1-A 45 year old male presents with a long-standing history of hypertension.
Investigations show a urea of 10.2 mmol/l and a Creatinine of 150 micromaol/l (50- 4-A 19-year-old female developed pleural effusions, ascites and ankle swelling. Her
100). Which one of the following would suggest a diagnosis of acute blood pressure was 112/76 mmHg.
glomerulonephritis? Investigations revealed:
1 ) 24 hour urinary protein excretion of 0.8g serum alanine transferase17 U/L (5 - 15)
2 ) Dyslipidaemia serum total bilirubin 17 umol/L (1 - 22)
3 ) RBC casts in urinary sediment serum albumin 21 g/L (34 - 94)
4 ) Shrunken glomeruli on renal biopsy serum total cholesterol 9.8 mmol/L (<5.2)
5 ) Unilaterally smaller kidney What is the next most appropriate investigation?
Comments: 1 ) Antinuclear antibody
Casts containing erythrocytes (red cell casts) are an indication of renal bleeding, and 2 ) Pregnancy test
are typically found when there is acute glomerular inflammation caused by 3 ) Prothrombin time
glomerulonephritis or vasculitis. Answers A, B, D, and E are non specific and do not 4 ) Serum protein electrophoresis
suggest an acute glomerulonephritis. 5 ) Urinary protein estimation
Comments:
2-A 46-year-old woman develops nephrotic syndrome and is awaiting further tests to The low albumin and elevated cholesterol would suggest nephrotic syndrome
establish the underlying aetiology. In which circumstance would corticosteroids be (>4gram protein/24hour urine). Other complications of nephritic syndrome include
most effective in reversing the nephrotic syndrome? susceptibility to infection, thromboses, renal failure and protein malnutrition. The
1 ) Membranous nephropathy normal BP makes preeclampsia unlikely. Besides, the hypercholesterolaemia is the
2 ) Minimal change disease big clue.
3 ) Primary amyloidosis
4 ) Renal vein thrombosis 5-Autosomal recessive conditions include:
5 ) Mesangial IgA disease 1 ) Vitamin D resistant rickets
Comments: 2 ) Huntingdon's chorea
Although there is no known effective treatment for IgA nephropathy, there have been 3 ) Wilson's disease
reports of favourable response to long term corticosteroid therapy. 80% adults with 4 ) Manic depression
minimal change GN will respond to steroids, although remissions can take up to 16 5 ) Turner's syndrome
weeks. Membranous GN does not respond to steroid treatment. No specific treatment Comments:
is available to cause regression of amyloid deposits. Vitamin D resistant rickets = X-linked dominant. No linkage has been established for
a particular gene in manic depressive disorder
3-The following are complications of nephrotic syndrome with the exception of
1 ) acute renal failure 6-A 68-year-old male is referred by his general practitioner with deteriorating
2 ) accelerated hypertension hypertension and renal function. His investigations disclose:
3 ) hypocalcaemia serum creatinine250 micromol/L (60 - 110)
4 ) pneumococcal infection urinalysis+ protein
5 ) venous thrombosis renal ultrasound examination:
Comments: left kidney 9cm long
Complications also include hyperlipidaemia, protein malnutrition and loss of binding right kidney 7cm, no obstruction (10 - 12cm)
proteins in urine. Nephrotic syndrome likely to be associated with hypocalcaemia (Vit Which of the following would be the most appropriate investigation for this patient?
D binding protein and Vitamin D lost in nephrotic urine) and hypovolaemia (low 1 ) intravenous renography
blood pressure). 2 ) isotope renography
,3 ) MR angiography 5 ) Normal renal handling of K+ and H+
4 ) renal biopsy Comments:
5 ) retrograde pyelography H+ secretion, sodium reabsorption and ammonia production diminishes. RTA 4 is in
Comments: effect hyporeninaemic hypoaldosteronism or failure of aldosterone action and thus
The diagnosis is likely to be atherosclerotic renal artery stenosis as suggested by the helped treated with mineralocorticoids. It is usually seen in chronic renal disease and
asymmetric reduction in renal size, with mild proteinuria quite common in the hence low GFR and particularly. Aminoaciduria and increased urine bicarbonate are
condition. Investigations include Captopril Renogarphy, MR angiography which is features of RTA types 1 and 2.
virtually as good as renal arteriography. None of the other investigations are
appropriate for RAS. 9-A 52 year old woman presents with left loin pain. Past history included
hypertension and progressive cognitive decline. On examination she was pyrexial,
7-A 45-year-old lady presents with fatigue and has established End Stage Renal had livedo reticularis and a blood pressure of 180/100 mmHg.
Failure. She has been on haemodialysis for the past three years and receives dialysis Examination of the abdomen revealed no masses but there was tenderness in the left
for 3 hours three times a week at a regional haemodialysis centre. flank.
At one of her regular visits for haemodialysis she is found to have the following Investigations revealed:
observations and investigations. haemoglobin12.9 g/dL (11.5-16.5)
Blood Pressure170/95 white cell count8.7 x 109/L (4-11)
serum K+5.7 mmol/L (3.5 - 4.9) platelet count83 x 109/L (150-400)
serum corrected calcium2.0 mmol/L (2.2 - 2.6) serum creatinine106 umol/L (60-110)
Hb9.0 g/dl (11.5 - 16.5) urine dipstick analysis: blood+++ protein+
Creatinine1300 mmol/l Which one of the following tests is most likely to be positive?
Post-dialysis her Blood Pressure is recorded as 160/95. 1 ) anticardiolipin antibody
Which of the following is the best managament for this lady? 2 ) antiglomerular basement membrane antibody
1 ) increase dialysis hours 3 ) antimitochondrial antibody
2 ) treat anaemia with erythropoietin 4 ) antineutrophil cytoplasmic antibody
3 ) treat hyperkalaemia 5 ) antistreptolysin O antibody
4 ) treat hypocalcaemia Comments:
5 ) treat hypertension with ramipril This patient has features of to suggest SLE with antiphopholipid syndrome with this
Comments: presentation possibly due to renal vein thrombosis (flank pain with blood and protein
This person's main complaints are of fatigue. Treating her with erythropoietin would in urine). The diagnosis would be supported by the thrombocytopaenia, history of
therefore be the most appropriate therapy particularly with her anaemia. Increasing hypertension and the livedo reticularis. Wegner¡¯s with positive ANCA would be a
dialysis is unlikely to be acceptable to most patients and renal units though this is an less likely diagnosis
option some patients would choose, especially those on 'home haemodialysis'.
Vascular disease is an important cause of death in dialysis patients and this lady may 10-A 55 year old man who has received haemodialysis for many years presents with
very well need additional treatment of blood pressure. deteriorating discomfort in both shoulders. Past medical history included bilateral
carpal tunnel decompression. His Investigations reveal:
8-Which of the following is true concerning a 68 year old male with type 2 diabetes haemoglobin10 g/dl
diagnosed with type IV renal tubal acidosis? ESR30 mm/1st hr (1-10)
1 ) Aminoaciduria would be expected. C-reactive protein12mg/L (1-10)
2 ) Fludrocortisone treatment is effective Urate0.58 mmol/L (less than 0.45)
3 ) Increased Glomerular filtration rate is expected. What is the most likely diagnosis?
4 ) Increased urinary bicarbonate would be expected. 1 ) b2 microglobulin amyloidosis
, 2 ) Gout Systemic sclerosis is a systemic disorder characterised by skin thickening due to the
3 ) Pseudogout deposition of collagen in the dermis. Adverse prognostic features are renal, cardiac or
4 ) Polymyalgia rheumatica pulmonary involvement. A major complication is the development of scleroderma
5 ) Osteoarthritis renal crisis. This is characterised by the abrupt onset of severe hypertension, usually
Comments: with retinopathy, together with rapid deterioration of renal function and heart failure.
The features of shoulder pain associated with a past history of carpal tunnel syndrome It develops in 8-15% of patients with diffuse systemic sclerosis, especially associated
in a patient receiving haemodialysis suggests a diagnosis of b2 microglobulin with rapid progression of diffuse skin disease. It usually presents early, within three
amyloidosis. Amyloid deposits composed of b2-microglobulin as the major years of diagnosis. The pathogenic mechanisms leading to renal damage are not
constituent protein are mainly localized in joints and periarticular bone and lead to known. The clinical presentation is typically with the symptoms of malignant
destructive arthropathy which tends to develop 5 to 10 years after the initiation of hypertension, with headaches, blurred vision, fits and heart failure. Renal function is
dialysis. Death from amyloidosis of gut and heart may occur after 20 years of dialysis.impaired and usually rapidly deteriorates. The hypertension is almost always severe
with a diastolic BP over 100 mmHg in 90% of patients. There is hypertensive
11-A 25 year old female is admitted with acute dyspnoea and chest pain. A diagnosis retinopathy in about 85% of patients, with exudates and haemorrhages and if severe,
of pulmonary embolism is confirmed and her investigations reveal urine dipstick papilloedema. Scleroderma renal crisis is a medical emergency. The hypertension
protein ++ but no blood, anti-double standed DNA antibodies of 200 U/mL (0 - 73), should be treated with an ACE inhibitor. The aim is to reduce the blood pressure
with a 24 hour urinary protein concentration of 5g (< 0.2). Which one of the following gradually, as an abrupt fall can lead to cerebral ischaemia or infarctions (as in any
diagnoses is most likely to be found on renal biopsy? accelerated hypertension). Calcium channel blockers may be added to ACE inhibitors.
1 ) AA amyloid Deterioration in renal function can be rapid, with gross pulmonary oedema; therefore
2 ) Focal segmental glomerulonephritis patients with scleroderma renal crisis should be managed in hospitals with facilities
3 ) IgA nephropathy for dialysis.
4 ) membranous nephropathy
5 ) minimal change nephropathy 13-Which of the following concerning renal blood flow is true?
Comments: 1 ) is 40% of the cardiac output at rest
This young woman has thromboembolic disease, the nephritic syndrome with positive 2 ) can be measured using the Fick principle
anti-ds DNA antibodies suggests a diagnosis of . Nephrotic syndrome in the absence 3 ) is higher in the medulla than the cortex
of hypertension, active urinary sediment, or significant hypocomplementemia 4 ) is increased when renal nerves are stimulated
suggests membranous nephropathy. The thromboembolic disease may arise due to 5 ) is decreased in response to hypoxia
nephritic syndrome per se or from an associated antiphospholipid syndrome. Comments:
Renal blood flow is approximately 25% of cardiac output. The 'Fick principle' can be
12-A 42-year-old female with a recent diagnosis of systemic sclerosis, is referred to used to estimate RBF through clearance. RBF is higher in the cortex than medulla as
hospital with a complaint of headaches and blurred vision. She has a past medical one might expect with the increasing glomeruli in this region. Sympathetic stimuli
history of asthma. On examination, her blood pressure is 230/120, and there is produce vasoconstriction and RBF should be increased in response to hypoxia.
bilateral papilloedema. Which of the following medications should be prescribed
immediately? 14-A 65 year old male patient is admitted with renal failure and is diagnosed with
1 ) IV Furosemide acute tubular necrosis. Which of the following is least likely to be the cause of acute
2 ) IV Labetolol tubular necrosis?
3 ) IV Sodium Nitroprusside 1 ) Rhabdomyolysis
4 ) Oral Enalapril 2 ) Paracetamol poisoning
5 ) Sublingual Nimodipine 3 ) Hypovolaemia
Comments: 4 ) Hypertension
5 ) Corticosteroid therapy
Investigations show a urea of 10.2 mmol/l and a Creatinine of 150 micromaol/l (50- 4-A 19-year-old female developed pleural effusions, ascites and ankle swelling. Her
100). Which one of the following would suggest a diagnosis of acute blood pressure was 112/76 mmHg.
glomerulonephritis? Investigations revealed:
1 ) 24 hour urinary protein excretion of 0.8g serum alanine transferase17 U/L (5 - 15)
2 ) Dyslipidaemia serum total bilirubin 17 umol/L (1 - 22)
3 ) RBC casts in urinary sediment serum albumin 21 g/L (34 - 94)
4 ) Shrunken glomeruli on renal biopsy serum total cholesterol 9.8 mmol/L (<5.2)
5 ) Unilaterally smaller kidney What is the next most appropriate investigation?
Comments: 1 ) Antinuclear antibody
Casts containing erythrocytes (red cell casts) are an indication of renal bleeding, and 2 ) Pregnancy test
are typically found when there is acute glomerular inflammation caused by 3 ) Prothrombin time
glomerulonephritis or vasculitis. Answers A, B, D, and E are non specific and do not 4 ) Serum protein electrophoresis
suggest an acute glomerulonephritis. 5 ) Urinary protein estimation
Comments:
2-A 46-year-old woman develops nephrotic syndrome and is awaiting further tests to The low albumin and elevated cholesterol would suggest nephrotic syndrome
establish the underlying aetiology. In which circumstance would corticosteroids be (>4gram protein/24hour urine). Other complications of nephritic syndrome include
most effective in reversing the nephrotic syndrome? susceptibility to infection, thromboses, renal failure and protein malnutrition. The
1 ) Membranous nephropathy normal BP makes preeclampsia unlikely. Besides, the hypercholesterolaemia is the
2 ) Minimal change disease big clue.
3 ) Primary amyloidosis
4 ) Renal vein thrombosis 5-Autosomal recessive conditions include:
5 ) Mesangial IgA disease 1 ) Vitamin D resistant rickets
Comments: 2 ) Huntingdon's chorea
Although there is no known effective treatment for IgA nephropathy, there have been 3 ) Wilson's disease
reports of favourable response to long term corticosteroid therapy. 80% adults with 4 ) Manic depression
minimal change GN will respond to steroids, although remissions can take up to 16 5 ) Turner's syndrome
weeks. Membranous GN does not respond to steroid treatment. No specific treatment Comments:
is available to cause regression of amyloid deposits. Vitamin D resistant rickets = X-linked dominant. No linkage has been established for
a particular gene in manic depressive disorder
3-The following are complications of nephrotic syndrome with the exception of
1 ) acute renal failure 6-A 68-year-old male is referred by his general practitioner with deteriorating
2 ) accelerated hypertension hypertension and renal function. His investigations disclose:
3 ) hypocalcaemia serum creatinine250 micromol/L (60 - 110)
4 ) pneumococcal infection urinalysis+ protein
5 ) venous thrombosis renal ultrasound examination:
Comments: left kidney 9cm long
Complications also include hyperlipidaemia, protein malnutrition and loss of binding right kidney 7cm, no obstruction (10 - 12cm)
proteins in urine. Nephrotic syndrome likely to be associated with hypocalcaemia (Vit Which of the following would be the most appropriate investigation for this patient?
D binding protein and Vitamin D lost in nephrotic urine) and hypovolaemia (low 1 ) intravenous renography
blood pressure). 2 ) isotope renography
,3 ) MR angiography 5 ) Normal renal handling of K+ and H+
4 ) renal biopsy Comments:
5 ) retrograde pyelography H+ secretion, sodium reabsorption and ammonia production diminishes. RTA 4 is in
Comments: effect hyporeninaemic hypoaldosteronism or failure of aldosterone action and thus
The diagnosis is likely to be atherosclerotic renal artery stenosis as suggested by the helped treated with mineralocorticoids. It is usually seen in chronic renal disease and
asymmetric reduction in renal size, with mild proteinuria quite common in the hence low GFR and particularly. Aminoaciduria and increased urine bicarbonate are
condition. Investigations include Captopril Renogarphy, MR angiography which is features of RTA types 1 and 2.
virtually as good as renal arteriography. None of the other investigations are
appropriate for RAS. 9-A 52 year old woman presents with left loin pain. Past history included
hypertension and progressive cognitive decline. On examination she was pyrexial,
7-A 45-year-old lady presents with fatigue and has established End Stage Renal had livedo reticularis and a blood pressure of 180/100 mmHg.
Failure. She has been on haemodialysis for the past three years and receives dialysis Examination of the abdomen revealed no masses but there was tenderness in the left
for 3 hours three times a week at a regional haemodialysis centre. flank.
At one of her regular visits for haemodialysis she is found to have the following Investigations revealed:
observations and investigations. haemoglobin12.9 g/dL (11.5-16.5)
Blood Pressure170/95 white cell count8.7 x 109/L (4-11)
serum K+5.7 mmol/L (3.5 - 4.9) platelet count83 x 109/L (150-400)
serum corrected calcium2.0 mmol/L (2.2 - 2.6) serum creatinine106 umol/L (60-110)
Hb9.0 g/dl (11.5 - 16.5) urine dipstick analysis: blood+++ protein+
Creatinine1300 mmol/l Which one of the following tests is most likely to be positive?
Post-dialysis her Blood Pressure is recorded as 160/95. 1 ) anticardiolipin antibody
Which of the following is the best managament for this lady? 2 ) antiglomerular basement membrane antibody
1 ) increase dialysis hours 3 ) antimitochondrial antibody
2 ) treat anaemia with erythropoietin 4 ) antineutrophil cytoplasmic antibody
3 ) treat hyperkalaemia 5 ) antistreptolysin O antibody
4 ) treat hypocalcaemia Comments:
5 ) treat hypertension with ramipril This patient has features of to suggest SLE with antiphopholipid syndrome with this
Comments: presentation possibly due to renal vein thrombosis (flank pain with blood and protein
This person's main complaints are of fatigue. Treating her with erythropoietin would in urine). The diagnosis would be supported by the thrombocytopaenia, history of
therefore be the most appropriate therapy particularly with her anaemia. Increasing hypertension and the livedo reticularis. Wegner¡¯s with positive ANCA would be a
dialysis is unlikely to be acceptable to most patients and renal units though this is an less likely diagnosis
option some patients would choose, especially those on 'home haemodialysis'.
Vascular disease is an important cause of death in dialysis patients and this lady may 10-A 55 year old man who has received haemodialysis for many years presents with
very well need additional treatment of blood pressure. deteriorating discomfort in both shoulders. Past medical history included bilateral
carpal tunnel decompression. His Investigations reveal:
8-Which of the following is true concerning a 68 year old male with type 2 diabetes haemoglobin10 g/dl
diagnosed with type IV renal tubal acidosis? ESR30 mm/1st hr (1-10)
1 ) Aminoaciduria would be expected. C-reactive protein12mg/L (1-10)
2 ) Fludrocortisone treatment is effective Urate0.58 mmol/L (less than 0.45)
3 ) Increased Glomerular filtration rate is expected. What is the most likely diagnosis?
4 ) Increased urinary bicarbonate would be expected. 1 ) b2 microglobulin amyloidosis
, 2 ) Gout Systemic sclerosis is a systemic disorder characterised by skin thickening due to the
3 ) Pseudogout deposition of collagen in the dermis. Adverse prognostic features are renal, cardiac or
4 ) Polymyalgia rheumatica pulmonary involvement. A major complication is the development of scleroderma
5 ) Osteoarthritis renal crisis. This is characterised by the abrupt onset of severe hypertension, usually
Comments: with retinopathy, together with rapid deterioration of renal function and heart failure.
The features of shoulder pain associated with a past history of carpal tunnel syndrome It develops in 8-15% of patients with diffuse systemic sclerosis, especially associated
in a patient receiving haemodialysis suggests a diagnosis of b2 microglobulin with rapid progression of diffuse skin disease. It usually presents early, within three
amyloidosis. Amyloid deposits composed of b2-microglobulin as the major years of diagnosis. The pathogenic mechanisms leading to renal damage are not
constituent protein are mainly localized in joints and periarticular bone and lead to known. The clinical presentation is typically with the symptoms of malignant
destructive arthropathy which tends to develop 5 to 10 years after the initiation of hypertension, with headaches, blurred vision, fits and heart failure. Renal function is
dialysis. Death from amyloidosis of gut and heart may occur after 20 years of dialysis.impaired and usually rapidly deteriorates. The hypertension is almost always severe
with a diastolic BP over 100 mmHg in 90% of patients. There is hypertensive
11-A 25 year old female is admitted with acute dyspnoea and chest pain. A diagnosis retinopathy in about 85% of patients, with exudates and haemorrhages and if severe,
of pulmonary embolism is confirmed and her investigations reveal urine dipstick papilloedema. Scleroderma renal crisis is a medical emergency. The hypertension
protein ++ but no blood, anti-double standed DNA antibodies of 200 U/mL (0 - 73), should be treated with an ACE inhibitor. The aim is to reduce the blood pressure
with a 24 hour urinary protein concentration of 5g (< 0.2). Which one of the following gradually, as an abrupt fall can lead to cerebral ischaemia or infarctions (as in any
diagnoses is most likely to be found on renal biopsy? accelerated hypertension). Calcium channel blockers may be added to ACE inhibitors.
1 ) AA amyloid Deterioration in renal function can be rapid, with gross pulmonary oedema; therefore
2 ) Focal segmental glomerulonephritis patients with scleroderma renal crisis should be managed in hospitals with facilities
3 ) IgA nephropathy for dialysis.
4 ) membranous nephropathy
5 ) minimal change nephropathy 13-Which of the following concerning renal blood flow is true?
Comments: 1 ) is 40% of the cardiac output at rest
This young woman has thromboembolic disease, the nephritic syndrome with positive 2 ) can be measured using the Fick principle
anti-ds DNA antibodies suggests a diagnosis of . Nephrotic syndrome in the absence 3 ) is higher in the medulla than the cortex
of hypertension, active urinary sediment, or significant hypocomplementemia 4 ) is increased when renal nerves are stimulated
suggests membranous nephropathy. The thromboembolic disease may arise due to 5 ) is decreased in response to hypoxia
nephritic syndrome per se or from an associated antiphospholipid syndrome. Comments:
Renal blood flow is approximately 25% of cardiac output. The 'Fick principle' can be
12-A 42-year-old female with a recent diagnosis of systemic sclerosis, is referred to used to estimate RBF through clearance. RBF is higher in the cortex than medulla as
hospital with a complaint of headaches and blurred vision. She has a past medical one might expect with the increasing glomeruli in this region. Sympathetic stimuli
history of asthma. On examination, her blood pressure is 230/120, and there is produce vasoconstriction and RBF should be increased in response to hypoxia.
bilateral papilloedema. Which of the following medications should be prescribed
immediately? 14-A 65 year old male patient is admitted with renal failure and is diagnosed with
1 ) IV Furosemide acute tubular necrosis. Which of the following is least likely to be the cause of acute
2 ) IV Labetolol tubular necrosis?
3 ) IV Sodium Nitroprusside 1 ) Rhabdomyolysis
4 ) Oral Enalapril 2 ) Paracetamol poisoning
5 ) Sublingual Nimodipine 3 ) Hypovolaemia
Comments: 4 ) Hypertension
5 ) Corticosteroid therapy
