Nephrology

Question 1

is a severe, chronic, inflammatory disorder of the skin characterized by painful sloughing ulceration with a purulent or vegetative base and an elevated dusky blue or reddish-purple undermined border surrounded by a rim of inflammation.

Answer 1

Pyoderma gangrenosum

Question 2

a paraneoplastic disorder associated with renal cell cancer
typically presents as cholestasis/hepatosplenomegaly
it is thought to be secondary to increased levels of IL-6

Answer 2

Stauffer syndrome

Question 3

In AKI, hyperkalaeamia which is refractory to medical management is an indicator for renal replacement therapy

Question 4

ADPKD is associated with

Answer 4

Mitral valve prolaspe
aortic root dilation

Extra-renal manifestations
liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
berry aneurysms (8%): rupture can cause subarachnoid haemorrhage
cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary

Question 5

Contrast media nephrotoxicity may be defined as a 25% increase in creatinine occurring within 3 days of the intravascular administration of contrast media.

Question 7

Contrast-induced nephropathy occurs***** after administration.

Answer 7

2 -5 days

Question 8

Fusion of podocytes and effacement of foot processes is an electron microscopy finding in

Answer 8

minimal change disease

Question 9

HIV-associated nephropathy (HIVAN) causes collapsing FSGS and usually presents as nephrotic syndrome

Answer 9

It manifests as rapidly advancing nephrotic syndrome. Ultrasound shows large echogenic kidneys. Light microscopy most commonly shows a pattern of collapsing focal segmental glomerulosclerosis (FSGS) which often shows marked focal or global collapse of the basement membrane associated with hypertrophy and hyperplasia of the overlying podocytes. Therefore, podocyte proliferation with marked focal collapse of the glomerular basement membrane is correct.

Question 10

Mesangial hypercellularity with positive immunofluorescence for IgA & C3 is a finding in

Answer 10

IgA nephropathy

Question 11

Subendothelial and mesangial immune deposits resulting in a ‘tram-track’ appearance is an electron microscopy finding seen in

Answer 11

type 1 membranoproliferative glomerulonephritis which is associated with hepatitis C.

Question 12

HIV-associated nephropathy (HIVAN) causes collapsing FSGS and usually presents as nephrotic syndrome

Question 12

Thickened basement membrane with subepithelial electron-dense deposits creating a ‘spike and dome’ appearance is an electron microscopy finding associated with

Answer 12

membranous glomerulonephritis.

Question 13

Renal involvement in HIV patients may occur as a consequence of treatment or the virus itself. Protease inhibitors such as **** can precipitate intratubular crystal obstruction.

Answer 13

indinavir

Question 14

0.9% saline
if large volumes are used there is an increased risk of

Answer 14

hyperchloraemic metabolic acidosis

Question 15

Spontaneous coronary artery dissection (SCAD) is defined by an abrupt separation within the layers of the coronary artery wall, which may precipitate myocardial infarction. SCAD is typically linked to heritable connective tissue disorders like Ehlers-Danlos syndrome and Marfan syndrome but has no established link to ADPKD.

Question 16

SLE Lupus nephritis not responding to steroids

Answer 16

A large body of evidence from the use of azathioprine in pregnancy for the treatment of both rheumatological conditions and inflammatory bowel disease, supports its use. Although it is less effective in the management of SLE with renal disease versus other options, balance of benefit risk makes it the preferred intervention.

Ciclosporin appears to be associated with premature delivery and low birth weight, although it does not seem to be associated with malformations, this drives its use as an alternative to azathioprine in patients who fail to gain control of their disease. Cyclophosphamide, methotrexate and mycophenolate are all contraindicated for use in pregnancy.

Question 17

Metabolic acidosis is commonly classified according to the anion gap. This can be calculated by: (Na+ + K+) - (Cl- + HCO-3). If a question supplies the chloride level then this is often a clue that the anion gap should be calculated.

Answer 17

The normal range = 10-18 mmol/L

Question 21

*** is an antibody used in the treatment of hypercalcaemia associated with malignancy.

Answer 21

Denosumab

Question 22

A high-arched palate is associated with a number of congenital conditions, particularly those affecting the connective tissues such as

Answer 22

Marfan and Ehlers-Danlos syndrome

Question 23

Primary HUS (‘atypical’) is due to

Answer 23

complement dysregulation

Question 24

Most cases are secondary (termed ‘typical HUS’):
classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7
‘

Answer 24

verotoxigenic’, ‘enterohaemorrhagic’
this is the most common cause in children, accounting for over 90% of cases
pneumococcal infection
HIV
rare: systemic lupus erythematosus, drugs, cancer

Question 25

Exposure to Aflatoxin, a mycotoxin produced by the fungi Aspergillus flavus and Aspergillus parasiticus, has been strongly associated with*****

Answer 25

liver cancer

Question 26

This parasitic infection primarily affects the intestines and can cause abdominal pain, diarrhoea, and rash. In severe cases or in immunocompromised individuals, it can lead to hyperinfection syndrome or disseminated disease affecting multiple organs

Answer 26

Strongyloides stercoralis infection

Question 27

when HLA matching for a renal transplant the relative importance of the HLA antigens are as follows

Answer 27

DR > B > A

Question 28

is a selective androgen synthesis inhibitor that works by blocking cytochrome P450 17 alpha-hydroxylase. It blocks androgen production in the testes and adrenal glands, and in prostatic tumour tissue.

Answer 28

Abiraterone acetate

Question 29

non-steroidal anti-androgen blocks the androgen receptor

Answer 29

bicalutamide

Question 30

androgen synthesis inhibitor option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated

Answer 30

abiraterone

Question 31

V1 receptors are found on vascular smooth muscle and when activated cause vasoconstriction. V3 receptors are expressed in the pituitary gland and modulate ACTH secretion.

Answer 31

Tolvaptan blocks the action of vasopressin at the V2 receptor. This receptor is found on the basolateral membrane of the principal cells in the collecting ducts of the kidney. This reduces water absorption (through decreased aquaporin 2) and increases aquaresis without sodium loss. Desmopressin is a synthetic analogue of vasopressin that exerts agonism at the V2 receptor.

Question 32

Complications of plasma exchange

Answer 32

hypocalcaemia: due to the presence of citrate used as an anticoagulant for the extracorporeal system metabolic alkalosis removal of systemic medications coagulation factor depletion immunoglobulin depletion

Question 33

*******, (also known as struvite), kidney stones are formed by urea-splitting bacteria, of which Proteus is an example.

Answer 33

Magnesium ammonium phosphate stones can form very large calculi known as staghorn calculi which may significantly impact on renal function due to chronic obstruction and failure to clear urinary tract infection adequately. Treatment of the underlying urinary tract infection, coupled with a urology consult to assess the need for removal of any larger stones are the cornerstone of management.

Question 34

Calcium phosphate renal stones are associated with hyperparathyroidism, and urate stones are associated with gout. Cystine stones are seen in patients with inherited cystinuria, and oxalate stones are primarily associated with short bowel syndrome.

Question 35

this organism typically presents with more severe clinical manifestations like necrotizing fasciitis or streptococcal toxic shock syndrome.

Answer 35

Streptococcus pyogenes

Question 36

Streptococcus agalactiae, also known as

Answer 36

Group B Streptococcus (GBS),

Question 37

Rx for PD associated peritonitis

Answer 37

the BNF recommends vancomycin (or teicoplanin) + ceftazidime added to dialysis fluid OR vancomycin added to dialysis fluid + ciprofloxacin by mouth aminoglycosides are sometimes used to cover the Gram negative organisms instead of ceftazidime

Question 38

******* describes the proliferation of cells in the walls of the arteries causing the vessels to bulge or narrow. This most commonly affects women. These patients are susceptible to AKI after the initiation of an ACE inhibitor. The classic description is 'string of beads' appearance

Answer 38

Fibromuscular dysplasia

Question 39

****** manifests as membranoproliferative glomerulonephritis (MPGN) or a diffuse proliferative glomerulonephritis rather than membranous glomerulonephritis.they are immunoglobulins that precipitate at low temperatures and can deposit in small vessels, leading to vasculitis and glomerular injury

Answer 39

Cryoglobulinemia

Question 42

CKD stage 1 . This would be the case if there was supporting evidence of kidney damage but an eGFR > 90ml/minute. CKD stage 2 . This would be the case if there was supporting evidence of kidney damage and an eGFR between 60 and 90ml/minute. CKD stage 3a . This would be the case if eGFR was 45-59 ml/min, irrespective of other evidence of kidney damage. CKD stage 4 . This would be the case if the eGFR was 15-29 ml/min, irrespective of other evidence of kidney damage.

Answer 42

CKD stage GFR range 1 Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests* are normal, there is no CKD) 2 60-90 ml/min with some sign of kidney damage (if kidney tests* are normal, there is no CKD) 3a 45-59 ml/min, a moderate reduction in kidney function 3b 30-44 ml/min, a moderate reduction in kidney function 4 15-29 ml/min, a severe reduction in kidney function 5 Less than 15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed

Question 43

***** plays a role in preventing iron absorption by blocking the action of ferroportin, a transmembrane protein that maintains iron homeostasis. Due to increased levels of this in CKD, iron absorption is pathologically reduced, leading to iron-deficiency anaemia.

Answer 43

Hepcidin Hepcidin is an acute-phase reactant that is often increased in CKD due to inflammation and reduced renal clearance.

Question 44

*******is the most common and important viral infection in solid organ transplant recipients

Answer 44

Cytomegalovirus

Question 45

Metabolic acidosis, leads to anaemia in CKD

Answer 45

This is because metabolic acidosis (common in CKD) inhibits the conversion of ferric iron (Fe 3+) to its absorbable form, ferrous iron (Fe 2+), in the duodenum, resulting in reduced absorption.

Question 46

Chromosome 12 - hypochondroplasia, and colorectal cancer

Answer 46

Chromosome 8 - Burkitts lymphoma Chromosome 20 - Alagille syndrome and Creutzfeldt-Jakob disease.

Question 47

Tubular re absorption

Answer 47

PCT- presentation of increased urinary glucose and phosphate and a decrease in potassium levels combined with growth retardation and muscle weakness strongly suggest Fanconi syndrome. and decreased serum Bicarbonate DLOH - Water re absorbed through osmosis ALOH - significant role in the absorption of sodium, chloride, and potassium ions, it can contribute to the resorption of magnesium and calcium ions Water and sodium reabsorption occur within the collecting duct. Reabsorption of sodium and chloride occurs in the distal convoluted tubule across its apical membrane

Question 48

describes a generalised reabsorptive disorder of renal tubular transport in the proximal convoluted tubule resulting in: type 2 (proximal) renal tubular acidosis polyuria aminoaciduria glycosuria phosphaturia osteomalacia

Answer 48

Fanconis syndrome Causes cystinosis (most common cause in children) Sjogren's syndrome multiple myeloma nephrotic syndrome Wilson's disease

Question 49

Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed.

Answer 49

Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant.

Question 50

Drugs causing ACUTE INTERSTITIAL NEPHRITIS

Answer 50

Causes drugs: the most common cause, particularly antibiotics penicillin rifampicin NSAIDs allopurinol furosemide systemic disease: SLE, sarcoidosis, and Sjogren's syndrome infection: Hanta virus , staphylococci

Question 51

CKD on haemodialysis - most likely cause of death is

Answer 51

IHD

Question 52

Spironolactone is an aldosterone antagonist which acts in the*******

Answer 52

cortical collecting duct.

Question 53

RALES NYHA III + IV, patients already taking ACE inhibitor low dose spironolactone reduces all cause mortality

Question 54

By administering exogenous******, we can correct the anaemia, which leads to improved oxygen delivery to tissues. This results in better exercise tolerance, reduced fatigue, and improved quality of life for patients.

Answer 54

EPO

Question 55

Patients who have received an organ transplant are at risk of skin cancer (particularly******) due to long-term use of immunosuppressants

Answer 55

squamous cell carcinoma

Question 56

A gain of function mutation affecting epithelial Na channels occurs in*****. In Liddle syndrome, excessive sodium reabsorption from the collecting tubule leads to hypertension and also creates a negative potential within the collecting tubule that traps hydrogen and potassium ions, leading to metabolic alkalosis and hypokalaemia.

Answer 56

Liddle syndrome

Question 57

mutation affecting the reabsorption of sodium/chloride at the distal convoluted tubule (DCT) is responsible for********. These patients experience metabolic alkalosis and hypokalaemia (due to a rise in aldosterone, secondary to sodium loss), hypomagnesaemia, hyponatraemia and hypercalcaemia (due to increased calcium reabsorption). This condition is analogous to long-term thiazide diuretic use.

Answer 57

Gitelman syndrome

Question 58

A mutation affecting the reabsorption of sodium/potassium/chloride ions in the thick ascending loop of Henle is responsible for******. These patients experience metabolic alkalosis and hypokalaemia (due to a rise in aldosterone, secondary to sodium loss) and hypercalciuria. This condition is analogous to long-term loop diuretic use.

Answer 58

Bartter syndrome

Question 59

MDMA (Ecstasy) abuse can cause****** and the phenomenon is well described in adults.

Answer 59

SIADH

Question 60

Alcohol bingeing can lead to ****** in the posterior pituitary gland subsequently leading to polyuria

Answer 60

ADH suppression

Question 61

******** is a group of signs/symptoms indicative of liver dysfunction arising due to underlying renal cell carcinoma. Biochemically, there is can be an elevated alkaline phosphatase (ALP), γ-glutamyl transferase (GGT), platelets; prolonged prothrombin time (PT) with hepatosplenomegaly without hepatic metastasis or jaundice.

Answer 61

Stauffer's syndrome

Question 62

The******* which affects the ADH receptor in the distal convoluted tubule and collecting ducts is the more common genetic mutation which causes congenital nephrogenic diabetes insipidus (74.7% of cases). The V2R gene mutation which affects the ADH receptor in the distal convoluted tubule and collecting ducts is the more common genetic mutation which causes congenital nephrogenic diabetes insipidus (74.7% of cases).

Answer 62

V2R gene mutation

Question 63

A mutation in the Wolframin gene would cause DIDMOAD or Wolfram syndrome, another cause of******

Answer 63

cranial diabetes insipidus.

Question 64

Renal stones on x-ray cystine stones: semi-opaque urate + xanthine stones: radio-lucent

Answer 64

struvite or magnesium ammonium phosphate stones, are associated with urinary tract infections caused by urease-producing bacteria such as Proteus, Klebsiella, and Pseudomonas species. They are fully radiopaque on X-ray due to their mineral content and often form large staghorn calculi that fill the renal pelvis and calyces. They appear distinctly white on X-ray rather than semi-opaque.

Question 65

drugs that promote calcium stones: loop diuretics, steroids, acetazolamide, theophylline

Answer 65

Prevent - thiazide diuretics

Question 66

Risk factors for urate stones

Answer 66

gout ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid

Question 67

Rapidly progressive glomerulonephritis, causes:

Answer 67

Goodpasture's ANCA positive vasculitis

Question 68

Anti-Mi-2 antibodies are specific for

Answer 68

dermatomyositis. This presents with rashes and proximal muscle weakness,

Question 69

Calcium resonium results in removal of potassium from the body,

Answer 69

It increases potassium excretion by preventing enteral absorption

Question 70

Young female, hypertension and asymmetric kidneys →

Answer 70

fibromuscular dysplasia

Question 71

******, is a metabolic disorder that can lead to thromboembolic events due to increased levels of homocysteine. It can also cause ocular abnormalities, skeletal abnormalities like osteoporosis and marfanoid habitus, and cognitive impairment.

Answer 71

Homocystinuria

Question 72

Epididym-orchitis Rx if STI

Answer 72

IM ceftriaxone stat + oral doxycycline for 2 weeks. if enteric organisms are the most likely cause send an MSU as above treating empirically with an oral quinolone for 2 weeks (e.g. ofloxacin)

Question 73

IgA Nephropathy

Answer 73

Prognosis 25% of patients develop ESRF markers of good prognosis: frank haematuria markers of poor prognosis: male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

Question 74

Antiretroviral therapy is the treatment of choice. If a patient is already taking antiretroviral therapy (which should be all HIV-diagnosed patients) adherence should be checked.

Answer 74

HIVAN

Question 75

diseases would give a positive cyanide-nitroprusside test?

Answer 75

Cystinuria, Homocystinuria

Question 76

Flash pulmonary oedema, U&Es worse on ACE inhibitor, asymmetrical kidneys → renal artery stenosis - Ix of choice?

Answer 76

do MR angiography

Question 77

combination of hypercoagulability, sudden-onset unilateral flank pain, acute deterioration in renal function and new haematuria point towards the unifying diagnosis of******

Answer 77

renal vein thrombosis

Question 78

Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III via the kidneys

Answer 78

Nephrotic syndrome is associated with hypercoagulability, due to loss of antithrombin III through an excessively permeable glomerular filtration barrier. This makes patients susceptible to venous thromboembolism. In this scenario, the combination of hypercoagulability, sudden-onset unilateral flank pain, acute deterioration in renal function and new haematuria point towards the unifying diagnosis of renal vein thrombosis.

Question 79

Tumour markers germ cell tumours

Answer 79

seminomas: seminomas: hCG may be elevated in around 20% non-seminomas: AFP and/or beta-hCG are elevated in 80-85% LDH is elevated in around 40% of germ cell tumours

Question 80

Use of 0.9% Sodium Chloride for fluid therapy in patients requiring large volumes =

Answer 80

risk of hyperchloraemic metabolic acidosis

Question 81

When prescribing for routine maintenance alone, consider using 25-30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 (there are other regimens to achieve this).

Question 82

The classic tetrad of symptoms in HSP

Answer 82

non-thrombocytopenic palpable purpura, arthritis or arthralgia, abdominal pain and renal disease. Thrombocytopenia is not typically associated with HSP.

Question 83

Non blanching rash

Answer 83

HSP Meningococcal septicaemia Immune thrombocytopenic purpura HUS

Question 84

****** (a C5 inhibitor monoclonal antibody) has evidence of greater efficiency than plasma exchange alone in the treatment of adult atypical HUS

Answer 84

eculizumab

Question 85

The time taken for an arteriovenous fistula to develop is

Answer 85

6 to 8 weeks

Question 86

In VUR , chronic can produce renal scar leading to increased quantities of renin causing hypertension

Question 87

Serum C4 is the most reliable and widely used screening tool

Answer 87

Hereditary angioedema

Question 88

Retroperitoneal fibrosis

Answer 88

Lower back/flank pain is the most common presenting feature. Fever and lower limb oedema is also seen in some patients. Associations Riedel's thyroiditis previous radiotherapy sarcoidosis inflammatory abdominal aortic aneurysm drugs: methysergide

Question 89

Markers of good prognosis in IgA Nephropathy

Answer 89

markers of good prognosis: frank haematuria markers of poor prognosis: male gender, proteinuria (especially > 2 g/day), hypertension, smoking, hyperlipidaemia, ACE genotype DD

Question 90

Complications following nephrotic syndrome

Answer 90

Complications increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine deep vein thrombosis, pulmonary embolism renal vein thrombosis, resulting in a sudden deterioration in renal function hyperlipidaemia increasing risk of acute coronary syndrome, stroke etc chronic kidney disease increased risk of infection due to urinary immunoglobulin loss hypocalcaemia (vitamin D and binding protein lost in urine)

Question 91

Reduction of principal cells in the collection duct is incorrect. This is the mechanism by which lithium is postulated to cause nephrogenic diabetes insipidus (DI) and polyuria.

Question 92

Increased rate of ADH degradation .

Answer 92

In pregnancy, there is an increased rate of ADH degradation via placental mechanisms which can cause polyuria.

Question 94

Nephrogenic diabetes insipidus may be caused genetic mutations:

Answer 94

the more common form affects the vasopression (ADH) receptor the less common form results from a mutation in the gene that encodes the aquaporin 2 channel