Renal RACP MCQs Flashcards
Patient presents with altered consciousness and an acute kidney injury. Blood film shows features suggestive of microscopic angiopathic haemolytic anaemia. Which investigation would help decide the course of definitive treatment?
A. ADAMTS13 level
B. Fibrinogen
C. D-dimer
D. Complement C3/C4
A
MAHAs can be split into primary or secondary causes. Primary MAHA (TMAs) include TTP, HUS, aHUS. Secondary MAHA includes autoimmune diseases e.g. SLE, as well as DIC, HELLP, malignant hypertension, prosthetic heart valves.
TTP can present with neurological symptoms and reduced ADAMTS13 (<10%) level is diagnostic.
What enema should you avoid in patients with CKD?
A. Sodium phosphate
B. Glycerol
A
Avoid aperients with electrolytes due to risk of absorption/large electrolyte shifts.
What is the most common cause of peritoneal dialysis failure?
A. Constipation
B. UF failure
A
Approach to PD failure:
- fluid balance: input»_space; output
- mechanical: adequate catheter positioning, constipation, fibrin
- membrane: peritonitis, acute GI infection, PD prescription
- ultimately if the above are optimised, suggests PD is failing and patient will need transition to HD
An 80F is admitted to ED following a fall. She is mildly confused, afebrile, and euvolemic. She takes sertraline 50mg daily for the past 6 months with a dose increase 2 weeks ago. She takes no other medications. Other than cessation of sertraline, what is the next best intervention for her electrolyte abnormality?
Na: 124
K: 3.9
Urea: 8.4
Cr: 89
Serum osmolality: 240
Urine osmolality: 500
A. IV hypertonic saline
B. IV NaCl
C. PO salt tablets
D. 1L fluid restriction
Answer D: 1L FR
EMQ: Most likely cause of hyponatremia in an elderly lady with IHD and HTN on aspirin, combined anti-hypertensive and beta-blocker?
A. Thiazide induced
B. Loop diuretics
C. Psychogenic polydipsia
D. SIADH
E. Diabetes insipidus
F. Salt wasting
G. ACTH deficiency
H. Nephrotic syndrome
A
Depends on the actual question - most antihypertensive combinations with diuretics include a thiazide or thiazide-like. Most likely either indapamide or hydrochlorothiazide, both are associated with hyponatremia particularly in the elderly.
EMQ: Most likely cause of hyponatremia in a 40M with a long psychiatric history stable on an antipsychotic for years
A. Thiazide induced
B. Loop diuretics
C. Psychogenic polydipsia
D. SIADH
E. Diabetes insipidus
F. Salt wasting
G. ACTH deficiency
H. Nephrotic syndrome
C
Whilst antipsychotics are a common class of drugs that can cause SIADH, it is unlikely to suddenly cause hyponatremia in a patient who has remained on the same medication and dose. Psychiatric conditions, e.g. schizoaffective, often can cause dry mouth and psychogenic polydipsia.
What causes dialysis related amyloidosis?
A. Beta-2-microglobulin
B. AL
C. AA
D. ATTR
Beta-2-microglobulin
B2-microglobulin deposition is associated with long-term haemodialysis usually >10Y duration. Site of deposits commonly joints and tendons
What is seen on renal histology with normal ageing?
A. Global sclerosis
B. Focal segmental sclerosis
C. Nodular sclerosis
D. Collapsing glomerulus
Global sclerosis
Primary structural finding of aging kidney on LM is nephrosclerosis: characterised by two or more of global glomerulosclerosis, tubular atrophy, interstitial fibrosis, or arteriosclerosis.
Nodular glomerulosclerosis is pathognomic of diabetic nephropathy.
What is the mechanism of renal injury in APLS?
A. ATN
B. Immune complex deposition
C. Vascular thrombosis
Vascular thrombosis
Renal injury associated with antiphospholipid syndrome is as a result of thrombosis in any renal vessel (from large to microangiopathic).
A patient on 4L NP has an ABG showing the following:
pH 7.48
pCO2 50
HCO3 36
What is the interpretation?
A. Metabolic alkalosis without compensation
B. Metabolic alkalosis with compensation
C. Respiratory acidosis without compensation
D. Respiratory acidosis with compensation
Metabolic alkalosis with (partial) compensation
Aside from urine output, what other factor is outlined in the KDIGO diagnosis of AKI?
A. eGFR
B. FeNa
C. Serum Cr
D. Cr to urea ratio
Serum creatinine
KDIGO guidelines define AKI as any of the following:
- increase in serum Cr by ≥ 26.5umol/L within 48h
- increase in serum Cr to ≥1.5x baseline which has occurred within the prior 7 days
- urine volume <0.5ml/kg/h for 6h
A 37 year old man who has a family history of autosomal dominant polycystic kidney disease wishes to donate a kidney to his sister, who has end stage renal failure.
Genetic testing for autosomal polycystic kidney disease is expensive and time-consuming. In order to preserve resources and for the best planning for the future of the organ donation for this family, who should be tested for polycystic kidney disease?
A. The man
B. His sister
C. His mother
D. His father
The man
Genetic testing is not routinely performed and is reserved for the following scenarios:
- equivocal/non-diagnostic imaging results and need for definitive diagnosis
- atypical presentations i.e. early or severe ADPKD, renal failure without significant enlargement, marked asymmetry between kidneys
- sporadic ADPKD with no family Hx
Other scenarios include:
- reproductive counselling
- selection of unaffected relatives as possible kidney transplant donors
A man presents with nephritic syndrome and bilateral shin petechial rash. Renal biopsy shows a pauci immune glomerulonephritis. What is the most likely diagnosis?
A. Anti-basement (GBM) disease
B. Cryoglobulinaemia
C. ANCA vasculitis
D. Infection-related glomerulonephritis
ANCA vasculitis
Majority of pauci-immune glomerulonephritis is ANCA vasculitis - generally either GPA or MPA.
Anti-GBM would have anti-GBM antibodies; cryoglobulinemia would have positive immune complexes; post-infection GN characteristically have C3 and IgG deposits.
A 37 year old woman presents with hypertension. Her GP organises screening for secondary causes of hypertension. Her renal CT with contrast is shown.
CT shows abdominal aorta branching into L and R renal arteries. There is a single R renal artery with multifocal beading and narrowing in the distal 2/3
What is the most likely cause of her secondary hypertension?
A. Atherosclerotic renal artery stenosis
B. Fibromuscular dysplasia
C. Polyarteritis nodosa
D. Renal artery dissection
Fibromuscular dysplasia
Characteristic radiographic appearance of renovascular FMD includes alternating stenosis and dilatation of the vessel resulting in a “string of beads” appearance. Other typical angiographic features include vascular loops, fusiform vascular ectasia.
Atherosclerotic stenosis more commonly involves the proximal 1/3 of the vessel.
PAN is associated with the presence of large aneurysms, stenosis or occlusion on CTA, and numerous microaneurysms on DSA.
Which of the following is the most likely cause of inadequate drainage in peritoneal dialysis?
A. Constipation
B. Fibrin clots
C. Peritonitis
D. Poor membrane function
A
Approach to PD failure:
- fluid balance: input»_space; output
- mechanical: adequate catheter positioning, constipation, fibrin
- membrane: peritonitis, acute GI infection, PD prescription
- ultimately if the above are optimised, suggests PD is failing and patient will need transition to HD
What drug is most associated with scleroderma renal crisis?
A. Corticosteroids
B. Cyclophosphamide
C. NSAIDS
D. Penicillamine
Corticosteroids
The use of glucocorticoids, particularly in high doses, is associated with the development of SRC. In a case-control study of 110 patients with SSc, moderate- to high-dose glucocorticoid therapy (≥15 mg/day of prednisone or equivalent) in the preceding six months was associated with a markedly increased risk of SRC. (UpToDate)
Which is the most common cause of hypertension in haemodialysis patients?
A. Erythropoietin administration
B. Intravascular volume overload
C. Secondary hyperparathyroidism
D. Sympathetic nervous system activation
Intravascular volume overload
Whilst all options can be causes of hypertension in haemodialysis patients, intravascular volume overload is by far the most common cause of hypertension in ESRF and haemodialysis patients.
What is the most common electrolyte abnormality with a patient on peritoneal dialysis?
A. Hypokalaemia
B. Hypocalcemia
C. Hyponatraemia
D. Hypomagnesimia
Hypokalaemia
Present in 10-35% of patients on PD (UpToDate)
Which cell is most responsible for the production of erythropoietin?
A. Renal cell
B. Liver cell
C. Blood cell
D. Bone marrow cell
Renal
EPO is produced by the interstitial cells of the kidney and stimulates the production of erythrocytes in the bone marrow
What is the benefit of using Icodextrin vs glucose solutions in peritoneal
dialysis?
A. Better ultrafiltration
B. Ease of use
C. Reduced hyperglycaemia
D. Reduced peritonitis
Better ultrafiltration
Icodextrin (7.5) is a glucose polymer containing solution. Its main benefit is its high molecular weight allowing for greater osmotic ultrafiltration. Other benefits also include a lower carbohydrate (glucose load) and less glucose absorption through the gut. It is generally used for longer dwell times though there is mixed evidence whether it is associated with reduced technique failure.
Which Cytotoxic drug is most nephrotoxic?
A. Bleomycin
B. Cisplatin
C. Etoposide
D. Rhubarb
Cisplatin
Young patient, presents with hypertension 160/90, asymptomatic haematuria, eGFR 21, biopsy shows crescentic glomerulonephritis with acute tubular necrosis. What’s the diagnosis?
A. Lupus
B. Anti-GBM
Lupus
With limited information from the question the key points are: young age, hypertensive, nephritic syndrome, and RPGN with tubular necrosis.
Anti-GBM has two peaks (20-30Y and 50-60Y) with younger patients more associated with pulmonary manifestations and older patients more associated with renal manifestations. Biopsy classically shows linear IgG deposits of the glomerular capillaries and sometimes tubules.
Lupus nephritis (usu. type IV) is the only presentation that is associated with young age, acute hypertension, and cellular necrosis.
A 35 year old male has chronic hepatitis, managed with tenofovir. Dipstick urinalysis show glycosuria and proteinuria. Which of the following findings are most consistent with tenofovir-induced Fanconi syndrome?
A) Hypocalcaemia
B) Hypomagnesaemia
C) Hypophosphataemia
D) Hypouricaemia
Either C or D
Fanconi syndrome is a variant of RTA type 2 (PCT acidosis) which is an acquired dysfunction of the PCT and consequently impaired HCO3, K, PO4, uric acid, amino acid and glucose reabsorption. It is characterised by hypouricemia, hypophosphatemia, glucosuria, and amino aciduria in addition to features of isolated proximal RTA type 2 including NAGMA, and hypokalemia.
What is the pathophysiology of dialysis dysequilibrium syndrome?
A) Abnormal calcium phosphate products
B) Cerebral oedema
C) Relative hypotension
D) Uraemic platelet dysfunction
Cerebral oedema
Dialysis disequilibrium is caused by the rapid extraction of osmotically active substances in the blood (e.g. urea, sodium) which results in acute cerebral oedema. The brain is slower to adjust to osmotic changes and retains its solutes, resulting in movement of free water into the brain cells.
Sandra is 6 months post renal transplant on tacrolimus, prednisolone, and mycophenolate with increasing BK viraemia. What is an effective strategy to reduce the risk of BK nephropathy?
A) Add cidofovir
B) Prednisolone
C) Reduce tacrolimus and mycophenolate
D) Add bactrim DS
Reduce immunosuppression
BK polyomavirus is ubiquitous in the general population (prevalence of up to 90%), and reactivation infection occurs in up to 10% of renal transplant patients. There are no targeted anti-viral therapies available for BK polyomavirus so the mainstay of therapy involves reduction of maintenance immunosuppression in response to increasing viraemia. The goal is to restore immunity toward the virus without triggering transplant rejection.
In the elderly creatinine levels may underestimate the GFR due to:
A) Reduced muscle mass
Explanation: creatinine is a metabolite of creatine, which is mostly present in skeletal muscle. Factors that result in decreased creatinine include loss of muscle mass in ageing, malnutrition, amputation, cachexia. Factors that result in elevated creatinine include higher muscle mass (on the roids).
Medications can cause reduced PCT secretion of creatinine including trimethoprim, cobicistat, dolutegravir, bictegravir, cimetidine.
Which form of amyloidosis rarely affects kidney
A) Amyloid A
B) AL Amyloid
C) TTR
D) Apolipoprotein A1
TTR
Nephropathy is common in AA and AL amyloidosis. Apolipoprotein-A1 is a rare form of amyloidosis but commonly presents with hepatic and/or renal amyloidosis. TTR rarely involves renal disease.
RACP 2022a Q68
68.An 80yo female is admitted to ED following a fall. She is mildly confused,
afebrile, and Euvolaemic. She takes sertraline 50mg daily for the past 6 months, with a dose increase 14 days ago. She takes no other medications. Other than cease her sertraline, what is the next best intervention for her electrolyte abnormality?
Electrolytes shown: Na 124 ; Urea ~8.4, K3.9, Creat
89, Serum osmolality 240, urine osmolality 500.
a. IV hypertonic saline
b. IV normal Saline
c. Oral salt tablets
d. 1.0L fluid restriction
Answer D 1L FR
RACP 2022a Q70
70.What deficiency causes restless leg syndrome?
a. Iron
b. Magnesium
c. Zinc
d. Copper
A
RACP 2021a Q54
Q54. A 37 year old woman presents with hypertension. Her GP organises screening for secondary causes of
hypertension. Her renal CT with contrast is shown below. What is the most likely cause of her secondary hypertension?
A. Atherosclerotic renal artery stenosis
B. Fibromuscular dysplasia
C. Polyarteritis nodosa
D. Renal artery dissection
