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  • Question 1 - A 54-year-old woman with a long-standing history of poorly controlled type 2 diabetes...

    Correct

    • A 54-year-old woman with a long-standing history of poorly controlled type 2 diabetes mellitus presents to clinic complaining of swelling in her ankles, face and fingers. She states she can no longer wear her wedding ring because her fingers are too swollen. On examination, her blood pressure is 150/90 mmHg; she has pitting oedema in her ankles and notably swollen fingers and face. Her blood results show:
      Investigation Results Normal value
      Creatinine 353.6 μmol/l 50–120 μmol/l
      Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
      Phosphate 1.9 mmol/l 0.70–1.40 mmol/l
      Parathyroid hormone (PTH) Elevated
      Urinalysis 3+ glucose, 3+ protein
      Which of the following is the most likely mechanism of this woman's increased PTH?

      Your Answer: Decreased glomerular filtration rate (GFR)

      Explanation:

      Understanding the Causes of Secondary Hyperparathyroidism

      Secondary hyperparathyroidism is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH) in response to low calcium levels in the blood. This can be caused by a variety of factors, including chronic renal failure, vitamin D excess, and the use of certain medications like diuretics.

      In cases of chronic renal failure, decreased glomerular filtration rate (GFR) can lead to raised creatinine levels and proteinuria. This can cause diabetic nephropathy, which can result in hyperphosphataemia and secondary hyperparathyroidism. Over time, this can also lead to osteoporosis as a long-term complication of hyperparathyroidism.

      Vitamin D excess is another cause of secondary hyperparathyroidism, but it is associated with low phosphate levels rather than hyperphosphataemia. In cases of parathyroid adenoma, a less likely cause in this patient, there is an overproduction of PTH by a benign tumor in the parathyroid gland.

      Finally, the use of diuretics can increase phosphate excretion, leading to hypophosphataemia. This can also contribute to the development of secondary hyperparathyroidism.

      Understanding the various causes of secondary hyperparathyroidism is important for proper diagnosis and treatment. By addressing the underlying condition, it may be possible to reduce the production of PTH and prevent further complications.

    • This question is part of the following fields:

      • Renal
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  • Question 2 - A 35-year-old teacher is tested for compatibility to donate a kidney to his...

    Correct

    • A 35-year-old teacher is tested for compatibility to donate a kidney to his older brother, who has end-stage renal failure. To his joy, he is found to be a suitable match. The patient is then thoroughly counselled regarding the operative procedure, short- and long-term risks, and the implications of living with one healthy kidney. He is particularly interested to learn how his body will adapt to having only one kidney.
      What will be decreased in the donor after the kidney transplant?

      Your Answer: Creatinine clearance

      Explanation:

      Effects of Kidney Donation on Renal Function and Electrolytes

      Kidney donation involves the removal of one healthy kidney, which can have various effects on the donor’s renal function and electrolyte levels. One notable change is a decrease in creatinine clearance due to the reduced number of glomeruli. However, creatinine production remains unaffected by the surgery and depends on factors such as muscle mass, diet, and activity.

      Serum sodium levels should remain stable as long as the remaining kidney functions properly. Similarly, serum potassium levels should not change if the remaining kidney is healthy. However, plasma creatinine concentration may initially increase after kidney donation due to hyperfiltration, but it will eventually plateau and decrease over time.

      Overall, kidney donation can have significant effects on the donor’s renal function and electrolyte levels, but with proper monitoring and care, most donors can lead healthy and normal lives with one kidney.

    • This question is part of the following fields:

      • Renal
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  • Question 3 - A 56-year-old teacher presents to the Emergency Department with nausea and vomiting, with...

    Incorrect

    • A 56-year-old teacher presents to the Emergency Department with nausea and vomiting, with associated lethargy. She has mild asthma which is well controlled with a steroid inhaler but has no other medical history of note. She does not smoke but drinks up to 20 units of alcohol a week, mostly on the weekends. Observations are as follows:
      Temperature is 37.2 oC, blood pressure is 110/70 mmHg, heart rate is 90 bpm and regular.
      On examination, the patient appears to be clinically dehydrated, but there are no other abnormalities noted.
      Blood tests reveal:
      Investigation Result Normal Values
      Haemoglobin (Hb) 140 g/l 135–175 g/l
      White cell count (WCC) 7.8 × 109/l 4–11 × 109/l
      Urea 8.5 mmol/l 2.5–6.5 mmol/l
      Creatinine 190 µmol/l
      (bloods carried out one year
      previously showed a creatinine
      of 80) 50–120 µmol/l
      Potassium (K+) 4.7 mmol/l 3.5–5.0 mmol/l
      Sodium (Na+) 133 mmol/l 135–145 mmol/l
      Which of the following is most suggestive of acute kidney injury rather than chronic renal failure?

      Your Answer: Raised parathyroid hormone levels

      Correct Answer: Oliguria

      Explanation:

      Signs and Symptoms of Acute and Chronic Renal Failure

      Renal failure can be acute or chronic, and it is important to differentiate between the two. Acute renal failure may present with symptoms such as acute lethargy, dehydration, shortness of breath, nausea and vomiting, oliguria, acute onset peripheral edema, confusion, seizures, and coma. On the other hand, chronic renal failure may present with symptoms such as anemia, pruritus, long-standing fatigue, weight loss, and reduced appetite. A history of underlying medical conditions such as diabetes or hypertension is also a risk factor for chronic kidney disease.

      Oliguria is a clinical hallmark of renal failure and can be one of the early signs of acute renal injury. Raised parathyroid hormone levels are more commonly found in chronic renal failure, while peripheral neuropathy is likely to be present in patients with chronic renal failure due to an underlying history of diabetes. Nocturia or nocturnal polyuria is often found in patients with chronic kidney disease, while in acute injury, urine output tends to be reduced rather than increased. Small kidneys are seen in chronic renal failure, while the kidneys are more likely to be of normal size in acute injury.

      Understanding the Signs and Symptoms of Acute and Chronic Renal Failure

    • This question is part of the following fields:

      • Renal
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  • Question 4 - A 68-year-old woman was admitted to hospital seven days ago with moderate symptoms...

    Correct

    • A 68-year-old woman was admitted to hospital seven days ago with moderate symptoms of community-acquired pneumonia and was treated with amoxicillin. She has developed a fever, maculopapular skin rash and haematuria over the last two days. You suspect that her new symptoms may be due to acute tubulointerstitial nephritis caused by a reaction to the amoxicillin she was given.
      Which of the following investigations would provide a definitive diagnosis?

      Your Answer: Kidney biopsy

      Explanation:

      Investigations for Tubulointerstitial Nephritis

      Tubulointerstitial nephritis is a condition that affects the kidneys and can lead to renal failure if left untreated. There are several investigations that can be done to help diagnose this condition.

      Kidney Biopsy: This is the most definitive investigation for tubulointerstitial nephritis. It involves taking a small sample of kidney tissue for examination under a microscope. This is usually only done if other tests have been inconclusive or if the diagnosis is unclear.

      Full Blood Count: This test can help identify the presence of eosinophilia, which is often seen in cases of tubulointerstitial nephritis. However, the absence of eosinophilia does not rule out the condition.

      Kidney Ultrasound: This test can help rule out other conditions such as chronic renal failure, hydronephrosis, or renal calculi. In cases of tubulointerstitial nephritis, the kidneys may appear enlarged and echogenic due to inflammation.

      Serum Urea and Electrolytes: This test measures the levels of urea and creatinine in the blood, which can be elevated in cases of tubulointerstitial nephritis.

      Urinalysis: This test can detect the presence of low-grade proteinuria, white blood cell casts, and sterile pyuria, which are all indicative of tubulointerstitial nephritis. However, it is not a definitive diagnostic tool.

      In conclusion, a combination of these investigations can help diagnose tubulointerstitial nephritis and guide appropriate treatment.

    • This question is part of the following fields:

      • Renal
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  • Question 5 - A 45-year-old writer presents to his routine follow up at the Nephrology Clinic...

    Correct

    • A 45-year-old writer presents to his routine follow up at the Nephrology Clinic complaining of numbness and tingling sensation of his right fingers. This worsens when he types for more than an hour and slightly improves when he stops typing. He suffers from diabetes mellitus and end-stage kidney disease and has been on regular haemodialysis via brachiocephalic fistula on his right antecubital fossa. On examination, his right radial artery is palpable and he has reduced sensation in all his right fingers, predominantly affecting the fingertips. The numbness does not worsen with tapping over the wrist nor with forced flexion of his wrists. His capillary refill time over his right fingers is prolonged to three seconds.
      Which of the following is the most likely diagnosis?

      Your Answer: Fistula steal syndrome

      Explanation:

      Differential Diagnosis for Numbness in a Patient with Arteriovenous Fistula

      Fistula Steal Syndrome, Carpal Tunnel Syndrome, and Diabetic Neuropathy are Possible Causes of Numbness in a Patient with Arteriovenous Fistula

      Arteriovenous fistula is a common procedure for patients undergoing hemodialysis. However, up to 20% of patients may develop complications such as fistula steal syndrome, which occurs when the segment of artery distal to the fistula is narrowed, leading to reduced arterial blood flow to the limb extremities. This can cause numbness and worsening of symptoms on usage of the hands.

      Other possible causes of numbness in this patient include carpal tunnel syndrome, which is a common complication among patients on long-term renal replacement therapy due to protein deposition in the carpal tunnel, and diabetic neuropathy, which is a common complication of chronic diabetes mellitus. However, the loss of sensation in peripheral neuropathy in diabetic patients is symmetrical in nature, commonly following a glove and stocking pattern.

      Radial nerve palsy and ulnar styloid fracture are less likely causes of numbness in this patient, as they typically present with muscle weakness and a history of trauma, respectively. A thorough differential diagnosis is necessary to determine the underlying cause of numbness in patients with arteriovenous fistula.

    • This question is part of the following fields:

      • Renal
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  • Question 6 - A 55-year-old man with chronic kidney disease has recently received a renal transplant....

    Incorrect

    • A 55-year-old man with chronic kidney disease has recently received a renal transplant. After three months he starts to feel unwell with flu-like symptoms, fever, and pain over the transplant area.
      What is the most likely type of reaction that has occurred in the patient?

      Your Answer: Chronic graft failure

      Correct Answer: Acute graft failure

      Explanation:

      Understanding Different Types of Graft Failure After Transplantation

      Acute graft failure is a type of graft failure that occurs within six months after transplantation. If a patient presents with symptoms such as fever, flu-like symptoms, and pain over the transplant after three months, it may indicate acute graft failure. This type of failure is usually caused by mismatched human leukocyte antigen and may be reversible with steroids and immunosuppressants.

      Wound infection is not a likely cause of symptoms after three months since any wounds from the transplant would have healed by then. Chronic graft failure, on the other hand, occurs after six months to a year following the transplant and is caused by a combination of B- and T-cell-mediated immunity, infection, and previous occurrences of acute graft rejections.

      Hyperacute rejection is a rare type of graft failure that occurs within minutes to hours after transplantation. It happens because of pre-existing antibodies towards the donor before transplantation. In cases of hyperacute rejection, removal of the organ and re-transplantation is necessary.

      It is important to understand the different types of graft failure after transplantation to properly diagnose and treat patients who may be experiencing symptoms.

    • This question is part of the following fields:

      • Renal
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  • Question 7 - A 35-year-old woman presents with an incidental finding of a blood pressure of...

    Correct

    • A 35-year-old woman presents with an incidental finding of a blood pressure of 180/130 mmHg on three separate occasions. Her cardiovascular examination is unremarkable, but further investigation reveals a significantly smaller left kidney with a 'string of beads' appearance in the left renal artery. What is the most appropriate management option for this patient?

      Your Answer: Balloon angioplasty

      Explanation:

      Management of Renal Artery Stenosis: Fibromuscular Dysplasia

      Fibromuscular dysplasia is a rare cause of renal artery stenosis, typically affecting young women and presenting with hypertension. The characteristic ‘string of beads’ appearance on CT imaging helps in diagnosis. While atherosclerotic disease is the most common cause of renal artery stenosis, a combination of antihypertensive therapy and renal artery balloon angioplasty is curative for fibromuscular dysplasia. Kidney transplantation is not usually required, but it is important to recognize the condition in donors to prevent complications in recipients. Nephrectomy is not typically necessary, and surgical reconstruction is rarely recommended. Statins are not used in the management of fibromuscular dysplasia, but may be used in atherosclerotic renal artery stenosis.

    • This question is part of the following fields:

      • Renal
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  • Question 8 - A 58-year-old man is admitted with severe shortness of breath during the early...

    Correct

    • A 58-year-old man is admitted with severe shortness of breath during the early hours of the morning. Past history of note includes difficult-to-manage hypertension, for which he now takes amlodipine 10 mg, indapamide 1.5 mg and doxazosin 8 mg. He failed a trial of ramipril 1 year earlier due to a rise in his creatinine of 40% at the 1-week post-initiation stage. On examination, he has a blood pressure of 185/100 mmHg and a pulse of 100 bpm regular and is in frank pulmonary oedema. When you review his old notes, you find this is the second episode during the past 6 months. Echocardiography has shown a preserved ejection fraction. An electrocardiogram (ECG) reveals no abnormalities.
      Which of the following is the most likely diagnosis in this case?

      Your Answer: Renal artery stenosis

      Explanation:

      Differential diagnosis of hypertension with rising creatinine and pulmonary oedema

      When a patient presents with difficult-to-control hypertension and rising creatinine, accompanied by episodes of pulmonary oedema without signs of myocardial infarction, the differential diagnosis should include renovascular disease. Abdominal ultrasound may reveal kidneys of different sizes due to poor arterial supply to one side, but angiography or magnetic resonance angiograms are needed for confirmation. Vascular intervention, mainly via angioplasty, may improve the condition, but patients may have other arterial stenoses and be at risk of other vascular events.

      Renal vein thrombosis is another possible cause of rising creatinine, especially in nephrotic syndrome, but it tends to have an insidious onset. Phaeochromocytoma, a rare tumor that secretes catecholamines, can present with hypertension, palpitations, and flushing, but it is unlikely to cause a rise in creatinine after starting an ACE inhibitor. Myocardial infarction is ruled out by a normal ECG and preserved left ventricular ejection fraction. Nephritic syndrome, which is associated with hypertension and oedema, is also unlikely to cause a rise in creatinine after an ACE inhibitor trial.

    • This question is part of the following fields:

      • Renal
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  • Question 9 - An 80-year-old woman with a history of cervical carcinoma has been brought to...

    Incorrect

    • An 80-year-old woman with a history of cervical carcinoma has been brought to the Emergency Department in a confused and dehydrated state. Her blood tests reveal significant abnormalities, including a potassium level of 7.2 mmol/l (NR 3.5–4.9), creatinine level of 450 μmol/l (NR 60–110), and urea level of 31.2 mmol/l (NR 2.5–7.5). Upon retesting, her serum potassium remains elevated. What is the most appropriate initial management for this patient?

      Your Answer: Give 250 mg furosemide IV to reduce the potassium concentration

      Correct Answer: Arrange continuous ECG monitoring and consider giving 10 ml of 10% calcium gluconate intravenous (IV)

      Explanation:

      Managing Hyperkalaemia in a Patient with Renal Dysfunction

      Hyperkalaemia is a medical emergency that requires prompt management. Once confirmed via a repeat blood sample, continuous ECG monitoring is necessary. For cardioprotection, 10 ml of 10% calcium gluconate IV should be considered. Insulin can also be administered to drive potassium ions from the extracellular to the intracellular compartment. A third blood sample is not necessary and may delay treatment. An urgent ultrasound scan should be arranged to determine the underlying cause of renal dysfunction. Furosemide should be reserved until fluid balance assessment results are known. Renal replacement therapy may be considered as a final option, but prognosis should be assessed first. Nebulised salbutamol may also have positive effects in reducing serum potassium, but IV administration carries a significant risk of arrhythmia. Correction of severe acidosis may exacerbate fluid retention in patients with kidney disease.

    • This question is part of the following fields:

      • Renal
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  • Question 10 - A 6-year-old boy presents to the Emergency Department with periorbital pain, ascites, and...

    Correct

    • A 6-year-old boy presents to the Emergency Department with periorbital pain, ascites, and oedema. He has no past medical history and is typically healthy, without recent illnesses. Upon examination, his serum urea is elevated and protein in his urine is ++++. What is the probable cause of his symptoms?

      Your Answer: Minimal change glomerulonephritis

      Explanation:

      Overview of Different Types of Glomerulonephritis

      Glomerulonephritis is a group of kidney diseases that affect the glomeruli, the tiny blood vessels in the kidneys that filter waste and excess fluids from the blood. Here are some of the different types of glomerulonephritis:

      1. Minimal Change Glomerulonephritis: This is the most common cause of nephrotic syndrome in children. It is caused by T-cell-mediated injury to the podocytes of the epithelial cells. The diagnosis is made by electron microscopy, and treatment is with steroids.

      2. Membranous Glomerulonephritis: This is the second most common cause of nephrotic syndrome in adults. It can be primary or secondary, and some causes of secondary membranous glomerulonephritis include autoimmune conditions, malignancy, viral infections, and drugs. On light microscopy, the basement membrane has characteristic spikes.

      3. Mesangiocapillary Glomerulonephritis: This is associated with immune deposition in the glomerulus, thickening of the basement membrane, and activation of complement pathways leading to glomerular damage. It presents with nephrotic syndrome and is seen in both the pediatric and adult population. It is the most common glomerulonephritis associated with hepatitis C.

      4. Post-Streptococcal Glomerulonephritis: This presents with haematuria, oedema, hypertension, fever, or acute kidney failure following an upper respiratory tract infection or pharyngitis from Streptococcus spp.

      5. IgA Nephropathy Glomerulonephritis: This is a condition associated with IgA deposition within the glomerulus, presenting with haematuria following an upper respiratory tract infection. It is the most common cause of glomerulonephritis in adults.

      Understanding the Different Types of Glomerulonephritis

    • This question is part of the following fields:

      • Renal
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  • Question 11 - An 80-year-old man comes to his General Practitioner complaining of loin pain, haematuria...

    Incorrect

    • An 80-year-old man comes to his General Practitioner complaining of loin pain, haematuria and a palpable abdominal mass. He is diagnosed with renal clear cell carcinoma. Upon staging, it is discovered that the tumour has spread to the adrenal gland. What would be the primary management option for this patient?

      Your Answer: Radical nephrectomy

      Correct Answer: Immunomodulatory drugs

      Explanation:

      Treatment Options for Stage 4 Renal Cancer with Metastases

      Loin pain, haematuria, and a palpable abdominal mass are the classic symptoms of renal cancer, which is not very common. When the cancer has metastasized to the adrenal gland, it becomes a stage 4 tumor. Targeted molecular therapy is the first-line treatment for stage 4 renal cancer with metastases. Immunomodulatory drugs such as sunitinib, temsirolimus, and nivolumab are commonly used for this purpose.

      Other treatment options for renal cancer include cryotherapy, partial nephrectomy, radiofrequency ablation, and radical nephrectomy. Cryotherapy uses liquid nitrogen to freeze cancerous cells, but it is usually only used for early-stage disease and is not first-line here. Partial nephrectomy is reserved for patients with small renal masses, usually stage 1. Radiofrequency ablation can be used for non-surgical candidates with small renal masses without metastasis, usually stage 1 or 2. Radical nephrectomy involves removal of the entire kidney, which is primarily done for stage 2 and 3 renal cell cancers.

    • This question is part of the following fields:

      • Renal
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  • Question 12 - A 69-year-old man, with CCF is admitted with SOB and a productive cough....

    Correct

    • A 69-year-old man, with CCF is admitted with SOB and a productive cough. Clinical findings, and a chest X-ray suggest a diagnosis of both pulmonary oedema and pneumonia. He is put on high flow oxygen and treated with furosemide, GTN spray and morphine, and started on antibiotics.
      His breathlessness improves, and a repeat chest X-ray shows decreased pulmonary oedema. An ABG shows the following:
      pH: 7.01 (normal 7.35–7.45)
      p(CO2): 8 kPa (normal 4.5–6.0 kPa)
      p(O2): 11 kPa (normal 10–14 kPa)
      HCO3–: 18 mmol (normal 24–30 mmol/l)
      base excess: 1.2 mmol/l (normal −2 to +2.0 mmol/l)
      sodium: 142 mmol/l (normal 135–145 mmol/l)
      potassium: 5.9 mmol/l (normal 3.5–5.0 mmol/l)
      glucose: 7.5 mmol/l (normal 5–5.5 mmol/l)
      lactate: 3.1 mmol/l (normal 2.2–5 mmol/l).
      Based on the patient, which of the following does he have that is an indication for acute dialysis?

      Your Answer: Metabolic acidosis

      Explanation:

      Indications for Acute Dialysis: Assessing the Patient’s Condition

      When considering whether a patient requires acute dialysis, several factors must be taken into account. Severe metabolic acidosis with a pH below 7.2 is a clear indication for dialysis. Similarly, severe refractory hyperkalaemia with levels above 7 mmol/l may require dialysis, although standard measures to correct potassium levels should be attempted first. However, if the patient’s potassium levels are only mildly elevated, dialysis may not be necessary.

      A raised lactate level is not an indication for acute dialysis. Refractory pulmonary oedema, which has not responded to initial treatment with diuretics, may require dialysis. However, if the patient’s pulmonary oedema has responded to treatment, dialysis may not be necessary.

      In summary, the decision to initiate acute dialysis depends on a careful assessment of the patient’s condition, taking into account factors such as metabolic acidosis, hyperkalaemia, lactate levels, and pulmonary oedema.

    • This question is part of the following fields:

      • Renal
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  • Question 13 - A 35-year-old woman with haematuria underwent a kidney biopsy, but light microscopy results...

    Correct

    • A 35-year-old woman with haematuria underwent a kidney biopsy, but light microscopy results were inconclusive. As a result, the specimen was sent for electron microscopy. Which renal disease requires electron microscopy for diagnosis?

      Your Answer: Thin membrane disease

      Explanation:

      Renal Diseases and their Diagnostic Methods

      Renal diseases can be diagnosed through various methods, including electron microscopy, blood tests, and renal biopsy. Here are some examples:

      Thin Membrane Disease: Electron microscopy is crucial in diagnosing thin membrane disease, as well as Alport syndrome and fibrillary glomerulopathy.

      Anti-GBM Disease: Blood tests for anti-GBM can confirm Goodpasture’s syndrome, but a renal biopsy can also be taken to show IgG deposits along the basement membrane.

      Lupus Nephritis: While electron microscopy can show dense immune deposits in lupus nephritis, diagnosis can also be made through immunofluorescence without the need for electron microscopy.

      IgA Nephropathy: A renal biopsy can confirm IgA nephropathy, showing mesangium proliferation and IgA deposits on immunofluorescence.

      Churg-Strauss Syndrome: Also known as eosinophilic granulomatosis with polyangiitis (EGPA), Churg-Strauss syndrome can be diagnosed through blood tests showing high eosinophils and ANCA, as well as renal biopsy showing eosinophil granulomas.

      Diagnostic Methods for Renal Diseases

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      • Renal
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  • Question 14 - A 30-year-old man presents to the general practitioner (GP) with hypertension which fails...

    Incorrect

    • A 30-year-old man presents to the general practitioner (GP) with hypertension which fails to fall into the normal range after three successive measurements at the practice nurse. These were 155/92 mmHg, 158/96 mmHg and 154/94 mmHg. He has a past history of some urinary tract infections as a child. The GP arranges some routine blood tests.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 139 g/l 135–175 g/l
      White cell count (WCC) 5.4 × 109/l 4–11 × 109/l
      Platelets 201 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine 187 μmol/l 50–120 μmol/l
      USS Left kidney 8.4 cm and appears scarred.
      Right kidney 10.3 cm
      Which of the following is the most likely diagnosis?

      Your Answer: Renal artery stenosis

      Correct Answer: Chronic reflux nephropathy

      Explanation:

      Differential Diagnosis for a 25-Year-Old Man with Renal Issues

      Upon reviewing the history and test results of a 25-year-old man with renal issues, several potential diagnoses can be considered. Chronic reflux nephropathy appears to be the most likely diagnosis, given the patient’s history of urinary tract infections as a child, ultrasound scan results, and elevated creatinine levels. Further testing, such as renal tract computed tomography and a voiding cystourethrogram, can confirm this diagnosis.

      Essential hypertension, while a risk factor for reno-vascular disease, would not explain the patient’s creatinine rise or asymmetrical kidneys. Renal artery stenosis, while potentially causing a unilaterally reduced kidney size, is rare in young patients and does not fit with the patient’s history of urinary tract infections. White coat hypertension, which is a transient rise in blood pressure in a medical setting, would not explain the patient’s creatinine rise or reduced kidney size and scarring.

      IgA nephropathy, which typically presents with haematuria following an upper respiratory or other infection, does not fit with the patient’s history of urinary tract infections or lack of haematuria. Therefore, chronic reflux nephropathy remains the most likely diagnosis for this patient.

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      • Renal
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  • Question 15 - A 72-year-old man comes to the Emergency Department with haematuria and haemoptysis. His...

    Incorrect

    • A 72-year-old man comes to the Emergency Department with haematuria and haemoptysis. His vital signs are heart rate 88 bpm, blood pressure 170/110 mmHg, respiratory rate 22 breaths per minute, and temperature 37.8 °C. Urinalysis shows protein and red cell casts. Serum testing reveals antibodies to the glomerular basement membrane. A renal biopsy is conducted.
      What is the probable finding in the renal biopsy?

      Your Answer: Immune complex deposition in the basement membrane

      Correct Answer: Linear immunofluorescence

      Explanation:

      Different Renal Pathologies and their Histological Features

      Nephritic syndrome is a condition characterized by proteinuria, haematuria, and hypertension. Anti-glomerular basement membrane antibodies suggest hypersensitivity angiitis (Goodpasture’s syndrome) as the underlying cause. In hypersensitivity angiitis, crescents are seen on light microscopy of a renal biopsy specimen. Immunofluorescence shows linear IgG deposits along the basement membrane.

      Diffuse membranous glomerulonephritis is characterized by ‘wire looping’ of capillaries. Hereditary nephritis (Alport syndrome) shows splitting of the basement membrane and is associated with deafness. Acute post-streptococcal glomerulonephritis, typically seen in children, shows a ‘lumpy bumpy’ appearance of the glomeruli. Immunoglobulin A (IgA) nephropathy is characterized by immune complex deposition in the basement membrane.

    • This question is part of the following fields:

      • Renal
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  • Question 16 - A 50-year-old man with long-standing insulin-dependent diabetes mellitus was on dialysis, secondary to...

    Correct

    • A 50-year-old man with long-standing insulin-dependent diabetes mellitus was on dialysis, secondary to end-stage renal disease (ESRD). Three months ago, he received a kidney transplant, with his old kidney left in place. The transplanted kidney is attached to the central circulation, mimicking natural circulation. There are absolutely no signs of rejection, and the kidney is working perfectly. The patient is surprised to find out that he no longer has ‘thin blood’ because it has been years since he has not required medical management for his anaemia.
      What is the main factor responsible for the normalization of his blood parameters and his recovery, following the kidney transplant?

      Your Answer: Erythropoietin (EPO)

      Explanation:

      The Role of Kidney Function in Anaemia of ESRD Patients

      Erythropoietin (EPO) is synthesized and secreted by the kidney, making it a crucial factor in maintaining haematopoiesis. Patients with end-stage renal disease (ESRD) often suffer from severe anaemia and require exogenous EPO to address this issue. A hypoproliferative disorder, ESRD may or may not be accompanied by anaemia of chronic disease or iron deficiency, leading to decreased reticulocytes. Iron supplementation is often necessary in conjunction with EPO to maintain haematopoiesis in dialysis patients.

      Renin, on the other hand, is not implicated in anaemia. Aldosterone, which is part of the renin-angiotensin pathway that originates in the kidney, is not directly involved in anaemia either. Any derangement in aldosterone levels secondary to ESRD would have been normalized by now in the kidney.

      Normalizing kidney function may improve the iron levels of the patient, but the primary effect of renal disease is insufficient EPO secretion, leading to anaemia. Patients with ESRD are typically phosphate-overloaded and calcium-deficient. While a transplant may lead to decreased phosphate levels due to increased clearance, this is not directly implicated in haematopoiesis.

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      • Renal
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  • Question 17 - A 67-year-old retired bus driver presents to the Emergency Department with end-stage renal...

    Incorrect

    • A 67-year-old retired bus driver presents to the Emergency Department with end-stage renal disease due to diabetic nephropathy. What is the most probable histological finding on kidney biopsy for this patient?

      Your Answer: Mesangial amyloid deposits

      Correct Answer: Kimmelstiel–Wilson nodules

      Explanation:

      Renal Biopsy Findings in Diabetic Nephropathy and Other Renal Diseases

      Diabetic nephropathy is a progressive kidney disease that damages the glomerular filtration barrier, leading to proteinuria. Renal biopsy is a diagnostic test that can reveal various findings associated with different renal diseases.

      Kimmelstiel–Wilson nodules are a hallmark of diabetic nephropathy, which are nodules of hyaline material that accumulate in the glomerulus. In contrast, immune complex deposition is commonly found in crescentic glomerulonephritis, anti-GBM disease, lupus, and IgA/post-infectious GN.

      Rouleaux formation, the abnormal stacking of red blood cells, is not associated with diabetic nephropathy but can cause diabetic retinopathy. Clear cells, a classification of renal cell carcinoma, are not a finding associated with diabetic nephropathy either.

      Finally, mesangial amyloid deposits are not associated with diabetic nephropathy but may be found in the mesangium, glomerular capillary walls, interstitium, or renal vessels in amyloidosis. Renal biopsy is a valuable tool in diagnosing and managing various renal diseases, including diabetic nephropathy.

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      • Renal
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  • Question 18 - A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever,...

    Incorrect

    • A 49-year-old man, with known polycystic kidney disease (PKD), presents with acute-onset fever, left mid-back pain and occasional chills. He has no dysuria or haematuria. The left renal angle is tender. The white cell count is 27.8 × 109/l, with 92% of neutrophils (54–62%). What is the most appropriate diagnostic tool to confirm the suspected diagnosis?

      Your Answer: Computed tomography (CT) scan of the abdomen

      Correct Answer: Blood culture

      Explanation:

      Diagnosing and Treating Infection in Kidney Cysts: Medical Tests and Procedures

      Infection in kidney cysts is a common complication in patients with polycystic kidney disease (PKD). However, diagnosing and treating this condition can be challenging. Here are some medical tests and procedures that are commonly used to diagnose and treat infection in kidney cysts.

      Blood Culture
      Blood cultures are more reliable than urine cultures in detecting infection in kidney cysts. Gram-negative bacteria are the most common cause of infection in these cases. Antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. Treatment may last for 4-6 weeks, and surgical drainage may be necessary in some cases.

      Computed Tomography (CT) Scan of the Abdomen
      CT scans can detect internal echoes in one or more cysts, but they cannot differentiate between infection and hemorrhage. Therefore, CT scans alone cannot confirm an infection.

      Urine Culture
      Urine cultures may be unreliable in detecting infection in kidney cysts because cysts often have no communication with the collecting system.

      Ultrasonography of the Kidneys
      Ultrasonography can detect internal echoes within a cyst, but it cannot differentiate between infection and hemorrhage.

      Scintiscan of the Kidneys
      Scintiscans are not used to diagnose infected cysts.

      In conclusion, diagnosing and treating infection in kidney cysts can be challenging. Blood cultures are the most reliable test for detecting infection, and antibiotics such as fluoroquinolones, co-trimoxazole, or chloramphenicol are often used to treat the infection. CT scans and ultrasonography can detect internal echoes in cysts, but they cannot differentiate between infection and hemorrhage.

    • This question is part of the following fields:

      • Renal
      42.9
      Seconds
  • Question 19 - A middle-aged woman with a history of renal cell carcinoma complains of swelling...

    Incorrect

    • A middle-aged woman with a history of renal cell carcinoma complains of swelling in both legs extending from the groin area and dilated veins around the belly button. What is the underlying mechanism responsible for these symptoms?

      Your Answer: Hyponatraemia

      Correct Answer: Inferior vena cava obstruction

      Explanation:

      Causes of Bilateral Lower Limb Edema: Differential Diagnosis

      Bilateral lower limb edema can have various causes, and a thorough differential diagnosis is necessary to determine the underlying condition. In this case, the patient presents with inferior vena cava obstruction, which is caused by extrinsic compression from a renal mass. This obstruction prevents venous drainage of the lower limbs and leads to bilateral edema and distended superficial abdominal veins. Other causes of bilateral lower limb edema include hyponatremia, hypoalbuminemia, deep venous thrombosis, and heart failure. However, each of these conditions presents with distinct symptoms and signs. Hyponatremia and hypoalbuminemia cause generalized edema, while deep venous thrombosis presents with painful swelling and erythema in the affected limb. Heart failure also causes bilateral dependent edema but does not lead to venous engorgement and dilated veins around the umbilicus. Therefore, a careful evaluation of the patient’s history, physical examination, and laboratory tests is crucial to establish the correct diagnosis and initiate appropriate treatment.

    • This question is part of the following fields:

      • Renal
      43.4
      Seconds
  • Question 20 - A 40-year-old piano teacher presented to the Emergency Department with an acute kidney...

    Correct

    • A 40-year-old piano teacher presented to the Emergency Department with an acute kidney injury (AKI) and was referred to the renal team for urgent haemodialysis. Which of the following is not a reason for immediate dialysis?

      Your Answer: Alkalosis

      Explanation:

      Indications for Urgent Dialysis in Renal Failure Patients

      Dialysis is a life-saving treatment for patients with renal failure. Urgent dialysis is required in certain situations to prevent serious complications. Acidosis, not alkalosis, is an urgent indication for dialysis. Pulmonary edema caused by furosemide-resistant fluid overload is another indication for urgent dialysis. Severe hyperkalemia, with potassium levels greater than 6.5 mmol/l or less if electrocardiographic changes are apparent, is also an indication for dialysis. Severe uraemia, with symptoms such as vomiting, encephalopathy, and urea levels greater than 60 mmol/l, requires urgent dialysis. Uraemic pericarditis is another indication for urgent dialysis. It is important to recognize these indications and initiate dialysis promptly to prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Renal
      27.8
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Renal (11/20) 55%
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