of infection, it is important to obtain an ECG and check for signs of myocardial infarction. In summary, when a patient on haemodialysis becomes rapidly unwell, line infection should be considered as a potential cause.

    • This question is part of the following fields:

      • Nephrology
      49.5
      Seconds
  • Question 4 - As a GP, you examine a 28-year-old pregnant woman who complains of mild...

    Incorrect

    • As a GP, you examine a 28-year-old pregnant woman who complains of mild ankle swelling. She denies any symptoms of a urinary tract infection. Upon conducting a urinalysis, the following results are obtained:

      Haemoglobin: Negative
      Urobilinogen: Negative
      Bilirubin: Negative
      Protein: ++
      Glucose: ++
      Nitrites: Negative
      Leucocytes: ++
      Ketones: Negative

      What could be the possible explanation for these findings?

      Your Answer: Nephrotic syndrome

      Correct Answer: Healthy pregnancy

      Explanation:

      Urinalysis in Pregnancy: Common Abnormalities and Importance of Monitoring

      Urinalysis is a crucial diagnostic tool for detecting renal diseases and other medical conditions. During pregnancy, even asymptomatic and healthy women may exhibit abnormalities on urinalysis. These abnormalities include small amounts of glucose, as pregnancy alters the renal threshold for glucose, and small amounts of protein, which can be a sign of pre-eclampsia. Ketones should not be present unless the patient is fasting, and prolonged fasting is not recommended. Pregnant women may also have sterile pyuria and non-specific changes in leukocytes.

      It is important to monitor pregnant women for urinary infections, as they have been linked to premature labor. However, minor and non-specific changes on urinalysis can falsely reassure clinicians. Pregnant women are at an increased risk of UTIs and may present with atypical symptoms or unusual urinalysis features. Therefore, urine should be sent for culture if there are any concerns.

      In summary, urinalysis is a vital investigation during pregnancy to detect abnormalities and monitor for urinary infections. Clinicians should be aware of the common abnormalities seen on urinalysis during pregnancy and the importance of careful monitoring to ensure the health of both the mother and the developing fetus.

    • This question is part of the following fields:

      • Nephrology
      34.3
      Seconds
  • Question 5 - Dr. Patel is a nephrologist who has five patients attending his clinic. The...

    Incorrect

    • Dr. Patel is a nephrologist who has five patients attending his clinic. The patients' results are as follows:
      Adam Ahmed Bella Brownie Charlie Chen David Davis
      Urine protein mg/24 hrs: 150 4000 3000 200 300
      Haematuria: Present Absent Present Present Absent
      Oedema: Absent Present Present Absent Absent
      Serum albumin g/l: 24 18 26 17 32
      Serum creatinine µmol/l: 430 110 280 560 120

      Which patient is diagnosed with nephrotic syndrome?

      Your Answer: Celia Creutzfeldt

      Correct Answer: Bella Barnard

      Explanation:

      Nephrotic Syndrome

      Nephrotic syndrome is a condition characterized by low serum albumin levels, high urinary protein levels, and marked pitting edema. Only individuals who meet all three criteria are diagnosed with this syndrome. Other features of nephrotic syndrome include little or no hematuria, glomerular pathology as the cause, marked hyperlipidemia that increases cardiovascular risk, reduced immunoglobulins that increase the risk of infection, and loss of certain proteins that increase the risk of thrombosis, including renal vein thrombosis. Creatinine levels can be normal or elevated.

      The causes of nephrotic syndrome include glomerulonephritis, such as minimal change disease and membranous glomerulonephritis, focal segmental glomerulosclerosis, diabetic nephropathy, amyloid (AL form), and connective tissue disease such as systemic lupus erythematosus. the diagnostic criteria and features of nephrotic syndrome is crucial for early detection and management of this condition.

    • This question is part of the following fields:

      • Nephrology
      93.2
      Seconds
  • Question 6 - A 55-year-old male patient complains of swelling and is diagnosed with nephrotic syndrome....

    Correct

    • A 55-year-old male patient complains of swelling and is diagnosed with nephrotic syndrome. What is a frequently occurring complication of this condition?

      Your Answer: Increased risk of pneumococcal pneumonia

      Explanation:

      Nephrotic Syndrome and its Complications

      Nephrotic syndrome is a condition characterized by three main symptoms: hypoalbuminemia, proteinuria, and edema. Patients with this condition are at an increased risk of developing complications such as thrombosis, infections, and hyperlipidemia. Chronic kidney disease (CKD) is also a possible complication of nephrotic syndrome, although not all patients with the condition will have a history of established renal disease prior to presentation. The risk of developing CKD depends on the underlying cause of the nephrotic syndrome.

      One unusual complication of nephrotic syndrome is hypercalcemia, which is not commonly seen in this condition. Abnormal plasma protein proportions can cause changes in the binding of electrolytes, drugs, and other solutes, leading to low ionized calcium levels. In severe cases, this may result in symptoms of hypocalcemia. However, in CKD, hypocalcemia is a common occurrence and can cause secondary hyperparathyroidism.

      In summary, the symptoms and complications of nephrotic syndrome is crucial for proper management and treatment of the condition. While hypercalcemia is not a common complication, patients with nephrotic syndrome are at an increased risk of developing thrombosis, infections, and hyperlipidemia. Additionally, the risk of developing CKD depends on the underlying cause of the condition.

    • This question is part of the following fields:

      • Nephrology
      4.8
      Seconds
  • Question 7 - A 45-year-old patient presents to their GP with a general feeling of unwellness....

    Incorrect

    • A 45-year-old patient presents to their GP with a general feeling of unwellness. They have previously been diagnosed with a condition by their former GP. The GP orders blood tests and the results are as follows:

      Adjusted calcium 2.0 mmol/L (2.2-2.4)
      Phosphate 2.8 mmol/L (0.7-1.0)
      PTH 12.53 pmol/L (1.05-6.83)
      Urea 22.8 mmol/L (2.5-7.8)
      Creatinine 540 µmol/L (60-120)
      25 OH Vit D 32 nmol/L (optimal >75)

      What is the most likely diagnosis?

      Your Answer: Vitamin D deficiency

      Correct Answer: CKD 5

      Explanation:

      Differentiating Chronic Kidney Disease from Acute Renal Failure

      Chronic kidney disease (CKD) and acute renal failure (ARF) can both result in elevated creatinine levels, but other factors can help differentiate between the two conditions. In the case of a patient with hypocalcaemia, hyperphosphataemia, and an elevation of parathyroid hormone, CKD is more likely than ARF. These metabolic changes are commonly seen in CKD 4-5 and are not typically present in ARF of short duration. Additionally, the relatively higher creatinine result compared to urea suggests CKD rather than ARF, which can be caused by dehydration and result in even higher urea levels.

      This patient likely has CKD and may already be dependent on dialysis or under regular review by a nephrology team. The decision to start dialysis is based on various factors, including fluid overload, hyperkalaemia, uraemic symptoms, life expectancy, and patient/clinician preference. Most patients begin dialysis with an eGFR of around 10 ml/min/1.73m2.

    • This question is part of the following fields:

      • Nephrology
      56.1
      Seconds
  • Question 8 - What is the name of the newer induction drug that selectively targets B...

    Correct

    • What is the name of the newer induction drug that selectively targets B cells to quickly control ANCA associated vasculitides while sparing other lymphocytes?

      Your Answer: Rituximab

      Explanation:

      Treatment Options for ANCA Vasculitis

      ANCA vasculitis is a condition that causes inflammation of blood vessels, leading to organ damage. There are several treatment options available for this condition, depending on the severity of the disease. Cyclophosphamide and rituximab are induction agents used in severe or very active disease. Cyclophosphamide is a chemotherapy drug that causes DNA crosslinking and apoptosis of rapidly dividing cells, including lymphocytes. Rituximab is a monoclonal antibody that causes profound B cell depletion.

      Azathioprine and mycophenolate mofetil are maintenance agents used for their steroid sparing effect. They can also be used to induce remission in mild disease, but their maximal effect takes three to four weeks. Therefore, they are not appropriate for severe or very active disease. Ciclosporin is a calcineurin inhibitor that blocks IL-2 production and proliferation signals to T cells. However, it is not widely used in the treatment of ANCA vasculitis. Overall, the choice of treatment depends on the severity of the disease and the individual patient’s needs.

    • This question is part of the following fields:

      • Nephrology
      42
      Seconds
  • Question 9 - A 67-year-old man has been diagnosed with multiple myeloma. His serum protein electrophoresis...

    Incorrect

    • A 67-year-old man has been diagnosed with multiple myeloma. His serum protein electrophoresis reveals an IgA paraprotein of 60 g/l. Upon diagnosis, his urine shows protein levels of approximately 900 mg/24 hours. However, after undergoing chemotherapy, his urinary protein excretion returns to normal levels. What is the probable reason for his proteinuria?

      Your Answer: Nephrogenic proteinuria

      Correct Answer: Pre-renal proteinuria

      Explanation:

      Causes of Overflow Proteinuria

      Overflow proteinuria is a condition where there is an excessive amount of protein in the urine due to elevated levels of protein in the serum. This condition is often caused by pre-renal factors such as paraproteins or Bence Jones protein in multiple myeloma, myoglobin in rhabdomyolysis and after excessive exercise, amylase in pancreatitis, haemoglobin in intravascular haemolysis, and lysozyme in haematological malignancies.

      While myeloma can also cause intrinsic renal damage, in cases where the proteinuria has normalized, overflow proteinuria is the most likely cause. This condition can be identified through urine tests and is often treated by addressing the underlying cause. the causes of overflow proteinuria can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Nephrology
      53.2
      Seconds
  • Question 10 - What are the expected urinalysis results for a 23-year-old patient with abdominal pain,...

    Incorrect

    • What are the expected urinalysis results for a 23-year-old patient with abdominal pain, dehydration, anorexia, and marked hyperglycemia who may have a new diagnosis of type 1 diabetes?

      A) Haemoglobin: Negative
      Urobilinogen: Negative
      Bilirubin: Negative
      Protein: Positive
      Glucose: Positive (+++)
      Nitrites: Negative
      Leucocytes: Positive

      B) Haemoglobin: Negative
      Urobilinogen: Negative
      Bilirubin: Negative
      Protein: Negative
      Glucose: Positive
      Nitrites: ++
      Leucocytes: ++

      C) Haemoglobin: Negative
      Urobilinogen: Negative
      Bilirubin: Negative
      Protein: Negative
      Glucose: +
      Nitrites: +++
      Leucocytes: +++

      D) Haemoglobin: Negative
      Urobilinogen: Negative
      Bilirubin: Negative
      Protein: Negative
      Glucose: Negative
      Nitrites: Negative
      Leucocytes: Negative

      E) Haemoglobin: +++
      Urobilinogen: +
      Bilirubin: +
      Protein: Negative
      Glucose: Negative
      Nitrites: Negative
      Leucocytes: Negative

      Your Answer: A

      Correct Answer: B

      Explanation:

      Diabetic Ketoacidosis and Urinary Tract Infection

      This patient is exhibiting symptoms that are commonly associated with diabetic ketoacidosis (DKA), a serious complication of diabetes. The presence of high levels of glucose and ketones in the urine, as indicated by the urinalysis, further supports this diagnosis. DKA can occur in both new and established type 1 diabetic patients and is often triggered by an infection. In this case, it is likely that a urinary tract infection (UTI) was the precipitating factor.

      It is important to recognize the signs and symptoms of DKA, as prompt treatment is necessary to prevent serious complications. Patients with DKA may experience symptoms such as excessive thirst, frequent urination, nausea, vomiting, abdominal pain, and confusion. If left untreated, DKA can lead to coma or even death. In addition to treating the underlying infection, treatment for DKA typically involves insulin therapy, fluid replacement, and electrolyte management.

    • This question is part of the following fields:

      • Nephrology
      29.5
      Seconds
  • Question 11 - A 59-year-old man is undergoing his routine dialysis treatment when he suddenly experiences...

    Incorrect

    • A 59-year-old man is undergoing his routine dialysis treatment when he suddenly experiences intense chest pain and difficulty breathing. He has been on dialysis for the past nine years and uses a fistula for the procedure. So far, there have been no issues with the dialysis machine or circuit. After the session, his blood pressure is 150/85 mmHg, and an ECG is performed. What could be the probable reason for his chest pain?

      Your Answer: Pulmonary embolism

      Correct Answer: Acute coronary syndrome

      Explanation:

      Acute coronary syndrome is the most common cause of chest pain and shortness of breath in dialysis patients due to their increased risk of coronary disease. Air embolism, hypotension, massive haemolysis, and pulmonary embolism are also possible causes but are less likely. Air embolism is rare but can occur in patients with central lines, while hypotension is more common in the elderly and new starters on dialysis. Massive haemolysis is rare but serious, and pulmonary embolism can occur if there is a known thrombus in the fistula.

    • This question is part of the following fields:

      • Nephrology
      34.3
      Seconds
  • Question 12 - A 32-year-old smoker presents with acute shortness of breath and oxygen saturation of...

    Incorrect

    • A 32-year-old smoker presents with acute shortness of breath and oxygen saturation of 84% on air. He has been feeling unwell and fatigued for a week, with worsening shortness of breath over the past 24 hours and two episodes of haemoptysis. On examination, he has sinus tachycardia, a blood pressure of 140/85 mmHg, normal JVP, and widespread coarse crackles on chest auscultation. Blood tests reveal a haemoglobin level of 92 g/L (130-180), urea level of 40 mmol/L (2.5-7.5), and creatinine level of 435 μmol/L (60-110). The urine dipstick shows +++ blood and ++ protein. A chest radiograph shows widespread patchy opacification. What is the most likely cause of his presentation?

      Your Answer: Flash pulmonary oedema

      Correct Answer: Goodpasture's syndrome

      Explanation:

      Pulmonary Renal Syndrome and Anti-GBM Disease

      This medical condition is also known as anti-GBM disease and is characterized by a pulmonary renal syndrome. It is commonly seen in patients with anti-GBM disease. Smokers are more likely to experience pulmonary hemorrhage, and the presence of blood and protein on urine dipstick suggests renal inflammation, which is consistent with this diagnosis. Although pulmonary renal syndrome can also occur with systemic lupus erythematosus, this is less likely in this patient due to his sex and lack of systemic symptoms.

      Pulmonary edema is a significant differential diagnosis for pulmonary hemorrhage, especially in the context of acute kidney injury. However, the patient’s normal JVP makes fluid overload less likely. Atypical or opportunistic infections can also present with renal impairment, but the low hemoglobin level suggests hemorrhage rather than infection. Overall, this patient’s presentation is consistent with pulmonary renal syndrome and anti-GBM disease.

    • This question is part of the following fields:

      • Nephrology
      35.1
      Seconds
  • Question 13 - A 50-year-old man visits his doctor with symptoms of a vasculitic rash, joint...

    Incorrect

    • A 50-year-old man visits his doctor with symptoms of a vasculitic rash, joint pains, and swollen ankles. He reports feeling unwell, fatigued, and experiencing weight loss. During the visit, his urine dipstick shows blood and protein, and urgent blood tests reveal worsening kidney function with elevated inflammatory markers. The doctor suspects microscopic polyangiitis and requests an autoimmune screening. What autoantibody is expected to be positive in this case?

      Your Answer: c-ANCA with MPO specificity

      Correct Answer: p-ANCA with MPO specificity

      Explanation:

      ANCA and its association with small vessel vasculitides

      Antineutrophil cytoplasmic antibodies (ANCA) are a characteristic feature of small vessel vasculitides such as microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA). These antibodies can also be seen in eosinophilic granulomatosis with polyangiitis (eGPA), previously known as Churg-Strauss syndrome. ANCA has two staining patterns, cytoplasmic (c-ANCA) and perinuclear (p-ANCA), which are detected through immunofluorescence. These antibodies are directed against proteins within the cytoplasmic granules of neutrophils. In most cases, c-ANCA has specificity for proteinase 3 (PR3) and p-ANCA has specificity for myeloperoxidase (MPO).

      In patients with GPA, ANCA positivity is observed in approximately 90% of cases, with 80-90% being c-ANCA positive with PR3 specificity. In contrast, in patients with MPA, approximately 60% are p-ANCA positive with MPO specificity, and around 35% have c-ANCA.

      The history of the patient in question is more consistent with MPA, and therefore, the most likely test to be positive is p-ANCA with MPO specificity. ANA is usually associated with systemic lupus erythematosus, which could present with similar symptoms, but the patient’s age and sex are more in line with ANCA vasculitis.

    • This question is part of the following fields:

      • Nephrology
      20.4
      Seconds
  • Question 14 - As a locum GP, you have been presented with blood results for five...

    Incorrect

    • As a locum GP, you have been presented with blood results for five patients you have never met before. Your task is to review the results and identify which patient is likely to have nephrotic syndrome. The results are as follows:

      Patient A: Adjusted calcium - 2.3 mmol/L, Phosphate - 0.9 mmol/L, PTH - 8.09 pmol/L, Urea - 7.8 mmol/L, Creatinine - 132 μmol/L, Albumin - 36 g/L.

      Patient B: Adjusted calcium - 2.9 mmol/L, Phosphate - 0.5 mmol/L, PTH - 7.2 pmol/L, Urea - 5 mmol/L, Creatinine - 140 μmol/L, Albumin - 38 g/L.

      Patient C: Adjusted calcium - 2.0 mmol/L, Phosphate - 2.8 mmol/L, PTH - 12.53 pmol/L, Urea - 32.8 mmol/L, Creatinine - 540 μmol/L, Albumin - 28 g/L.

      Patient D: Adjusted calcium - 2.5 mmol/L, Phosphate - 1.6 mmol/L, PTH - 2.05 pmol/L, Urea - 32.8 mmol/L, Creatinine - 190 μmol/L, Albumin - 40 g/L.

      Patient E: Adjusted calcium - 2.2 mmol/L, Phosphate - 0.7 mmol/L, PTH - 5.88 pmol/L, Urea - 4.6 mmol/L, Creatinine - 81 μmol/L, Albumin - 18 g/L.

      It is important to note that the normal values for each of these parameters are also provided. With this information, you must determine which patient is likely to have nephrotic syndrome.

      Your Answer: Patient C

      Correct Answer: Patient E

      Explanation:

      Nephrotic Syndrome

      Nephrotic syndrome is a condition characterized by heavy proteinuria, low serum albumin, and peripheral edema. Patients with this condition may also have severe hyperlipidemia and altered clotting due to the loss of clotting factors in the urine. It is important to note that in the early stages of nephrotic syndrome, the levels of urea and creatinine may appear normal despite underlying renal pathology.

      One of the key indicators of nephrotic syndrome is proteinuria, which is the presence of excessive protein in the urine. Patients with this condition typically have proteinuria greater than 3-3.5 g/24 hours. Additionally, low serum albumin levels, which are less than 25 g/L, are also common in patients with nephrotic syndrome. Peripheral edema, or swelling in the extremities, is another hallmark of this condition.

      Patients with nephrotic syndrome may also experience severe hyperlipidemia, which is characterized by high levels of total cholesterol, often exceeding 10 mmol/L. The loss of clotting factors in the urine can also cause altered clotting, leading to a procoagulant effect. This can be treated with antiplatelet agents and/or low molecular weight heparin.

      Overall, the key features of nephrotic syndrome is important for proper diagnosis and treatment. Further investigation, such as urinalysis, may be necessary to confirm the presence of heavy proteinuria.

    • This question is part of the following fields:

      • Nephrology
      43.8
      Seconds
  • Question 15 - A 50-year-old man is struggling with hypertension that is not responding to his...

    Incorrect

    • A 50-year-old man is struggling with hypertension that is not responding to his current medications. His GP added ramipril to his amlodipine and doxazosin two months ago, but his blood pressure remains high at 162/75 mmHg. The GP decides to increase the ramipril dose to 1.25 mg once daily. However, the patient already has mild renal impairment due to his hypertension, so the GP follows NICE guidance and orders further renal function testing in two weeks. Unfortunately, the patient's creatinine level has increased from 150 to 210 μmol/L. What should the GP's next course of action be?

      Your Answer: Stop the ACE inhibitor and start an angiotensin receptor blocker

      Correct Answer: Refer to renal services for further investigation

      Explanation:

      Possible Renal Artery Stenosis in Resistant Hypertension

      When a patient experiences a rise in their serum creatinine of more than 30% after starting an ACE inhibitor, it may suggest that they have underlying renal artery stenosis causing their resistant hypertension. However, a rise of less than 23% can be considered normal, and it is recommended to repeat blood tests in two weeks to ensure that the creatinine levels are not increasing.

      A renal ultrasound may not provide a clear answer, and it is ideal to perform an angiogram to confirm the diagnosis. This can be done as a CT or MR angiogram for planning purposes, or as a combined angiogram with or without angioplasty if renal artery stenosis is found. Therefore, it is important to consider the possibility of renal artery stenosis in patients with resistant hypertension and a significant rise in serum creatinine after starting an ACE inhibitor.

    • This question is part of the following fields:

      • Nephrology
      198.8
      Seconds
  • Question 16 - A patient who has been on peritoneal dialysis for two years complains that...

    Incorrect

    • A patient who has been on peritoneal dialysis for two years complains that her bags, previously clear, have become cloudy.

      She is in good health, with slight abdominal discomfort, and has successfully instilled fluid, although she only removed 1.5 liters from a 2-liter bag instilled earlier. Her abdomen is soft and only slightly tender.

      What is the probable complication?

      Your Answer: Fibrin blockages of the catheter

      Correct Answer: Peritonitis

      Explanation:

      Symptoms and Treatment of PD Peritonitis

      Peritonitis in patients undergoing peritoneal dialysis (PD) may not present with typical symptoms seen in non-dialysis patients. Patients may only experience mild abdominal discomfort or tenderness, or may not have any symptoms at all. The most common sign of PD peritonitis is a cloudy bag, which indicates bacterial growth. In severe cases, the fluid may resemble pea soup. It is important to note that any patient with a cloudy bag should be treated for PD peritonitis immediately with antibiotics, such as vancomycin, administered intraperitoneally, and oral antibiotics, such as ciprofloxacin. PD exchanges should continue during treatment to flush out the peritoneal cavity.

      While surgical problems, such as appendicitis, can occur in PD patients, they typically present with local peritonism and symptoms like vomiting. Constipation may cause abdominal discomfort and outflow problems, but it does not cause cloudy bags. Fibrin can block the catheter and cause abnormal fluid appearance, but it tends to appear as strands rather than a cloudy bag and does not cause abdominal discomfort or tenderness. It is important for PD patients to be aware of the symptoms of PD peritonitis and seek immediate treatment if they notice a cloudy bag or any other concerning symptoms.

    • This question is part of the following fields:

      • Nephrology
      36.2
      Seconds
  • Question 17 - A 63-year-old man was diagnosed with granulomatosis with polyangiitis (GPA) two years ago...

    Correct

    • A 63-year-old man was diagnosed with granulomatosis with polyangiitis (GPA) two years ago and achieved remission after receiving pulsed cyclophosphamide. He has been maintained on oral azathioprine and a low dose of prednisolone since then. Recently, he returned to the clinic before his scheduled appointment with worsening ENT symptoms, haemoptysis, and declining renal function. Two months prior, he had a superficial bladder cancer (stage Ta, no invasion, single lesion) that was resected, followed by a single dose of postoperative chemotherapy. Given his new diagnosis, what is the most appropriate treatment for his vasculitis flare?

      Your Answer: Rituximab therapy

      Explanation:

      Treatment Dilemma for a Patient with Vasculitis

      This patient is facing a difficult situation as he requires immunosuppressive therapy to manage his vasculitis, which is organ-threatening, but most immunosuppressants increase the risk of cancer. Increasing oral steroids would provide short-term relief but come with significant side effects. Azathioprine and mycophenolate mofetil are unlikely to control his disease in time and are associated with an increased risk of malignancy. Cyclophosphamide should be avoided as it is known to cause bladder cancer.

      However, there is a potential solution in rituximab, a monoclonal antibody that targets CD20, a surface marker on most B cells. Rituximab has been shown to be as effective as cyclophosphamide in treating ANCA vasculitis, but with a much better side effect profile. A two-year course of rituximab therapy can even allow for the withdrawal of other immunosuppressants, which would be particularly helpful in this patient’s case. Overall, while the patient’s situation is challenging, rituximab may provide a viable treatment option.

    • This question is part of the following fields:

      • Nephrology
      25.8
      Seconds
  • Question 18 - In the treatment of autoimmunity and prevention of rejection after solid organ transplantation,...

    Incorrect

    • In the treatment of autoimmunity and prevention of rejection after solid organ transplantation, various immunosuppressant drugs are used. Despite their effectiveness, these drugs have unwanted side effects that increase the risk of infection and malignancy. However, specific side effects are associated with each drug due to their unique mechanism of action. What is the immunosuppressant drug that is commonly linked to hirsutism and gingival hypertrophy in patients? Also, is there any age group that is more susceptible to these side effects?

      Your Answer: Prednisolone

      Correct Answer: Ciclosporin

      Explanation:

      Ciclosporin’s Side Effects and Decreased Popularity as a Transplantation Maintenance Therapy

      Ciclosporin is a medication that is commonly linked to gingival hypertrophy and hirsutism. These side effects can be unpleasant for patients and may lead to decreased compliance with the medication regimen. Additionally, ciclosporin is not as effective as tacrolimus at inhibiting calcineurin, which is a key factor in preventing transplant rejection. As a result, ciclosporin is becoming less popular as a maintenance therapy for transplantation. Physicians are increasingly turning to other medications that have fewer side effects and are more effective at preventing rejection. While ciclosporin may still be used in some cases, it is no longer considered the first-line treatment for transplantation maintenance therapy.

    • This question is part of the following fields:

      • Nephrology
      19.3
      Seconds
  • Question 19 - A 65-year-old woman with known CKD stage 4 due to type 2 diabetes...

    Correct

    • A 65-year-old woman with known CKD stage 4 due to type 2 diabetes and obesity is admitted with cellulitis that has not responded to oral antibiotics. MRSA is detected in swabs, and she is started on IV vancomycin. She is also taking carbamazepine, omeprazole, warfarin, and chloramphenicol eye drops. Three days later, the laboratory urgently calls to report her vancomycin level is 54 (therapeutic range 10-20), and regular dosing is immediately stopped. What is the most likely cause of her elevated levels?

      Your Answer: Inadequate renal clearance

      Explanation:

      Vancomycin and its Clearance in CKD Patients

      Vancomycin is a drug that is primarily cleared through the kidneys. In patients with stage 4 chronic kidney disease (CKD), the drug may accumulate in the body due to regular dosing in excess of what the kidneys can handle. This can lead to high levels of vancomycin in the bloodstream. However, liver enzyme inhibitors such as omeprazole and carbamazepine do not affect vancomycin clearance. Therefore, they are unlikely to increase the drug levels in the body.

      Warfarin, on the other hand, does not affect liver enzymes but may be altered by enzyme inducers or inhibitors. It is important to monitor warfarin levels in patients taking vancomycin to avoid any potential drug interactions. Although obesity may affect the volume of distribution of vancomycin, dosing for normal renal function is unlikely to lead to high levels in obese patients. Overall, it is crucial to consider the patient’s renal function and adjust the vancomycin dose accordingly to prevent toxicity.

    • This question is part of the following fields:

      • Nephrology
      27.3
      Seconds
  • Question 20 - A 35-year-old male was given steroids after a kidney transplant. After two years,...

    Incorrect

    • A 35-year-old male was given steroids after a kidney transplant. After two years, he experienced hip pain and difficulty walking. What is the most probable cause of his symptoms?

      Your Answer: Primary osteoarthritis

      Correct Answer: Avascular necrosis

      Explanation:

      Avascular Necrosis and Its Causes

      Avascular necrosis (AVN) is a condition that occurs when the blood supply to the bones is temporarily or permanently lost. This can be caused by various factors, including trauma or vascular disease. Some of the conditions that can lead to AVN include hypertension, sickle cell disease, caisson disease, and radiation-induced arthritis. Additionally, certain factors such as corticosteroid therapy, connective tissue disease, alcohol abuse, marrow storage disease (Gaucher’s disease), and dyslipoproteinaemia can also be associated with AVN in a more complex manner.

      Of all the cases of non-traumatic avascular necrosis, 35% are associated with systemic (oral or intravenous) corticosteroid use. It is important to understand the causes of AVN in order to prevent and manage the condition effectively. By identifying the underlying factors that contribute to AVN, healthcare professionals can develop appropriate treatment plans and help patients manage their symptoms. With proper care and management, individuals with AVN can lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Nephrology
      14.9
      Seconds
  • Question 21 - A 40-year-old male presents with weakness in his left upper and both lower...

    Incorrect

    • A 40-year-old male presents with weakness in his left upper and both lower limbs for the last six months. He developed digital infarcts involving his second and third toes on his left side and the fourth toe on his right side.

      On examination, his blood pressure was 170/110 mmHg, all peripheral pulses were palpable and there was an asymmetrical neuropathy.

      Investigations showed:

      - Haemoglobin 118 g/L (120-160)
      - White cell Count 11 ×109/L (3.5-10)
      - Platelets 420 ×109/L (150-450)
      - ESR 55mm/hr (0-15)

      Urine examination showed proteinuria +++ and RBC 10-15/hpf without casts.

      What is the most likely diagnosis?

      Your Answer: Mixed cryoglobulenaemia

      Correct Answer: Polyarteritis nodosa

      Explanation:

      Polyarteritis Nodosa

      Polyarteritis nodosa (PAN) is a type of vasculitis that affects small and medium-sized arteries. It can cause damage to various organs, including the skin, joints, peripheral nerves, gastrointestinal tract, and kidneys. The symptoms of PAN can range from mild to severe, depending on the extent of the damage. Some of the common symptoms include hypertension, nephropathy, digital infarcts, and mononeuritis multiplex.

      One of the key diagnostic features of PAN is the presence of multiple aneurysms at vessel bifurcations, which can be detected through angiography. Treatment for PAN typically involves the use of immunosuppressive drugs to reduce inflammation and prevent further damage to the affected organs. With proper management, many people with PAN are able to achieve remission and maintain a good quality of life.

    • This question is part of the following fields:

      • Nephrology
      76.8
      Seconds
  • Question 22 - A 28-year-old female patient complains of epistaxis and has been experiencing a fever....

    Incorrect

    • A 28-year-old female patient complains of epistaxis and has been experiencing a fever. Upon examination by an ENT specialist, she was found to have serous otitis media. Further tests revealed protein +++ and 20 RBC/hpf in her urine, while her serum rheumatoid factor was negative. What is the most probable diagnosis for this patient?

      Your Answer: Goodpasture's syndrome

      Correct Answer: Granulomatosis with polyangiitis

      Explanation:

      Granulomatosis with Polyangiitis: Symptoms and Diagnosis

      Granulomatosis with polyangiitis (GPA) is a disease that can develop slowly or suddenly, and its full range of symptoms may take years to appear. The initial symptoms of GPA include severe nosebleeds, sinusitis, nasal ulcers, ear infections, hearing loss, coughing, and chest pain. Renal involvement is also common, with glomerulonephritis causing proteinuria, haematuria, and red cell casts. Serum complement levels are usually normal or elevated, while the erythrocyte sedimentation rate (ESR) is elevated, and leukocytosis and anaemia may be present. Unlike other autoimmune diseases, antinuclear antibodies and LE cells are not present in GPA. However, high levels of antineutrophil cytoplasmic antibodies (ANCA) are almost always present, making it a useful marker for diagnosing and monitoring the disease.

      Symptoms of GPA can be varied and may take time to develop fully. Renal involvement is a common feature of the disease, and proteinuria, haematuria, and red cell casts are often seen. Serum complement levels are usually normal or elevated, while the ESR is elevated, and leukocytosis and anaemia may be present. Unlike other autoimmune diseases, antinuclear antibodies and LE cells are not present in GPA. However, high levels of ANCA are almost always present, making it a useful marker for diagnosing and monitoring the disease.

    • This question is part of the following fields:

      • Nephrology
      46.8
      Seconds
  • Question 23 - A 44-year-old woman underwent a kidney transplant four years ago due to end...

    Correct

    • A 44-year-old woman underwent a kidney transplant four years ago due to end stage renal failure caused by lupus nephritis. The transplant was from her sister, and she received anti-thymocyte globulin (ATG) induction and plasma exchange pre-transplant due to low-grade donor specific antibodies. She has been stable on tacrolimus, mycophenolate mofetil and prednisolone, with only one episode of acute cellular rejection at six months post-transplant. During her four-year follow-up, she presented with a creatinine level of 150 umol/l and high blood pressure at 150/95 mmHg, which increased to 160 umol/l in a repeat sample one month later. She was admitted for further investigations and biopsy, which revealed double contouring of the glomerular capillary basement membrane, without inflammatory infiltrate and negative C4d. Donor specific antibodies were still present, but titres were low. What is the most likely diagnosis?

      Your Answer: Transplant glomerulopathy

      Explanation:

      Pathological Processes in Renal Transplant Patients

      Double contouring of the glomerular capillary basement membrane is a characteristic feature of transplant glomerulopathy, a chronic antibody-mediated rejection that affects up to 15% of renal transplant patients at five years post-transplant. Acute cellular rejection, on the other hand, is characterized by interstitial inflammation, tubulitis, and/or arthritis, and is unlikely to occur in patients on stable medication doses. Acute humoral rejection, which is characterized by C4d deposition, capillaritis, and/or arthritis, is another possible pathological process in renal transplant patients.

      BK viral nephropathy, which occurs in 1-8% of renal transplant patients, is associated with T cell depleting agents such as ATG. Biopsy findings in BK viral nephropathy typically show nuclear viral inclusions in the tubular epithelial cells, which can be limited to the medulla in early disease, and tubulointerstitial inflammation. Urine cytology can also be used to detect decoy cells and urothelial cells with characteristic nuclear viral inclusions, thus avoiding the need for biopsy.

      Finally, acute calcineurin inhibitor (CNI) toxicity is unlikely in patients on stable doses of tacrolimus, but almost all patients develop chronic CNI nephrotoxicity. Biopsy findings in chronic CNI nephrotoxicity typically show interstitial fibrosis, tubular atrophy, and arteriolar hyalinosis. In the case of this patient, some background CNI toxicity is likely, but the biopsy findings are more consistent with transplant glomerulopathy as the primary pathological process.

    • This question is part of the following fields:

      • Nephrology
      37.9
      Seconds
  • Question 24 - An 80-year-old man arrives at the Emergency department feeling generally ill. The laboratory...

    Incorrect

    • An 80-year-old man arrives at the Emergency department feeling generally ill. The laboratory contacts you to report dangerously low serum sodium levels before you can see him. After diagnosis, it is discovered that he has a hormone excess. Which hormone could be the cause?

      Your Answer: Aldosterone

      Correct Answer: Antidiuretic hormone

      Explanation:

      Hormonal Imbalances and Their Effects on Sodium Levels

      Hormones play a crucial role in regulating various bodily functions, including water and sodium balance. Antidiuretic hormone (ADH) allows for water reabsorption in the collecting ducts, independent of sodium. However, an excess of ADH can lead to hyponatraemia, a condition characterized by low levels of sodium in the blood. This is commonly caused by dehydration, but can also be due to medications, tumours, or lung diseases.

      On the other hand, aldosterone is responsible for tubular Na+ and Cl- reabsorption, water retention, and K+ excretion. In excess, one would expect hypernatraemia, or high levels of sodium in the blood. However, the elevation in plasma sodium is usually mild, as the increased sodium is balanced by water retention.

      When ADH is excessively produced, it is known as the syndrome of inappropriate ADH (SIADH). This results in net retention of water and a decrease in sodium levels. In mild cases, this can cause confusion and unsteadiness, but in severe cases, it can lead to coma and even death.

      It is important to note that hyponatraemia is a common finding in hospitalized patients, and inappropriate ADH secretion is often blamed. However, this should only be considered in the context of a euvolaemic patient, meaning they are not dehydrated or overloaded. Correction of this imbalance should be prioritized before seeking other potential causes.

    • This question is part of the following fields:

      • Nephrology
      29.2
      Seconds
  • Question 25 - In the treatment of autoimmunity and to prevent rejection following solid organ transplantation,...

    Incorrect

    • In the treatment of autoimmunity and to prevent rejection following solid organ transplantation, there are various immunosuppressant drugs available. Despite their effectiveness, these drugs come with unwanted side effects, such as an increased risk of infection and malignancy. However, specific side effects may vary depending on the drug's mechanism of action. Which immunosuppressant drug is linked to an elevated risk of bladder cancer in the long run and can cause haemorrhagic cystitis? Additionally, is this drug safe for use in elderly patients?

      Your Answer: Prednisolone

      Correct Answer: Cyclophosphamide

      Explanation:

      Cyclophosphamide and its Effects on the Body

      Cyclophosphamide is a chemotherapy drug that is commonly used to treat autoimmune diseases such as ANCA associated vasculitis and systemic lupus erythematosus. Once it is metabolized in the liver, it is converted into its active form, phosphoramide mustard, which causes DNA crosslinking and apoptosis of rapidly dividing cells, including lymphocytes.

      However, the drug can also produce a toxic compound called acrolein, which is harmful to the urothelium. Since the drug is excreted by the kidney, the bladder can accumulate high concentrations of acrolein, leading to potential damage. To prevent this, patients are often pre-hydrated to ensure that urine remains dilute and high concentrations are avoided.

      In some cases, mesna is used to prevent urothelial damage. Mesna is believed to act as an antioxidant and can be particularly useful for patients receiving high doses of therapy. By taking these precautions, the harmful effects of cyclophosphamide can be minimized, allowing patients to receive the benefits of the drug without experiencing unnecessary harm.

    • This question is part of the following fields:

      • Nephrology
      26.6
      Seconds
  • Question 26 - A 15-year-old girl comes to the clinic complaining of myalgia and brown-coloured urine....

    Correct

    • A 15-year-old girl comes to the clinic complaining of myalgia and brown-coloured urine. She has been diagnosed with rhabdomyolysis for the fourth time, and the cause is still unknown.

      What investigation should be considered at this point?

      Your Answer: Muscle biopsy

      Explanation:

      Investigating Recurrent Rhabdomyolysis: Genetic Causes and Diagnostic Tests

      Rhabdomyolysis is a condition characterized by the breakdown of muscle tissue, leading to the release of muscle fibers into the bloodstream. This can cause kidney damage and other complications. In some cases, rhabdomyolysis may be caused by genetic polymorphisms or mutations that affect processes such as ATP production and calcium movement. Patients who have had recurrent episodes of unexplained rhabdomyolysis, especially those without obvious traumatic, drug-related, or toxic cause, should be investigated for genetic causes. Muscle biopsy is a useful diagnostic test in these cases.

      Other diagnostic tests may also be helpful in certain situations. For example, the Gal-1 PUT test can be used to diagnose galactosaemia, a rare genetic disorder that can cause rhabdomyolysis in infants. Renin and aldosterone levels may be useful if primary hyperaldosteronism causing hypokalaemia is suspected as the cause of rhabdomyolysis, but this is rare in children. GFR testing is only necessary if there is renal impairment, and haemodialysis may be necessary in cases of severe renal failure.

      In summary, recurrent rhabdomyolysis should be investigated for genetic causes, and muscle biopsy is a useful diagnostic test in these cases. Other diagnostic tests may be helpful in certain situations, but their use should be guided by the patient’s clinical presentation and history.

    • This question is part of the following fields:

      • Nephrology
      13.2
      Seconds
  • Question 27 - A 65-year-old man comes to the clinic with a history of mild anaemia....

    Correct

    • A 65-year-old man comes to the clinic with a history of mild anaemia. The physician orders several urine tests. The results are as follows:

      - Negative for haemoglobin, urobilinogen, and bilirubin
      - Positive for protein
      - Negative for glucose, nitrites, and leucocytes
      - Positive for ketones
      - +++ for Bence Jones

      What could be the possible reason for these results?

      Your Answer: Multiple myeloma

      Explanation:

      Myeloma Diagnosis and Blood Results

      Myeloma is a type of cancer that can be diagnosed through various tests. One of the most common indicators is a positive test for Bence Jones protein, which is a type of protein found in the urine. This cancer can also cause proteinuria, which is the presence of excess protein in the urine due to renal damage or overflow from high blood total protein. Additionally, longstanding anaemia is another sign of myeloma.

      Blood results for a patient with myeloma are likely to show elevated total protein, possibly with low albumin. There may also be an abnormally high level of one type of globulin, while other immunoglobulins may be suppressed. Protein electrophoresis testing can reveal the presence of a monoclonal (paraprotein) band with immunosuppression. High serum calcium with suppressed parathyroid hormone consistent with hypercalcaemia of malignancy is also common. Furthermore, high phosphate levels are often seen in haematological malignancy where there is a large amount of cell turnover. Renal impairment is another common finding, usually due to the deposition of myeloma casts in the nephrons. However, hypercalcaemia can also cause dehydration in addition.

      In summary, a diagnosis of myeloma can be made through various tests, including a positive Bence Jones protein test, proteinuria, and longstanding anaemia. Blood results for a patient with myeloma are likely to show elevated total protein, a monoclonal band, high serum calcium, high phosphate, and renal impairment.

    • This question is part of the following fields:

      • Nephrology
      23.5
      Seconds
  • Question 28 - A 59-year-old man of Afro-Caribbean descent presented with bipedal oedema. He was a...

    Incorrect

    • A 59-year-old man of Afro-Caribbean descent presented with bipedal oedema. He was a retired teacher with occasional international travel. On examination, his body weight was 40 kg with some oral ulcers.
      Tests revealed:
      Investigation Result Normal value
      Haemoglobin 112g/l 135–175 g/l
      White cell count (WCC) 5 × 109/l 4–11 × 109/l
      Neutrophils 1.2 × 109/l 2.5–7.58 × 109/l
      Lymphocytes 1.4 × 109/l 1.5–3.5 × 109/l
      Eosinophils 0.8 × 109/l 0.1–0.4 × 109/l
      Urine Protein 2+
      Cholesterol 4.5 <5.2 mmol/l
      Which of the following tests is next indicated for this patient?

      Your Answer: Renal biopsy

      Correct Answer: CD4 count

      Explanation:

      Diagnosis and Management of HIV Nephropathy

      HIV infection is a high possibility in a patient with risk factors and presenting with emaciation, oral ulcers, and lymphopenia. A CD4 count and HIV serological testing should be done urgently. HIV nephropathy is a common complication, with focal and segmental glomerulosclerosis being the most common pathological diagnosis. Other variants include membranoproliferative nephropathy, diffuse proliferative glomerulonephritis, minimal change disease, and IgA nephropathy. Treatment involves ACE inhibitors and antiretroviral therapy, with dialysis being necessary in end-stage disease. Renal biopsy is required to confirm the diagnosis, but HIV testing should be performed first. Serum IgA levels are elevated in IgA nephropathy, while serum complement levels and anti-nuclear factor are needed in SLE-associated nephropathy or other connective tissue diseases or vasculitis. However, the lack of systemic symptoms points away from these diagnoses.

    • This question is part of the following fields:

      • Nephrology
      39.7
      Seconds
  • Question 29 - A 26-year-old man with chronic renal failure received a renal transplant from a...

    Incorrect

    • A 26-year-old man with chronic renal failure received a renal transplant from a matched related donor. After being discharged with a functioning graft, he returned to the nephrology clinic a month later with a high fever and was admitted for further investigation. During his first evening in the hospital, his condition rapidly worsened, and he became dyspneic. A full blood count revealed significant leukopenia, and his liver function tests were severely abnormal. What is the probable cause of his illness?

      Your Answer: Parvovirus B19

      Correct Answer: Cytomegalovirus

      Explanation:

      CMV Infection and Organ Transplantation

      Cytomegalovirus (CMV) infection is a significant cause of morbidity and mortality in patients who have undergone organ transplantation. The likelihood of developing CMV infection after transplantation depends on two primary factors: whether the donor or recipient has a latent virus that can reactivate after transplantation and the degree of immunosuppression after the procedure.

      The most severe type of post-transplant CMV infection is primary disease, which occurs in individuals who have never been infected with CMV and receive an allograft that contains latent virus from a CMV-seropositive donor. This type of infection is the most common and can be particularly dangerous for patients who have undergone organ transplantation. Proper monitoring and management of CMV infection are essential for ensuring the best possible outcomes for these patients.

    • This question is part of the following fields:

      • Nephrology
      40.4
      Seconds
  • Question 30 - A 30-year-old woman underwent a renal transplant two years ago due to end...

    Incorrect

    • A 30-year-old woman underwent a renal transplant two years ago due to end stage renal failure caused by haemolytic uraemic syndrome. She has been in good health since the transplant, without instances of rejection, and has been stable on antirejection therapy consisting of tacrolimus, prednisolone, and azathioprine. As both she and her donor were CMV seropositive, she is on valganciclovir prophylaxis. Additionally, she takes aspirin, bisoprolol, and paracetamol. She and her partner are contemplating trying to conceive. Which of her medications should she discontinue before attempting to conceive?

      Your Answer: Azathioprine

      Correct Answer: Valganciclovir

      Explanation:

      The only teratogenic drug must be stopped prior to conception, while the risks of other medications must be balanced against the risks to the mother. The combination of tacrolimus, azathioprine, and steroids is considered the safest. If the patient is taking mycophenolate or sirolimus, they should be changed to azathioprine or a calcineurin inhibitor, respectively. Bisoprolol is generally safe in pregnancy, but if the patient becomes pregnant, they may need to switch to methyldopa or labetalol as alternative antihypertensives and receive closer monitoring in a joint clinic. Transplant patients should wait at least 12 months after surgery before trying to conceive and should be stable for at least six months without complications before doing so.

    • This question is part of the following fields:

      • Nephrology
      50.9
      Seconds
  • Question 31 - A 67-year-old man with diabetes comes in for his annual check-up. He reports...

    Correct

    • A 67-year-old man with diabetes comes in for his annual check-up. He reports occasional cramping in his calf after walking about a mile on flat ground, but is otherwise feeling well. He admits to smoking five cigarettes a day. During the exam, his blood pressure is measured at 166/98 mmHg, with a pulse of 86 bpm and a BMI of 30.2. Neurological exam is normal and his fundi appear normal. However, examination of his peripheral circulation reveals absent feet pulses and weak popliteal pulses. He is started on antihypertensive therapy and his U+Es are measured over a two-week period, with the following results:

      Baseline:
      Sodium - 138 mmol/L
      Potassium - 4.6 mmol/L
      Urea - 11.1 mmol/L
      Creatinine - 138 µmol/L

      2 weeks later:
      Sodium - 140 mmol/L
      Potassium - 5.0 mmol/L
      Urea - 19.5 mmol/L
      Creatinine - 310 µmol/L

      Which class of antihypertensives is most likely responsible for this change?

      Your Answer: Angiotensin converting enzyme (ACE) inhibitor therapy

      Explanation:

      Renal Artery Stenosis and ACE Inhibitors

      This individual with diabetes is experiencing hypertension and arteriopathy, as indicated by mild claudication symptoms and absent pulses in the feet. These factors, combined with macrovascular disease and mild renal impairment, suggest a potential diagnosis of renal artery stenosis (RAS). The introduction of an antihypertensive medication, specifically an ACE inhibitor, resulted in a decline in renal function, further supporting the possibility of RAS. In RAS, hypertension occurs due to the activation of the renin-angiotensin-aldosterone system in an attempt to maintain renal perfusion. However, ACE inhibition can lead to relative renal ischemia, exacerbating the condition. This highlights the importance of considering RAS as a potential cause of hypertension and carefully monitoring the use of ACE inhibitors in individuals with this condition.

    • This question is part of the following fields:

      • Nephrology
      37.4
      Seconds
  • Question 32 - A 25-year-old man is brought to the Emergency department by his friends after...

    Correct

    • A 25-year-old man is brought to the Emergency department by his friends after being found on the floor following a night out. There are suspicions that he may have taken drugs, although the exact substance is unknown. Upon examination, he is found to be semi-conscious with a rapid respiratory rate. A catheterisation procedure yields 25 mls of dark brown coloured urine which tests positive for haemoglobin using urinalysis.

      What potential blood and electrolyte imbalances should be anticipated in this patient?

      Your Answer: Hyperuricaemia with acidosis

      Explanation:

      Rhabdomyolysis: Symptoms and Treatment

      Rhabdomyolysis is a medical condition that occurs when there is a rapid breakdown of skeletal muscle. This condition is associated with several biochemical abnormalities, including elevated levels of creatine kinase (CK), potassium, urate, and myoglobinuria. Additionally, calcium levels may be elevated intracellularly in myocytes, but normal or low in the blood during the early stages of the disease. However, as the disease progresses, calcium levels in the blood may increase. Acidosis is also a common symptom of rhabdomyolysis.

      Early and aggressive treatment is crucial in managing rhabdomyolysis. Rehydration and managing hyperkalemia can help reduce the likelihood of developing complications such as arrhythmias due to electrolyte disturbance, renal failure, disseminated intravascular coagulation, and compartment syndrome. By the symptoms and seeking prompt medical attention, individuals with rhabdomyolysis can receive the necessary treatment to manage the condition and prevent further complications.

    • This question is part of the following fields:

      • Nephrology
      23
      Seconds
  • Question 33 - A 25-year-old woman with a history of glomerulonephritis is scheduled to undergo a...

    Incorrect

    • A 25-year-old woman with a history of glomerulonephritis is scheduled to undergo a 24-hour urinary protein collection. What is the recommended starting time for the collection?

      Your Answer: He should be catheterised to allow for an exact 24 hour collection

      Correct Answer: Start after the first morning void

      Explanation:

      Guidelines for Accurate 24 Hour Urine Collection

      Twenty four hour urine collections are essential for measuring urinary protein levels and diagnosing various conditions. However, the accuracy and reproducibility of the test can be limited due to the difficulty in performing it correctly. To ensure accurate results, laboratories provide guidelines to patients for the procedure of taking a 24 hour urine collection.

      The guidelines advise patients to use the correct bottle for the test and to read the leaflet about dietary requirements during the test. Some analytes can be affected by diet before and during the test, so it is important to follow the instructions carefully. Patients should also be aware that some bottles contain acid, which prevents degradation of certain analytes and prevents false negative results. If there is a small amount of liquid already in the bottle, patients should not throw it out as it is usually there as a preservative.

      To start the collection, patients should begin after the first void of the day and collect all urine for 24 hours, including the first void the following day. Although the start time does not technically matter, starting after the first void tends to be at a similar time on consecutive days, minimizing error.

      The main errors made in urine collections are overcollection and undercollection. Overcollection occurs when patients collect for more than 24 hours, leading to a falsely high urine protein result. Patients should consider overcollection if urine volumes are greater than 3-4L/day. Undercollection occurs when patients collect for less than 24 hours, leading to a falsely low result. Patients should suspect undercollection if urine volumes are less than 1 L/day. By following these guidelines, patients can ensure accurate and reliable results from their 24 hour urine collection.

    • This question is part of the following fields:

      • Nephrology
      78.2
      Seconds
  • Question 34 - A 40-year-old male visits his doctor two days after finishing a marathon. He...

    Incorrect

    • A 40-year-old male visits his doctor two days after finishing a marathon. He expresses worry about the reddish-brown hue of his urine and his overall feeling of illness. What is the pigment responsible for the urine discoloration?

      Your Answer: Bilirubin

      Correct Answer: Myoglobin

      Explanation:

      Rhabdomyolysis and Myoglobinuria

      Rhabdomyolysis is a common condition that occurs after extreme physical exertion, such as running a marathon. It is characterized by the breakdown of muscle tissue, which releases myoglobin into the bloodstream. Myoglobin is a small molecule that is normally found in muscle cells, but when released into the circulation, it can cause urine to turn a dark color.

      There are several causes of rhabdomyolysis and myoglobinuria, including trauma, compartment syndrome, crush injuries, ischemia, severe electrolyte imbalances, bacterial and viral infections, and inherited metabolic disorders like McArdle’s disease. In rare cases, certain drugs like barbiturates and statins can also cause rhabdomyolysis.

      It is important to recognize the signs and symptoms of rhabdomyolysis, such as muscle pain, weakness, and dark urine, as it can lead to serious complications like kidney failure if left untreated. Treatment typically involves addressing the underlying cause, such as rehydration and electrolyte replacement, and may require hospitalization in severe cases.

    • This question is part of the following fields:

      • Nephrology
      7.8
      Seconds
  • Question 35 - A 60-year-old patient presents to her GP with a general feeling of unwellness....

    Correct

    • A 60-year-old patient presents to her GP with a general feeling of unwellness. The following blood test results are obtained:

      - Adjusted calcium: 2.9 mmol/L (normal range: 2.2-2.4)
      - Phosphate: 0.5 mmol/L (normal range: 0.7-1.0)
      - PTH: 7.2 pmol/L (normal range: 1.05-6.83)
      - Urea: 5 mmol/L (normal range: 2.5-7.8)
      - Creatinine: 140 µmol/L (normal range: 60-120)
      - 25 OH Vit D: 50 nmol/L (optimal level >75)

      What is the most likely diagnosis?

      Your Answer: Primary hyperparathyroidism

      Explanation:

      Primary Hyperparathyroidism

      Primary hyperparathyroidism is a condition where the parathyroid glands produce too much parathyroid hormone (PTH), leading to elevated calcium levels and low serum phosphate levels. This condition can go undiagnosed for years, with the first indication being an incidental finding of high calcium levels. However, complications can arise from longstanding primary hyperparathyroidism, including osteoporosis, renal calculi, and renal calcification. The high levels of PTH can cause enhanced bone resorption, leading to osteoporosis. Additionally, the high levels of phosphate excretion and calcium availability can predispose patients to the development of calcium phosphate renal stones. Calcium deposition in the renal parenchyma can also cause renal impairment, which can develop gradually. Patients with chronic kidney disease may also have elevated PTH levels, but hypocalcaemia is more common due to impaired hydroxylation of vitamin D. primary hyperparathyroidism and its potential complications is crucial for early diagnosis and management.

    • This question is part of the following fields:

      • Nephrology
      24.6
      Seconds
  • Question 36 - A 28-year-old female presents with acute kidney injury and pulmonary haemorrhage, and is...

    Incorrect

    • A 28-year-old female presents with acute kidney injury and pulmonary haemorrhage, and is diagnosed with anti-GBM disease (Goodpasture's disease) with very high antibody titres. She is started on plasma exchange with daily treatments for five days in addition to methylprednisolone. What is a complication of plasma exchange that is unlikely to occur?

      Your Answer: Bleeding

      Correct Answer: Hypercalcaemia

      Explanation:

      Plasma Exchange and its Side Effects

      Plasma exchange is a medical procedure that involves taking blood from a patient, separating the cells and large proteins from the plasma and smaller proteins, and replacing the plasma with either donated fresh-frozen plasma or human albumin solution. This process removes low molecular weight proteins such as antibodies, but it also has a number of side effects. These side effects are partly due to the removal of other components such as clotting factors, but they are also due to the blood products and anticoagulants used.

      To address these complications, more specific methods of antibody removal have been developed, such as immunoabsorption. This method uses a column of beads coated in specific antigen, which separates the plasma and passes it over the column. Antigen-specific antibodies bind to the column, and antibody-free plasma can then be returned to the patient. This method is better for the patient because they do not lose clotting factors and avoid exposure to blood products.

      Common side effects of plasma exchange include hypocalcaemia, which is a decrease in plasma ionised calcium due to the citrate anticoagulants used for replacement fluids such as human albumin solution and fresh frozen plasma. Bleeding can also occur due to the loss of clotting factors in the exchange, and transfusion with any blood products can lead to allergic reactions. Infection is also a risk due to the loss of protective immunoglobulins along with the autoantibodies, so it is important to monitor immunoglobulin levels during treatment.

    • This question is part of the following fields:

      • Nephrology
      31.4
      Seconds
  • Question 37 - A 60-year-old patient presents to their GP with a general feeling of unwellness....

    Correct

    • A 60-year-old patient presents to their GP with a general feeling of unwellness. The following blood test results are obtained:

      - Adjusted calcium: 2.5 mmol/L (normal range: 2.2-2.4)
      - Phosphate: 1.6 mmol/L (normal range: 0.7-1.0)
      - PTH: 2.05 pmol/L (normal range: 1.05-6.83)
      - Urea: 32.8 mmol/L (normal range: 2.5-7.8)
      - Creatinine: 160 µmol/L (normal range: 60-120)
      - 25 OH Vit D: 56 nmol/L (optimal level >75)

      What is the most likely diagnosis?

      Your Answer: Acute renal failure

      Explanation:

      Biochemical Indicators of Dehydration-Induced Acute Kidney Injury

      The biochemical indicators suggest that the patient is experiencing acute renal failure or acute kidney injury due to dehydration. The slightly elevated levels of calcium and phosphate indicate haemoconcentration, while the significantly increased urea levels compared to creatinine suggest AKI. A urea level of 32 mmol/L is common in AKI, but in a patient with stable chronic kidney disease, it would typically be associated with a much higher creatinine level.

      It is important to note that chronic kidney disease often presents with multiple biochemical abnormalities that are not typically seen in AKI. These include hypocalcaemia, increased levels of PTH (secondary hyperparathyroidism in compensation for hypocalcaemia), and anaemia due to erythropoietin and iron deficiency. Therefore, the absence of these indicators in the patient’s blood work supports the diagnosis of dehydration-induced AKI.

    • This question is part of the following fields:

      • Nephrology
      42.5
      Seconds
  • Question 38 - Are there any immunosuppressant drugs that can cause severe myelosuppression along with unpleasant...

    Correct

    • Are there any immunosuppressant drugs that can cause severe myelosuppression along with unpleasant gastrointestinal side effects? It is important to note that while all immunosuppressants have potential side effects such as increased risk of infection and malignancy, certain drugs may have specific side effects due to their unique mechanisms of action.

      Your Answer: Mycophenolate mofetil

      Explanation:

      Myelosuppression and Gastrointestinal Side Effects of Immunosuppressive Drugs

      Immunosuppressive drugs are commonly used in the treatment of autoimmune diseases and organ transplantation. However, they can cause myelosuppression, a condition where the bone marrow is suppressed and the production of blood cells is reduced. Mycophenolate mofetil (MMF) is known to cause myelosuppression even at low doses, so it is important to monitor patients’ full blood count (FBC) after starting treatment with MMF or azathioprine. Azathioprine is also associated with myelosuppression, but it is more commonly linked to abnormal liver function tests (LFTs) than gastrointestinal (GI) upset.

      Patients taking MMF often experience diarrhea, which can be managed by starting with a low dose and gradually increasing it over several weeks. It is crucial to monitor patients for myelosuppression and other side effects of immunosuppressive drugs to ensure their safety and well-being. By doing so, healthcare providers can adjust the dosage or switch to a different medication if necessary. Proper monitoring and management of side effects can help patients achieve better outcomes and improve their quality of life.

    • This question is part of the following fields:

      • Nephrology
      17.6
      Seconds
  • Question 39 - What is the most optimal choice for establishing a permanent entry point for...

    Correct

    • What is the most optimal choice for establishing a permanent entry point for haemodialysis treatment?

      Your Answer: Radiocephalic arteriovenous fistula

      Explanation:

      Haemodialysis Access Options

      Haemodialysis access is the formation of a permanent connection between an artery and a vein to allow for efficient dialysis treatment. The ideal location for this connection is in the arm, where the radial artery is joined to the cephalic vein on the non-dominant arm. If this is not possible, a brachial artery-cephalic vein connection is formed higher up the arm. Leg fistulas are used as a last resort due to complications such as infection and positional access.

      In cases where a direct arteriovenous connection is not possible, a PTFE graft is used. However, this foreign material has a higher risk of infection. A tunnelled internal jugular dialysis catheter is a good option for urgent access, but it is not as efficient as fistulas in clearing waste products due to recirculation of blood.

      Tenckhoff catheters are used for peritoneal dialysis. It is important to consider the pros and cons of each option when choosing the best haemodialysis access for a patient. Fistulas are the preferred option, but in some cases, other options may be necessary.

    • This question is part of the following fields:

      • Nephrology
      8.4
      Seconds
  • Question 40 - As a locum GP, you are seeing a 60-year-old patient who is known...

    Correct

    • As a locum GP, you are seeing a 60-year-old patient who is known to be alcohol-dependent. He informs you that he has been staying at a hostel but has had very little to eat in the last week.

      Which urinalysis results would you expect to see in this situation?

      A. Haemoglobin: Negative
      B. Urobilinogen: Negative
      C. Bilirubin: Negative
      D. Protein: +
      E. Glucose: + + +

      F. Nitrites: Negative ++ +++
      G. Leucocytes: + ++ +++
      H. Ketones: Negative +++ Negative +++ Negative

      Please note that the urinalysis results may vary depending on the individual's health condition and other factors.

      Your Answer: D

      Explanation:

      The Significance of Urinalysis in Identifying High Levels of Urinary Ketones

      Urinalysis is a crucial diagnostic tool that can help identify various renal and non-renal conditions. One of the significant findings in urinalysis is the presence of high levels of urinary ketones. This condition can be observed in patients with diabetic ketoacidosis, which is characterized by high levels of glucose in the body. Additionally, individuals who are experiencing starvation or anorexia nervosa may also exhibit high levels of urinary ketones. Patients with severe illnesses that cause short-term anorexia and those who consume excessive amounts of alcohol may also show this condition.

      In summary, urinalysis is a valuable investigation that can help identify high levels of urinary ketones, which can be indicative of various medical conditions. By detecting this condition early on, healthcare professionals can provide prompt and appropriate treatment to prevent further complications.

    • This question is part of the following fields:

      • Nephrology
      52.7
      Seconds
  • Question 41 - You are part of the transplant team on call and have been asked...

    Correct

    • You are part of the transplant team on call and have been asked to assess a potential kidney donor. The patient is an 86-year-old man who has been in the ICU for ten days due to severe pneumonia. He has required ventilatory support, inotropes, and filtration during his stay. His creatinine levels have rapidly risen since admission, with a current level of 350 umol/l. However, a sample taken six months ago by his GP showed a creatinine level of 95 umol/l. The patient's medical history includes hypertension and a malignant melanoma that was treated to remission three years ago with a hemicolectomy, but no adjuvant therapy was required. His screening colonoscopies have been normal in the years since.

      What factor would lead you to decide against this patient as a potential donor?

      Your Answer: History of malignancy

      Explanation:

      Donor Evaluation for Organ Transplantation

      This patient’s stay in the ICU has been complicated, but the only absolute contraindication to organ donation is malignancy. Although the patient had a limited malignancy without evidence of spread, the risk of cancer in the recipient is too high due to potential micrometastases and immunosuppression. The only other absolute contraindications are HIV or CJD associated illness.

      Despite being elderly, a kidney from a relatively healthy 85-year-old donor could be a good match for an elderly recipient in their mid-70s. The patient’s creatinine levels suggest acute tubular necrosis and delayed graft function, but this is likely due to severe sepsis and the patient’s previous normal creatinine levels indicate good baseline renal function. The need for inotropes also suggests acute tubular necrosis, but this is consistent with the patient’s septic shock and acute illness, which could potentially improve after transplantation.

      In summary, organ donation evaluation involves considering absolute contraindications such as malignancy, HIV, or CJD associated illness. Age and medical history of the donor and recipient are also important factors to consider. The patient’s current condition and potential for recovery after transplantation should also be taken into account.

    • This question is part of the following fields:

      • Nephrology
      51.8
      Seconds
  • Question 42 - A 20-year-old woman discovers she is pregnant and despite it being unplanned, she...

    Incorrect

    • A 20-year-old woman discovers she is pregnant and despite it being unplanned, she is excited to become a mother. During her initial check-up, her blood pressure is measured at 170/120 mmHg. She has a clean medical history, except for a childhood bout of Henoch-Schönlein purpura. Additionally, there is no relevant family history and she does not smoke. What could be the probable reason for her hypertension?

      Your Answer: Membranous glomerulonephritis

      Correct Answer: Chronic renal impairment

      Explanation:

      Possible Causes of Hypertension in Pregnancy

      This patient is experiencing hypertension during pregnancy, which is commonly associated with pre-eclampsia. However, pre-eclampsia usually occurs later in pregnancy and should not be present during the initial booking visit. The patient’s medical history of Henoch-Schölein purpura suggests the possibility of chronic kidney disease as a potential cause of her hypertension.

      Congenital adrenal hyperplasia is a group of related disorders that can cause abnormal development of sexual characteristics, adrenal crisis, and hypertension. This condition is often diagnosed during puberty when girls experience virilization due to the production of androgens while cortisol levels remain deficient. As a result, many patients with congenital adrenal hyperplasia may have reduced fertility compared to their peers.

      While stress can contribute to hypertension, it is less likely to explain consistently high blood pressure readings. Membranous glomerulonephritis is another potential cause of hypertension, but it is uncommon in a woman of this age. This condition can be caused by heavy metal toxicity, malignancy, or infection with hepatitis C virus.

      In summary, hypertension during pregnancy can have various underlying causes, including pre-eclampsia, chronic kidney disease, congenital adrenal hyperplasia, stress, and membranous glomerulonephritis. Further investigation and medical evaluation are necessary to determine the specific cause and appropriate treatment for this patient.

    • This question is part of the following fields:

      • Nephrology
      16.7
      Seconds
  • Question 43 - A 47-year-old patient arrives at the dialysis center for their thrice-weekly haemodialysis. They...

    Incorrect

    • A 47-year-old patient arrives at the dialysis center for their thrice-weekly haemodialysis. They have end stage renal failure caused by membranous glomerulonephritis and no other health issues. The patient reports feeling fatigued but is otherwise in good health. During routine blood work, their haemoglobin level is found to be 89 g/L (115-165). If the anaemia is a result of their renal disease, what is the appropriate treatment for this patient?

      Your Answer: Packed red cell transfusion within one week

      Correct Answer: Intravenous iron plus or minus parenteral erythropoietin

      Explanation:

      Patients with end stage kidney disease have poor iron absorption and lack endogenous erythropoietin, making parenteral iron replacement and erythropoietin the best management. Anaemia is common in these patients due to poor oral iron absorption and GI blood loss. Acute packed red cell transfusion is extreme and renal transplant may be an option, but the patient’s haemoglobin can be modified with increased IV iron and epo doses. Oral iron tablets are poorly absorbed and tolerated.

    • This question is part of the following fields:

      • Nephrology
      36.5
      Seconds
  • Question 44 - A 39-year-old man is discovered on the roadside after a single-vehicle car accident....

    Correct

    • A 39-year-old man is discovered on the roadside after a single-vehicle car accident. The duration of his lying there is uncertain. Upon the arrival of paramedics, his GCS is 10, and his blood pressure is 92/66 mmHg with a pulse of 96 bpm. Upon arrival at the Emergency department, his blood test results reveal a urea level of 44 mmol/l (normal range: 2.5 - 7.5) and a creatinine level of 620 µmol/l (normal range: 60 - 110). A catheterization procedure produces 50 mls of brown-colored urine. What additional blood test should be requested to determine the cause of his kidney dysfunction?

      Your Answer: Creatine kinase

      Explanation:

      Rhabdomyolysis and Compartment Syndrome

      Rhabdomyolysis is a condition that can occur as a result of various factors, including trauma, crush injury, compartment syndrome, ischaemia, severe electrolyte disturbances, bacterial and viral infections, inherited metabolic disorders, and certain drugs. In order to diagnose rhabdomyolysis, a CK test should be requested.

      One of the common causes of rhabdomyolysis is trauma, such as a road traffic accident. In such cases, it is important to rule out compartment syndrome, which can develop due to the effects of rhabdomyolysis on muscle fibres. Compartment syndrome is characterized by a disruption to the oxygen supply to the muscle, leading to ATP depletion and a build-up of intracellular calcium. This can cause myocyte swelling and impaired function, leading to hypovolaemia and excess fluid sequestration.

      Restoring the blood supply can cause reperfusion injury, which can further damage the myocytes and cause them to swell further, leading to the development of compartment syndrome. Therefore, it is crucial to address compartment syndrome in trauma patients in order to improve their clinical picture. By the causes and effects of rhabdomyolysis and compartment syndrome, healthcare professionals can provide appropriate treatment and management for their patients.

    • This question is part of the following fields:

      • Nephrology
      17.5
      Seconds
  • Question 45 - A 60-year-old man visits the clinic with his 35-year-old son, who has been...

    Incorrect

    • A 60-year-old man visits the clinic with his 35-year-old son, who has been diagnosed with IgA nephropathy and is in CKD stage 5. The man wishes to be evaluated as a potential live kidney donor for his son. He has a history of mild hypertension that is managed with 2.5 mg of ramipril daily. He has never had any surgeries, does not smoke, and only drinks alcohol in moderation.

      As part of the consent process for kidney donation, what advice should be provided to the patient?

      Your Answer: A 10% risk of major complications

      Correct Answer: There is no significant increase in hypertension in donors compared to the general population

      Explanation:

      The Health Benefits and Risks of Being a Kidney Donor

      Surprisingly, being a kidney donor can have health benefits. Studies have shown that live donors have lower long-term morbidity and mortality rates than the general population. This is likely due to the rigorous screening process that selects only those with excellent overall health.

      While reducing renal mass could potentially lead to a decrease in glomerular filtration rate and an increased risk of end-stage renal failure or hypertension, large-scale studies with up to 35 years of follow-up have shown no increased risk compared to the general population. However, potential donors should be warned about the possibility of end-stage renal failure, particularly those with borderline GFR for donation.

      As with any surgery, there are risks involved in kidney donation. The risk of death is quoted at 1 in 3000, and there is a 1-2% risk of major complications such as pneumothorax, injury to other organs, renovascular injury, DVT, or PE. There is also a 20% risk of minor complications such as post-operative atelectasis, pneumonia, wound infection, hematoma, incisional hernia, or urinary tract infection.

      To ensure the safety of potential donors, they undergo thorough screening, including a comprehensive medical history, family history, and physical examination. They also undergo extensive investigations of cardiovascular, respiratory, and psychological fitness, as well as multiple tests of renal function and anatomy to determine if it is safe to proceed and select the kidney to be removed.

      In conclusion, kidney donation can have health benefits for the donor, but it is not without risks. Only the healthiest individuals are selected as donors, and they undergo rigorous screening to ensure their safety.

    • This question is part of the following fields:

      • Nephrology
      37.2
      Seconds
  • Question 46 - As a locum GP, you have a pregnant patient who denies symptoms or...

    Correct

    • As a locum GP, you have a pregnant patient who denies symptoms or urinary tract infection. What urinalysis results might be expected for patients A, B, C, D, and E?

      Patient A:
      - Haemoglobin: Negative
      - Urobilinogen: Negative
      - Bilirubin: Negative
      - Protein: Negative
      - Glucose: +++
      - Nitrites: Negative
      - Leucocytes: +

      Patient B:
      - Haemoglobin: Negative
      - Urobilinogen: Negative
      - Bilirubin: Negative
      - Protein: Negative
      - Glucose: Negative
      - Nitrites: ++
      - Leucocytes: ++

      Patient C:
      - Haemoglobin: Negative
      - Urobilinogen: Negative
      - Bilirubin: Negative
      - Protein: Negative
      - Glucose: Negative
      - Nitrites: +++
      - Leucocytes: +++

      Patient D:
      - Haemoglobin: Negative
      - Urobilinogen: Negative
      - Bilirubin: Negative
      - Protein: Negative
      - Glucose: Negative
      - Nitrites: Negative
      - Leucocytes: Negative

      Patient E:
      - Haemoglobin: +++
      - Urobilinogen: +
      - Bilirubin: +
      - Protein: Negative
      - Glucose: Negative
      - Nitrites: Negative
      - Leucocytes: Negative

      Your Answer: A

      Explanation:

      Urinalysis in Pregnancy: Common Abnormalities and Importance of Monitoring

      Urinalysis is a crucial diagnostic tool for detecting renal diseases and other medical conditions. During pregnancy, even asymptomatic women may exhibit abnormalities on urinalysis. These abnormalities include small amounts of glucose, increased protein loss associated with pre-eclampsia, and the presence of ketones only during fasting. Pregnant women are also prone to sterile pyuria and non-specific changes in leukocytes.

      Monitoring for urinary infections is particularly important during pregnancy, as it has been linked to premature labor. However, minor and non-specific changes on urinalysis can sometimes falsely reassure clinicians. Pregnant women are at a higher risk of UTIs due to their immunosuppressed state, and may present with atypical symptoms or unusual urinalysis features. Therefore, urine should be sent for culture if there are any concerns.

      In summary, urinalysis is an essential tool for monitoring the health of pregnant women. the common abnormalities associated with pregnancy and the importance of monitoring for urinary infections can help clinicians provide the best care for their patients.

    • This question is part of the following fields:

      • Nephrology
      32
      Seconds
  • Question 47 - A 67-year-old woman presents to her GP with a four month history of...

    Incorrect

    • A 67-year-old woman presents to her GP with a four month history of general malaise, weight loss, night sweats and fevers.

      Examination shows a non-blanching rash across her lower legs, feet and hands. She has mild widespread wheeze and a systolic murmur consistent with her known COPD and aortic stenosis.

      Temperature is 38°C, BP 150/100 mmHg. Urine dipstick is positive for blood and protein. Bloods show a raised creatinine at 140 umol/l, CRP of 230 mg/l, ESR of 45 mm/hr, with mild anaemia and mild leucocytosis. Her autoimmune screen is pending.

      She is admitted for further investigation. What would be the next investigation of choice?

      Your Answer: Renal biopsy

      Correct Answer: Peripheral blood cultures

      Explanation:

      Diagnosis and Investigation of a Patient with Chronic Symptoms

      The most probable diagnosis for a patient presenting with constitutional symptoms, a known valve lesion, fever, vasculitic rash, and raised inflammatory markers is subacute bacterial endocarditis (SBE). Therefore, the most appropriate investigation would be blood cultures. Although her symptoms are consistent with a chronic infection, inflammatory process, or malignancy, the combination of her symptoms makes bacterial endocarditis the most likely diagnosis. A false positive ANCA test can be seen in chronic infections, and it is well described in SBE.

      A chest radiograph would be appropriate to look for malignancy or infection in a woman with a smoking history and known COPD. However, the examination findings are not consistent with a lung malignancy, and the history is too chronic for pneumonia. It is important to consider the patient’s symptoms and medical history when determining the appropriate investigation and diagnosis. Proper diagnosis and investigation can lead to effective treatment and management of the patient’s condition.

    • This question is part of the following fields:

      • Nephrology
      581.9
      Seconds
  • Question 48 - A 14-year-old girl presents with proteinuria at 1500 mg/24 hours. Upon examination, her...

    Incorrect

    • A 14-year-old girl presents with proteinuria at 1500 mg/24 hours. Upon examination, her urine reveals the presence of significant amounts of large proteins, including albumin and transferrin. What could be the possible reason for her proteinuria?

      Your Answer: Tubular proteinuria

      Correct Answer: Glomerular proteinuria

      Explanation:

      Glomerular Proteinuria

      Although a small amount of protein is typically found in urine, an elevated level of protein indicates a potential health issue. The diagram below illustrates the various sources of protein in urine, with glomerular proteinuria being the likely cause in this case due to the presence of larger proteins. This type of proteinuria can result in significant loss of protein through urine. It is important to identify the underlying cause of glomerular proteinuria and seek appropriate medical treatment to prevent further damage to the kidneys. Proper management can help reduce the risk of complications and improve overall health outcomes.

    • This question is part of the following fields:

      • Nephrology
      6.9
      Seconds
  • Question 49 - A 65-year-old man is presenting to the low clearance clinic with chronic kidney...

    Correct

    • A 65-year-old man is presenting to the low clearance clinic with chronic kidney disease of unknown origin. He is experiencing general malaise, fatigue, and shortness of breath. His GFR has remained stable at 15 with a baseline creatinine of 385 μmol/L (and urea of 21 mmol/L) for over a year. However, recent blood work shows abnormal levels of Na, K, urea, creatinine, bicarbonate, Ca, Phos, Hb, and MCV.

      Which medication would be the most beneficial to alleviate his symptoms?

      Your Answer: Erythropoietin

      Explanation:

      Recommended Treatment for a Patient with CKD Stage 5

      Of the drugs listed, erythropoietin is the most appropriate for a patient with chronic kidney disease (CKD) stage 5 who is experiencing fatigue and shortness of breath due to low hemoglobin levels. However, it is important to check the patient’s haematinics to ensure that iron, B12, or folate supplementation would not be more beneficial. Alfacalcidol is typically used to treat hyperparathyroidism, but it is not necessary for CKD stage 5 patients until their parathyroid hormone levels rise above 28 pmol/L, according to the Renal Association Guidelines. Since the patient’s bicarbonate levels are normal, oral supplementation is not required. Calcichew D3 and sevelamer are phosphate binders that prevent hyperphosphataemia, but they are not necessary for this patient. For further information, refer to the Renal Association Clinical Practice Guidelines.

    • This question is part of the following fields:

      • Nephrology
      46.6
      Seconds
  • Question 50 - A 28-year-old woman with type 1 diabetes comes in for her yearly check-up....

    Incorrect

    • A 28-year-old woman with type 1 diabetes comes in for her yearly check-up. During the examination, her urine test shows positive results for protein. Upon reviewing her medical records, it is discovered that this is the first time she has had proteinuria. What further tests should be conducted to investigate this finding?

      Your Answer: 24 hour urine protein collection and serum urea

      Correct Answer: ACR (albumin:creatinine ratio) and microbiology

      Explanation:

      Investigating Proteinuria in Diabetic Patients

      Proteinuria or microalbuminuria is a significant finding in diabetic patients. It indicates an increased risk of developing diabetic nephropathy in type 1 diabetes and an additional risk factor for cardiovascular disease in type 2 diabetes. When a diabetic patient presents with proteinuria, it is crucial to rule out infection, which is a common cause of increased urinary protein excretion. A urine microbiology test can identify the presence of infection, while an albumin-to-creatinine ratio (ACR) can quantify the degree of proteinuria and allow for future monitoring. Although HbA1c, serum urea/creatinine, and plasma glucose are standard tests for monitoring diabetic patients, they do not help quantify urinary protein loss or exclude infection. A high HbA1c in this situation could indicate longstanding poor glycemic control or poor glycemic control for several weeks due to infection. Therefore, ACR and urine microbiology are the most useful investigations to investigate proteinuria in diabetic patients.

    • This question is part of the following fields:

      • Nephrology
      15.4
      Seconds
  • Question 51 - A 50-year-old woman presents to the rheumatology clinic with joint pain, weight loss,...

    Incorrect

    • A 50-year-old woman presents to the rheumatology clinic with joint pain, weight loss, a vasculitic rash, and overall fatigue. Upon examination, she has elevated inflammatory markers, blood and protein in her urine, and positive MPO ANCA antibodies. She is urgently referred to renal physicians and undergoes a renal biopsy, which reveals crescentic glomerulonephritis. The diagnosis is microscopic polyangiitis. What is the most suitable initial treatment?

      Your Answer: Cyclophosphamide

      Correct Answer: IV methylprednisolone

      Explanation:

      Treatment Options for ANCA Vasculitis

      In patients with a new diagnosis of ANCA vasculitis and multi-organ involvement, it is crucial to start reducing inflammation as soon as possible. The most appropriate initial therapy is IV steroids due to their rapid onset of action. Azathioprine is used for maintenance therapy and preventing relapse, but it takes several weeks to have its full effect and is not suitable for organ-threatening disease. Cyclophosphamide is the next choice of treatment and is often used in combination with IV steroids. Plasma exchange is used in severe cases, but its benefit over other therapies is still unclear. Rituximab is becoming more popular as an alternative to cyclophosphamide and has been shown to be as effective at inducing remission. However, all patients will receive IV steroids before receiving a definitive agent such as cyclophosphamide or rituximab. In patients with pulmonary haemorrhage or rapid deterioration, plasma exchange should be considered as a means of reducing antibody titres. Proper treatment is essential for managing ANCA vasculitis and preventing further complications.

    • This question is part of the following fields:

      • Nephrology
      56.2
      Seconds
  • Question 52 - What is not a cause of haematuria in children? ...

    Incorrect

    • What is not a cause of haematuria in children?

      Your Answer: Schistosomiasis

      Correct Answer: Measles

      Explanation:

      Causes of Haematuria

      Haematuria, or blood in the urine, can be caused by various factors. Measles is not one of them. However, conditions such as meatal ulcer and urinary tract infection can lead to haematuria. Additionally, an advanced Wilms’ tumour can also cause this symptom. Another cause of haematuria is Schistosomiasis, which is a parasitic infection caused by Schistosoma haematobium. In this case, the blood in the urine is due to bladder involvement. It is important to identify the underlying cause of haematuria in order to provide appropriate treatment and prevent further complications.

    • This question is part of the following fields:

      • Nephrology
      6.4
      Seconds
  • Question 53 - A 40-year-old woman presents to the hypertension clinic with a blood pressure reading...

    Correct

    • A 40-year-old woman presents to the hypertension clinic with a blood pressure reading of 185/95 mmHg and grade 1 hypertensive retinopathy. She has no known medical history. What clinical or biochemical finding could indicate a potential diagnosis of primary hyperaldosteronism?

      Your Answer: Hypokalaemia

      Explanation:

      Primary Hyperaldosteronism: A Common Cause of Hypertension

      Primary hyperaldosteronism is a prevalent cause of hypertension that typically affects individuals between the ages of 20 and 40. However, it is often asymptomatic in its early stages and may not be diagnosed until several decades later. This condition may account for approximately 10% of hypertension cases and is characterized by hypokalemia, metabolic alkalosis, onset of hypertension at a young age, and hypertension that is difficult to control with more than three medications.

      The primary cause of primary hyperaldosteronism is either adrenal adenoma or adrenal hyperplasia, which preferentially affects the zona glomerulosa. Adrenal adenomas are usually unilateral, but bilateral adenomas can occur in a minority of cases. On the other hand, adrenal hyperplasia typically causes bilateral disease. Despite the decreased occurrence of hypokalemia and metabolic alkalosis in primary hyperaldosteronism, it remains a significant contributor to hypertension and should be considered in patients with uncontrolled hypertension.

    • This question is part of the following fields:

      • Nephrology
      19.3
      Seconds
  • Question 54 - A 35-year-old man visits the renal clinic eight weeks after a successful renal...

    Correct

    • A 35-year-old man visits the renal clinic eight weeks after a successful renal transplant. He has some inquiries about his immunosuppression. The consultant explains that the typical regimen for renal transplant patients involves the use of an induction agent initially, followed by a combination of a calcineurin inhibitor, antimetabolite, and steroids. This combination is intended to prevent rejection of the transplanted kidney. Can you identify the agent that acts as a purine analogue to disrupt DNA synthesis and induce apoptosis in rapidly dividing cells?

      Your Answer: Azathioprine

      Explanation:

      Mechanisms of Action of Immunosuppressive Drugs

      Azathioprine and mycophenolate mofetil are two immunosuppressive drugs that interrupt DNA synthesis and act as antimetabolites. However, they achieve this through different mechanisms. Mycophenolate indirectly inhibits purine synthesis by blocking inosine monophosphate dehydrogenase, while azathioprine is a pro-drug that is metabolized to 6-mercaptopurine, which is inserted into the DNA sequence instead of a purine. This triggers apoptosis by recognizing it as a mismatch.

      Basiliximab is an anti-CD25 monoclonal antibody that blocks T cell proliferation by inhibiting CD25, the alpha chain of the IL-2 receptor. On the other hand, sirolimus inhibits mTOR, the mammalian target of rapamycin, which is a protein kinase that promotes T cell proliferation and survival downstream of IL-2 signaling. Finally, tacrolimus is a calcineurin inhibitor that reduces the activation of NFAT, a transcription factor that promotes IL-2 production. Since IL-2 is the main cytokine that drives T cell proliferation, tacrolimus effectively suppresses the immune response.

    • This question is part of the following fields:

      • Nephrology
      35.1
      Seconds
  • Question 55 - An older woman is brought to the Emergency department with sudden chest pain...

    Incorrect

    • An older woman is brought to the Emergency department with sudden chest pain and coughing up blood. She has been experiencing fatigue, weakness, and weight loss for the past six weeks. Prior to this, she had occasional nosebleeds and hearing loss. Upon admission, she is confused and has a fever of 37.7°C, high blood pressure of 165/102 mmHg, and acute kidney injury with elevated potassium, urea, and creatinine levels. Her albumin is low, CRP is high, and she is anemic with an elevated ESR. A urine dipstick test shows blood and protein, and an ultrasound reveals normal-sized kidneys without obstruction or hydronephrosis. A chest X-ray shows widespread rounded opacities. What is the most likely diagnosis?

      Your Answer: Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

      Correct Answer: Granulomatosis with polyangiitis

      Explanation:

      Diagnosing Pulmonary Renal Syndrome: Considerations and Differential Diagnoses

      When a patient presents with a pulmonary renal syndrome, it is important to consider the possible diagnoses as the treatments differ. Granulomatosis with polyangiitis is a multisystem disorder that presents with a combination of pulmonary and renal symptoms, as well as nodular lesions on chest radiographs and ENT symptoms. Other immune-mediated causes of pulmonary renal syndrome include Anti-GBM disease, systemic lupus erythematosus, Henoch-Schönlein purpura, and cryoglobulinemia. Non-immune mediated causes include acute kidney injury with pulmonary edema, severe pneumonia leading to acute tubular necrosis, respiratory infections causing acute interstitial nephritis, and thrombotic events.

      eGPA or Churg-Strauss disease is more likely to present with an asthma-like background and less likely to cause acute kidney injury. Anti-GBM disease tends to present with acute pulmonary hemorrhage rather than nodular lesions and has no ENT associations. Disseminated malignancy may be suspected from nodular lesions on x-ray and a history of hemoptysis and weight loss, but this is less likely given the rapid onset of renal failure in this case. The presence of blood and protein on dipstick suggests an active glomerulonephritis, and hypertension fits with an acute glomerulonephritis rather than sepsis.

      In summary, when a patient presents with a pulmonary renal syndrome, the combination of symptoms and diagnostic tests can help narrow down the possible causes. It is important to consider both immune-mediated and non-immune mediated causes, as well as the patient’s medical history and presenting symptoms.

    • This question is part of the following fields:

      • Nephrology
      99.9
      Seconds
  • Question 56 - As a locum GP, you are tasked with reviewing blood results for five...

    Correct

    • As a locum GP, you are tasked with reviewing blood results for five patients you have never met before. The following results have been provided for each patient:

      Patient A: Adjusted calcium - 2.3 mmol/L, Phosphate - 0.9 mmol/L, PTH - 8.09 pmol/L, Urea - 7.8 mmol/L, Creatinine - 132 μmol/L, Albumin - 36 g/L

      Patient B: Adjusted calcium - 2.9 mmol/L, Phosphate - 0.5 mmol/L, PTH - 7.2 pmol/L, Urea - 5 mmol/L, Creatinine - 140 μmol/L, Albumin - 38 g/L

      Patient C: Adjusted calcium - 2.0 mmol/L, Phosphate - 2.8 mmol/L, PTH - 12.53 pmol/L, Urea - 32.8 mmol/L, Creatinine - 540 μmol/L, Albumin - 28 g/L

      Patient D: Adjusted calcium - 2.5 mmol/L, Phosphate - 1.6 mmol/L, PTH - 2.05 pmol/L, Urea - 32.8 mmol/L, Creatinine - 190 μmol/L, Albumin - 40 g/L

      Patient E: Adjusted calcium - 2.2 mmol/L, Phosphate - 0.7 mmol/L, PTH - 5.88 pmol/L, Urea - 4.6 mmol/L, Creatinine - 81 μmol/L, Albumin - 18 g/L

      Your task is to identify which patient is likely to have CKD 5.

      Your Answer: Patient C

      Explanation:

      Interpretation of Patient C’s Lab Results

      Patient C’s lab results indicate chronic kidney disease (CKD) rather than acute renal failure (ARF). The creatinine result corresponds to an eGFR of less than 15 ml/min/1.73m2, which is consistent with CKD 5 in a male or female aged 20-80-years-old. Additionally, the patient has hypocalcaemia, hyperphosphataemia, and an elevation of parathyroid hormone, which are metabolic changes commonly seen in CKD 4-5 but not in ARF of short duration. The relatively higher creatinine result compared to urea also suggests CKD rather than ARF, where dehydration can lead to even higher urea levels.

      It is likely that this patient is already dialysis-dependent or will require regular review by a nephrology team. The decision to start dialysis is based on various factors, including fluid overload, hyperkalaemia, uraemic symptoms, life expectancy, and patient/clinician preference. Most patients start dialysis with an eGFR of around 10 ml/min/1.73m2.

    • This question is part of the following fields:

      • Nephrology
      28.9
      Seconds
  • Question 57 - Which patient has abnormal blood results that suggest they may have myeloma?

    Patient...

    Incorrect

    • Which patient has abnormal blood results that suggest they may have myeloma?

      Patient A:
      Adjusted calcium - 2.3 mmol/L
      Phosphate - 0.9 mmol/L
      PTH - 8.09 pmol/L
      Urea - 7.8 mmol/L
      Creatinine - 132 μmol/L
      Albumin - 36 g/L
      Total protein - 77 g/L

      Patient B:
      Adjusted calcium - 2.9 mmol/L
      Phosphate - 0.5 mmol/L
      PTH - 7.2 pmol/L
      Urea - 5 mmol/L
      Creatinine - 140 μmol/L
      Albumin - 38 g/L
      Total protein - 68 g/L

      Patient C:
      Adjusted calcium - 2.8 mmol/L
      Phosphate - 1.2 mmol/L
      PTH - 0.45 pmol/L
      Urea - 7.2 mmol/L
      Creatinine - 150 μmol/L
      Albumin - 28 g/L
      Total protein - 88 g/L

      Patient D:
      Adjusted calcium - 2.5 mmol/L
      Phosphate - 1.6 mmol/L
      PTH - 2.05 pmol/L
      Urea - 32.8 mmol/L
      Creatinine - 190 μmol/L
      Albumin - 40 g/L
      Total protein - 82 g/L

      Patient E:
      Adjusted calcium - 2.2 mmol/L
      Phosphate - 0.7 mmol/L
      PTH - 5.88 pmol/L
      Urea - 4.6 mmol/L
      Creatinine - 81 μmol/L
      Albumin - 18 g/L
      Total protein - 55 g/L

      Your Answer: Patient D

      Correct Answer: Patient C

      Explanation:

      Myeloma Diagnosis in Patient C

      Patient C has been diagnosed with myeloma, a type of cancer that affects the plasma cells in the bone marrow. This diagnosis is supported by several indicators, including elevated total protein levels with low albumin and abnormally high globulins. Additionally, the patient has high serum calcium levels and suppressed parathyroid hormone, which are consistent with hypercalcaemia of malignancy. High phosphate levels are also present, which is a common occurrence in haematological malignancies where there is a large amount of cell turnover.

      Furthermore, the patient is experiencing renal impairment, which is typically caused by chronic kidney deterioration due to the deposition of myeloma casts in the nephrons. However, the hypercalcaemia can also cause dehydration, exacerbating the renal impairment. Overall, these indicators point towards a diagnosis of myeloma in Patient C.

    • This question is part of the following fields:

      • Nephrology
      13.6
      Seconds
  • Question 58 - As a GP, you come across a 42-year-old man who had an incidental...

    Correct

    • As a GP, you come across a 42-year-old man who had an incidental discovery of hyperlipidaemia during a recent insurance medical examination at work. His test results showed cholesterol levels of 22 mmol/L (ideal <5 mmol/L) with triglycerides of 18 mmol/L (<1.5 mmol/L). He is generally healthy but has low albumin and peripheral oedema. Upon conducting a urinalysis, the results are as follows:

      Haemoglobin: Negative
      Urobilinogen: Negative
      Bilirubin: Negative
      Protein: +++
      Glucose: Negative
      Nitrites: Negative
      Leucocytes: Negative
      Ketones: +

      What could be the possible explanation for these findings?

      Your Answer: Nephrotic syndrome

      Explanation:

      Nephrotic Syndrome

      Nephrotic syndrome is a condition characterized by excessive protein loss in the urine, low levels of serum albumin, and peripheral edema. Patients with this condition often have severe hyperlipidemia, with total cholesterol levels exceeding 10 mmol/L. Additionally, the loss of natural anticoagulants in the urine can lead to altered clotting, which requires treatment with antiplatelet agents and/or low molecular weight heparin.

      It is important to note that in the early stages of nephrotic syndrome, the levels of urea and creatinine may appear normal despite underlying renal pathology. Therefore, it is crucial to monitor patients with marked hyperlipidemia and proteinuria on urinalysis for signs of nephrotic syndrome. If diagnosed, patients should be referred to a local renal team for management.

    • This question is part of the following fields:

      • Nephrology
      23.1
      Seconds
  • Question 59 - A 63-year-old man presents to the Emergency department with severe abdominal pain and...

    Incorrect

    • A 63-year-old man presents to the Emergency department with severe abdominal pain and hypotension. A CT scan reveals a ruptured diverticular abscess, and he undergoes a Hartmann's procedure and faecal peritonitis washout. postoperatively, he is transferred to HDU and given broad spectrum IV antibiotics. During surgery, he had poor urine output and low blood pressure, prompting the anaesthetist to administer fluids. The next day, the F1 for surgery notes that the patient had a urine output of 5 mls per hour for three hours and then complete anuria overnight. His blood pressure is 110/65 mmHg, and his CVP is 10 cm. What is the probable cause of his anuria?

      Your Answer: Acute interstitial nephritis

      Correct Answer: Acute tubular necrosis

      Explanation:

      Acute Tubular Necrosis and Tubulo-Interstitial Nephritis

      Acute tubular necrosis (ATN) is a condition that occurs when the kidneys experience prolonged hypotension and poor perfusion, leading to the death of tubular epithelium. This can result in complete anuria, which is the absence of urine output. While a blocked catheter is unlikely, a bladder scan should be performed to rule it out. ATN can also be caused by nephrotoxins and sepsis. The condition usually recovers over a few days to weeks, but if the patient has underlying renal disease, the recovery may be partial, leading to long-term chronic kidney disease (CKD). Therefore, pre-renal failure should be corrected as quickly as possible to prevent irreversible damage.

      Tubulo-interstitial nephritis (TIN) is a histological diagnosis that occurs when the tubules and interstitium of the kidney become inflamed due to drugs or infections. This can lead to the release of cytokines and infiltration by acute inflammatory cells, particularly lymphocytes and eosinophils. If the causative agent is removed, TIN can resolve. However, if it persists, tubular atrophy and interstitial fibrosis may occur, leading to end-stage renal failure. Oral steroids can be used to dampen the inflammation and prevent fibrosis, but they need to be started early in the disease course.

      In summary, ATN and TIN are two conditions that can cause kidney damage and lead to CKD or end-stage renal failure. While ATN is caused by prolonged hypotension and poor perfusion, TIN is caused by drugs or infections. Early intervention is crucial to prevent irreversible damage and promote recovery.

    • This question is part of the following fields:

      • Nephrology
      33
      Seconds
  • Question 60 - A 45-year-old man underwent a renal transplant four weeks ago. The transplant was...

    Incorrect

    • A 45-year-old man underwent a renal transplant four weeks ago. The transplant was complicated by delayed graft function, which required haemodialysis on days one and three post-surgery due to hyperkalaemia. By day six, the transplant began to function, and he was discharged on day 10 with decreasing creatinine levels. He is currently taking immunosuppressants (tacrolimus, azathioprine, prednisolone), prophylaxis against opportunistic infections (co-trimoxazole, valganciclovir), aspirin, and amlodipine. Despite regular clinic visits, his potassium levels remain persistently high at 6.5 mmol/l. Which medication is likely causing this issue?

      Your Answer: Aspirin

      Correct Answer: Co-trimoxazole

      Explanation:

      Co-trimoxazole and its Side Effects

      Co-trimoxazole is a medication that is commonly used to treat and prevent Pneumocystis jiroveci pneumonia, which is more prevalent in immunocompromised individuals. It is a combination of two drugs, trimethoprim and sulfamethoxazole, and is known to cause side effects such as gastrointestinal discomfort, rashes, and hyperkalaemia. Hyperkalaemia is a condition where there is an excess of potassium in the blood, and it is a well-known side effect of co-trimoxazole. This is because the medication inhibits sodium channels in the distal nephron, similar to the potassium-sparing diuretic amiloride.

      Although co-trimoxazole is generally safe, it can cause rare but serious side effects such as Stevens-Johnson syndrome, bone marrow depression, and agranulocytosis. Patients who have documented allergies to either component of the medication should avoid it and use pentamidine nebulisers as an alternative. Additionally, co-trimoxazole may be teratogenic, meaning it can cause harm to a developing fetus, so female patients should be advised to use contraception and stop taking the medication if they plan to become pregnant. Overall, co-trimoxazole is an effective medication for treating and preventing Pneumocystis jiroveci pneumonia, but patients should be aware of its potential side effects.

    • This question is part of the following fields:

      • Nephrology
      40.9
      Seconds
  • Question 61 - A 65-year-old man undergoing haemodialysis experiences leg cramps towards the end of his...

    Incorrect

    • A 65-year-old man undergoing haemodialysis experiences leg cramps towards the end of his three-hour session. These cramps persist throughout the evening after dialysis and gradually subside. What substance are we removing excessively that could be causing these cramps?

      Your Answer: Urea

      Correct Answer: Fluid

      Explanation:

      The patient is likely experiencing cramps due to too much fluid being removed during dialysis, leading to hypoperfusion of muscles. Hypokalaemia, hyponatraemia, and hypocalcaemia can also cause cramps, but are less likely to be the cause in this case. Removal of urea is unlikely to cause any symptoms.

    • This question is part of the following fields:

      • Nephrology
      11.3
      Seconds
  • Question 62 - A 42-year-old previously healthy teacher visits her doctor complaining of headache and itching....

    Incorrect

    • A 42-year-old previously healthy teacher visits her doctor complaining of headache and itching. During her urine test, protein (3+) and blood (1+) are detected, but there are no splinter haemorrhages. What other bedside examination would be beneficial in evaluating her condition?

      Your Answer: Urinary ketones

      Correct Answer: Blood pressure

      Explanation:

      Assessment and Further Testing for Kidney Disease

      Assessing kidney disease at the bedside involves several steps, including urinalysis, blood pressure measurement, and assessment of volume status. However, further testing is necessary to confirm the diagnosis and determine the underlying cause of the disease. Blood testing for U&Es, autoantibodies, glucose, HbA1c, complement, and ANCA serology, as well as hepatitis and HIV viral screening, can provide valuable information.

      In this case, the patient presents with features consistent with kidney disease, including an abnormal urinalysis. While diabetes could be a possible cause, the patient’s age makes it less likely. Therefore, additional testing is necessary to determine the underlying cause of the disease. Checking the patient’s blood pressure is also important, as hypertension is often associated with renal diseases. Aggressive management of hypertension can help prevent the progression of chronic renal failure.

    • This question is part of the following fields:

      • Nephrology
      23.6
      Seconds
  • Question 63 - A 65-year-old patient presents to their GP with a general feeling of unwellness....

    Correct

    • A 65-year-old patient presents to their GP with a general feeling of unwellness. The following blood results are obtained:

      - Adjusted calcium 2.1 mmol/L (2.2-2.4)
      - Phosphate 0.7 mmol/L (0.7-1.0)
      - PTH 15.21 pmol/L (1.05-6.83)
      - Urea 4.6 mmol/L (2.5-7.8)
      - Creatinine 81 µmol/L (60-120)
      - 25 OH Vit D 12 nmol/L (optimal >75)

      What is the most likely diagnosis?

      Your Answer: Vitamin D deficiency

      Explanation:

      Vitamin D Deficiency and its Effects on the Body

      Vitamin D deficiency is a common condition that can be caused by a lack of dietary vitamin D or insufficient exposure to sunlight. This deficiency is more common in certain populations, such as the elderly, institutionalized patients, and ethnic groups with dark skin tones. Additionally, reduced sunlight exposure due to cultural dress codes, poor intake of dairy foods, and malabsorption states affecting fat-soluble vitamins can also contribute to vitamin D deficiency.

      When the kidneys are functioning normally, they activate vitamin D through the 1-alpha hydroxylase mechanism. The actions of 1,25(OH)2 Vitamin D have various effects on the body. It has a direct effect on the gut, increasing the absorption of calcium and phosphate. It also has a direct effect on the kidney, inhibiting its own synthesis by reducing 1-alpha hydroxylase activity. Furthermore, it has a direct effect on the parathyroids, inhibiting PTH synthesis. At high concentrations, activated vitamin D increases osteoclastic activity, promoting bone resorption.

      In conclusion, the risk factors and effects of vitamin D deficiency is crucial for maintaining overall health and preventing related conditions. Adequate exposure to sunlight and a balanced diet can help prevent vitamin D deficiency.

    • This question is part of the following fields:

      • Nephrology
      14.3
      Seconds
  • Question 64 - What is the name of the drug used to quickly achieve disease control...

    Incorrect

    • What is the name of the drug used to quickly achieve disease control in ANCA associated vasculitides by inducing DNA crosslinkage and apoptosis of rapidly dividing cells during induction therapy?

      Your Answer: Azathioprine

      Correct Answer: Cyclophosphamide

      Explanation:

      Treatment Options for ANCA Vasculitis

      ANCA vasculitis is a condition that causes inflammation of blood vessels, leading to organ damage. To treat this condition, induction agents such as cyclophosphamide and rituximab are used in severe or very active cases. Cyclophosphamide is a chemotherapy drug that causes DNA crosslinking, leading to apoptosis of rapidly dividing cells, including lymphocytes. On the other hand, rituximab is a monoclonal antibody that targets CD20, causing profound B cell depletion.

      For maintenance or steroid-sparing effects, azathioprine and mycophenolate mofetil are commonly used. However, they take three to four weeks to have their maximal effect, making them unsuitable for severe or very active cases. Ciclosporin, a calcineurin inhibitor, is not widely used in the treatment of ANCA vasculitis, despite its use in transplantation to block IL-2 production and proliferation signals to T cells.

      In summary, the treatment options for ANCA vasculitis depend on the severity of the disease. Induction agents such as cyclophosphamide and rituximab are used in severe or very active cases, while maintenance agents like azathioprine and mycophenolate mofetil are used for mild cases. Ciclosporin is not commonly used in the treatment of ANCA vasculitis.

    • This question is part of the following fields:

      • Nephrology
      8.5
      Seconds
  • Question 65 - A 44-year-old man presents with nephrotic syndrome and is undergoing further investigations to...

    Correct

    • A 44-year-old man presents with nephrotic syndrome and is undergoing further investigations to determine the underlying cause.

      Under what condition would corticosteroids be the most successful in reversing the nephrotic syndrome?

      Your Answer: Minimal change disease

      Explanation:

      Treatment Options for Different Types of Glomerulonephritis

      Glomerulonephritis (GN) is a group of kidney diseases that affect the glomeruli, the tiny blood vessels in the kidneys. While there is no known effective treatment for IgA nephropathy, long-term corticosteroid therapy has shown favourable response in some cases. On the other hand, 80% of adults with minimal change GN can respond to steroids, but it may take up to 16 weeks for remissions to occur. Unfortunately, membranous GN does not respond to steroid treatment. Lastly, there is no specific treatment available to cause regression of amyloid deposits. It is important to note that treatment options may vary depending on the type of GN and individual patient factors.

    • This question is part of the following fields:

      • Nephrology
      11.7
      Seconds
  • Question 66 - A 7-year-old girl presents with oedema and proteinuria of 4.2 g/24 hours. She...

    Correct

    • A 7-year-old girl presents with oedema and proteinuria of 4.2 g/24 hours. She is diagnosed with minimal change disease and started on steroid therapy. What could be the possible reason for her proteinuria?

      Your Answer: Glomerular proteinuria

      Explanation:

      Glomerular Proteinuria and Minimal Change Disease

      Glomerular proteinuria is a condition characterized by the presence of protein in the urine due to damage to the glomeruli, the tiny filters in the kidneys responsible for removing waste from the blood. This condition can be caused by primary glomerular disease, glomerulonephritis, anti-GBM disease, immune complex deposition, and inherited conditions such as Alport’s syndrome. Additionally, secondary glomerular disease can result from systemic diseases like diabetes.

      One type of glomerulonephritis that is particularly common in children is minimal change disease. This condition has a good prognosis and can often be treated effectively with steroids. It is important to promptly diagnose and treat glomerular proteinuria to prevent further damage to the kidneys and maintain overall kidney function.

    • This question is part of the following fields:

      • Nephrology
      26.6
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Nephrology (26/66) 39%
Passmed