MRCP Nephrology
MRCP Nephrology
MRCP Nephrology
Tricorn Books,
131 High Street,
Old Portsmouth,
PO1 2HW
www.tricornbooks.co.uk
200 Best of Five Questions
for Nephrology Specialty Certificate Exam
with Revision Notes and Guidelines
Authors
Dr Ebadur Rahman
FRCP, FRCPl, FASN, MMedSci Nephrology (Sheffield,UK)
Renal SCE (UK)
Consultant Nephrologist
Prince Sultan Military Medical City, Riyadh
Regional Adviser RCPE, Riyadh
Co Authors
Dr Ramesh Abdullah
Dr Roshni Rathore
Editors
Dr Puchimada Uthappa, FRCP
Nephrology Consultant, Salford Royal Hospital, Manchester
Dr Fancesco Rainone, MD
Consultant Renal Physician, Salford Royal Hospital
Contents
Foreword
Authors
Preface
Normal lab ranges
Questions & Answers
Radiology for SCE Exam
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54,
55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71,
72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88,
89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103,
104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115,
116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127,
128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139,
140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151,
152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163,
164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175,
176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187,
188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200
Foreword
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About the Authors
Dr Ebadur Rahman
Nephrology
Dr Farhan Mushtaq graduated from Liaquat University Jamshoro, Hyderabad
Pakistan in 1992 securing 6th position on merit. He then went to the UK for
his postgraduate studies. With the blessing of his parents, he embarked on
his postgraduate training in Nephrology at Hammersmith Hospital, London
under the supervision of Dr Jeremy Levy (author of the best selling book, The
Oxford Handbook of Dialysis), and Prof Charles D Pusey. Dr Farhan gained
his Postgraduate Diploma and Masters Degree (MSc in Renal Medicine) from
Imperial College of Science, Technology and Medicine (University of London)
and his MRCP from the Royal College of Physicians of Ireland. He passed Renal
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Specialty Certificate Exam from RCP (UK) in 2012.
Dr Mushtaq has full registration with the General Medical Council in the UK and
a license to practice. From 2009 to 2013 he worked as an adult Nephrologist
in Prince Sultan's Military Medical City, Riyadh, one of the top ranked tertiary
care hospitals in the kingdom. His major achievement was the setting up
of a Nephrology Clinic Service in the Primary Health Center, which was the
first of its kind in Saudi Arabia. With a profound interest in teaching, he and
his colleague, Dr Ebad made the Renal Specialty Exam Course website,
which consists of 750 Best of Five Questions, currently the largest bank of
Nephrology questions available on the Internet.
Since 2012 Dr Mushtaq and Dr Ebad have been running a very successful
interactive course in Dubai, preparing candidates for the difficult Renal
Specialty Exam.
Currently he is working as an adult Nephrologist at Salford Royal Hospital,
Manchester, the top ranked Tertiary Care NHS Trust in UK.
Dr Mushtaq's keen area of interest is in slowing down the progression of
Diabetic Kidney Disease, CKD disease and Haemodialysis.
Co Authors
Dr. Ramesh Nair (Abdullah)
Diplomate American Board of Pathology
Consultant Renal Histopathologist
Prince Sultan Military Medical City, Riyadh Saudi Arabia
Dr. Nair Graduated from the Kozhikode Medical College in India in 1989. He
received his Diplomate in the American Board of Pathology in 1999 and Renal
Pathology Fellowship Certification from Johns Hopkins University Hospital,
Baltimore, USA in 2000. He has more than a decade of experience as a Renal
Pathologist in the USA and has worked in prestigious institutions such as the
University of Iowa Hospitals where he served as Clinical Associate Professor. He
has received several teaching accolades and including best 2nd year Medical
Student Teacher of the Year award. He is currently a Consultant in Renal
Pathology at the Prince Sultan Military Medical City in Riyadh, Saudi Arabia.
Dr Roshni Rathore
MBBS, MRCP Nephrology
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Editors
Dr P M Uthappa, FRCP
Consultant Renal Physician
Dr P M Uthappa completed his undergraduate medical training
in Bellary, India. He attained his membership from the Royal
college of Physicians, Edinburgh after general medical training at
Victoria Hospital Kirkcaldy, Scotland. He entered specialist training
in Nephrology and General Internal Medicine in West Midlands
with training posts at University Hospital Birmingham, University
Hospital Coventry and Warwickshire NHS Trust and Royal Wolverhampton
Hospital NHS Trust. After obtaining his CCT in renal medicine and General
Medicine in 2008, he was awarded Fellowship of the Royal College of Physicians,
London in 2012.
At present he is working as a Renal Physician at Salford Royal NHS Foundation
Trust and has been in the post since 2008. His special interests include, CKD,
Hypertension, Haemodialysis, access for dialysis, pregnancy and renal disease.
He has significant experience in Medical Education, training of the renal trainees
and is the lead for undergraduate Medical education in the renal department.
Dr Francesco Rainone, MD
Consultant Renal Physician
Salford Royal & WWL NHS Foundation Trusts
Dr Francesco Rainone was born and raised in Italy where he
graduated magna cum laude in 2007 at Vita-Salute San Raffaele
University, Milan. He subsequently entered the Nephrology
training programme at Vita-Salute University, Milan and obtained
the specialization title cum laude in March 2013. He spent 10
months of his training at Salford Royal NHS Foundation Trust where he stayed
as visiting research fellow. He eventually moved to the UK and is a Consultant
Nephrologist at Salford Royal NHS Foundation Trust. His clinical areas of interest
are transplantation, early CKD, glomerulonephritis and myeloma-associated
kidney damage.
Contributors
Dr Kishore Gopalakrishnan
Pathologist at NHS
Birmingham, United Kingdom
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Preface
Our goal was to create a valuable tool for all trainees revising for the SCE exam,
American Board of Nephrology and Arab Board of Nephrology Exam.
Our authors were supported by consultants in the region and we offer our
thanks to them all.
We would like to extend our gratitude to our parents and families. Without
their support, blessings and encouragement this would not be possible.
Finally, much appreciation is given to Professor Philip Kalra for providing his
inspirational commentary for this book.
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Normal Lab ranges
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Question 1 Q
A 17-year-old boy was referred for investigation of renal impairment and
hypertension. These had been identified during an assessment for possible
diabetes mellitus. He gave a 13-month history of increasing polyuria and
polydipsia. He was taking no regular medications. Slit lamp examination
findings are shown in the picture (1). His blood pressure was 154/96 mmHg.
Investigations:
serum potassium 3.1 mmol/L (3.54.9)
serum bicarbonate 17 mmol/L (2028)
serum creatinine 109 mol/L (60110)
eGFR 80 ml/min
serum phosphate 0.61 mmol/L (0.81.4)
serum chloride 113 mmol/L (95107)
urinalysis trace blood, 2+ protein
1+ glucose
urinary protein: creatinine ratio 57 mg/mmol (<15)
A Cysteamine
B Elimination of dietary lactose
C Penicillamine
D Prednisolone
E Pyridoxine
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A nswer A - Cysteamine
Diagnosis:
The diagnosis of cystinosis is commonly made by examining the eyes for the
presence of corneal crystals, and confirmed by measuring the level of cystine in
blood cells. Individuals with cystinosis exhibit cystine levels up to 100 times the
level found in persons without this disorder.
Treatment:
Symptomatic- Rehydration, replacement of bicarbonate losses with sodium
citrate or bicarbonate
Topical cysteamine eyedrops results in dissolution of corneal crystals.
Drug- Cysteamine (It forms a complex with cystine that can leave lysosomes,
ameliorating disease)
Dialysis or Kidney Transplantation in those who developed ESRD
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Question 2 Q
A 69-year-old man with stage 4 CKD, diabetes mellitus, hypertension, and
stable coronary artery disease is seen in your clinic for routine follow-up. He
complains of occasional morning nausea, decreased appetite, and nocturnal
leg cramps. His weight is stable. He denies chest pain, shortness of breath,
and fatigue.
Laboratory studies show a white cell count of 7500/l, haemoglobin level of 9.6
g/dl (9.2 g/dl 3 months ago), platelet count of 300,000/l, transferrin saturation
(TSAT) of 34%, and ferritin level of 602 ng/ml. eGFR using the Modification of
Diet in Renal Disease formula is 23 ml/min per 1.73 m2. Serum vitamin B12
and folate levels are normal. Reticulocyte count is 40,000/l (reference range,
23,00090,000/l).
Which one of the following is the most appropriate next step in the
management of this patients anaemia?
A Continue current regimen
B Initiate an erythropoiesis-stimulating agent (ESA)
C Begin intravenous iron
D Measure serum erythropoietin level
E Begin oral iron
Options B, C, D and E are incorrect, option A is the correct answer. The most
appropriate management of this patient is to continue the current regimen with
continued regular monitoring of his clinical status and anaemia. This patient
has stage 4 CKD and associated anaemia. The 2012 Kidney Disease Improving
Global Outcomes (KDIGO) Practice Guideline for Anaemia in Chronic Kidney
Disease recommends that the decision to treat anaemia in such patients
should be an individual one balancing the risk of stroke, hypertension, and
vascular access loss against the benefit of lowering the requirement for blood
transfusions and improving anaemia-related symptoms. He has no symptoms
attributable to his anaemia, and his haemoglobin level has been stable.
There is therefore no indication to treat this patients anaemia.
The iron indices indicate adequate iron stores. The KDIGO guidelines for
anaemia in CKD recommend a trial of intravenous iron or a 1- to 3-month trial
of oral iron if an increase in haemoglobin concentration without starting ESA
treatment is desired and the TSAT is <30% and ferritin is <500 ng/ml. This
patient does not have a compelling indication for treatment of anaemia,
and the iron studies do not indicate absolute or functional iron deficiency.
Therefore, iron therapy is not likely to be of benefit.
Furthermore, intravenous iron should not be used unless they patient cannot
tolerate or did not benefit from oral iron.
If he had an indication to start an ESA, the goal haemoglobin would be
1012 g/dl. (NICE & KDOQI)
KDIGO guidelines recommend that the evaluation of anaemia in CKD patients
include a complete blood count, absolute reticulocyte count, serum ferritin
level, serum TSAT, serum vitamin B12, and folate levels. Routine measurement
of the serum erythropoietin level is not recommended.
Kidney Disease Global Outcomes Anemia Work Group. KDIGO Clinical Practice Guideline for
anaemia in chronic kidney disease. Kidney Int Suppl 2, 279-335, 2012
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A
Learning point: if a CKD Patient is anaemic in CKD stage 1, 2 & 3 A then
unlikely to be due solely EPO deficiency.
CKD, Chronic kidney disease; ESA, erythropoiesis-stimulating agent; KDIGO, Kidney Disease:
Improving Global Outcomes; QoL, quality of life.
Most common
Iron deficiency, infection, under dialysis
Less common
Poor compliance
Blood Loss
Hyperparathyroidism, Vit B12, folate deficiency
Bone marrow disorders, Sickle cell disease, ACEi, ARB,
AntiEPO antibodies causing PRCA (Pure red cell aplasia)
References:
Kidney Disease Global Outcomes Anaemia Work Group. KDIGO Clinical Practice
Guideline for anaemia in chronic kidney disease. Kidney Int Suppl 2, 279-335, 2012
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Question 3 Q
Look at the image.
Which one of the following is the most likely complication seen in the above
image during insertion of right tunnelled line for dialysis in this patient?
A Clot in catheter
B Kink in catheter
C Malposition of Catheter
D Pneumothorax
E Perforation of Heart
Complications
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A
Septic thrombophlebitis
Death
UK Renal association guidelines for Tunnelled HD CVC
(central venous catheters)
Tunnelled cuff catheters are preferred for temporary HD needed for >3
weeks
Preferred site is internal jugular vein
Chest x-ray should be done to check position of catheter and R/O
Pneumothorax prior to use
<20% patients on long term HD should be on tunnelled CVC
All units should use US guidance for insertion, and full barrier precautions
during insertion.
Peripheral and central cultures should be taken before starting antibiotics
Audit data should be collected for bacteraemia rates.
Rules for Treatment of catheter related bacteraemia
Principles Practice
Always document the infection Routine survelliance cultures post therapy
is cured 1 week.
Fever or rigors highly predictive Start antibiotics without waiting for culture
of bacteraemia results
Gram -ve are common up to 40% Empiric coverage includes GPC and GNR
Fungal catheter infection Daily blood cultures and treat for at least 2
weeks from the first -ve culture
Staphlococcus aureus organism Empiric antibiotics should include
often methicillin resistant vancomycin
GPC-gram+ve cocci, GNR-gram-ve rods
Algorithm of Vancomycin
Cefazohn
Treatment of dialysis If unit with high
Ceflazidlme
catheter related prevalence of MRSA
Use vancomycin for
Daptomycin
Bacteraemia empiric treatment
Teicoplanin
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A
Start antibiotic empirically if fever>38 C, rigors or low BP
Cover for both Gram positive and Gram negative organisms
For Gram positive cover use either vancomycin (10-20 mg/kg iv- usually 1
gm) check trough level at 20 hr and redose if<15 mg/L) or teicoplanin
For Gram negative cover use gentamycin (2mg/kg) iv check trough level at
20 hr and redoes if <2mg/L.
Vancomycin is partially removed by HD, Gentamycin completely
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Question 4 Q
A 44-year-old male attended accident and emergency with a 2-week history
of skin rash (See image). He had a past medical history of known case of ESRD
secondary to ADPKD received a cadaveric kidney transplant 4 years back.
He was on triple immunosuppression (tacrolimus, Mycophenolate mofetil
and Prednisolone).
eGFR 81umol/L
A Molluscum contagiosum
B Chicken pox
C Herpes zoster
D Kaposi Sarcoma
E Folliculitis
Options B, C, D and E are incorrect, option A is the correct answer. Patient with
kidney transplant are on immunosuppressive drugs have high risk of infections
as compared to others. Below is the time table of most common infections post
kidney transplant.
Molluscum contagiosum is a pox virus that causes a chronic localised infection
consisting of flesh colour dome shape papules with indentation or umbilication
on the skin of an infected individual. Its incubation period is 2 to 6 weeks. In
immunocompromised patients the lesions can be large (aka giant Molluscum).
In immunocompetent patients it is self-limiting but might not be so in
immunocompromised patients.
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Question 5 Q
In renal transplantation the risk of recurrence in the allograft is lowest for which
of the following renal diseases?
A Oxalosis
B FSGS (Focal Segmental Glomerulosclerosis)
C IgA nephropathy
D Lupus nephritis
E MPGN Type 1 (Membranoproliferative Glomerulonephritis Type 1)
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Question 6 Q
You are in a Chronic Kidney Disease clinic (pre-dialysis). One of your CKD stage
5 patient is approaching the need for renal replacement. He is contemplating
continuous ambulatory peritoneal dialysis(CAPD) and asks you about medical
contraindications to this modality.
A Diabetes mellitus
B Bilateral inguinal hernia
C Severe chronic obstructive pulmonary disease
D Previous perforated diverticular disease and sigmoid colectomy
E Severe Rheumatoid arthritis
Haemodialysis Contraindications
Absolute contraindications Relative contraindications
Thrombosed central veins Severe vascular disease
No Vascular access Severe hemodynamic instability
Hypotensive heart failure Long distance from HD unit
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Question 7 Q
An 18-year-old woman was referred for investigation of progressive generalised
muscle weakness and lethargy. She was taking no regular medications.
Examination was unremarkable. Her blood pressure was 108/60 mmHg.
Her body mass index was 20.
Investigations:
serum potassium 2.8mmol/L (3.54.9)
serum bicarbonate 33 mmol/L (2028)
serum creatinine 77 mol/L (60110)
eGFR >90 ml/min
serum magnesium 0.61 mmol/L (0.751.05)
serum chloride 85mmol/L (95107)
urinary chloride 61
urinary sodium 57
24-hour urinary calcium 1.6 mmol (2.57.5)
A Bartters syndrome
B Gitelmans syndrome
C Hypokalaemic periodic paralysis
D Liddles syndrome
E Gordans syndrome
Treatment
Oral potassium supplementation,
Spironolactone and NSAID
Adjuvant use of ACEi has also been successful.
Treatment
Oral potassium supplementation, Amiloride 5-40 mg od.
NSAID are not helpful.
Liddle syndrome
Very rare
Mutation in ENaC (epithelial sodium channel expressed on the apical surface of
collecting duct cells).
Treatment:
Low salt diet,
Response to amiloride / triamterene (which directly inhibit ENaC).
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A
Key difference of common Rare Syndromes
Bartters Syndrome
Gitlemans Syndrome
Pseudohypoaldosteronism Type 1
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Questions 8 & 9 Q
Question 8
In double positive patients (ANCA and anti-GBM antibodies) with standard
treatment, one year Patient survival in patients with Creatinine less than
500 was nearly
A 25%
B 30%
C 50%
D 75%
E 100%
Question 9
Which of the following is the Pathognomonic Eye abnormality
seen in XLinked Alport's Syndrome?
A Posterior Lenticonus
B Anterior Lenticonus
C Peri Macular Flecks
D Corneal Ulcers
E Blindness
Answer 8
Options A, B, C and D are incorrect, option E is the correct answer. Patient
survival was 100% at one year when Creatinine was less than 500 in the
presence of both ANCA and anti-GBM antibodies in a retrospective analysis by
Levy et al.
Image Showing
Anterior lenticonus
of Alport's syndrome
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Question 10 Q
Which of the following immune responses is specific to kidney transplantation?
A Direct allorecognition
B Indirect allorecognition
C Activation of adaptive immune response
D Activation of innate immune response
E None of above
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Question 11 Q
A 71-year-old woman first noticed bilateral lower extremity oedema in
November of 2014. She reduced her sodium intake and a week later saw her
primary care physician who, in working up the oedema, sent her for a urinalysis
that showed 3+ proteinuria and no haematuria. Previous blood and urine tests,
done in June of 2013 as part of a routine yearly visit, had been unremarkable,
including no detectable proteinuria.
She was referred to a nephrologist in December of 2014 at that visit, she
reported no symptoms other than oedema, which persisted in both lower
extremities to the ankles. Specifically, she denied fevers, anorexia, weight loss
night sweats, rash, joint pain, or change in urine color. Her past medical history
included 50 pack-years of cigarette smoking with ongoing tobacco abuse,
osteoarthritis, and hyperlipidaemia. The only medications that she was taking
at this time were an over the counter fish oil preparation and acetaminophen
as needed for pain. Her family history was negative for renal disease, but her
mother had died of leukemia and her sister had died of uterine cancer.
Her vital signs (including BP) were in normal range, and her physical
examination was notable only for 1-mm pitting edema to the ankles.
Laboratory workup revealed 11g/d proteinuria on 24-
hour collection, Serum Creatinine of 62 umol/l, total
cholesterol of 9.0 mmo/l, and albumin of 26g/L.
The following tests were either negative or in the
normal range: serum protein electrophoresis, urine
protein electrophoresis, antinuclear antibody, C3
and C4, hepatitis B and C, serological tests for A
syphilis, Myeloperoxidase (MPO) and PR3 ANCA.
Renal ultrasound was unremarkable, including no
evidence of renal vein thrombosis, and ultrasound
of the legs showed no deep venous thrombosis.
She was started on lisinopril, atorvastatin, and
furosemide. A Kidney Biopsy was undertaken which
showed: see images B
What is the lesion noted on light, IF, and electron
microscopy?
A Minimal change disease
B Membranoproliferative GN
C Membranous nephropathy (MN)
D Focal segmental glomerulosclerosis C
E Amyloidosis See Kidney Biopsy (A-LM, B-IF, C-EM)
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A
EM - Showing Subepithelial Immune deposits of Membranous Nephropathy
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A
Membranous Nephropathy Good & Poor prognostic factors
KDIGO Guidelines
Treatment should be restricted to high-risk patients
Renal function impairment
Persistent massive proteinuria >8gm/day associated with worse outcome.
Anti-PLA2R antibodies
Sensitivity 70-78% and specificity 90-99% for primary membranous GN
Not present in patients with non-membranous nephrosis
Correlates with outcome and disease activity; not always with proteinuria; with
recurrence post Transplant
Swedish registry: 9% of patients with positive antibody developed malignancy
vs 37% of those without antibodies (Timmermans 2013 AJKD)
PLA2R-Ab detection in serum and glomerular PLA2R staining are helpful tools
for the diagnosis of MN
PLA2R antibody levels are useful biomarkers in primary MN and allow
individual treatment monitoring
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Question 12 Q
A 29-year-old man presented with a 7-month history of polyuria, polydipsia
and worsening shortness of breath on exertion for the past 3 weeks.
He had also experienced pain in both feet but could not remember injuring
them recently. On examination blood pressure was 165/83 mmHg,
there were bibasal crepitations on auscultation of the chest and a number
of abdominal telangectasia.
Investigations:
serum creatinine 290 mol/l (60 110)
protein/creatinine ratio 312 mg/mmol (<3.5)
Fabrys disease is the second most common lysosomal storage disorder after
Gauchers disease
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A
Kidney biopsy electron microscopy shows characteristic tubuloreticular
inclusion bodies (also known as Myelin or Zebra Bodies)
Treatment
Enzyme replacement therapy (ERT) with recombinant alpha-Gal A
ERT should be continued in ESRD patients for its non-renal benefits.
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Question 13 Q
A 51-year-old man presented with a palpable purpuric rash (look at the image)
predominantly over his legs and marked dependent oedema.
Further examination revealed 4cm hepatomegly and 1 cm splenomegaly.
Investigations:
serum creatinine 275 mol/L (60110)
urine protein/creatinine ratio 429 mg/mmol (<15)
serum albumin 20 g/dL g/L (3749)
HbA1C 5.7%
ANCA negative
Anti-GBM negative
dsDNA negative
C3 Normal
C4 low
Pre-dialysis screen HIV ab neg, Hep B ab neg, Hep C ab positive
A Conservative management
B Chlorambucil and glucocorticoids
C Pegylated interferon
D Pegylated interferon and ribavirin
E Rituximab
Options A, B, C and E are incorrect, option D is the correct answer. This man
has nephrotic range proteinuria with moderate renal impairment. The rash
and reduced complement levels make membranous nephropathy less likely
as a diagnosis. The presence of Hepatitis C antibody in this setting should
prompt consideration of Type II cryoglobulinaemic vasculitis. A reduction in
proteinuria with the treatment of HCV using interferon alpha without significant
improvement in renal function (milder dysfunction, however, sCr average
1.8mg/dl). In all studies, there are large numbers of relapses when treatment
is withdrawn. Interferon alfa has been shown to be safe in advanced (dialysis
dependent) renal dysfunction Concurrent treatment with ribavirin has been
shown to increase the chances of sustained viral clearance but there have been
many concerns about its use in renal dysfunction due to severe haemolytic
anaemia anaemia as a side effect when levels accumulate.
However there have been two trials suggesting that with dose reduction it
can be a safe treatment. The use of ribavirin was safe in dialysis dependent
patients. One study demonstrated that with close monitoring of Hb and
appropriate iron and epo. Supplementation use of ribavirin was safe down to
an eGFR of 10ml/min at entry.
Ref: Alric et al Am J Kid Dis 2004 Apr;43(4):617-23.
Johnson et al KI 46(1994) 1700-1704
Kokoglu et al J Gastroenterol Hepatol 2006 Mar;21(3):575-80.
Bruchfeld et al NDT (2003) 18: 1573-1580
Rendina et al J Hepatol 2007 May;46(5):768-74
Transplant candidates and patients with long life expectancy: (IFN or PEG-
IFN combined with RBV, for 24 wk in In genotype 2 and 3 or 48 wk in HCV
genotype 1, 4, 5, and 6)
IFN (3 MU) 3 times weekly or PEG- IFN--2a 135 g/wk
RBV initial dose 200 mg daily with further adaptation to plasma concentration
10 to 15 mol/L; with erythropoietin administration.
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Question 14 Q
Which of the following statements is incorrect for treatment in crescentic
glomerulonephritis?
NICE Guideline
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Question 15 Q
A 24-year-old army recruit presents with acute renal failure. Which one of the
following features is not consistent with a diagnosis of rhabdomyolysis?
Complications of Rhabdomyolysis
Early complications
Hyperkalemia
Hypocalcaemia
Hepatic inflammation
Cardiac arrhythmia
Cardiac arrest
Late complications
Acute renal failure
Disseminated intravascular coagulation
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Questions 16 & 17 Q
Question 16
A haemodialysis patient is troubled by gout.
A Colchicine
B Allopurinol
C Prednisolone
D Increase Dialysis
E Probenecid
Question 17
Which of the following is not a cause of hypokalemic distal (type 1) renal
tubular acidosis?
A Sjogrens syndrome
B Primary biliary cirrhosis
C Amphotericin B
D Hypogammaglobulinaemia
E Vitamin D intoxication
Answer 16
Options A, B, C and D are incorrect, option E is the correct answer. Probenecid
is a uricosuric agent, likely to produce little benefit in a patient with severe
renal impairment necessitating haemodialysis. Allopurinol, if tolerated, will
reduce urate production, and increased dialysis will improve urate clearance,
both reducing the serum urate level and thus the predisposition to attacks.
Prednisolone and colchicine both have anti-inflammatory properties, beneficial
in the treatment of acute attacks.
Answer 17
Options A, B, C and E are incorrect. Option D is the correct answer-
Hypogammaglobulinaemia Hypergammaglobulinaemia causes hypokalaemic
distal renal tubular acidosis hypogammaglobulinaemia is not reported to cause
the distal renal tubular acidosis.
Renal tubular acidosis (RTA)
Type1(distal) Type 2 (proximal) Type 4
Associated with - + _
Fanconi syndrome
Nephrolithiasis + - -
Treatment Na or K bicarbonate Na or K bicarbonate
or citrate-2mEQ/kg/d or citrate- 5-15
adults mEq/kg/d+/- HCTZ
Causes Sjogren syndrome Multiple myeloma Diabetic or
Rheumatoid arthritis, with cast hypertensive
active cirrhosis, nephropathy, retinopathy,
obstructive uropathy, Acetazolamide, tubulointerstitial
ifosfamide, disease, spironolactone,
toluene toxicity,
tenofovir, heavy ARBs or ACE inhibitors,
amphotericin metals K sparing diuretics
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Question 18 Q
A 61-year-old woman on haemodialysis complained of progressive abdominal
pain and bloating for three months. She was otherwise well. Her primary renal
illness was Focal segmental glomerulosclerosis (FSGS), diagnosed 8 years ago.
She was started on peritoneal dialysis immediately and was only changed to
haemodialysis nine months ago following an episode of fungal peritonitis.
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Question 19 Q
A 55-year-old female with end stage renal disease from cresentric IgA
nephropathy on automated peritoneal dialysis (APD) for 10 years and anuric for
6 yrs. She is doing well overall. Weekly KT/V has always been>1.7/wk. Initial
Hb was 11 g/dl whilst on an Darbepoetin. Recent Hb was 12.6g/dl while not on
oral iron or Darbepoetin. Ferritin is 450 and Transferrin saturation is 30%.
This patient has acquired cystic disease. A long term dialysis patients are at risk
of developing Acquired cystic kidney disease.
The cyst may become malignant -Renal cell carcinoma(RCC).These RCC often
produce Erythropoietin about 10% have polycythemia although majority
present with anaemia.
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A
CT Scan showing Atrophic Kidneys and Renal cell Carcinoma
(ACKD, acquired cystic kidney disease; ADPKD, autosomal dominant polycystic kidney disease;
AML, angiomyolipoma; ARPKD, autosomal recessive polycystic kidney disease; ESRD, end-stage
renal disease; IC, intracranial; MCDK, multicystic dysplastic kidney; MCKD, medullary cystic kidney
disease; MSK, medullary sponge kidney; NPHP, nephronophthisis; RCC, renal cell carcinoma; TIN,
tubulointerstitial nephritis; TSC, tuberous sclerosis complex; VHL, von Hippel-Lindau syndrome.)
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Question 20 Q
A 72-year-old Caucasian man with a 10-year history of well-controlled type
II diabetes and hypertension presents with nephrotic syndrome (8.4 g/day
proteinuria) and microscopic hematuria. His blood pressure is well controlled
at 128/76 mm Hg, and his BMI is high at 40. He does not have retinopathy.
Serologic testing is negative, but he is found to have a small IgG k monoclonal
spike in the serum and monoclonal k light chains in the urine Serum creatinine
is 305 umol/l with an eGFR of 20-mL/min/1.73 m2.
Which one of the following is the most likely diagnosis in his scenario?
Dysproteinemias
amyloidosis
fibrillary glomerulonephritis
immunotactoid glomerulonephritis
fibronectin glomerulopathy
cystic fibrosis
Idiopathic nodular glomerulosclerosis (often associated with smoking and chronic hypertension)
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Question 21 Q
A 64-year-old Caucasian man with a history of hypertension is found to have a
light chain monoclonal spike in both the serum and urine. He reports no history
of diabetes. A 24-hour urine collection reveals 2.8 g proteinuria of which 1.8g
is free light chain. Serum creatinine is 132 umol/L (eGFR, 47 mL/min/1.73
m2 ). Urinalysis reveals glucosuria. A bone marrow biopsy shows few atypical
-restricted plasma cells.
Which one of the following is the most likely diagnosis in this patient?
The crystals are easy to distinguish from abnormal mitochondria or other types
of tubular epithelial inclusions.
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Question 22 Q
A 17-year-old boy is referred to outpatients with nocturnal enuresis. His mother
comments that he is easily tired by sport and is not doing well at school. He
is normotensive and on the 8th centile for height.
Investigations
Bicarbonate 35 mmol/l
Chloride 80 mmol/l
Urea 5 mmo/l
24 hr urine K 60 mmol/l
24 hr Urine Na 60 mmol/l
A Laxative abuse
B Diuretic abuse
C Bartter syndrome
D Adrenal tumour
E Villous adenoma
Villous adenoma and laxative abuse is associated with Diarrhoea and low K
loss, adrenal tumour is associated with hypertension.
Symptoms Tetany,
Chondrocalcinosis Variable
K+ Low Low
Nephrocalcinosis No Sometimes
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A
Algorithm 1
Hypokalemia
Spurious Redistribution
Potassium depletion
Metabolic alkalosis
Algorithm 2
Metabolic alkalosis
Normotensive
Normotensive
Vomiting
diuretics
gastric drainage Hypertensive Bartters syndrome
diuretic use
severe k depletion
post-hypercapnea
cl-closing diarrhea Gitelman's syndrome
High aldosterone
and normal renin
Cushings syndrome
High aldosterone
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Question 23 Q
A 68-year-old Caucasian man with a 14-year history of type II diabetes,
hypertension, and chronic obstructive pulmonary disease has a light
chain monoclonal spike in the serum that was interpreted as monoclonal
gammopathy of undetermined significance. Over the last year, his serum
creatinine increased from 153 umol/l (eGFR, 50 mL/min/1.73 m2) to 800 umol/l
(eGFR, 7 mL/min/1.73 m2).
Clinical Features
Diagnostic criteria for Multiple Myeloma
Serum and/or urine monoclonal protein and/or clonal bone marrow plasma
cells, Presence of plasma cell dyscrasia-related lytic bone lesions, anaemia,
Hypercalcaemia, or renal failure.
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A
TYPICAL
Progressive renal insuffiency over 1-3 months
Bland urine sediment
SFLC>1500mg/L (Serum Free light chains)
Dipstick negative for albumin,but positive on
heat/sulfosalicylic acid
(High UP/Creat, but low MALB/Creat)
Consider biopsy if above not present
Other features
Hypercalcaemia
Hyperphosphatemia and anaemia out of proportion to renal
failure
Low or positive serum anion gap
Heavy-chain deposition
Deposition of heavy chains
disease
Tubular disturbance
Fanconi syndrome Hyperaminoaciduria, glucosuria
MPGN. Cryoglobulins
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Question 24 Q
Current UK guidelines for combined liver kidney transplant do not include:
B Chronic liver disease meeting at least one of the three current criteria for
transplant selection + end stage renal disease on long term dialysis program
C Chronic liver disease meeting at least one of the three current criteria for
transplant selection + Hepatorenal syndrome with serum creat >200 and
dialysis >8 weeks
D Chronic liver disease meeting at least one of the three current criteria for
transplant selection + MDRD stage 3b or GFR <30 ml/min or renal biopsy
showing >30% fibrosis and/or glomerulosclerosis
E Mitochondrial disorders
Primary hyperoxaluria
Hereditary amyloidosis
HUS secondary to hereditary complement mutations
ADPKD:ESRD with large , symptomatic polycystic liver disease
Hepatorenal syndrome with irreversible renal failure
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Question 25 Q
A 65-year-old man started Haemodialysis with a 14-week-old left
Brachiocephalic AVF which is now successfully needled. It has a strong thrill
and is well matured.
The patient developed pins and needles in the fistula hand, acro-cyanosis and
dull aching pain whilst on dialysis.
On examination his hand was cold to touch with absent radial pulse and
reduced grip. There were signs of nail dystrophy, shiny skin and areas of patchy
redness.
Options A, B, D and E are incorrect, option C is the correct answer. This Patient
has Steal syndrome. Dialysis Ischaemic Steal syndrome is an uncommon but
serious condition of arterial insufficiency distal to a permanent haemodialysis
fistula. When severe it can lead to digital gangrene.
This has to be differentiated from Ischaemic Monomelic Neuropathy which
occurs immediately after the access surgery due to damage to the nerves
of the hand.
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Question 26 Q
A 77-year-old man with lower extremity edema for many months now presents
with nephrotic syndrome and 10 g of proteinuria. He has no other past medical
history. Complements are normal and other serologies including
A Immunotactoid Glomerulonephritis
B AL Amyloidosis
C Lupus Nephritis
D Cryoglobulinemic glomerulonephritis
E Light chain deposition disease
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Questions 27 & 28 Q
Question 27
Which one of these antibiotics least likely to achieve therapeutic concentration
in cystic fluid when treating UTI in polycystic disease?
A Ciprofloxacin
B Trimethoprim
C Chloramphenicol
D Cephalosporins
E Co-trimoxazole
Question 28
A 55-year-old male who has end stage renal disease secondary to hypertension
is stable on peritoneal dialysis for the last 2 years. He is on Automated
peritoneal dialysis (APD) with 2 litre Icodextrin as his last fill. He has remained
stable but for the last two weeks, he has become more volume overloaded.
There is no change in his dialysis prescription or ultra-filtration.
No history of infection or change in medication in the recent past.
Answer 27
Options A, B, C and E are incorrect, option D is the correct answer.
Cephalosporins, Penicillins and aminoglycosides do not penetrate adequately
into cysts. (Muther J Urology 124:596,1980) (Elzinger. KI 32:884, 1987)
Answer 28
Options A, B, C and D are incorrect, option E is the correct answer. Patient
has dropped down urine output. Urine output is contributory factor
to maintain Kt/V. and euvolaemia. It is common finding with patient
on peritoneal dialysis.
The overall prognosis and wellbeing of the PD patient is closely linked to
the degree of residual kidney function at the start and maintained during
PD therapy.
Well marked CANSUSA study showed for every 5ml/min of residual kidney
glomerular filtration rate there was 12% decrease in the relative risk of death
and for every 250 ml of urine the relative risk was reduced by 36%.
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Question 29 Q
A 60-year-old male is on haemodialysis for the last 3 years. He suffers from
repeated episodes of intra dialytic hypotension. His average weight gain is
one kilogram over his dry weight between dialysis. He is not hypertensive.
Examination did not reveal any signs of volume overload.
Options A, B, D and E are incorrect, option C is the correct answer. This patient
has intradialytic hypotension(IDH), In this scenario with the above findings,
reducing dialysate temperature during dialysis may help in stabilising blood
pressure. Low dialysate temp (36.5) will cause vasoconstriction so raising the BP
without tachycardia or increased myocardial contractility.
Cooled dialysate reduces IDH (intradialysis hypotension). Low sodium and
calcium bath will further lower down blood pressure during dialysis. Intravenous
albumin will not add anything, as patient is having normal albumin level.
IDH is defined as fall in SBP >20 mmHg, associated with symptoms or fall
to SBP<100 mmHg.
Symptoms associated with IDH
Cramps, abdominal pain or nausea (reduced gut perfusion)
Dizziness (reduced cereberal perfusion)
Chest pain or arrhythmias
Second line
Perform cardiac evaluation- Echocardiography
Gradual reduction of dialysate temperature from 36.5 to 35 C
Switch to haemodiafiltration
Use dialysate calcium concentration of 1.50 mmol/L
Prolong dialysis time or increase dialysis frequency
Third line
Consider midodrine po 2.5-10 mg before dialysis
Consider L carnitine(IV 20mg/kg/treatment) supplementation after
dialysis
Consider PD
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Question 30 Q
A 50-year-old male with end stage renal disease secondary to diabetic
nephropathy is on CAPD for the last 1 year. For the last month or so, he
is developing fluid retention in his extremities. His CAPD regime has not
changed and his ultra- filtration is going down. He is on 2 litre dwell volume
with 1.25% dextrose base solution. On examination he is oedematous while
his D/P ratio is 0.9.
A Change to haemodialysis
B Increase the dialysate concentration to 4.25%
C Change to automated peritoneal dialysis
D Continue the same regimen
E Encourage the patient to decrease fluid intake.
D/P=Dialysate/Plasma
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A
High transport implies a structural or functional alteration of the peritoneum
High transporters are prone to lose the osmotic gradient required for sustained
ultrafiltration because of rapid absorption of glucose from the dialysate.
High transporters tends to have problems achieving ultrafiltration goal but are
efficient with clearance
Low transporters tend to achieve ultrafiltration goal but have difficulty with
clearance targets.
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Questions 31 & 32 Q
Question 31
A 60-year-old male, ex-smoker, suffered from right sided hemiparesis four
weeks ago. He has a family history of type 2 Diabetes mellitus. Lab tests
revealed hyperlipidemia, HbA1c of 5.5 and normal renal profile.
He was started on simvastatin 10 mg daily by his general practitioner.
Recent clinical trials demonstrated that statins are associated with increase
development of one the following?
A Hypertension
B Hyperlipidemia
C Diabetes mellitus
D Cancer
E Cerebrovascular accident
Question 32
Incidence of anti-GBM disease in patients with Alports undergoing kidney
transplant is ?
A 5%
B 10%
C 25%
D 50%
E 75%
Answer 31
Options A, B, D and E are incorrect, option C is the correct answer. Statins are
associated with increased risk of developing Diabetes mellitus, while initially it
was labelled that statins are carcinogenic but later studies proved that statins
do not increase risk of cancer.
Answer 32
Options B, C, D and E are incorrect, option A is the correct answer. Less than
5% of patients with Alports syndrome develop de novo anti-GBM disease
following renal transplantation.
More common in males. Antibodies are directed against alpha-5(IV) and
alpha-3(IV) chains on the basement membrane.
Plasma exchange and Cyclophoshamide(which is used in primary anti-GBM) is
of limited value. High rate of recurrence on re transplantation.
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Questions 33 & 34 Q
Question 33
The CYCLOPS trial for induction of remission of ANCA associated vasculitis
showed following results
A I.V. cyclophosphamide has comparable same remission and relapse rate with
oral cyclophosphamide but reduces cumulative cyclophosphamide dose.
B I.V. cyclophosphamide has comparable same remission and relapse rate with
oral cyclophosphamide but increases cumulative cyclophosphamide dose.
C I.V. cyclophosphamide does not has comparable same remission and relapse
rate with oral cyclophosphamide but reduces cumulative cyclophosphamide
dose.
D I.V. cyclophosphamide has same remission but more relapse rate with oral
cyclophosphamide but decreases cumulative cyclophosphamide dose.
E None of above.
Question 34
Which of the following disease is not associated with linear deposits of IgG on
the Glomerular basement membrane?
A Diabetes mellitus
B Light chain disease
C SLE
D Membranous nephropathy
E Cadaver kidneys.
Answer 33
Options B, C, D and E are incorrect, option A is the correct answer. I.V.
cyclophosphamide has comparable same remission and relapse rate with oral
cyclophosphamide but reduces cumulative cyclophosphamide dose.
Long term outcomes were ascertained from the patients previously recruited
in the CYCLOPS study which showed pulsed cyclophosphamide is associated
with a higher relapse risk than daily oral cyclophosphamide. However, this is
not associated with increased mortality or long-term morbidity
Ann Rheum Dis. 2012 Jun;71(6):955-60. doi: 10.1136/annrheumdis-2011-200477. Epub 2011 Nov 29
Answer 34
Options A, B, C and E are incorrect, option D is the correct answer.
Membranous nephropathy.
1. Goodpasture's syndrome
2. Alport's syndrome after renal transplantation
3. Fibrillary glomerulonephritis
4. Diabetic Nephropathy
5. LCDD (Light chain deposition disease)
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Questions 35 & 36 Q
Question 35
All of the following factors favours the aggressive treatment of Goodpastures
syndrome except?
Question 36
A 32 year old female was admitted to hospital due to community acquired
pneumonia. During her stay, she was found to have haematuria, proteinuria
and mild renal impairment. Her hepatitis serology came back as negative,
complements and ASO titres were normal, Anti GBM, ANCA, ANA & anti-ds
DNA antibodies also came back as negative. She went on to have a kidney
biopsy which showed IgA Nephropathy with Crescents in 10% of glomeruli.
Bloods were sent off including blood cultures, the results of which
were pending.
A Antibiotics
B Mycophenolate mofetil
C Cyclophosphamide
D Plasmaphresis
E Corticosteroids
Answer 35
Options A, B, C and D are incorrect, option E is the correct answer.
Creatinine more than 500umol/L at presentation.
Answer 36
Options B, C, D and E are incorrect, option A is the correct answer, Antibiotics.
Patient has mild renal impairment and kidney biopsy showed crescents in 10%
of glomeruli. The patient has active infection and the priority here is to treat the
infection first.
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Question 37 Q
One of the trials showed intensive blood pressure control improves renal and
patient survival. The effect is independent of baseline renal profile,
but there was increased mortality after reducing blood pressure to below the
following target?
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Question 38 Q
38 year old male comes to you for consultation two days after an upper
respiratory tract infection with haematuria. He was investigated further
and found to have a urine protein to creatinine ratio of 550. All serological
markers were negative. Complements level were normal. A Kidney biopsy was
suboptimal and tissue was sent, only for immunofluorescence.
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A
The Oxford classification of lgA nephropathy:
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Question 39 Q
All of the following are Indications of kidney biopsy in diabetic patients with
proteinuria except?
A No retinopathy
B New onset nephrotic range proteinuria
C Macroscopic hematuria
D Red cell cast
E. Type 1 diabetes mellitus more than10 years
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Questions 40 & 41 Q
Question 40
Clinical trials prove the following effect of statins on cardiovascular outcome in
end stage renal disease patients?
Question 41
Which of the following glomerular disease is associated with higher percentage
of crescents formation on kidney biopsy?
Answer 40
Options A, C, D and E are incorrect, option B is the correct answer.
Statins have no effect on cardiovascular outcome. In CKD patients, who are not
on dialysis, treatment with statins improve cardiovascular outcome.
In ESRD and dialysis dependent patients statins showed no beneficial effect in
terms of cardiovascular outcome.
Statins do not prevent the loss of renal function.
2013 KDIGO guideline suggests continuation of statins which was initiated
prior to dialysis.
Answer 41
Options B, C, D and E are incorrect, option A is the correct answer. AntiGBM
antibody mediated Glomerulonephritis.
All of the options in question are associated with crescents formation but
Anti GBM antibody mediated GN is associated with about 95% of crescents
formation.
Avg
with> Glomeruli
% with 50% with
Disease Crescents Crescent with Crescents
Anti-GBM antibody-mediated GN 95 81 77
ANCA-associated GN 90 48 48
Immune complex-mediated GN
Lupus GN (class Ill and rv) 40 11 31
HSP 53 5 24
lgA nephropathy 27 5 24
Acute postinfectious GN 25 4 17
Fibrillary GN 20 7 29
Type I membranoproliferative 20 3 21
GN
Membranous lupus GN {class V) 12 1 17
Membranous GN {non-lupus) 5 0 17
Which one of the following is not indicated in the initial treatment of this
patient?
A Intravenous calcium
B Intravenous glucose and insulin
C Dialysis
D Sodium polystyrene sulfonate (Kayexalate, Kionex)
E Beta blockers
Question 43
22-year-old woman presents to the emergency department with nausea,
vomiting, and abdominal pain of 4 days' duration. Her fluid balance profile is as
follows: Na+, 145; K+, 5.0; Cl-, 105; HCO3-, 15; urea, 37mmol/L; Cr, 175umol/l
glucose, 780; Urine analysis 4+ ketones.
A Free water
B Normal saline
C Normal saline, sodium bicarbonate, and insulin
D Half normal saline and insulin
E Normal saline and insulin
Answer 42
Options A, B, C and D are incorrect, option E is the correct answer.
Beta-blockers.
The initial manifestations of hyperkalemia are usually neuromuscular in
origin and are non-specific. Diagnosis is based on serum potassium level;
emergent treatment is based on whether cardiac arrhythmias are present or
electrocardiographic changes are occurring. Treatment involves the use of
intravenous calcium to reduce the excitability of cardiac cell membrane and
use of intravenous glucose and insulin to facilitate transport of potassium into
the intracellular space. Sodium polystyrene sulfonate is used to increase the
excretion of potassium in the colon. In refractory cases, dialysis may be initiated
to rapidly remove serum potassium. In addition, intranasal beta agonists may
be used to transiently reduce serum potassium levels in the acute setting. Beta-
blockers can increase potassium levels.
Answer 43
Options A, B, C and D are incorrect, option E is the correct answer.
Normal saline and insulin.
To understand the diagnosis and treatment of diabetic ketoacidosis Metabolic
acidosis can be classified into two types: that associated with an elevation
in the anion gap, and that in which the anion gap is normal. A calculation
of the anion gap in this patient reveals a gap of 25. Among the causes of
acidosis associated with an elevated anion gap are alcoholic ketoacidosis,
lactic acidosis, starvation, ingestion of alcohols, ingestion of salicylates, and
diabetic ketoacidosis. In patients with diabetic ketoacidosis (such as this
patient), optimal initial treatment includes fluid replacement with normal saline
to promote ketonuria and insulin to facilitate glucose transport. Bicarbonate
therapy is not usually indicated unless the acidosis is severe or severe
hyperkalemia is present.
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Question 44 Q
A 58-year-old woman with end-stage kidney disease due to diabetic kidney
disease is evaluated 4 weeks following pre-emptive living donor kidney
transplantation. The serum creatinine level fell from 670 umol/L prior to
transplantation to 98 umol/L at discharge. One week ago, a double-J ureteral
stent placed at the time of surgery was found coiled in the bladder and was
removed cystoscopically.
Which one of the following is the most likely diagnosis in this patient?
A Urine leak
B Liquefied hematoma
C Seroma
D Sterile abscess
E Lymphocele
Options B, C, D and E are incorrect, option A is the correct answer. The fluid
characteristics are most consistent with a urine leak. Urinary leak or urinoma
is usually due to ureteral or bladder injury resulting in collection of the urine
outside the bladder. The frequency of this complication is approximately
0.8%9.3%, usually occurring in the first month following transplantation.
The most frequent causes include trauma to the ureter during dissection or
ischemia of the distal ureter resulting in necrosis or acute rejection. Urine
leaks can also occur at the ureteral-vesical anastomosis, particularly in patients
with diabetes mellitus that may have a friable and thin bladder mucosa. The
dislodgement of the ureteral stent in this case could have contributed to the
development the leak.
The increased level of creatinine in the fluid aspirate relative to the serum
creatinine is consistent with a urine leak. Bladder decompression with a
catheter is a critical initial step in the management of suspected leaks. The
catheter reduces intravesical pressure and in some cases may resolve the
leak completely. The diagnosis is confirmed by demonstration of contrast
on cystogram, antegrade nephrostogram, or radioactive tracer on nuclear
medicine scanning outside the collecting system and bladder. Definitive
treatment depends on the etiology and may often require surgical intervention.
Lymphoceles also cause pelvic fluid collections but show creatinine values
equal to that of the serum, as well as increased triglyceride values.
The creatinine level in seromas, liquefied hematomas, and sterile abscesses
is also equivalent to that of the serum, inconsistent with the findings in this
patient.
Surgical complications of kidney transplantation
Early
Bleeding
Wound infection
Graft thrombosis
Urinary leak
Lymphocoele
Late
Ureteric stenosis
Renal artery stenosis
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Question 45 Q
A 68-year-old man with chronic renal failure secondary to type 2 diabetes
mellitus presents with hematemesis. Initial laboratory values indicate a
hematocrit of 23%, platelet count of 267,000/mm3, Blood urea 65, and
creatinine of 995 umol/l. A decision is made to transfuse the patient with
2 units of packed red blood cells and to arrange for upper endoscopy. In
addition, preparations are made for temporary access to initiate haemodialysis.
What other therapy would be most likely to minimize bleeding in this patient?
A Platelet transfusion
B IV Desmopressin
C IM Vitamin K
D IV Protamine
E IV Octreotide
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Question 46 Q
A 54-year-old man with stage 3 CKD due to IgA nephropathy presents for
further evaluation of a 2-week history of persistent gross hematuria. He denies
flank pain, fever, or dysuria. He was diagnosed with IgA nephropathy at age
34. At that time, he presented with normal kidney function, dysmorphic
hematuria, and 1.6 g of urinary protein excretion per day. Kidney biopsy
showed IgA nephropathy with focal proliferative glomerulonephritis. He was
treated with enalapril, and the proteinuria declined and has remained stable at
approximately 0.4 g/day.
On physical examination, the blood pressure is 180/95 mmHg, increased
from 130/80 mmHg 4 months ago. A bruit is heard over the left kidney
and is present during both systole and diastole. The remainder of the
examination is normal.
Laboratory studies show a stable serum creatinine level of 102 umol/L,
haemoglobin level of 12.2 g/dl, and platelet count of 350,000/l. The urine
albumin:creatinine ratio is 53 mg/g.
Urinalysis shows trace protein and 2+ blood. Microscopic examination of the
urinary sediment shows too numerous to count red cells per high power field,
most of which have normal morphology.
A kidney ultrasound with colour Doppler is shown.
Remaining material is same with no change.
A kidney ultrasound with colour Doppler is shown.
Which one of the following is the most likely diagnosis in this patient?
A Renal cell carcinoma
B Renal infarction
C Arteriovenous fistula (AVF)
D Renal artery stenosis
E Simple renal cyst
Options A, B, D and E are incorrect, option C is the correct answer. The most
likely diagnosis is an AVF that most likely developed as a consequence of the
previous kidney biopsy. Doppler ultrasound shows a blue-red flow pattern within
the hypoechoic area in the lower pole of the left kidney characteristic of AVF.
The frequency of AVF formation following kidney biopsy ranges from 0.4% to
18% but may be more common with renal transplant biopsies. Most AVFs are
asymptomatic, do not require intervention, and resolve spontaneously.
In some cases, however, they may become aneurysmal and present years later
with hematuria and hypertension as noted in this patient. High-output cardiac
failure, rupture, infection, mass effect, and impaired kidney function have also
been reported. An abdominal or flank bruit is an important diagnostic clue.
Computed tomography (CT) angiography and magnetic resonance angiography
serve as complimentary diagnostic studies. Digital subtraction angiography is
reserved for percutaneous intervention or for definitive anatomic evaluation prior
to surgery. Transcatheter arterial embolization or surgery is usually indicated for
symptomatic or enlarging lesions, particularly when symptoms are more severe.
The diagnosis in this case was confirmed angiography (see figure). This patient
was successfully treated with embolization.
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Questions 47 & 48 Q
Question 47
There is no benefit in treating asymptomatic bacteriuria except in?
A Diabetes
B Elderly
C Neurogenic bladder
D Pregnancy
E Catheterised patients
Question 48
KDIGO recommendations for management of AKI do not include
Answer 47
Options A, B, C and E are incorrect, option D is the correct answer.
Pregnancy
There is proven benefit in treating asymptomatic bacteriuria in pregnant
patients. There is 8% chance of asymptomatic UTI to become symptomatic
within 7 days.
No benefit of treatment shown in Diabetes, Elderly, Neurogenic bladder
and in catheterised patients.
In CKD patients alteration of dose is required to avoid toxicity
NICE Guideline suggest 5-10 days treatment for uncomplicated Lower UTI in
women with CKD.
(Smaill, Cochrane database 2007)
Answer 48
Options A, B, C and E are incorrect, option D is the correct answer.
Using Fenoldopam to prevent or treat AKI
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Question 49 Q
A 50-year-old man with end-stage kidney disease secondary to diabetic
kidney disease maintained on peritoneal dialysis is seen in follow-up 5 days
after presenting with a third episode of peritonitis over the last 3 months. Two
months ago, he was treated for culture-negative peritonitis with intraperitoneal
cefazolin. One month ago, he was treated with intraperitoneal cefazolin for
oxacillin-sensitive Staphlococcal epidermidis peritonitis. On both occasions, the
patient admitted to touch contamination. Peritoneal fluid analysis 5 days ago
showed 804 white cells/mm3, with 70% neutrophils.
Gram stain was negative. The patient was started on empiric intraperitoneal
vancomycin and ceftazidime.
He currently complains of abdominal pain and persistently cloudy peritoneal
fluid. On physical examination, he appears ill. The blood pressure is 114/80
mmHg, pulse is 99 beats/min, and temperature is 38.3o C (100.9oF).
The abdomen shows diffuse tenderness with guarding, rebound tenderness,
and decreased bowel sounds. The exit site of the peritoneal dialysis catheter
shows no erythema or exudate. There is no induration or tenderness along the
catheter tunnel.
Peritoneal fluid analysis shows 6600 white cells/mm3, of which 80% are
neutrophils. Peritoneal dialysis fluid cultures show no growth at 5 days.
Which one of the following is the most appropriate next step in management
of this patient ?
Options B, C, D and E are incorrect, option A is the correct answer. The patient
has refractory peritonitis, defined as failure of the effluent to clear after 5 days
of appropriate antibiotics, and removal of the dialysis catheter is indicated.
Causes of refractory peritonitis include antibiotic-resistant pathogens,
fungal peritonitis, tunnel infection, or atypical pathogens. Recent treatment
for two episodes of bacterial peritonitis significantly increases the risk for
fungal peritonitis, and the worsening clinical picture despite broad-spectrum
antibiotics should raise suspicion for this diagnosis.
Fungal peritonitis is often difficult to diagnose. Gram stain of peritoneal fluid
is positive in only 30% of cases, and culture may take several days to weeks to
show growth.
The International Society for Peritoneal Dialysis guideline on peritoneal
dialysisrelated infections recommends catheter removal in cases of refractory
peritonitis. In cases of fungal peritonitis, immediate catheter removal is
recommended after fungi are identified by microscopy or culture.
Empiric addition of an aminoglycoside antibiotic would be appropriate for
documented Pseudomonas infection, but this patient has negative cultures and
refractory peritonitis necessitating catheter removal.
Addition of antifungal therapy pending culture results, in addition to
catheter removal, is appropriate for this patient because there is high clinical
suspicion for fungal peritonitis. Therapy with oral fluconazole, or alternatively
with intravenous amphotericin B or an intravenous echinocandin such as
caspofungin (when there is significant prior exposure to azole antifungals),
is indicated. Use of intraperitoneal amphotericin is discouraged because
of associated chemical peritonitis, pain, peritoneal membrane injury, and
treatment failure.
It would not be appropriate to continue current therapy because the patient
meets criteria for refractory peritonitis. Moreover, given the high suspicion for
fungal peritonitis, this strategy places the patient at increased risk for significant
morbidity and mortality.
An ultrasound of the catheter can help assess whether a tunnel infection
is present. However, there are clear indications for catheter removal in this
patient, and results of this study would not change management.
References
Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, Johnson DW, Kuijper EJ, Lye WC,
Salzer W, Schaefer F, Struijk DG; International Society for Peritoneal Dialysis: Peritoneal dialysis-
related infections recommendations: 2010 update. Perit Dial Int 30:393423, 2010
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Question 50 Q
A 40-year-old male with alcoholic liver disease and portal hypertension was
admitted with confusion. He was taking spironolactone, thiamine, Vitamin B12
and propranolol. He was treated initially with intravenous fluids and lactulose.
Investigation on admission
Urea 4 mmol/L 2.5-7.0
Creatinine 80 umol/L 60-110
Hepatorenal syndrome
Type 1
Type 2
Nephrotoxic drugs
NSAID
Aminoglycosides
Contrast agents
Hypovolaemia induced
Gastrointestinal bleeding
Diuretics
Diarrhoea
Parenchymal renal disease
Acute tubular necrosis
Glomerulonephritis (Hepatitis B, Hepatitis C)
IgA Nephropathy
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Question 51 Q
A 51-year-old man presents with marked peripheral oedema .
His UPCR (Urine protein Creatinine ration) 900
Serum Albumin 27 g/L
eGFR of 85 ml/min.
Which one of the following is least likely to be associated with this disease?
A Gold therapy
B Graft versus host disease
C Heavy metal ingestion
D Hodgkins disease
E Diclofenac use
Idiopathic 87%
Secondary 13%
Drugs NSAID
Alpha Interferon
Lithium
Gold (Usually Membranous)
Allergy 1. Pollens
2. House dust
3. Immunisations
4. Insect stings
Malignancy 1. Hodgkins
2. Mycosis fungoides
3. CLL (but usually MPGN)
Initial treatment
Prednisone
Daily single dose of 1 mg/kg (maximum 80 mg) or alternate-day single
dose of 2 mg/kg (maximum 120 mg) until complete remission (minimum
4 weeks to a maximum of 16 weeks)after complete remission, tapered
slowly over 6 months.
FR (frequent relapsing) Remission in >90% of patients or SD (steroid
dependent) MCD (minimal change disease)
1. Cyclophosphamide (oral) single course 22.5 mg/kg/d as tolerated for 8
weeks.
2. Relapsed despite cyclophosphamide, or patients of childbearing age a
Cyclosporine starting dose 35 mg/kg/d (in two equally divided doses)
b. Tacrolimus 0.050.1 mg/kg/d (in two equally divided doses)
Following 3 months of stable remission, tapered to reach the minimum
dosage that maintains remission, for 12 years
3. Intolerant to corticosteroids, cyclophosphamide, and/or CNIs
a. Mycophenolate mofetil 5001000 mg twice daily for 12 years
Frequency of relapses
Steroid denpendence
Contraindications for use of steroids (Diabetes mellitus, obesity,
Psychiatric conditions, severe osteoporosis)
Fertility concerns
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Question 52 Q
Which one of the following statements is incorrect with regards to duration of
treatment in Uncomplicated UTI?
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Questions 53 & 54 Q
Question 53
KDIGO guideline suggestions for management of AKI do not include?
Question 54
A 65-year-old male presented with nephrotic syndrome receives steroid
therapy without benefit. His investigations show an albumin of 20 g/L , Total
cholesterol of 13 mmol/l, dipstick urinalysis reveals ++++ protein and a renal
biopsy shows Idiopathic focal segmental glomerulosclerosis.
Which one of the following is most likely to preserve renal function in this
patient?
A Ramipril
B Dietary salt restriction
C Mycophenolate mofetil
D Low dietary protein intake
E Atorvastatin
Answer 53
Options A, B, C and D are incorrect, option E is the correct answer. KDIGO
suggest providing nutrition preferentially via enteral route
(Kidney International 2012; Vol 2:1-141)
Answer 54
Options B, C, D and E are incorrect, option A is the correct answer.
Approximately 50% of subjects with FSGS do not respond to steroid therapy
but ACE inhibitors with a target BP <130/80 is a recognized strategy to
slow the progression of renal disease. This patient is clearly at high risk of
cardiovascular disease with a very high cholesterol .
KDIGO Guidelines for Treatment of Idiopathic FSGS
Steroid-resistant FSGS
cydosporine at 3-5 mgl/kg/d in divided doses to be given for at least
4-6 months
If there is a partial or complete remission. continue cyclosporine
treatment for at least 12 months. followed by a slow taper.
Those who do not tolerate cydosporine. be treated with a combination
of mycophenolate mofetil and highdose dexamethasone
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Questions 55 & 56 Q
Question 55
A 77-year-old woman presents with sudden onset atrial fibrillation (ventricular
rate of 170/minute). Her serum creatinine concentration was 258umol with
eGFR 24 ml/min.
What is the main factor that determines the choice of loading dose of digoxin
in this patient?
A Lipid solubility
B Plasma half-life
C Renal excretion
D Volume of distribution
E Absorption
Question 56
A 42-year-old man comes to follow up clinic for a kidney biopsy result
His Blood pressure was 138/82
His recent 24 hr urine protein is 1.3g/day and serum creatinine was 80umol/l.
What is the target Blood pressure in this patient to slow down the progression
of his kidney disease?
A 125/75
B 125/80
C 130/80
D 135/80
E 140/80
Answer 55
Options A, B, D and E are incorrect, option C is the correct answer.
Digoxin is cleared by the kidneys so the maintenance dose would require
adjustment in renal failure.
The pharmacokinetics of digoxin is complex and best explained by a two
Compartment model. The loading dose is mainly dependent on the Volume of
Distribution of a drug but this patient has moderate renal failure. The loading
dose is calculated (using various models) by taking into account age, Creatinine
clearance, body surface area etc. Volume of distribution becomes important
particularly when body weight is 40kg or less. On balance it is the renal failure
that is the most important factor in this patient in determining the loading dose.
Answer 56
Options B, C, D and E are incorrect, option A is the correct answer. Total
number of glomeruli seen on the biopsy is not an independent predictor of
clinical outcome.
Blood pressure >- 130/80 mm Hg and spot urine <130/80 A ACE inhibitor A Diuretic preferred, then beta A
total protein-to-creatinine ratio >- :200 mg/g mm Hg or ARB blocker or calcium-channel blocker
Blood pressure ->130/80 mm Hg and spot urine <130/80 B None preferred Diurelic preferred, then ACE A
total protein-to-crealinine ratio <200 mglg mm Hg inhibitor, ARB, beta-blocker or
calcium-channel blocker
Blood pressure <130/80 mm Hg and spot urine ACE inhibitor C Diuretic preferred, then beta- A
total protein-to-creatinine ratio <- 200 mglg or ARB blocker or calcium-channel blocker
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Question 57 Q
Which one of the following statements is true regarding use of corticosteroid
for IgA nephropathy as per KDIGO guidelines?
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Question 58 Q
Which one of the following blood work up is not recommended for CKD stage
5D care in a Haemodialysis unit?
Serum calcium should be maintained between 2.2 and 2.5 mmol/L, with
avoidance of hypercalcaemic episodes.
Serum phosphate in patients with CKD stage 3b-5 should be maintained
between 0.9 and 1.5 mmol/L.
Serum phosphate in dialysis patients (stage 5D) between 1.1 and 1.7 mmol/L
CKD stages 3b-5 not on dialysis therapy in whom serum PTH -higher than the
upper reference limit for the assay, despite correction of modifiable factors
Stage 5D- target range for parathyroid hormone measured using an intact PTH
assay should be between 2 and 9 times the upper limit of normal for the assay
PTH range corresponds to approximately 130-600pg/mL
Bone-specific alkaline phosphatase
can be used to evaluate bone
markedly high or low values predict underlying bone turnover
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Question 59 Q
A 67-year-old man was referred to the nephrologists after he was noted to be
oliguric following an elective coronary angiography. He had a past medical
history of hypertension, for which he was taking ramipril. On examination he
was euvolemic and had mottled skin changes on his legs.
Labs shows
serum sodium 134 mmol/L (137144)
serum potassium 5.5 mmol/L (3.54.9)
serum urea 33.3 mmol/L (2.57.0)
serum creatinine 356 mol/L (60110)
creatine kinase 460 U/L (24170)
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Question 60 Q
Compared to general population which one of the following malignancy occurs
after kidney transplantation with the highest relative risk compared to general
population?
Unexplained Fever
Mononucleosis like syndrome
( Fever, malaise, pharyngitis,tonsillitis)
Gastrointestinal bleeding,obstruction, perforation
Abdominal mass lesion
Infiltrative disease of allograft
Hepatocellular or pancreatic dysfunction
Central nervous system disease
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Question 61 Q
72-year-old female was referred with diagnosis of 6 gram proteinuria/day
Patient seen on Wednesday, admitted on Friday for kidney biopsy but she
developed pulmonary embolism on Saturday morning.
Investigations showed antiPLA2R negative but positive lupus serology.
Clinically she has no features of SLE.
Which is the best treatment option for her in long-term maintenance phase?
A Rituximab
B Corticosteroid alone
C Mycophenolate mofetil (MMF)+Low dose Prednisolone
D RAAS(Renin angiotensin aldosterone blockade) Blockade only
E Calcineurin inhibitor (CNI) with or without corticosteroid
Class IV: diffuse lupus 50% of glomeruli on LM display endocapillary and/or Nephritic and nephrotic
nephritis* extracapillary proliferation or sclerosis; class IV-S denotes syndromes, hypertension,
50% of affected glomeruli have segmental lesions; class reduced kidney function
IV-G denotes 50% of affected glomeruli have global lesions;
mesangial and diffuse subendothelial IC deposits on IF and EM
Class V: membranous Diffuse thickening of the glomerular capillary walls on LM Nephrotic syndrome
lupus nephritis with subepithelial IC deposits on IF and EM, with or without
mesangial IC deposits
Class VI: advanced >90% of glomeruli on LM are globally sclerosed with no Markedly reduced kidney
sclerosing lupus nephritis residual activity function, hypertension
A Collecting duct
B Ascending limb
C Proximal tubule
D Distal tubule
E Descending limb
The thin ascending limb is found in the medulla of the kidney, and the thick
ascending limb can be divided into a part that is in the renal medulla and a
part that is in the renal cortex.
Ascending limb is impermeable to water and ions, except sodium and chloride
which cross by diffusion.
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Question 63 Q
Which one of the following statement is incorrect about collapsing variant of
Focal segmental glomerulosclerosis?
A Associated with HIV and parvovirus infection and pamidronate and IFN
treatment
B May be idiopathic
C Much more common in AfroCaribbeans
D Typically present as mild nephrotic syndrome
E Biopsy Changes may look similar to crescents
Electron microscopy
Endothelial
tubuloreticular
inclusions in a
specimen with
collapsing FSGS
increase the likelihood
of HIV associated
FSGS
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Question 64 Q
A 59-year-old man with stage 3 CKD receiving therapy with sunitinib for stage
IV renal cell carcinoma is seen for new onset hypertension. He denies shortness
of breath, leg edema, headache, or focal neurologic symptoms.
On physical examination, he is alert and oriented. The blood pressure is 160/94
mmHg, which is increased from 130/80 mmHg 1 month ago. Fundoscopic
examination shows no papilledema. There is trace pretibial edema bilaterally.
There are no neurologic deficits.
Laboratory studies show a serum creatinine level of 160 umol/L (stable from
previous measurements), Modification of Diet in Renal Disease eGFR of 54
ml/min per 1.73 m2, white cell count of 10,000/l, haemoglobin level of 11
g/dl, and platelet count of 300,000/l. Peripheral blood smear shows no
schistocytes.
The urine protein:creatinine ratio is 1200 mg/g, increased from 200 mg/g one
month ago.
Which one of the following is the most appropriate next step in the
management of this patient?
A Abdominal magnetic resonance venography
B Begin a non-dihydropyridine calcium antagonist
C Discontinue sunitinib
D Renal artery duplex doppler ultrasonography
E Start an angiotensin converting enzyme inhibitor
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Question 65 Q
A 51-year-old man known case of chronic kidney disease stage 4 admitted with
right lower abdominal pain
CT abdomen is requested
A Cyst infection
B Cyst torsion
C Cyst rupture
D Cyst haemorrhage
E UTI
Star pointed towards increase density of cyst which indicate cyst haemorrhage,
arrow indicates cyst compressing inferior vena cava (IVC).
ADPKD is the 4rth most common cause of ESRD in UK. 10% of prevalent ESRD
in UK. 100% suffers renal cyst, 80% suffers liver cysts.
Liver function usually normal (alkphos and GGT can increase to 5x normal)
Women more prone to severe liver cysts than men (prevalence equivalent)
Oestrogen therapy risk factor
Number of pregnancies a risk factor
Severity of renal disease a risk factor
No data to suggest a genetic cause for massive PLD (polycystic liver disease)
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Question 66 Q
Which one of the following is a relatively more accurate parameter to monitor
renal function in patients with diabetes who have co existent liver cirrhosis?
A Urinary C peptide
B Albumin Creatinine ratio
C Serum Creatinine
D Serum cystatin C
E Serum chromogranin B
Cystatin C (Serum)
Increased:
Acute or chronic renal failure, HIV, increased BMI, high C-reactive
protein, hyperthyroidism, corticosteroid use
Decreased:
Atherosclerotic vascular disease, cyclosporine treatment
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Question 67 Q
A 50-year-old kidney transplant patient admitted with a acute rise in serum
Creatinine.
Which one of the following is the most likely diagnosis on Graft Biopsy?
A Severe tubulitis.
B BK virus inclusions.
C Cytomegalovirus inclusions.
D Arteritis
E Oxalate crystal deposits
The Banff 97 Working Classification of Renal Allograft Pathology, Kidney International, Vol 55, 1999,
pp 713-723
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Question 68 Q
A 42-year-old man known case of ESRD secondary to IgA Nephropathy
received a live related kidney transplant from his brother 4 years ago;
attended an accident and emergency with a 2 day history of skin rash.
His immunosuppressive medications are Tacrolimus, Prednisolone and
Mycophenolate mofetil.
His eGFR is 70 ml/min stable
Which one of the following is the most likely aetiology of skin rash in
this patient?
A Chicken pox
B HHV6 infection
C HHV8
D Molluscum contagiosum
E Fungal infection
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Question 69 Q
A 70-year-old retired politician was reviewed in the diabetes clinic on a
routine follow up visit. He was diagnosed as having type 2 diabetes about
8 years earlier and was taking metformin and gliclazide tablets. He was
known patient with hypertension, currently on ramipril and amlodipine
tablets. On examination he had a BMI of 31 kg/m2, with evidence of central
adiposity. There was evidence of bilateral background diabetic retinopathy on
ophthalmological examination.
Investigations
A Systemic hypertension
B Absence of RBC cast in urine
C Duration of Type 2 DM >5 years
D The presence of diabetic retinopathy
E Rapid decline in eGFR
Ref: KDOQI clinical practice guidline for Diabetes and CKD 2012
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Question 70 Q
A 69-year-old woman with hypertension and stage 4 chronic kidney disease
(eGFR 24 ml/min per 1.73 m2) attended a clinic for her routine review.
Investigations:
serum cholesterol 6.9 mmol/L (<5.2)
serum LDL cholesterol 3.9 mmol/L (<3.36)
Which one of the following is most likely to be true in patients with CKD?
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Question 71 Q
A 26-year-old male patient with end stage renal disease on peritoneal dialysis
from previous 5 years admitted with recently decrease history of appetite
along with flatulence. He lost 2 kg in weight over the last two months.
Peritoneal nurse noticed that from the last week, his Ultrafiltration is usually
<400 ml/day.
A PD Peritonitis
B Paralytic ileus
C Encapsulating peritoneal sclerosis
D Bowel obstruction
E None of above
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Questions 72 & 73 Q
Question 72
Gitelmans syndrome transporter protein defect is located on which one of the
segment of Nephron?
A Proximal Tubule
B Thick Ascending Limb
C Thin Ascending Limb
D Distal Convoluted Tubule
E Collecting Duct
Question 73
Which one of the following chronic metal exposure is associated with an
increase risk of developing renal cell carcinoma?
A Lead
B Arsenic
C Nickel
D Cadmium
E None of above
Answer 72
Options A, C, D and E are incorrect. Option B is the correct answer. Gitelmans
syndrome transporter defect is located at distal convoluted tubule.
Nephron defects in Transport Proteins resulting in Renal Disease
Cystinuria
Proximal Tubule
Proximal renal tubular acidosis
Bartter syndrome Thick ascending limb
Gitelmans syndrome Distal convoluted tubule
Liddles syndrome
Distal renal tubular acidosis Collecting duct
Nephrogenic Diabetes insipidus
Answer 73
Options A, B, C & E are incorrect. The correct answer is D - Cadmium.
Cadmium is highly oncogenic and is associated with lung, prostate and renal
cell carcinoma
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Questions 74 & 75 Q
Question 74
All of the following are poor prognostic factors for lupus nephritis except?
A Male gender
B Female gender
C Younger age <24 years
D Low socioeconomic status
E Black race
Question 75
Which one of the following drug is least likely to be associated with thrombotic
microangiopathy ?
A Ticlodipine
B Quinine
C Calcineurin inhibitors
D Oral contraceptives
E Aspirin
Answer 74
Options A, C, D and E are incorrect. Option B is the correct answer. All
above mentioned factors are related to bad prognosis except the female
gender. Other laboratory and clinical factors associated with poor prognosis
include higher serum creatinine at presentation, higher baseline proteinuria,
hypertension, severe anaemia, thrombocytopenia, and hypocomplementemia
with elevated anti-double stranded DNA levels, delay in starting therapy,
response to treatment, and nephritic relapse.
Answer 75
Options A, B, C and D are incorrect. Option E is the correct answer. Thrombotic
microangiopathy is associated with many drugs including anticancer drugs.
Mitomycin C, Tamoxifen, Bleomycin, Cisplatin, Gemcitabine. Other drugs,
OKT3, Interferon alpha, Penicillin, Rifampin, Metronidazole.Aspirin use is not
associated with thrombotic microangiopathy
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Questions 76, 77 & 78 Q
Question 76
A 26-year-old female recently diagnosed to have Systemic lupus erythmatosis
fulfilling the American college Rheumatology (ACR )Criteria for SLE, found to
have active urinary sediment.
Urine PCR 225 (<15)
Kidney biopsy was performed found Class IV diffuse proliferative SLE.
She was offered induction therapy with cyclophosphamide & steroids but
refused due to fertility problems in future.
Question 77
Which one of the following is approved drug therapy for atypical Haemolytic
uraemic syndrome?
A Basiliximab
B Infliximab
C Etanercept
D Eculizumab.
E Bortezomib
Question 78
Disease activity in lupus nephritis is monitored by all of the following
parameters except?
A Blood pressure
B GFR (Glomerular filteration rate)
C Proteinuria
D Urinary sediment
E Elevated anti-ds DNA level.
Answer 76
Options A, B, C and D are incorrect, option E is the correct answer. No
difference in cyclophosphamide and mycophenolate mofetil of achieving
remission.
Answer 77
Options A, B, C and E are incorrect, option D is the correct answer. Eculizumab
approved for the treatment of atypical haemolytic uraemic syndrome. It is
humanized monoclonal antitbody against complement C5 and blocks the
membrane attacking complex C5b-9. Basiliximab is IL2 blocker and used as
induction therapy in kidney transplant recipients. Infliximab and etanercep used
in autoimmune diseases. Bortezomib is treatment for multiple myeloma.
Answer 78
Options A, B, C and D are incorrect, option E is the correct answer. Disease
activity in lupus nephritis is monitored by blood pressue, GFR, Proteinuria,
Urinary sediment. An elevated anti-ds DNA level usually correlates with the
relapse. Many patients with elevated anti-ds DNA level for years without any
relapse. It is not wise to treat only serologic activity in absence clinical active
disease.
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Question 79 Q
What are the possible treatments for cell mediated rejection in a Kidney
transplant patient ?
A Plasmaphersis
B Corticosteroids, Rituximab, Plasmaphersis
C Corticosteroids, IVIG (Immunoglobulin), Thymoglobulin
D Corticosteroids, Thymoglobulin and increase signal 1 Blockers
E Corticosteroids, Bortezomib, Thymoglobulin
Phases of immunosuppression
Tac=tacrolimus; CsA=cyclosporine; Ster=corticosteroids; Sir=sirolimus;
MMF=mycophenolate mofetil; AZA=azathioprine
T-cell activation and proliferation
require at least three signals
mediated by the interaction with
alloantigens. Signal 1 is the first
signal in the activation of the
IL-2 transcription pathway by
a specific antigen and involves
the T cell receptor complex
(C3+CD4) recognizing the MHC
+ peptide presented to it by an
antigen presenting cell (APC).
Costimulation (signal 2) is non-
specific and is mediated by
interaction between the B7 ligand
on the APC and the CD28 ligand
on the T cell. This signal is required
for full T-cell activation. These two
signals activate the intracellular
pathway for IL-2 and other growth
factor expression.
Signal 3 is induced by IL-2 and
other growth factors and leads
to cell cycle progression and proliferation. They are activated via the mTOR
(mammalian target of rapamycin). The fourth "signal" is programmed cell death
-- a natural consequence of T-cell activation.
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Questions 80 & 81 Q
Question 80
According to NICE guidelines, which one of the following is the correct
indication to stop metformin therapy in the presence of renal impairment?
Question 81
Which one of following is a non-modifiable risk factor for NODAT ?
(New onset diabetes after transplant)
A HCV Infection
B CMV Infection
C Pre-transplant IGT
D Acute rejection History
E Proteinuria
Answer 80
Options A, B, D and E are incorrect, option C is the correct answer.
According to NICE guidelines the metformin therapy should be stopped if
serum Creatinine >150 umol/L or eGFR<45ml/min/1.73 m2
Answer 81
Options A, B, C and E are incorrect, option D is the correct answer. Non-
modifiable risk factor for NODAT is acute rejection history others all are
modifiable risk factors.
Immunosuppression
Black Hispanic Corticosteroid
Age >40 yrs Tacrolimus
Male Gender HCV infection
Cyclosporine
ADPKD CMV infection
Sirolimus
HLA mismatches Pre - TxIGT
Acute rejection Obesity/metabolic
FH Diabetes syndrome
Hypomagnesemia
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Questions 82 & 83 Q
Question 82
Which one of the following tools accurately measure GFR (Glomerular filtration
rate) in Pregnancy?
A MDRD
B CKD-EPI
C Cystatin C
D Cockcroft and Gault
E None of above
Question 83
Which one of the following is the least likely cause of uraemic pruritis?
A Adequate dialysis
B Hyperparathyroidism
C Allergic manifestation to heparin or acetate
D Xerosis
E Derangements in immune system
Answer 82
Options A, B, C and D are incorrect, option E is the correct answer.
In pregnancy the best tool is
Pre-pregnancy eGFR OR 24 hour creatinine clearance or TRACK
INDIVIDUAL CREATININE. So, option E is the correct answer
Table showing different modality of GFR estimation and there use in pregnancy
Answer 83
Options B,C,D and E are incorrect Option A is the correct answer. Inadequate
dialysis often causes pruritis
Causes of uraemic pruritis
Hypercalcaemia
Hyperphosphataemia
Severe Hyperparathyroidism
Inadequate removal of middle Molecular weight Uraemic toxins
Treatment
First line - Moisturising creams and lotions
Other treatment include
Antihistamines (hydroxyzine)
UV B Phototherapy- need to be given 2-3 times per week
Topical capsaicin cream
Gabapentin- especially in peripheral diabetic neuropathy (300 mg
after each session of dialysis) confirmed in RCT.
Topical tacrolimus ointment
If pruritis occurs only during HD
Change formulation of heparin
Change type of dialysis membrane
Increase rinsing volume
If all modalities failed - Kidney transplant
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Questions 84 & 85 Q
Question 84
Which one of the following is the most common sleep disorder in dialysis
patients?
A Insomnia
B Restless leg syndrome
C Nightmares
D Daytime sleepiness
E Sleep apnoea
Question 85
Which one of the following laboratory parameter is associated with an increase
probability of death in End stage renal disease populations?
A Increase PTH
B Low haemoglobin
C High Serum Calcium
D Low Serum Albumin
E None of above
Answer 84
Options B, C, D and E are incorrect. Option A is the correct answer.
Insomnia is the most common sleep disorder seen in 70% of Dialysis patients.
Mostly seen in morning shift.
Merlino,Nephrol.Dial.Transpl.(2006) 21:184
Treatment
Behavioural treatment
Medications- benzodiazepines(temazepam or triazolam) and non
benzodiazepines (zolpidem) can be use
Antihistamines and tricyclic antidepressants has no role
Answer 85
Options A, B, C and E are incorrect. Option D is the correct answer.
Low serum albumin strongly associated with increase risk of death in ESRD.
Owen, WF Jr, Lew, NL, Liu, Y, et al, N Engl J Med 1993; 329:1001.
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Question 86 Q
A 38-year-old female who got cadaveric kidney transplant one week ago
found to have worse graft function. Her baseline serum creatinine is 700
umol/L started to drop initially but became static around 420 umol/L from
previous three days. She developed right sided weakness which recovered
over 24 hours.
Which one of the following is the most likely diagnosis in her clinical scenario?
A Chronic rejection
B Thrombotic thrombocytopenic purpura
C Calcineurin inhibitors toxicity
D Infection
E Renal vein thrombosis.
HUS TTP
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A
Secondary causes of TMA
Pregnancy-(Preclampsia, HELP)
Malignant HTN
Systemic sclerosis
Infection(HIV)
Autoimmune -SLE
Disseminated Malignancy- gastric ca, colon ca
Stem cell Transplant
Antiphospholipid syndrome
Pregnancy - (Preclampsia, HELP)
Drugs -
Calcineurin inhibitors- Cyclosporine, Tacrolimus
Quinine
Antiplatlet Ticlopidine
Chemotherapy- Mitomycin, VEGF inhibitors
Gemcitabine
First line
Daily Plasma exchange( 1-1.5 Litre plasma volume with Fresh frozen
Plasma (FFP) or cryo poor plasma
Plasma exchange continues until platelet count>150 and haemolysis
markers(eg LDH normalize)
20% of patients shows transient or minimal response to initial plasma
exchange
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Question 87 Q
Which one of the following statements is correct about
Myeloma Cast Nephropathy?
Myeloma cast is typical hyaline, fractured casts (strong stain with Eosin, weak
with PAS), are seen in the distal tubuli and the collecting ducts (rarely in the
proximal tubuli) together with degenerative changes and atrophy of tubular
cells . They are surrounded by multinucleated cells of macrophage origin.
Myeloma cast is the most common cause of renal insufficiency. Severe AKI
in Myeloma is a medical emergency, rapid confirmation of diagnosis, urgent
referral to haematological service and immediate commencement of disease
specific treatment is very important.
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Question 88 Q
A 22-year-old university student of Malaysian origin, admitted with generalised
lethargy, vomiting, and diarrhoea. She has had an Indian takeaway the night
before and has started with gastrointestinal symptoms this morning. She is fit
and well and on no regular medications apart from Chinese slimming herbal
tea that she bought over the internet 3 months ago, which she religiously
drinks 3 times a day. Her blood tests show K 3.4, Urea 15mmol/L, Creatinine
345 umol/L, Urine dip shows 1+ protein. No previous blood tests are available
to compare.
Which one of the following is the most appropriate step in her further
management?
Clinical feature - Acute Kidney Injury, Nonnephrotic range proteinuria and mild
hypertension but most common renal histology lesion is Chronic hypocellular
tubulointerstitial fibrosis therefore on kidney ultrasound is small shrunken
kidneys.There is high incidence of uroepithelial cancers and risk persist lifelong.
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Questions 89 & 90 Q
Question 89
A 33-year-old lady presenting with right flank pain, bilateral leg swelling for 2
weeks which is rapidly worsening, urine dip shows 4+ blood and 4+ protein,
other investigations include Alb 17 g/L, Creat 200 umol/L, Urine PCR 1200.
Her ultrasound shows atrophic left kidney and normal sized right kidney, it was
difficult to do duplex.
Which one of the following is the most appropriate investigation in her clinical
scenario?
A Renal biopsy
B CT KUB
C CT Venography
D MR Venography
E Urinary catheter
Question 90
Which one of the following Heavy metal causes Nephrotic syndrome?
A Lead
B Cadmium
C Nickel
D Mercury
E Arsenic
Answer 89
Options A, B, D and E are incorrect. Option C is the correct answer.
MR Venography (to minimise risk of contrast induced nephrotoxicity) needs to
be done urgently to rule out renal vein thrombosis(in the context of nephrotic
syndrome- thrombogenic state) in the single functioning right kidney.
Answer 90
Options A, B, C and E are incorrect. Option D is the correct answer. Mercury
is the only heavy metal which cause nephrotic syndrome Lead, Arsenic and
Cadmium cause nonnephrotic range proteinuria.
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Questions 91 & 92 Q
Question 91
A 82-year old Asian male with a complicated past medical history , including
gastrointestinal (GI) bleeding from esophageal varices, colon cancer and
chronic kidney disease stage 4, is hospitalized with a deep vein venous
thrombosis (DVT). He is obese (BMI- 41) and had a hemicolectomy 2 weeks
ago.
Labs
Which of the following parameter would you check to know enoxaparin dose is
therapeutic?
A Factor Xa
B PTT
C PT
D anti-Xa level
E None of the above
Question 92
Which of the following metal exposure from industrial pollution of food
supply has shown an increase in the incidence of HTN, CKD and Kidney stone
disease?
A Cadmium
B Arsenic
C Lead
D Zinc
E Nickel
Answer 91
Options A, B, C and E are false.
Correct answer is you have to check anti-Xa level. This is NOT factor Xa level,
which most likely will be normal with Lovenox (enoxaparin) therapy.
PTT is not useful in monitoring therapy with LMWH. PTT should be used to
monitor treatment with UFH, i.e. regular IV heparin.
What is anti-Xa level? Is it some "special" factor anti-Xa?
No, there is no factor anti-Xa. There is a factor Xa, just like the other 12 factors
in the anticoagulation cascade (there is no factor VI).
Anti-Xa level is determined by a simple mixing study. Patient plasma is added
to a known amount of factor Xa with antithrombin. LMWH in the patient plasma
will bind to antithrombin and inhibit factor Xa. The amount of residual factor Xa
is inversely proportional to the amount of LMWH the plasma.
Low anti-Xa value indicates a high level of anticoagulation. High anti-Xa level
indicates a low level of anticoagulation. For example, anti-Xa level of 0.5
indicates adequate anticoagulation, a level of 3 is not sufficient.
When is anti-Xa level monitoring indicated?
Answer 92
Options B, C, D and E are incorrect, option A is the correct answer Number of
population based studies from Sri Lanka, Japan, South Korea, Thailand and
Pakistan has shown increase incidence of HTN, CKD and kidney stones after
exposure to cadmium
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Question 93 Q
A 72-year-old man with stage II nonsmall cell lung cancer is found to have
an asymptomatic rise in creatinine coincident with the use of cisplatin. He
denies shortness of breath, leg edema, hematuria, or foamy urine. On physical
examination, he is alert and oriented. The blood pressure is 110/64 mmHg.
There is trace pretibial edema bilaterally.
Which one of the following is the most appropriate intervention to limit further
cisplatin-induced kidney injury?
A Intravenous magnesium
B Oral N-acetylcysteine
C Isotonic saline infusion
D Isotonic saline plus mannitol
E Isotonic saline plus furosemide
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Question 94 Q
A 25-year-old Afro-Carribean male presenting with 20 kg weight gain,
generalized swelling, BP 170/100, Creatinine 200 umol/L, Urine PCR 2000
mg/mmol. His immunology including ANA, ANCA, Anti-GBM and Serum
electrophoresis are unremarkable.
The histological features on the biopsy report show collapse and sclerosis of
the entire glomerular tuft, marked hypertrophy and hyperplasia of podocytes,
severe tubular injury and wrinkling and retraction of the glomerular basement
membrane.
Which one of the following is the most likely diagnosis in his clinical scenario?
A Global glomerulosclerosis
B Focal segmental glomerulosclerosis tip variant
C Collapsing glomerulopathy
D Focal segmental glomerulosclerosis cellular variant
E Focal segmental glomerulosclerosis perihilar variant
Collapsing variant
Associated with HIV, Parvovirus,
alpha Interferon and Pamidronate
treatment
Much more common in Afro-
carribeans
Typical presentation is severe
nephrotic syndrome with rapidly
declining renal function
Tip variant
Its significance is controversial
Has a good prognosis with response to steroids
Perihilar variant
Associated with hyperfiltration injury of secondary FSGS
It is the appearance characteristically seen in obesity related FSGS
Causes of Secondary FSGS Familial Form for Exams
(detected in <3% adults with FSGS)
-actinin 4
NPHSI = nephrin
NPHS2 = podocin
WT-I
TRPC6
SCARB2 (LIMP2)
INF2
CD2-associated proteins
Mitochondrial cytopathies
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Question 95 Q
A 24-year-old woman is seen in consultation for polyuria after sustaining
traumatic brain injury in a motor vehicle accident. The 24-hour urine volume
was 3.5 L over the last day. She has been receiving intravenous 0.45% saline
at a rate of 80 ml/h and has not been able to eat or drink. She was diagnosed
with bipolar disorder 1 year ago and has been maintained on lithium since
that time.
On physical examination, the blood pressure is 130/80 mmHg. The heart and
lungs are normal, and there is no peripheral edema.
Laboratory studies show a serum sodium level of 146 mEq/L and osmolality of
299 mOsm/kg. Urine osmolality is 200 mOsm/kg.
A 24-hour urine shows a total daily solute excretion of 700 mosmol/day.
Under close observation, intravenous fluids are discontinued at 8:00 am,
and the patients nil by mouth status is maintained. Four micrograms of
intravenous desmopressin is administered at 10:00 am.
A Salt-wasting nephropathy
B Complete central diabetes insipidus
C Partial nephrogenic diabetes insipidus
D Partial central diabetes insipidus
E Osmotic diuresis
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Question 96 Q
A 67-year-old man with stage G4 A1 CKD and a history of polycythemia vera
was recently started on trimethoprim-sulfamethoxazole (TMP-SMX) for cellulitis
of the left leg. He presents to the clinic with nausea, vomiting, diarrhoea, and
anorexia. He has no history of diabetes mellitus. Medications include low-dose
aspirin, folic acid, hydroxyurea, and TMP- SMX 160/800 mg twice daily.
Electrocardiogram shows mildly peaked T waves in leads II, V2, and V3.
Laboratory studies reveal a sodium level of 134 mEq/L, potassium (serum) level
of 9.1 mEq/L (1 month ago, it was 4.1 mEq/L), potassium (plasma) level of 8.2
mEq/L, chloride level of 110 mEq/L, total CO2 of 15 mEq/L (1 month ago, it
was 24 mEq/L), Blood urea 15 mmol/L, creatinine level of 220 umol/L(1 month
ago, it was 260 umo/L), calcium level of 21.mmol/L, and a platelet count of
707,000/l.
Which one of the following factors contributed the most to the pathogenesis of
the hyperkalemia in this patient?
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Question 97 Q
Hypomagnesaemia from urinary magnesium loss is seen with all of the
following medications except ?
A Cisplatin
B Carboplatin
C Cetuximab
D Omeprazole
E Diclofenac sodium
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Question 98 Q
Which one of the following statements is incorrect regarding collapsing
glomerulopathy?
Rapid onset
Median 10- 14 days post transplant but can be within 24 hrs.
More likely to have had acute Kidney Injury and develop rejection.
Biopsy changes take weeks to develop except Podocyte Foot process
effacement.
Management
No good data
Plasma exchange
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Questions 99 & 100 Q
Question 99
A 60-year-old male, previously fit and well, has admitted with backache,
tiredness and a Creatinine of 1500 umol/L. He had a normal renal function 2
years ago.
He is started on haemodialysis. He has raised kappa light chains and abnormal
serum electrophoresis.
Which one of the following management offers him the best chance of renal
recovery?
A Bone marrow biopsy, Dexamethasone and Bortezomib
B Renal biopsy, Dexamethasone
C Renal biopsy, skeletal survey, dexamethasone
D Renal biopsy, skeletal survey, dexamethasone, plasma exchange
E Dexamethasone, Bortezomib and plasma exchange
Question 100
A 27-year-old woman presents to the clinic for management of kidney pain.
A detailed family history reveals that her paternal grandfather has autosomal
dominant polycystic kidney disease (ADPKD), hypertension, and a serum
creatinine level of 223umol/L (eGFR, 33 ml/min per 1.73 m2) at the age of 70.
Her father has ADPKD, hypertension, and a serum creatinine level of 90umol/L
at the age of 51. She has never been diagnosed with high blood pressure.
Current medications include a multivitamin and a daily oral contraceptive. On
physical examination, her blood pressure is 115/70 mmHg and her height is
1.7m. The remainder of the examination is unremarkable.
Laboratory data are notable for no protein or blood on urinalysis.
Serum creatinine level is 90umol/L.
Volumetric magnetic resonance imaging (MRI) is performed. The right kidney
volume is 148 ml and the left is 350 ml.
Which one of the following statements best describes the risk of progressive
loss of kidney function in this patient?
A The risk is increased because she has kidney pain
B The risk will increase after her first term pregnancy
C The risk is increased due to the use of estrogen-containing oral
Contraceptives
D The risk is high based on her family history
E The risk of progressive loss of kidney function is low over the next 8 years.
Answer 99
Options B, C, D and E are incorrect, option A is the correct answer. Bone
marrow biopsy confirming increased plasma cell clones, Bortezomib and
Dexamethasone is the best plan out of all of them. The others are either high
risk, unnecessary or do not influence renal recovery.
There is role of some high cut off dialysis means protein permeable dialysis
remove far more light chain then plasma exchange.
Answer 100
Options A, B, C and D are incorrect, option E is the correct answer. Volumetric
MRI is not currently recommended as part of the management for patients
with ADPKD, but this information can be helpful to identify individuals at high
risk for progression. In addition, it is likely to be used in future clinical studies
to assess response to therapeutic intervention. This patient has a total kidney
volume (TKV) of 498 ml, and a height-adjusted TKV (htTKV) of 293 ml/m. This
is well below the threshold of an htTKV of 600 ml/m associated with loss of
kidney function in 8 years in the Consortium for Radiologic Imaging Studies of
Polycystic Kidney Disease study.
In addition, no one in her family has developed ESRD before the age of
70, arguing in favor of a PKD2 mutation, which is also associated with later
progression of CKD. Her risk for progression of CKD will increase after three
term pregnancies. Pain is not associated with an increased risk of loss of kidney
function. Estrogen exposure may potentially increase her risk of liver cysts but
should not affect her kidney disease.
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Question 101 Q
A 37-year-old man recently experienced bilateral parotid swelling and weight
loss. His serum Creatinine rose from 133umol/L (eGFR, 73 mL/min) to 385
umol/L (eGFR, 23 mL/min) within three months. He has been taking NSAID.
He was found to have bilateral hilar lymphadenopathy. Serum calcium level
was slightly elevated. Urine protein/creatinine ratio was 0.3. Urinalysis showed
only 1-2 RBCs/HPF and 1+ protein. Other serologies, including ANA, ANCA,
hepatitis B and C, are negative. Serum complement levels are normal.
Which one of the following is the most likely diagnosis in his clinical scenario?
This patient was diagnosed with sarcoidosis. He also underwent a lymph node
biopsy, which showed nonnecrotizing granulomatous lymphadenitis.
Sarcoidosis 5-10%
Idiopathic 15-20%
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Question 102 Q
An 89-year-old man returns for follow-up with his adult daughter. He has a
history of advanced CKD attributed to long-standing hypertension. Over the
last year, his eGFR has declined from 14 to 9 ml/min per 1.73 m2 earlier this
week. His other medical problems include chronic obstructive pulmonary
disease and benign prostatic hypertrophy. At his previous visits, he has been
unwilling to discuss renal replacement therapy or participate in preparations for
this eventuality.
After reviewing the recent laboratory results, the patient and his daughter
both ask whether there are alternatives to dialysis. He notes that he has lived
an active life and values his freedom and independence over quantity of life
and is interested in more conservative therapy. Upset by this conversation, his
daughter asks about the prognosis for conservative, nondialytic therapy.
Which one of the following responses best describes the outcome of active
medical care without dialysis?
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Question 103 Q
Look at the images.
Image 1. (Nodular glomerulosclerosis)
Image 2. Periodic acidSchiff (PAS stain)
Image 3. (Silver stain positive for kappa light chains)
Image 4. (Silver stain negative for lambda light chains)
1 2
3 4
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A
Comparison of clinical manifestations, renal lesions, and hematologic features
in patients with Monoclonal immunoglobulin deposition disease (MIDD).
Hypertension (%) 53 90
Hematuria (%) 45 89
Biopsy of a superficial
organ/Kidney biopsyo
Positive Negative
* No extrarenal manifestation
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Questions 104 & 105 Q
Question 104
Median survival from dialysis onset in AL (Primary) Amyloidosis is?
A 12 Months
B 18 Months
C 24 Months
D 36 Months
E 44 Month
Question 105
A 48-year-old man who had undergone cadaveric kidney transplantation 5
months ago for end-stage kidney disease due to idiopathic FSGS is admitted
for further evaluation of hematemesis. Induction therapy was anti-thymocyte
globulin. Medications are tacrolimus and mycophenolate mofetil.
On physical examination, the blood pressure is 130/80 mmHg and pulse is 86
beats/min without postural changes. The allograft is nontender and without an
audible bruit. The remainder of the examination is normal.
Laboratory studies show a serum creatinine level of 140umol/L (stable from prior
values), white cell count of 6000/l, haemoglobin level of 12.1 g/dl, and platelet
count of 269,000/l. The tacrolimus trough is 9 ng/ml.
An upper endoscopy shows multiple sessile and pedunculated polyps ranging
from 3 to 13 mm in the gastric body. Biopsies are taken from the largest
polyps and show findings consistent with monomorphic post-transplant
lymphoproliferative disease, diffuse large B-cell type. Large malignant lymphoid
cells are CD20+. In situ hybridization for Epstein-Barr virus (EBV)-encoded RNA is
positive. EBV viral load is positive at 4000 copies/ml.
A positron emission tomography/computed tomography scan of the chest,
abdomen, and pelvis showed increased F-18 fluorodeoxyglucose (FDG)
uptake, numerous retroperitoneal and mesenteric lymph nodes worrisome for
malignancy, and three subcentimeter FDG-avid foci in the left hepatic lobe and
the spleen suspicious for malignancy.
Answer 104
E - 44 Months
Options A, B, C and D are incorrect. Median survival from dialysis onset in AL
amyloidosis is 44 months.
Median survival from dialysis onset in AA amyloidosis is 69 months
Answer 105
B - Rituximab with chemotherapy
Immunosuppression
+- Surgery/radiotherapy for
localised disease
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Question 106 Q
A 58-year-old lady referred through GP on Friday evening with 4 weeks history
of fatigue, joint pain and skin rash. She was known asthmatic since childhood
and had history of angina for which she take aspirin. GP prescribe her on
ibuprofen for joint pains, which she took for last 4 weeks.
Urine dipstick shows 3+ blood and 2+protein, UPCR 615
Serum creatinine 255 umol/L, eGFR 15% (baseline eGFR >90% one month ago)
Full Acute kidney injury workup was requested.
Which one of the following is the most appropriate step in her further
management?
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Question 107 Q
A 61-year-old male with ANCA +ve vasculitis was treated with iv
cyclophosphamide for 3 months and azathioprine for 1 year.
He presented with haemoptysis and kidney biopsy showed necrotizing
cresentic glomerulonephritis.
Over the 12 months course of treatment the extrarenal manifestations of
vasculitis disappeared.The patient eGFR was stable at 50ml/min.
Now patient coming back with another episode of haemoptysis.
There were 5 RBC/HPF.
Which of the following is the most appropriate step in his further management?
A Do urgent bronchoscopy
B IV Cyclophosphamide
C IV pulse Methylprednisolone
D Start Plasma exchange
E IV Rituximab
http://www.halls.md/body-surface- area/bsa.htm
(also contains equations for calculating lean body weight).
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Question 108 Q
Which of the following feature helps in differentiating acute Allergic interstitial
nephritis from atheroembolic disease?
A Eosinophilia
B Eosinophiluria
C Presence of Maculopapular /Morbiliform skin rash
D Urinalysis Hematuria and Pyuria
E Low C3 level
All of the above features are present in both conditions except option C that is
more typical of acute allergic interstitial nephritis where as presence of livedo
reticularis on lower extremities is highly indicates atheroembolic disease.
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Questions 109 & 110 Q
Question 109
The most common cells in the infiltrate of drug induced acute Interstitial
Nephritis is?
A Eosinophils
B T Cells
C Monocytes
D Neutrophils
E Plasma cells
Question 110
Which of the following kidney biopsy features are consistent with
the diagnosis of BK Virus Nephropathy?
Answer 109
B - Tcells
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110 - E A
Answer 110
Options A, B, C and D are incorrect. Option E is the correct answer. Kidney
biopsy is the gold standard for the diagnosis of BK virus nephropathy. The
histology of BK virus nephropathy is characterized by tubular atrophy and
fibrosis with an inflammatory lymphocytic infiltrate that can be mistaken
for acute cellular rejection. The presence of intranuclear inclusion bodies
which stain positive for the large T antigen is pathognomonic for BK virus
nephropathy (Papanicolaou et al). Owing to patchy involvement, a negative
biopsy cannot rule out early BK virus nephropathy. Most important prognostic
parameters in determining the outcome of BK virus nephropathy is the degree
of Interstitial fibrosis and tubular atrophy.
Interstitial Nephritis
Acute rejection
The presence of intranuclear inclusion bodies which stain positive for the large
T antigen is pathognomonic for BK virus nephropathy
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Question 111 Q
A 30-year-old female with HIV and normal kidney function started on HARRT
(Highly Active Anti Retroviral Therapy) comprising Lamivudine,Tenofovir and
Ritonavir. She was also started on trimethoprim (cotrimoxazole) prophylaxis
against pneumocystis.
She was reviewed in clinic 3 months later.
Labs
serum sodium 136 mmol/L (137144)
serum potassium 5.5 mmol/L (3.54.9)
serum creatinine 330 mol/L (60110)
urinalysis trace protein, trace blood
MSU WCC <10, RBC <10, hyaline casts and no growth
Which one of the following is the most likely aetiology in her clinical scenario?
Perazella MA. Acute renal failure in HIV-infected patients: A brief review of common causes. Am
J Med Sci 319:385-391; 2000. Coca S, Perazella MA. Rapid communication: acute renal failure
associated with tenofovir: evidence of drug induced nephrotoxicity. Am J Med Sci 324:342-4; 2002.
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Questions 112 & 113 Q
Question 112
Which one of the following factor is least favourable when considering
extracorporeal therapy for a removable substance?
Question 113
Conditions for which there is strong evidence for benefit of plasma exchange
do not include is?
A Multiple Myeloma
B ANCA associated systemic vasculitis
C Anti-GBM antibody disease
D ABO incompatible kidney transplantation
E Thrombotic thrombocytopaenic purpura
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113. A - Multiple Myeloma A
Options B, C, D and E are incorrect. Option A is the correct answer.
In multiple myeloma there is only some evidence,Plasma exchange is not
routinely used There is only some evidence, not routinely used.
Negative randomised controlled trial in 2005.
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Questions 114 & 115 Q
Question 114
A 25-year-old gentleman admitted with tremors, hyperkalaemia and confusion.
He had a cadaveric renal transplant 2 years ago. His baseline Serum creatinine
is 120 umol/L. He has been started on several new medications recently and
has not been able to attend transplant clinic appointments.
Which one of the following is the most likely culprit drug in his clinical scenario?
A St Johns Wort
B Phenytoin
C Carbamazepine
D Caspofungin
E Clarithromycin
Question 115
The most common renal manifestation of sarcoidosis is
A Hypercalciuria
B Hypercalcaemia
C Tubulointerstitial nephritis
D Nephrolithiasis
E Glomerulonephritis
Answer 114
Options A, B, C and D are incorrect.
Option E is the correct answer.
E - Clarithromycin increases blood levels of calcineurin inhibitors through
CYP450-3A4 inhibition
Common Drug Interactions of CNI (Calcineurin Inhibitors)
Important Drug interactions that decreases CNI (Calcineurin inhibitor) Level
by CYP450 enzyme induction
Granulomatous 15-40%
Fibrotic 10-20%
Glomerulopathy rare
Membranous
Proliferative
Focal segmental glomerulosclerosis
Retroperitoneal fibrosis
Retroperitoneal lymphadenopathy
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Questions 116 & 117 Q
Question 116
A 49-year-old woman with end-stage kidney disease due to IgA nephropathy
on maintenance haemodialysis is evaluated for possible kidney transplantation.
She was diagnosed with infiltrating ductal carcinoma of the right breast last
year, for which she underwent right mastectomy and radiation therapy. The
axillary nodes were negative for tumour, and she did not require chemotherapy.
She is currently doing well and is without evidence of recurrent disease. Her
sister, who is blood type compatible and in good health, would like to be
evaluated for a living kidney donor.
In the absence of recurrent breast cancer, which one of the following is the
most appropriate management regarding candidacy for kidney transplantation
for this patient?
Question 117
The DOPPS study (Dialysis Outcomes and Practice Patterns Study) observed a
45% higher risk of death in patients with pre-dialysis sodium levels less than
A <145 mEq/dL
B <140 mEq/dL
C <137 mEq/dL
D <130 mEq/dL
E < 125 mEq/dL
Answer 116
D - Proceed 5 years after breast cancer treatment
Answer 117
Options A, B, D and E are incorrect.
Option C is the correct answer.
C <137mEq/dL
The DOPPS (Dialysis Outcomes and Practice Patterns Study) observed a 45%
higher risk of death in patients with pre-dialysis sodium levels less than 137
mEq/dL
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Questions 118 & 119 Q
Question 118
Which one of the following statement is most appropriate about refractory
peritoneal dialysis (PD) Peritonitis?
Question 119
A 45-year-old male who had a terminal ileostomy for five years presented with
a renal colic.
A plain abdominal x-ray shows no stones.
Investigations
Serum sodium 138 mEq/L
Serum urea 7.2 mmol/L
serum Potassium 3.6 mmol/L
serum bicarbonate 17 mmol/L
serum albumin 39g/L
serum calcium 2.4 mmol/L
serum phosphate 0.9 mmol/L
Which one of the following is the most likely aetiology for his symptoms?
A Oxalate stone
B Calcium stone
C Uric acid stone
D Cystine stone
E Staghorn calculi
Answer 118
Options A, B, D and E are incorrect.
Option C is the correct answer.
Failure of effluent to
Refractory clear after 5 days of
antibiotic therapy
Adapted from Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, Johnson DW,
Kuijper EJ, Lye WC, Salzer W, Schaefer F, Struijk DG; International Society for Peritoneal Dialysis:
Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 30: 393423, 2010
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119. C - Uric acid stone
A
Answer 119
Options A, B, D and E are incorrect.
Option C is the correct answer. Uric acid stones are not uncommon in patients
with ileostomies.
The increase enteric losses of fluid and bicarbonate result in the production of
concentrated acidic urine, predisposing to the precipitation of uric acid.
Regular ingestion of sodium bicarbonate supplements usually prevents the
problem.
Visible
Not visible
* Stones are faintly radio-opaque or radiolucent
Calcium oxalate 60
Calcium phosphate 10
Magnessium, ammonium phosphate
5-10
(struvite)
Uric acid 5-10
Cystine 1
Others 1
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Question 120 Q
Treatment with cinacalcet should be stopped if the parathyroid hormone (PTH)
levels in the blood do not fall substantially within?
A 1 month
B 2 month
C 3 month
D 4 month
E 6 month
Ca and P Ca or P Ca and P Ca or P
controlled high controlled high
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Question 121 Q
A 48-year-old woman maintained on chronic haemodialysis is seen during
dialysis rounds 72 hours following subtotal parathyroidectomy. Postoperatively,
she required a calcium infusion for 24 hours and was discharged on calcium
carbonate 2.5 g twice a day between meals. The serum calcium level at the
time of discharge was 1.95 mmol/L, with a normal serum albumin level.
She complains of generalized weakness and muscle cramps.
Therapy can then be tapered, following the serum calcium level closely.
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Question 122 Q
A 61-year-old man known case of end stage renal disease secondary to ADPKD
on thrice per week maintenance haemodialysis since 4 years presented with a
skin rash.
Which one of the following is the most likely presentation of this skin rash?
Intense pain associated with cutaneous lesions and palpation of firm calcified
subcutaneous tissue is suggestive of calciphylaxis in dialysis patients and
patients with other risk factors for calciphylaxis.
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A
Calcific Uremic Arteriopathy (Calciphylaxis)
Risk Factors
Dialysis >6-7 yrs
Female sex
Obese
Diabetes
Hyperphosphataemia
Hypercalcaemia
Hyperparathyroidism
Adynamic bone disease
Steroids,Warfarin, active Vit D, Iron therapy, Calcium based supplements,
calcium based phosphate binders, Hypoalbuminemia, Heparin injections.
Mortality is > 50 %
Common areas affected
Lower extremities
Proximal localisation
Distal localisation
Abdomen
Breasts
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A
Management of Calciphylaxis
Wound management
Wound care team should be involved for recommendations regarding
selection of dressings, chemical debriding agents, frequency of dressing
changes, and negative pressure wound therapy.
Surgical wound debridement should be considered on a case-by-case
basis.
Hyperbaric oxygen therapy can be considered as a second-line
treatment if wounds not improving; claustrophobia, access to treatment,
and cost can be significant limiting factors of this therapy.
Antibiotic administration should be guided by clinical appearance of
lesions and accompanying systemic features.
Pain management
Often narcotic analgesics are required to control severe pain associated
with calciphylaxis.
Fentanyl may be preferred over morphine to minimize potential
hypotension episodes associated with morphine.
Sodium thiosulfate
Intravenous sodium thiosulfate at doses ranging from 12.5-25g in the
last 30 min of each haemodialysis session for patients on 3/wk dialysis
schedule47.
Nausea, metabolic acidosis, hypotension, and volume overload are
potential adverse effects.
Intralesional sodium thiosulfate has been described to aid in the
resolution of calciphylaxis lesions.
Dialysis prescription
Haemodialysis prescription should be optimized to achieve the
recommended NKF-KDOQI goals of adequacy.
NKF-KDOQI clinical practice guidelines for peritoneal dialysis adequacy
should be followed for peritoneal dialysis patients.
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Question 123 Q
Which one of the following is least likely to be present in normal pregnancy?
Metabolic alkalosis
Options A,B,C,D are correct with regard to normal pregnancy except option E
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A
Causes ok AKI in pregnancy
Volume depletion
Hyperemesis gravidarum
Postpartum bleeding
Placental abruption
Sepsis
Septic abortion
Acute pyelonephritis
Severe preeclampsia
Bilateral cortical necrosis
Thrombotic microangiopathies (TTP-HUS)
Acute fatty liver of pregnancy
Urinary tract obstruction from gravid uterus
Hormonal Changes
10- to 20-fold increase in aldosterone
8-fold increase in renin
4-fold increase in angiotensin
Metabolic Changes
Decrease in Blood urea 4.6mmol/L
and serum creatinine (to 35-45 umol/L)
Increase in total body water by 6 to 8 liters
Net retention of 900 mEq of sodium
Decrease in plasma osmolality by 10 mOsm/L
Decrease in serum sodium by 4 to 5 mEq/L
Mild respiratory alkalosis with compensatory metabolic acidosis
(bicarb of 18 to 22 mEq/L)
Decrease in serum uric acid levels (to 2.5 to 4 mg/dL)
Glucosuria irrespective of blood glucose levels
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Question 124 Q
A 68-year-old man known case of CKD stage 5 secondary to diabetic
nephropathy (eGFR 8ml/min) and with a working mature left AVF was seen
in the clinic 3 days ago when he was presented with uraemic symptoms and
was advised to start dialysis at that time but he refused and went home.
Now he presented to accident and emergency with Nausea and vomiting
Investigations.
Serum sodium 149 mmol/L, Serum potassium 5.8 mmol/L, Blood urea 79
mmol/L, Serum Creatinine 800 umol/L (eGFR 4 ml/min), Serum Bicarbonate
8mmol/L.
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QA
Capillary Cerebrospinal Brain
fluid
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Questions 125 &126 Q
Question 125
Which one of the following statement is most appropriate about visceral
peritoneal membrane ?
Question 126
A 56-year-old man on peritoneal dialysis since 6 years presented to you with
complain of poor ultrafiltration. His baseline 2.5% dextrose PET (Peritoneal
Equilibration test) test showed that D/P creatinine was 0.62 and 4 hrs
Ultrafiltration (UF) 450 ml.
Which one of the following will be a useful test to establish the diagnosis?
Answer 125
Options A, B,C and D are incorrect, whereas option E is the correct answer.
Visceral peritoneal memberane comprise of 80% of total surface area.
Answer 126
Options B, C, D and E are incorrect, option A is the correct answer.
4.25% Dextrose PET.
This Patient has a Peritoneal memberane failure.
Remember rule of 4 when working for peritoneal membrane failure.
4.25% Dextrose PET (as per ISPD guidelines), 4 hrs dwell, UF>400ml.
CT abdomen with intraperitoneal contrast is done when you suspect leak.
Option D is done when you suspect volume overload.
Laboratory
<400 ml UF(Drain volume <2400 ml after 4 hrs dwell with 2 L- 4.25% or
3.86% dialysate
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Questions 127 & 128 Q
Question 127
A 20-year-old male visited to your clinic for evaluation of recurrent urinary
tract infections and currently he is on prophylaxis for urinary tract infections.
Ultrasound of kidneys was done recently and he was told stones in the kidney.
His father is diagnosed for kidney stones. CT scan with stone protocol
was done.
A Acute pyelonephritis
B Chronic pyelonehritis with right atrophic kidney
C Stones obstructing the left kidney
D Emphysematous pyelonephritis
E None of the above.
Question 128
Which one of the following is the most common cause of death in patients
whose hypertension is under control?
A Aortic dissection
B Coronary artery disease
C Left ventricular dysfunction
D Renal failure
E Stroke
Answer 127
Options B, C, D and E are incorrect, option A is the correct answer.
Chronic pyelonehritis with right atrophic kidney Patient has right kidney
atrophic secondary to chronic pyelonephritis most likely the etiological factor
is stones but it does not shows the features of obstruction. Emphysematous
pyelonephritis is more common in diabetic patients and radiology findings
does not fit with it.
Answer 128
Options A, C, D and E are incorrect, option B is the correct answer.
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Questions 129 & 130 Q
Question 129
A 39 year old male of Asian origin is known to have kidney stone disease, he's
admitted to accident and emergency with a right renal angle pain. CT scan with
a stone protocol is done. See the image below.
Which one of the following is the most likely diagnosis in this patient?
Question 130
KDIGO Guidelines recommends that all of the following drugs be
contraindicated in the management of lupus nephritis in pregnancy except?
A Mycophenolate mofetil
B Hydroxychloroquine
C Cyclophosphamide
D ACE inhibitors
E ARB (angiotensin receptor blockers)
Answer 129
Option A, B, D and E are incorrect, option C is the correct answer.
Staghorn stone
The CT scan image is showing a staghorn stone (also known as struvite stone)
at the pelvi-ureteric junction of the right kidney, obstructing the kidney.
Staghorn stones are often caused by infections (urease splitting organisms) and
they most commonly occur after a urinary tract infection that has lasted a long
time. Struvite stones are more common in women than in men.
Answer 130
Hydroxychloroquine
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Questions 131 & 132 Q
Question 131
Which one of the following statements regarding the use of digoxin in dialysis
patients with atiral fibrillation is correct?
Question 132
A 54-year-old black man admitted with mild dry eyes, dry mouth, diffuse
abdominal pain, diffuse lymphadenopathy, arthralgia and acute kidney injury
Labs shows
Which one of the following is the most likely diagnosis in this patient?
A Sarcoidosis
B Sjogreen Syndrome
C Ig4 related Systemic disease
D TINU(Tubulointersitial nephritis uveitis)
E SLE
Answer 131
Options A, B, D and E are incorrect. Option C is the correct answer. Both
digoxin and potassium compete for the same Na+/Cl- transporter on the
cardiac myocyte. Digoxin is commonly used in dialysis patients with heart
failure and/or atrial fibrillation. However, caution is advised while prescribing
this medicine. In a retrospective study by Chan et al, digoxin use in incident
dialysis patients was associated with increased mortality, especially in patients
with pre-dialysis potassium levels less than 4.3 mEq/l. Both potassium and
digoxin compete for the Na+/K+-ATPase on the cardiac myocytes, causing
hyperkalaemia to decrease the effectiveness of the drug and hypokalaemia
to potentiate its toxicity.
Answer 132
Options A, B, C and D are incorrect. Option C is the correct answer.
Laboratory Findings
Elevated IgG4 60% of all patients 5% incidence in the normal population
Hypocomplementemia (C3 or C4) 56-78%
Peripheral Eosinophilia 33-48%
Positive ANA 30%
Parenchymal lesions 78%
Treatment
90% Steroid responsive
Ref: Raissian Y.J Am Soc Nephrol 2011 Jul;22(7):1343-52
Cornell L. Curr Opin Nephrol Hypertens. 2012 May;21(3):323-8
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Question 133 Q
An 80-year-old man was brought to the emergency department due to severe
agitation and vomiting which was worsening over the last two weeks. He
developed stroke 6 months ago and was bed bound. Previous medical history
of Diabetes mellitus and Hypertension, which was reasonably, controlled.
On examination, he is conscious but agitated, afebrile with blood pressure
of 110/70. He has some residual weakness of right side.
A 0.25 mmol/hour
B 0.5 mmol/hour
C 0.75 mmol/hour
D One mmol/hour
E Two mmol/hour
ECFV
Decreased Normal
Hypotonic fluid defecit Pure Water defecit
Urine sodium
Urine osmolality
urine osmolality
>20 mEq/L <10mEq/L <700 mOsm/L >700 mOsm/L
<700 mOsm/L >700 mOsm/L
Renal hypotonic Extrarenal hypotonic Renal water loss Extrarenal water loss
fluid loss fluid loss nephrogenic DI or hypodipsia
diuretics Skin Central DI insensible loss
Osmotic diuresis GIT Prmary hypodipsia
Secondary hypodipsia
The main causes of Hypernatraemia are:
Reduced water intake (e.g. coma, dysphagia, extreme depression). Because
hypernatraemia is an extremely strong stimulus to thirst, reduced water intake
is almost always involuntary. Increased losses of hypotonic fluid. Usually both
are present, though either alone can be sufficient.increased loss via gut, skin or
respiratory tract. Cholera syndromes (likely to be sodium depleted too); severe
sweating, etc Increased loss in urine caused by impaired ability to concentrate
urine (diabetes insipidus, central, nephrogenic or drug-induced) If circulating
volume is reduced hypernatraemia is exacerbated by reabsorption of sodium
due to aldosterone secretion.
Clinical features include thirst, oliguria and concentrated urine. More severe
cases may result in confusion and weakness, and possibly tachycardia, and finally
hypotension and coma. Plasma urea is usually increased. These findings, along
with a urine osmolality of over 600 mosm/kg confirm water depletion.
Treatment is by oral replacement of water in mild cases; 5% dextrose (i.v.) in
moderate cases; and a combination of 5% dextrose and 0.9% (150mmol/l) saline
(i.v.) if dehydration is severe, as volume expansion requires salt as well as water.
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Question 134 Q
A 26-year-old man was referred to the renal clinic with a 3 month history of
tiredness, weight gain and leg swelling. Dipstick urinalysis showed 4+protein
and 3+ blood. He had no previous medical problems and was taking no
medication. On examination (see image 1 & 2) his blood pressure was 160/95
mmHg and he had pitting oedema in his legs up to mid-thigh level.
Investigations:
haemoglobin 12.1g/L (13 - 18)
serum urea 8.1 mmol/L (2.5 - 7)
serum creatinine 130 umol/L (60 - 110)
serum albumin 27g/L (37 - 49)
serum cholesterol 8.0 mmol/L (5.2)
urine protein:creatinine ratio 980mg/mmol (<2.5)
Prognosis in DDD not the best. Spontaneous remissions are uncommon and
about 50% of affected individuals develop end-stage renal disease (ESRD)
within ten years of diagnosis.
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Questions 135 & 136 Q
Question 135
An 81-year-old Caucasian man with a history of diabetes, coronary artery
disease, hypertension, and proteinuria is treated by a general practitioner
with an angiotensin-converting enzyme inhibitor (ACEI) along with other
medications that are appropriate for his medical conditions.
The patient is referred to you and brings an Internet printout that refers to the
risks and benefits of combining the ACEI with an angiotensin receptor
blocker (ARB).
Which one of the following statements is correct for describing the effects of
the combination of ACEI and ARB compared with ACEI treatment alone?
Question136
A 35-year-old male admitted with nephrotic range proteinuria and microscopic
hematuria. All serologies results are negative.
Answer 135
Options A, B, C and E are incorrect.
Option D is the correct answer. There is increased risk for hypotension and
acute renal failure.
Answer 136
Options A, B, C and E are incorrect, option D is the correct answer.
IgA nephropathy.
The image shows a granular mesangial pattern of staining.
IgA and IgG can be codominant in IgA nephropathy. Absence of C1q staining
and negative serologies are supportive of IgA nephropathy. Lupus nephritis
would show a full house pattern and C1q would be positive.
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Question 137 Q
A 71-year-old man who received a kidney transplant for end-stage kidney
disease due to diabetes mellitus is evaluated 2 weeks after receiving treatment
for acute gout of the left metatarsophalangeal joint with a course of oral
corticosteroids. He is now asymptomatic. He has a history of gout, previously
averaging one flare per year, but over the last 3 months he has experienced
three episodes of symptomatic gout involving his hands, knees, and feet, most
recently 1 month ago. He does not drink alcohol. Medications are tacrolimus,
mycophenolate mofetil, aspirin, losartan, and atorvastatin.
Which one of the following is the most appropriate treatment for this patient?
A Change losartan to enalapril
B Allopurinol 50 mg daily
C Change tacrolimus to cyclosporine
D Colchicine 0.6 mg daily
E Probenecid
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Question 138 Q
A 20-year-old man is referred to the outpatient clinic for evaluation of
hypertension. He has no siblings. His father was diagnosed with hypertension
at a young age.
He does not take any medications. On physical examination, his blood pressure
is 184/90 mmHg, and his heart rate is 88 beats/min. His weight is 60 kg. The
physical examination is otherwise normal.
Laboratory data show a haemoglobin level of 14.2 g/dl, serum creatinine level
of 90 umol/L, serum potassium level of 4.9 mEq/L, supine normal sodium
diet serum aldosterone level of 487 pmol/L (reference range, 50138 pmol/L,)
seated morning plasma renin activity of 0.1 nmol/L per hour [reference range,
0.83 nmol/L per hour)].
Direct genetic testing confirms the presence of hybrid 11 -hydroxylase and
aldosterone synthase genes.
Which ONE of the following is the BEST initial treatment for this patient?
A Hydralazine
B Amlodipine
C Prednisone
D Low sodium diet
E Bendroflumethiazide
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Question 139 Q
A 78-year-old man was found collapsed on the floor by his carer after an
overnight mechanical fall. He had a background history of Hypertension and
dyslipidaemia. He was on amlodipine, Lisinopril and atorvastatin therapy.
Investigations
Which one of the following metabolic changes is seen in the early phase of
Rhabdomyolysis?
A Hypokalaemia
B Hypocalcaemia
C Hypercalcaemia
D Hypophosphataemia
E Hyperuricaemia
Ref:
1. Llach F, Felsenfeld AJ, Haussler MR. The pathophysiology of altered calcium metabolism
in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone,
25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol. N Engl J Med 1981; 305:117.
2. Akmal M, Bishop JE, Telfer N, et al. Hypocalcemia and Hypercalcaemia in patients with
rhabdomyolysis with and without acute renal failure. J Clin Endocrinol Metab 1986; 63:137.
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Question 140 Q
A 32-year-old man attends the clinic for an evaluation of kidney cysts and
haematuria. He was in his usual state of health until he helped friends move
furniture. He subsequently developed right flank pain and haematuria. His
family history is unknown as he was adopted.
He is on no medications. On physical examination, the blood pressure
is 135/80 mmHg and his heart rate is 70 beats/min. The remainder
of the examination is unremarkable.
Laboratory data show a serum creatinine level of 90 umol/L. Urinalysis shows a
pH of 5.5, 2+ blood, no protein, and 610 nondysmorphic red blood cells/HPF.
Kidney ultrasound shows enlarged kidneys (14 cm, right kidney; 13.7 cm, left
kidney) with five cysts in the right kidney and four cysts in the left kidney.
No kidney stones are seen. There is no hydronephrosis.
Which one of the following is the most appropriate next step in the diagnostic
evaluation of this patient?
Further testing first with imaging of the kidneys and liver with CT or MRI is
indicated for this patient. An ultrasound finding of at least two or more cysts per
kidney is sufficient to make a diagnosis of ADPKD in patients with a family history
of ADPKD by the Ravine Criteria or by the revised diagnostic criteria. However,
these criteria do not apply to patients without a documented family history of
ADPKD. In this patient with an unknown family history, more evidence is required
to make the diagnosis. Ten cysts per kidney would help establish the diagnosis.
Other findings of ADPKD, such as liver cysts, may be helpful in establishing the
diagnosis. Total kidney volume is useful for monitoring progression of ADPKD
but not for establishing a diagnosis.
Genetic testing may be considered, but testing may not always be fully
informative. In some cases, no mutation is found, or a new mutation is found
that may or may not be known to be pathogenic. Furthermore, in the absence of
available affected family members, the easier, linkage analyses cannot be done.
Repeat ultrasound measurements or volumetric MRI may be in following
progression of ADPKD.
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Question 141 Q
A 55-year-old man with a history of alcohol dependence is admitted for
alcohol detoxification. He develops symptoms of alcohol withdrawal 1
day into his hospitalization and is treated with intravenous diazepam, with
dosing based on the Clinical Institute Withdrawal Assessment (CIWA) score.
Three days into the hospitalization, he develops worsening confusion and
hypoxia. Medications are subcutaneous heparin, multivitamin, intravenous
thiamine, and intravenous diazepam. On physical examination, his blood
pressure is 102/75 mmHg, pulse is 106 beats/min, temperature is 36.3C,
and respiratory rate is 15 breaths/min. He is hypersomnolent, inattentive,
and disoriented to time and place.
The remainder of the examination is normal.
Laboratory Admission Hospital day 3
Serum
Sodium (mEq/L) 152 147
Potassium (mEq/L) 3.6 4
Chloride (mEq/L) 121 98
Total CO2 (mEq/L) 26 20
Blood urea (mmol/L) 33 25
Creatinine (umol/l) 97 129
Glucose (mmol/l) 3.8 10
Albumin (g/dl) 3.5
Osmolality (mOsm/kg) 336 415
Lactate (mEq/L) - 7
Ethanol (mg/dl) 74 0
Ketones Negative Negative
Arterial blood gas (ambient air)
pH - 7.28
PCO2 (mmHg) - 45
PO2 (mmHg) - 85
Which one of the following is the most likely cause of this patients metabolic
abnormalities?
A Sepsis
B Alcoholic ketoacidosis
C Ethylene glycol
D Diazepam infusion
E Isopropyl alcohol
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Question 142 Q
A 37-year-old man with diabetes mellitus complicated by microalbuminuria
is seen for a routine follow-up and is found to have asymptomatic
Hypercalcaemia.
Which one of the following is the most likely diagnosis in his clinical scenario?
The elevated serum calcium with an unsuppressed PTH level in this patient
suggests that PTH secretion is not appropriately regulated by systemic calcium
levels. The differential diagnosis includes autonomous secretion of PTH by
an adenoma or a defect in the calcium-sensing receptor. These entities can
be differentiated by an assessment of urinary calcium excretion. Primary
hyperparathyroidism is typically confirmed by high urine calcium and/or a
high urine Ca/Cr clearance. The latter can be calculated as: (24-h Urine Ca
Serum Cr)/(24-h Urine Cr Serum Ca)and is generally >0.02 in primary
hyperparathyroidism. This patient, however, has hypocalciuria and a urine Ca/
Cr clearance of <0.01, indicating avid renal reabsorption of calcium, despite
systemic Hypercalcaemia. This rare autosomal dominant condition, caused
by an inactivating mutation of the calcium-sensing receptor, is referred to as
familial hypocalciuric Hypercalcaemia. The serum phosphate level in this entity
is typically normal or mildly decreased.
Secondary hyperparathyroidism occurs in CKD when the GFR falls below the
6070 ml/min per 1.73 m2 range. A rise in the serum PTH level to 110 pg/ml
would be unusually high at this patients level of kidney function in the absence
of a concomitant condition such as vitamin D deficiency. Laboratory findings
in early secondary hyperparathyroidism include normal to low serum calcium
levels and not Hypercalcaemia as noted in this patient. Serum phosphorus
levels are typically normal to increased and not low as in this case. No obvious
secondary causes are evident in this patients laboratory data, and the unusual
elevation in serum calcium level should prompt an evaluation for alternative
explanations for the elevated PTH. Hypercalcaemia may complicate secondary
hyperparathyroidism, but this usually occurs in patients with advanced CKD
or end-stage kidney disease. Common causes in these settings include use
of vitamin D sterols or calcium-based phosphate binders, as well as severe
parathyroid hyperplasia and markedly increased serum PTH levels,
usually >800 pg/ml.
Extrarenal production of vitamin D would cause Hypercalcaemia with a
suppressed PTH level.
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Question 143 Q
A 59-year-old man is seen in a follow-up for management of increasing ascites
and oedema complicating alcohol-related liver disease and cirrhosis. He has
been sober for the last 4 months and is undergoing evaluation for a possible
future liver transplantation.
Medications are spironolactone 100 mg daily and furosemide 40 mg daily, and
the patient states that he has remained adherent with this regimen. Despite
this, the patient notes increased ascites, leg oedema, and has gained 3 kg in
weight over the last month.
On physical examination, he is afebrile, with a blood pressure of 98/50
mmHg, pulse of 90 beats/min, respiratory rate of 16 breaths/min, and oxygen
saturation of 92% on room air. He is alert and oriented.
The abdomen is nontender, and there is moderate ascites.
Serum Urine
Na 134 mEq/L Na 102 mEq/L
K 3.9 mEq/L K 60 mEq/L
Chloride 108 mEq/L
Total CO2 22 mmol/L
Blood urea2.14 mmol/L
Creatinine 53 umol/L
Which one of the following is the most appropriate next step in treating this
patient?
The urine sodium level >78 mEq/L and urine sodium:potassium ratio >1
indicates excessive dietary sodium intake in this patient that likely exceeds the
recommended 88 mEq/d (2000 mg). Dietary sodium restriction would therefore
be the next best step in managing this patients ascites, edema, and positive
sodium balance.
The management of ascites and edema in cirrhotic patients that have low
effective circulating volume can be a complicated matter. Careful choices
must be made about the use of diuretics (or combination of diuretics) and the
extent of diuresis necessary to balance alleviation of ascites with preservation
of renal perfusion. Patients with detectable ascites and edema require diuretic
therapy in combination with dietary sodium restriction. Diuretic therapy should
generally include an aldosterone antagonist such as spironolactone plus a
loop diuretic. The loop diuretic not only promotes natriuresis but also counters
hyperkalaemia resulting from aldosterone antagonism.
Addition of a thiazide diuretic would be a consideration if the urine sodium
level was 78 mEq/L and the urine sodium:potassium ratio was <1. Care
must be taken to avoid hypokalaemia, which possibly can precipitate hepatic
encephalopathy. Similarly, an increase in spironolactone or furosemide could
be considered if the urine sodium:potassium ratio was <1, reflecting increased
diuretic resistance.
Fluid restriction alone would not ameliorate this patients sodium overload
and would therefore be less effective in treating this patients hypervolemia.
The degree of Hyponatraemia in this patient is not sufficient to warrant fluid
restriction to <1 L/d. Moreover, most cirrhotic patients find it difficult to adhere
to this degree of fluid restriction because of increased thirst.
Infusion of albumin can facilitate urinary sodium excretion in patients with
decreased renal perfusion and prerenal azotemia. Albumin infusions would
be indicated for the management of acute kidney dysfunction, particularly
following overdiuresis, but would not be appropriate for this patient with stable
kidney function and sodium excess, secondary to excessive dietary sodium
intake.
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Question 144 Q
This is a kidney biopsy electron microscopy image of a 44-year-old female
patient.
Which one of the following is the most likely Diagnosis for this patient?
A -Interferon therapy
B Fabrys disease
C Post infectious glomerulonephritis
D IgA nephropathy
E Cryoglobulinemia
1 Lupus nephritis
2 -interferon therapy
3 HIV
4 Viral infections
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Question 145 Q
A 55-year-old male admitted with hypertension and 6.2 gram proteinuria/day.
Kidney biopsy done, See the image.
A HIV
B Indinavir toxicity
C Functional and adaptive changes in the kidney
D Primary FSGS (Focal segmental glomerulosclerosis)
E Pamidronate toxicity.
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A
Difference Between Primary and Secondary FSGS
Steroid-resistant FSGS
cyclosporine at 3-5 mg/kg/d in divided doses to be given for at least
4-6 months
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Question 146 Q
A 60-year-old man is seen in the clinic for progressive CKD secondary to Biopsy
proven focal segmental glomerulosclerosis. The trends of his laboratory data
are as follows:
Which one of the following best describes fibroblast growth factor-23 (FGF-23)
metabolism in this patient?
NKF KDOQI guidelines for Bone metabolism and disease in Chronic kidney
disease.
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Question 147 Q
A 17-year-old girl was referred for investigation of intermittent visible
haematuria. On examination she appeared small for her age but there were
no other abnormal physical findings.
Investigations:
GO Glycolate hydroxyproline
Glycolate hydroxypyruvate
oxidase
GRHPR
Glyoxylate reductase
B-6 Glyoxylate Hydroxypyruvic reductase
Glycine
Glycerate
Protein AGT
Alanine LDH
Glyoxylate Lactaye
Yeast
Amino dehydrogenase
Fungi
transferase
Oxalate Ascorbate
Arabinose
Oxalate diet
diet Ethylene glycol
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Question 148 Q
A 55-year-old woman undergoes a prolonged hysteroscopy complicated by
uterine perforation, extravasation of irrigant solution, and successful emergent
surgical repair. Postoperatively, she is promptly extubated, and her pain
is controlled with intravenous narcotics.
No additional intervention is indicated for this patient at this time. The patient
experienced a drop in the serum sodium level after prolonged exposure to an
irrigant solution used for hysteroscopy. The clinical context provides several
possible etiologies for hyponatraemia. The use of an irrigant solution for
hysteroscopy and the increased exposure due to visceral perforation are the
most obvious, but she was also exposed to narcotic medications, pain, nausea,
and surgical stress, all of which can stimulate anti-diuretic hormone secretion.
Determining which of these is causative requires a careful review of her
examination and laboratory findings.
On physical examination, she is stable, without neurologic deficiency, and
grossly euvolemic. The drop in the serum sodium level is accompanied by a
slight reduction in the serum osmolality and, importantly, a rather impressive
increase in the osmolal gap at 27 mOsm/kg. An increase in ADH would give
Hyponatraemia with a low serum osmolality; however, it cannot account for
the osmolal gap. This raises concern for an unmeasured solute acting as an
effective osmole. It is important to note that, although this often leads to a
normal or elevated serum osmolality, glycine and sorbitol irrigant solutions are
actually hypotonic with an osmolality of 200 and 165 mOsm/kg, respectively.
In this context, hypertonic saline has been cautiously used in those with
neurologic complications and significant hypoosmolality or in those with a drop
in serum sodium level by >5 mEq/L when mental status cannot be assessed
due to anesthesia. Patients with neurologic symptoms, severe hyponatraemia,
and normal or near normal serum osmolality, however, are probably best
treated with haemodialysis. Loop diuretics have been used in those with
concomitant volume overload and pulmonary edema. However, in the absence
of neurologic symptoms, impaired kidney function, or volume overload, the
serum sodium levels will correct without intervention as the retained solute
(glycine or sorbitol) is taken up intracellularly, metabolized, and excreted.
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Question 149 Q
A 55-year-old woman is admitted with 10 gram proteinuria.
eGFR >60ml/min. All immunology, vasculitic screen and serology results were
negative. A kidney biopsy image under polarized light is shown below.
Urine oxalate
crystals- Envelope shape
Investigations Target
Volume 2-3L/day
pH Between 5.5-7.0
Creatinine clearence Normal
Excretion
1. Calcium <0.1 mmol/kg/day
2. Sodium <100-150mmol/day
3. Uric acid
Women <4.5mmol/day
Man <4.8 mmol/day
4. Oxalate Minimize(<450umol/day)
5. Citrate Maximize(>0.6mmol/day)
6. Magnesium >3mmol/day
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Question 150 Q
A 59-year-old man attends his physician after a fall. He describes losing his
balance and stumbling into a wall before falling to the ground. He denies head
trauma or other injury from the fall. His wife notes he has become unsteady
over the last week and increasingly confused.
Laboratory data
Vasopressin receptor antagonists that block the ADH effect leading to urinary
dilution, loop diuretics that lower urine osmolality, and fluid restriction alone
are all treatments for SIADH, but would be most appropriate for chronic
management or patients who do not have clinically overt neurologic symptoms
indicative of increased intracranial pressure.
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A
Major causes of hypernatraemia
Sodium overload
Intake or administration of hypertonic sodium solutions
Causes of Hyponatraemia
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Question 151 Q
A 70-year-old female admitted with a 1 month history of back pain.
She took ibuprofen for last 1 month for pain relieve.
Her vital signs (including BP) were in normal range, and her physical
examination was notable only for 1-mm pitting edema to the ankles.
Laboratory workup revealed 11g/d proteinuria on 24-hour collection, Serum
Creatinine of 116 umol/l, total cholesterol of 9.0 mmo/l, and albumin of 26 g/dl.
The following tests were requested and awaiting results: serum protein
electrophoresis, urine protein electrophoresis, antinuclear antibody, C3 and C4,
hepatitis B and C,serological tests for syphilis, Myeloperoxidase (MPO) and PR3
ANCA. Renal ultrasound was unremarkable, including no evidence of renal vein
thrombosis, and ultrasound of the legs showed no deep venous thrombosis.
She was started on lisinopril, atorvastatin, and furosemide.
Which one of the following is the most likely diagnosis in this patient?
A AL Amyloidosis
B AA Amyloidosis
C Monoclonal light chain cast nephropathy
D Acute tubular necrosis
E Normal Light microscopy
Kidney biopsy Image shows tubular casts with multi nucleated giant cell
reaction (arrow).
Fibrillar AA or AL amyloidosis
Fibrillary GN
Microtubular Immunotactoid GN
Cryoglobulinaemia
Light chain deposition disease (LCCD), Heavy chain deposition disease (HCDD)
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A
Difference Between Amyloid and Fibrillar deposition
Amyloid Fibrillar
10 nm 20nm
Amyloidosis Fibrillary GN
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Questions 152 & 153 Q
Question 152
Occurrence of severe hypocalcaemia following parathyroidectomy may be
predicted by pre-operative levels of ?
Question 153
Urease producing bacteria are associated with the formation of?
A Calcium stones
B Uric acid stone
C Cystine stone
D Magnesium ammonium phosphate stone (Struvite)
E Oxalate stones
Answer 152
In a recent retrospective chart review, lower preoperative calcium levels and
higher preoperative intact parathyroid hormone, phosphorus, and alkaline
phosphatase levels were all found to be independent predictors of severe
hypocalcaemia following parathyroidectomy.
Answer 153
D - Magnesium ammonium phosphate stone (Struvite).
Options A, B, C and E are incorrect.
Option D is the correct answer.
Struvite (magnesium ammonium phosphate) stones are typically large
stones associated with urease producing bacteria and an alkaline urine. Urea
breakdown produces excess ammonium and hydroxyl ions, a rise in urinary pH,
and a decrease in phosphate solubility thus encouraging the precipitation of
insoluble magnesium ammonium phosphate.
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A
Dietary and pharmacological management of kidney stones according to
urinary abnormalities.
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Questions 154 & 155 Q
Question 154
The treatment of choice for transient diabetes insipidus of pregnancy is?
Question 155
Cystatin C is a low molecular weight protein filtered at the glomerulus and
metabolized by the tubules.
Which one of the following factors has been shown to affect cystatin C levels
independent of GFR(Glomerular Filtration rate)?
A Hyperthyroidism
B Hypothyroidism
C Steroid use
D Advanced age
E All of the above
Answer 154
Options A, C, D and E are incorrect.
Option B is the correct answer.
Transient diabetes insipidus of pregnancy is caused by increased expression
of vasopressin from the placenta. This results in a greater breakdown of
vasopressin. Desmopressin (DDAVP), however, is not a substrate for this
enzyme and remains effective.
Answer 155
Options A, B, C and E are incorrect.
Option D is the correct answer.
All of the mentioned factors have been associated with alterations in cystatin C
production. Manetti et al showed that cystatin C concentrations were increased
in overt hyperthyroidism and decreased in mild hypothyroidism. Rule et al
demonstrated that patients on chronic steroids had higher measured GFR by
19% as compared to patients off steroids with the same cystatin C level. Lastly,
cystatin C has been demonstrated to increase with advanced age independent
of affecting GFR.
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Questions 156 & 157 Q
Question 156
A 84-year-old man is referred for evaluation of proteinuria and edema. Other
than a remote history of tobacco abuse (he quit 15 years ago), he is healthy
with no other comorbidities. He takes no regular medications.
Which one of the following is the most appropriate next step in this patient
management?
Question 157
Which one of the following is not a cause of metabolic alkalosis in end stage
renal disease (ESRD) patients on dialysis?
A Malnutrition
B Hypercapnea
C Nasogastric suction.
D Massive blood transfusion
E Plasmapheresis with fresh frozen plasma
Answer 156
Option A is the correct answer.
Options B,C,D &E are incorrect. Age- and risk factorappropriate cancer
screening is indicated for patients with membranous nephropathy (MN). When
a patient is diagnosed with MN, the first determination is whether the lesion is
primary (idiopathic) or secondary to a systemic condition. Approximately 25%
of individuals with MN over age 65 will have a malignancy diagnosed within 1
year of diagnosis of MN.
Answer 157
B - Hypercapnea
In patients with ESRD, the kidney does not play a role in acid-base
homeostasis. Chronic hypercapnea does not produce a secondary elevation
in serum bicarbonate level since this compensatory response requires
kidney function. In the absence of kidney function, metabolic alkalosis can
occur from either exogenous administration of alkali or loss of HCL from the
gastrointestinal tract (vomiting, nasogastric suction).
Malnourished dialysis patients with poor protein intake and low muscle mass
have low endogenous acid production resulting in metabolic alkalosis.
Packed red cells and fresh frozen plasma are anticoagulated with citrate, which
generates bicarbonate upon metabolism.
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Question 158 Q
A 57-year-old female recently started on peritoneal dialysis with low volumes
Patient denies abdominal pain but peritoneal dialysis sister informed she has
poor drain out problem.
You requested a plain abdominal X-ray (see image)
Which one of the following is the most likely cause in her case?
A Constipation
B Kink in catheter
C Fibrin clot in catheter
D Hernia
E Perforation of viscus
X-ray shows faecal loading in large bowel and tip of catheter flip up
Most common cause of poor drain out of PD fluid is constipation.
Heavily loaded loops of bowel prevent the movement of fluid through the
peritoneal cavity, resulting in pools of located fluid and hence poor drainage.
Constipation is more common in-patient when starting PD, at the time when
they are more at risk of catheter malfunction.
Regular exercise also helps to avoid constipation and encourages the catheter
to remain in the pelvis.
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Questions 159 & 160 Q
Question 159
A first haemodialysis session should only reduced blood urea by?
A 10%
B 20%
C 30%
D 40%
E 50%
Question 160
You are doing a round in haemodialysis unit and you found one of your patient
is having a KT/V of 1.2.
Which one of the following is the most appropriate next step in his
management to increase his KT/V?
Answer 159
Options A, B, D and E are incorrect.
Option C is the correct answer.
Answer 160
Options A, B, C all can increase KT/V but best option is A. Increasing dialysis
time to 20% will increase the KT/V.
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Questions 161 & 162 Q
Question 161
Which one of the following statement is incorrect about haemodialysis
patients (HD)?
Question 162
A 26-year-old male presented with 4gm proteinuria and moderate renal
insufficiency. His kidney biopsy showed mild mesangial matrix expansion and
mesangialhypercellularity.
Immunofluorescence stains were done for IgG, IgA, IgM, C3, C1q, kappa light
chain and lambda light chain. Only C3 was positive in mesangial areas and
capillary loops.
See the images of kidney biopsy.
A Factor H levels
B Anti-nuclear cytoplasmic antibody
C Anti-nuclear antibody
D SCL-70
E Hgb-A1c
Answer 161
B - Treatment of sleep apnea has been shown to improve survival in HD
patient.
Options A, C, D and E are incorrect.
Option B is the correct answer.
Answer 162
A - Factor H levels
Options B, C, D and E are incorrect.
Option A is the correct answer.
The biopsy represents C3 glomerulopathy . The glomerulus shows mild
mesangial matrix expansion and mesangialhypercellularity.
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Question 163 Q
A 60-year-old male statuspost cadaveric kidney transplant, 2 months ago
presented with an acute rise in serum creatinine of 140 umol/L(Baseline was 82
umol/L).He denies any history of genitourinary or systemic symptoms.
On examination there is no graft tenderness.
Systemic examination was unremarkable.
His immunosuppressive medications include (prednisolone, cyclosporine and
Mycophenolate mofetil).
Kidney ultrasound showed no obstruction. His cyclosporine trough level result
is pending Graft biopsy is done.
Look at the biopsy image.
Which one of the following is the most likely diagnosis in his clinical scenario?
Both cyclosporine and tacrolimus have the same nephrotoxic effects with
indistinguishable histological lesions.
1. Ureteric obstruction
2. Transplant artery disease
3. Drug toxicity- Tacrolimus/cyclosporine
4. IFTA- Interstitial fibrosis tubular atrophy
5. Acute rejection
6. Infections- Viruses, BK
7. Recurrent primary disease
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Questions 164 & 165 Q
Question 164
See the electron microscopic kidney biopsy image of a 31-year-old male
patient with rheumatoid arthritis on long-term chloroquine treatment.
The patient does not have angiokeratomas on examination.
A Fabry disease
B Amyloidosis
C Chloroquine toxicity
D Lecithin cholesterol acyltransferase
deficiency
E Scleroderma
Question 165
The kidney biopsy image provided shows a nodular glomerulosclerosis.
A Fabry disease
B IgG4 associated diseases
C Henoch Schonlein purpura
D Monoclonal light chain deposition disease
E Cocaine abuse
Answer 164
Options A,B,D & E are incorrect.
Option C is the correct answer. The image shows myeloid bodies in tubules.
Both Fabry disease and chloroquine toxicity can cause this. However the
obvious association here is chloroquine toxicity.
Answer 165
Options A, B, C and E are incorrect.
Option D is the correct answer.
Causes of Nodular glomerulosclerosis
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Question 166 Q
Look at the electron microscopy image of a kidney biopsy
A Diabetic nephropathy
B Post-infectious glomerulonephritis
C Membranous nephropathy
D Fabry's disease
E MPGN type III
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Question 167 Q
An 18-year-old male presented with microscopic haematuria and a recent onset
of non-nephrotic range proteinuria.
Family history is negative for renal disease.
Physical examination reveals a BP of 145/80 mmHg, height of 5 ft, weight of
201 lb, and no Lower limb edema. Laboratory evaluation discloses a serum
creatinine of 140umol/l, 24-hour urine protein of 2 g, albumin of 32 g/dl, and
bland urine sediment. Serum complements are in the normal range. Serologic
workup is negative for anti-nuclear antibody, hepatitis B surface antigen,
hepatitis C antibody, and HIV. The kidneys measure 13.6 and 13.5 cm by
ultrasound. A renal biopsy is performed.
A Membranous nephropathy
B Membranoproliferative glomerulonephritis
C Minimal change nephropathy
D Alport disease
E IgA nephropathy
Presentation
Classically, persistent microscopic haematuria is the earliest manifestation
of disease and persists throughout childhood into adolescence. Occasional
episodes of gross haematuria may occur. With disease progression,
subnephrotic or nephrotic range proteinuria develops and is accompanied by
declining renal function. Most males with X-linked disease develop ESRD, often
by age 30.
Extrarenal manifestations of Alports
Sensorineural hearing loss and anterior lenticonus (of the eye), owing to the
presence of diseased collagen IV networks in the Organ of Corti and lens
capsule. Genetic testing for HN has recently become available and involves
se- quencing of the 3, 4, and5 chains of type IV collagen in an effort to identify
disease causing mutations.
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Question 168 Q
A 53-year-old male with history of diabetes mellitus and alcoholic liver disease.
He presented with cellulitis due to MRSA (Meticillin-Resistant Staphylococcus
aureus). He was treated with antibiotics however he developed acute renal
failure.
Urine analysis showed RBC casts.
Image of a glomerulus is provided. Immunofluorescence staining showed
positivity in mesangium and capillary loops for IgA and C3.
A Henoch-Schonlein purpura.
B IgA nephropathy superimposed on diabetic nephropathy.
C Post infectious glomerulonephritis associated with Staph. Aureus infection.
D Hepatitis C associated glomerulonephritis.
E Rheumatoid arthritis
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Questions 169 & 170 Q
Question 169
50-year-old female with breast cancer, admitted with nephrotic syndrome.
Kidney biopsy is undertaken. Look at the image.
Question 170
Withdrawal of dialysis will lead to death within?
A 1-2 days
B 3-4 days
C 5-6 days
D 7-14 days
E 15- 21 days
Answer 169
Options A, C, D and E are incorrect.
Option B is the correct answer.
Answer 170
Options A, B, C and E are incorrect.
Option D is the correct answer.
Withdrawal of dialysis will lead to death within 7-14 days in most cases but
this is very dependent on residual renal function.
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Question 171 Q
Which one of the following statements is correct as per K/DOQI guidelines
about vascular access?
AVF (arteriovenous fistula) more likely to be useable when they have flow is
>600 ml/min, fistula length 6cm and no more than 6 mm deep from skin.
Options A, C, D and E are incorrect.
Option B is the correct answer.
K/DOQI Guidelines
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A
Complications of AVF surgery.
(First 8 weeks).
Steal syndrome
Venous hypertension
Poor flow
Stenosis
Aneurysmal
Infection
High output cardiac failure
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Question 172 Q
65-year-old male on maintenance haemodialysis three times per week
presented to accident and emergency with progressive swelling of left arm.
Currently he is dialysing with left Brachiocephalic AVF (arteriovenous fistula)
that was created 10 weeks ago. On examination his AVF looks humpier.
Previously he was dialysing with left internal jugular permanent catheter.
Prolonged bleeding >10 mins post dialysis on more than one occasion
despite optimisation of anticoagulation regime
25% fall from baseline in either achieved blood flow on dialysis or fistula
flow (transonic measurement within first 1.5 hrs of HD)
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Questions 173 & 174 Q
Question 173
Which allele is associated with increased genetic susceptibility to anti-GBM
antibody disease?
A HLA-DR1
B HLA-DR15
C HLA-DR7
D HLA-DP1
E HLA-DP 2
Question 174
Which of the following statements is incorrect?
Answer 173
Options A, C, D and E are incorrect.
Option B is the correct answer.
Genetic factors, along with pulmonary infections, have been associated the
development of anti-GBM disease. There is evidence of increased susceptibility
of developing anti- GBM disease in patients with HLA-DR15.
(HLA-DRB1*1501 allele), which is especially true in the white, Chinese, and
Japanese populations. Similarly, studies have shown a reduced risk of anti-GBM
disease in patients with HLA-DR1 and DR7.
Answer 174
B. Double positive patients more often present with c-ANCA than p-ANCA.
Options A,C,D and E are incorrect Option B is the correct answer.
Patients who are double positive for ANCA and anti-GBM have a better overall
survival. These double positive patients also have more systemic manifestations
of vasculitis on presentation, and are more often p-ANCA or anti-MPO
positive. Prognosis for kidney recovery in patients presenting with anti-GBM
glomerulonephritis and 100% crescents on kidney biopsy when requiring
dialysis is very poor.
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Questions 175 & 176 Q
Question 175
What is the preferred GFR estimation equation for use in morbid
obesity individuals?
A MDRD equation
B CKD EPI (creatinine)
C Cockcroft Gault
D None of the above
E All of above
Question 176
What is the KDOQI recommended pre-dialysis serum bicarbonate
level in adults?
A 18 mEq/L
B 20 mEq/L
C 22 mEq/L
D >22mEq/L
E None of above
Answer 175
D. None of the above
Options A,B,C and E are incorrect
Each of the estimating equations for GFR has shown inconsistencies in
accurately determining GFR (either under- or over-estimating GFR). For
instance, Friedman et al demonstrated that neither creatinine- nor cystatin C
based equations (Cockcroft Gault or MDRD equations) correlated with GFR as
measured by iohexol in 44 obese individuals with normalkidney function,
with both equations overestimating GFR. Similarly, Verhave et al demonstrated
that both the MDRD and Cockcroft Gault equations were not accurate in
estimating GFR in subjects with BMI >30 kg/m2. Lastly, Bouquegneau et
al showed that the CKD-EPI (creatinine based) did not outperform MDRD
equation in 366 patients with a mean BMI >36 kg/m2)
Answer 176
C - 22 mEq/L.
Options A, B, D and E are incorrect.
Option C is the correct answer.
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Question 177 Q
You receive an ABO incompatible renal transplant patient with an acute rise in
serum creatinine. Kidney biopsy was done.
C4d stain does not correlate with acute rejection in ABO incompatible renal
transplants.
The image shows diffuse Peritubular capillary staining for C4d staining by
immunofluorescence. Peritubular capillary C4d does not correlate with AMR in
ABO incompatible patients.
Specificity of peritubular capillary staining for C4d is in association with HLA
antibody mediated rejection and not ABO mediated rejection. In ABO-
incompatible grafts, 80% of protocol biopsies and 59% performed for graft
dysfunction show C4d staining in peritubular capillaries. Note that glomerular
capillary loop C4d staining (as opposed to peritubular capillary staining) has
no significance.
(Ref: Am J Transplant. 2006 Aug;6(8):1829-40)
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Question 178 Q
25-year-old female presented with acute renal failure and the following biopsy
image. Serology, and other tests are not available.
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Question 179 Q
A 41-year-old Asian man presents with a 10 days history of lowgrade fever,
myalgias, cough, and decreased oral intake, more recently accompanied by
oliguria and a single episode of gross haematuria.
The patient was seen 5 days earlier and given a course of ciprofloxacin, without
symptomatic improvement. Laboratory evaluation reveals acute kidney injury
with a creatinine level of 900 umol/l, K 7.9 (with ECG changes) , albumin 25 g/
dl, hematocrit 30%, white blood cell count 11,500, and platelet count 352,000.
Past medical history is significant only for chronic lower back pain.
There is no history of hypertension, diabetes, obesity, or tobacco use.
The patient denies use of NSAID or overcounter medications.
Physical examination reveals a BP of 140/89 mmHg and no edema or skin rash.
Urine dipstick reveals 2+protein and 3 +blood.
Serologic results include a negative antinuclear antibody and normal C3 and
C4 complement levels.
After 2 sessions of haemodialysis, Kidney biopsy is undertaken.
Additional serologies are pending at the time of renal biopsy .
On day 3 patient condition is detoriated and he was transfer to the critical care
bed.
A Memberanoproliferative glomerulonephritis
B Cresenteric glomerulonephritis
C IgA Nephropathy
D Membranous nephropathy
E Cytomegalovirus (CMV) infection
1. Vasculitis-80%
2. Goodpastures syndrome-10%
3. SLE-5%
4. Others-5%
Haemoptysis/dyspnoea
Progressive anaemia
Hypoxia
Chest x-ray -diffuse airspace shadowing
Raised CO transfer coefficient
BAL (Broncho alveolar lavage) - frank blood/haemosiderin laden macrophages
Lung biopsy - pulmonary capillaritis
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A
Current approach to treatment of severe ANCA associated Vasculitis
INDUCTION
(Therapy to achieve remission)
Prednisolone (+/-) iv Methyl Pred
Cyclophosphamide iv/oral
Or consider Rituximab
Plasma exchange (60ml/kg-7 sessions)
MAINTENANCE
(Therapy to maintain remission (switch 3-6 months)
Low dose prednisolone
Convert cyclophosphamide to azathioprine 1.5 mg/kg/day (max 200 mg) or
MMF 1 g bd is an alternative in patients intolerant of azathioprine, or
consider Rituximab.
Maintenance therapy is not recommend in patients who are dialysis dependent and
have no extrarenal manifestations. Relapse rate are lower in patients with ESRD.
Presentation
Rapidly progressive glomerulonephritis (RPGN)
Rising creatinine + crescents presents on biopsy (oliguria) Urine
Haematuria+RBCCast+Proteinuria
Kidneys normal size
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Question 180 Q
A 60-year-old male known case of alcoholic liver cirrhosis was admitted
with left ankle fracture. He was known to have CKD stage 3. He was taking
spironolactone, which was stopped on admission, and he had moderate
volume ascites.
Labs on admission
After 48 hrs of fluid resuscitation, including human albumin solution his blood
results were as follows
A Renal biopsy
B Start haemodialysis
C Drainage of ascites
D Terlipressin
E Administer 3 L of IV colloid
One should ensure that the patient is adequately filled and there is an absence
of hypovolaemia prior to diagnosing Hepatorenal syndrome and starting
terlipressin. This patient has been fluid resuscitated, yet this has not reduced
his creatinine level to <133 umol/L.
The European association for the study of liver (EASL) has defined hepatorenal
syndrome as The occurrence of renal failure in a patient with advanced
liver disease in the absence of an identifiable cause of renal failure. Thus the
diagnosis is essentially one of exclusion of other causes of renal failure.
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A
International Ascites club (IAC) guidelines:
Criteria for the diagnosis of Hepatorenalsyndrome (2005)
Type 1 Type 2
Terlipressin
Liver transplantation remains best treatment for type 1 and type 2 HRS,
although many patients still require dialysis afterwards.
RRT with haemofiltration and haemodialysis may be useful in patients who fail
to respond to vasoconstrictor therapy and who fulfil criteria for renal support.
Salerno F,Gerbes A et al- diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis
GUT 2007
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Question 181 Q
50-year-old female admitted with a positive Rheumatoid factor and with acute
nephritic syndrome.
A Monoclonal gammopathy
B Cryoglobulinemia
C HIV
D Parvovirus B-19
E Factor H deficiency
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Question 182 Q
A 25-year-old female received a cadaveric kidney transplant 2 years ago.
She admitted with a worsening graft function. Her immunosuppession
medications include (Prednisolone, Cyclosporine and Mycophenolate mofetil),
Cyclosporine trough level and all other serology and immunology results are
pending.
Ultrasound transplant kidney shows no hydronephrosis.
Graft biopsy was done
A Haemolytic-Uraemic syndrome
B Cyclosporine toxicity
C Polyomavirus infection
D Acute tubular injury
E Acute vasculitis
The image shows a glomerular hilar arteriole with peripheral hyaline nodules
(arrows)which is indicative of chronic calcineurin inhibitor toxicity.
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Question 183 Q
66-year-old male admitted with acute on chronic renal failure, Had a recent
AAA (abdominal aortic aneurysm) repair done 2 weeks ago.
Kidney biopsy done.
A Thrombotic microangiopathy
B Endothelial inflammation
C Cholesterol crystal embolization
D Acute tubular injury.
E Acute interstitial nephritis
Atherosclerosis
Systemic hypertension
Cigarette smoking
Hypercholesterolemia
DM
Age>55 yrs
White race Trauma to atheromatous Plaque
Invasive vascular procedure involving aorta proximal to origin of
renal arteries
Thrombolytic therapy
Blunt trauma Prevention of healing of the eroded plaque
Anticoagulant therapy
Thrombolytics
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A
Differential Diagnosis of Cholesterol emboli renal disease
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Questions 184 & 185 Q
Question 184
A 79-year-old Caucasian man presents with florid nephrotic syndrome and
acute renal failure. The patient has a 24-hour urine protein of 20.0 g, serum
albumin level of 13g/dl, 3+ peripheral edema, bland urine sediment, and an
increase in creatinine from 80umol/l to 420umol/l over 2 weeks.
Kidney biopsy is undertaken
See the image
A Membranoproliferative glomerulonephritis.
B Minimal change nephropathy.
C Thin glomerular basement membrane disease.
D Membranous nephropathy.
E Diabetic nephropathy.
Question 185
According to KDIGO guideline which of the following statement is incorrect
about use of other therapies in the management of Acute Kidney Injury?
Answer 184
Membranous Nephropathy. Note glomerular basement membrane spikes
by silver stain.
Options A, B, C and E are incorrect.
Option D is the correct answer.
Answer 185
B - Guidelines recommend using low dose dopamine to treat or prevent AKI.
Options A, C, D and E are incorrect.
Option B is the correct answer.
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Question 186 Q
Which of the following drug is better removed by haemodialysis?
A Theophylline
B Phenytoin
C Digoxin
D Lithium
E None of above
You will definitely get 1 or 2 questions in the exam about this topic.
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Question 187 Q
Which of the following advice is unlikely to be beneficial When counselling a
female transplant patient with regards to conception and pregnancy?
Prednisolone
Cyclosporine
Tacrolimus
Azathioprine
Hydroxychloroquine
Sulfasalazine
Etarnercept
(Infliximab)
IVIG
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Questions 188 & 189 Q
Question 188
Which of the following statements is not true with regards to pregnancy and
SLE?
Question 189
A 27-year-old female known case of antiGBM disease, who is now dialysis
dependent asks you about the possibility of future kidney transplant.
Her recent anti GBM level is (10.6Eu/ml; the normal level is <5 Eu/ml).
what advice you will give about possibility of a future kidney transplant in this
patient?
Answer 188
Renal disease should be in remission for at least six months prior to conception.
Options A, B, D and E are incorrect.
Option C is the correct answer.
General guidelines
Answer 189
Kidney transplantation can be safely carried out in Goodpasture's disease
after anti-GBM antibodies are no longer detectable. The best advice is to
leave an interval of at least 6 -12 months after the first negative result (this will
depend on the sensitivity of the test being used). This may be a problem if no
treatment was given at the outset, as the time for safe transplantation may then
be 1-2 years away. But these precautions have largely removed the problem of
destruction of transplants caused by return of Goodpasture's disease.
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Questions 190 &191 Q
Question 190
Which of the following statements is not true with regards to pregnancy in renal
transplant patients?
Question 191
Which of the following surgical non-infectious complication of kidney
transplantation is more associated with use of mTOR inhibitors?
A Seromas
B Hematomas
C Lymphocele
D Graft rupture
E none of above
Answer 190
During pregnancy, the hepatic cytochrome P450 enzymes may be inhibited,
which can lead to decreased serum levels of tacrolimus Options A,C,D and
E are incorrect Option B is the correct answer During pregnancy, the hepatic
cytochrome P450 enzymes may be inhibited, which can lead to increased
serum levels of tacrolimus. The dose may therefore have to be significantly
reduced to prevent toxicity (sometimes by as much as 60 percent).
Answer 191
Lymphocele, option C is the correct answer. Options A, B, D and E are incorrect.
Lymphocele seen in 10% cases post kidney transplantation.
About 5-15% cases are associated with the use of mTOR inhibitors.
Management
Conservative if non obstructing
If obstructing- percutaneous drainage
30% require surgical repair.
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Questions 192 & 193 Q
Question 192
Which of the following is most common cause of mortality after kidney
transplantation?
Question 193
Which of the following is most strongly associated with development of
Post Transplant Diabetes (PTDM)?
A Tacrolimus use
B Hepatitis C
C advanced age of recipient
D Obesity
E Advanced donor age
Answer 192
CVD cardiovascular disease remains most common cause of mortality after
kidney transplant.
Options A, B, C and E are incorrect.
Option D is the correct answer.
Trends in reported causes of death with function during 1 post transplant
Answer 193
C - advanced age of recipient.
Options A, B, D and E are incorrect.
Option C is the correct answer.
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Questions 194 & 195 Q
Question 194
Which of the following factors is most strongly associated with post transplant
anaemia?
Question 195
The immunofluorescence microscopy finding in the image provided is
diagnostic of ?
Answer 194
B - Impaired allograft function.
Options A, C, D and E are incorrect.
Option B is the correct answer.
Answer 195
E - Anti-GBM disease.
The image shows linear capillary loop staining for IgG.
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Question 196 Q
A 46-year-old Caucasian man is discovered to have microscopic haematuria,
subnephrotic proteinuria, and renal insufficiency. Past medical history is
significant for hypertension for 2 years. There is no history of diabetes and no
family history of renal disease. Physical examination reveals no edema and BP
of 130/92 mmHg on antihypertensive medications. The patient denies any
history of recent infection, skin rash, arthralgias, or abdominal pain. Laboratory
evaluation includes serum creatinine level of 186umol/l, 24-hour urine protein
of 1.8 g, and serum albumin level of 36 g/dl. urine dipstick shows 2+protein
and 1+blood , and microscopic examination of the
urinary sediment reveals 10 red blood cells (RBCs) per high-power field
and no casts. Serum IgA level is mildly elevated, but all other serologies
are negative or normal, including serum complement levels (C3 and C4),
anti- nuclear antibody, hepatitis B surface antigen, hepatitis C antibody,
anti-neutrophil cytoplasmic antibody (ANCA), and antiglomerular basement
membrane (anti-GBM) antibody. No monoclonal spike is detected by serum
protein electrophoresis. The kidneys measure 11.3 and 12.2 cm in length by
ultrasound.
A kidney biopsy was performed
See the electron microscopy image
A Membranous nephropathy
B Memberoproliferative glomerulonephritis type 1
C IgA nephropathy
D Post streptococcal GN
E Alport syndrome
The Oxford Classification of IgA Nephropathy
Variable Score
Adapted from Cattran DC, Coppo R, Cook HT, et al. The Oxford classification of IgA nephropathy:
rationale, clinicopathological correlations, and classification. Kidney Int. 2009;76(5):534545.
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Questions 197 & 198 Q
Question 197
A 37-year-old Caucasian woman with a 12-year history of systemic lupus
erythematosus (SLE) but no previous history of renal disease presents with
new onset of haematuria and proteinuria. Laboratory evaluation reveals a
serum creatinine level of 120umol/l , 24-hour urine protein of 2.9 g, serum
albumin of 28 g/dl, white blood cell count of 2.4 109/L, hematocrit of 38.8%,
and platelet count of 122 109/L. Serologic evaluation reveals an anti-nuclear
antibody (ANA) titer of 1:1280, an anti-DNA antibody of 600 IU/ml, low C3 and
C4 complement levels, a positive IgG anticardiolipin antibody, and a negative
lupus anticoagulant.
Examination of the urine sediment discloses 6 to 10 red blood cells per high-
power field, no significant white blood cells, and no cellular casts. Previous
manifestations of SLE included pericarditis, alopecia, a malar rash, and
arthralgias. Physical examination reveals a BP of 122/76, an erythematous facial
rash, and no edema. Medications
include methylprednisolone 10 mg/day and hydroxychloroquine 200 mg/ day.
The kidneys measure 12.4 and 11.9 cm in length by ultrasound. Renal biopsy is
performed.
see the electron microscopy image
Which class of lupus nephritis does
the finding represent?
A WHO Class I
B WHO Class II
C WHO Class III
D WHO Class IV
E WHO class V
Question 198
Answer 197
The answer is E - WHO Class V, as the findings are of subepithelial
membranous deposits ( arrows). It is important to be familiar with basics of
WHO and RPS/ISN classifications of lupus nephritis.
Answer 198
Options A,B,D & E are incorrect
Option C is the correct answer
In a dialysis patient who makes no urine, sodium removal occurs through both
diffusion (15-20%) and convection (80%). Convective loss of sodium depends
on the prescribed UF, while diffusive clearance depends on the concentration
gradient between the plasma and dialysate. High dialysate sodium
prescriptions result in less disequilibrium symptoms, more vascular stability, and
lower incidence of muscle cramps. However, patients leave with a higher post
HD sodium concentration (relative hypernatraemia) and increased thirst, and
are prone to greater interdialytic weight gains and ultimately hypertension.
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Questions 199 & 200 Q
Question 199
Which one of the following option shows most effective treatment for sexual
dysfunction management in haemodialysis and peritoneal dialysis patients?
A Optimise Dialysis
B Psychological counselling
C Correction of anaemia with ESA
D Use of zinc supplement
E Use of sildenafil
Question 200
Which one of the following drug safely use in dialysis patient for pain control?
A Morphine
B Hydromorphone
C Oxycodone
D Fentanyl
E Demerol
Answer 199
Option E is the correct answer
There are several management guidelines for ED. The UK guidelines suggest
that a detailed history is the most important aspect in the assessment of
patients with ED. Treatment options for men with ED include psychosexual
therapy, drug therapy, transurethral or intracavernosal therapy, treatment with
vacuum-constriction devices, and surgical treatment .
Its use results in increased smooth muscle relaxation and improved erection
when nitric oxide is released in the presence of sexual stimulation.
Patients not to take sildenafil on dialysis days. There have been reports of
hypotension associated with sildenafil use by dialysis patients.
Oral sildenafil was an effective and safe treatment for ED in the present sample
of selected patients with chronic renal failure on HD.
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200 - D A
Answer 200
D is the correct answer.
Option A,B,C & E are incorrect. Pain is the most frequently reported symptom
in the dying patient with chronic kidney disease.
Images Index
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Image 1
Drawing showing course of
Peritoneal dialysis
catheter in abdominal wall
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Image 3
Plain Abdominal X-ray shows correct position
of Peritoneal Dialysis catheter, with the tip in
the Pelvis
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Image 5
Plain Abdominal x-ray shows kink in PD
Catheter
By
Dr Ebadur Rahman
& Dr Raees Farhan Mushtaq