Renal RACP MCQs Flashcards by Jaspreet Unknown

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

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.

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What enema should you avoid in patients with CKD?
A. Sodium phosphate
B. Glycerol

Avoid aperients with electrolytes due to risk of absorption/large electrolyte shifts.

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What is the most common cause of peritoneal dialysis failure?
A. Constipation
B. UF failure

Approach to PD failure:
- fluid balance: input&raquo_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

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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

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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

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.

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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

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.

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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

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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.

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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).

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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

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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

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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

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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.

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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.

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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

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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)

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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.

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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)

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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

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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.

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Which Cytotoxic drug is most nephrotoxic?
A. Bleomycin
B. Cisplatin
C. Etoposide
D. Rhubarb

Cisplatin

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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.

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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.

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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.

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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

RACP 2022a 75.Elderly lady had a fall. Na 124 with serum osmol 260 urine osmol 500. Besides stopping sertraline recently increased mildly confused. How would you manage? a. Salt tablet b. Fluid restrict 1L c. IV NaCl d. IV hypertonic saline

Answer B 1L FR

RACP 2022a Q181 81.EMQ: Most likely cause of hyponatraemia in an elderly lady with ischaemic heart disease and hypertension taking aspirin, combined anti-hypertensive and beta blocker? a. Thiazide-induced b. Loop diuretics c. Psychogenic polydypsia d. SIADH e. Diabetes insipidus f. Salt wasting g. ACTH deficiency h. Nephrotic syndrome

RACP 2022a 82. EMQ: Most likely cause of hyponatraemia in a 40 year old man with a long psychiatric history stable on an antipsychotic for years a. Thiazide-induced b. Loop diuretics c. Psychogenic polydypsia d. SIADH e. Diabetes insipidus f. Salt wasting g. ACTH deficiency h. Nephrotic syndrome

RACP 2022b Q15 15. What causes dialysis related amyloidosis? A. Beta 2 microglobulin B. AL C. AA D. ATTR

Answer: A beta 2 microglobulin

RACP 2022b 41. What is seen on renal histology with normal ageing? A. Global sclerosis B. Focal segmental sclerosis C. Nodular sclerosis D. Collapsing

RACP 2022b Q53 53. Patient on 4LNP. ABG with 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

RACP 2022b Q54. What serum marker is increased with commencing of angiotensin receptor- neprilysin inhibitors (ARNI)? A. BNP B. NT-proBNP C. ADH

RACP 2022b Q 60 60. What is the other factor in the KDIGO diagnosis of AKI (apart from urine output)? A) eGFR B) FeNa C) Serum Cr D) Cr to urea ratio

RACP 2021a Q9 Q9. A 46 year old woman with Addison’s disease presents with flank pain and dysuria. Her maintenance medications are hydrocortisone 10mg twice daily and fludrocortisone 100mcg daily. Her temperature is 38.4C, BP is 124/76 and her heart rate is 106. She is diagnosed with pyelonephritis and admitted for IV antibiotics. She is tolerating oral intake. What is the best plan for her regular medications? A. Add prednisone 20mg daily B. IV hydrocortisone 100mcg three times daily C. Increase oral hydrocortisone to 20mcg twice daily D. Increase oral hydrocortisone to 20mcg twice daily and fludrocortisone to 200mcg daily This question and the answer options were well recalled.

RACP 2021a Q48. 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

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

RACP 2021a Q58. An 84 year old female presented to the medical ward for management of congestive cardiac failure. A routine urine MCS was done on admission. Patient has no urinary symptoms. Urine culture: E.coli WCC 10-100 RBC <10 Squamous epithelial cells <10 Sensitivities: Amoxicillin sensitive Cefuroxime parenteral sensitive Cefuroxime oral intermediate Trimethoprim resistant What's the next best step? A. No additional intervention/management B. Repeat urine culture C. Oral urine alkalinating agent D. Oral amoxicillin

RACP 2021 Q79. 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

Outflow failure, which is defined as incomplete recovery of instilled dialysate can be caused by: - Constipation/obstipation - Catheter malposition - Intraluminal catheter occlusion (often by thrombus) - Extraluminal catheter occlusion (usually by omentum or adhesions) Catheter kinking Constipation is the commonest cause of outflow failure and should be eliminated as a cause before performing further evaluation by a plain abdominal Xray. Outflow obstruction is frequently heralded by irregular outflow, fibrin in the dialysate outflow, and/or constipation. Outflow obstruction in association with pain suggests catheter abutment.

RACP 2021a Q92. What drug is most associated with scleroderma renal crisis? A. Corticosteroids B. Cyclophosphamide C. NSAIDS D. Penicillamine

RACP 2021o 23. What is the most common electrolyte abnormality with a patient on peritoneal dialysis? a. Hypokalaemia b. Hypocalcemia c. Hyponatraemia d. Hypomagnesimia

RACP 2021o 36. Which cell is most responsible for the production of erythropoietin? a. Renal cell b. Liver cell c. Blood cell d. Bone marrow cell

RACP 2021o 65. 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

RACP 2021o 98. 45 y/o female. with a history of primary Pulmonary embolism. Abdominal imaging showed a renal mass. what is the diagnosis? There is multiple small ? thin wall cysts in thorax and abdo. a. Lymphangioleiomatosis b. Emphysema c. Renal cell carcinoma

RACP 2021o 100. Amiloride is used in the treatment of nephrogenic diabetic insipidus. What electrolyte does amiloride block? a. Potassium b. calcium c. magnesium d. sodium

Answer D Inhibits action of ENAC channels on the apical membrane of principal cells in the collecting duct

RACP 2020 4. 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

RACP 2020a 26. What is the pathophysiology of dialysis dysequilibrium syndrome? A) Abnormal calcium phosphate products B) Cerebral oedema C) Relative hypotension D) Uraemic platelet dysfunction

RACP 2020a 54. EMQ Choose the best treatment option in the following scenarios: Patient with steroid- dependent minimal change disease with severe osteoporotic fractures A) ACE Inhibitors B) Calcium Channel Blockers C) Vasopressin receptor, V2 antagonist D) Anti-CD20 antibody E) Terminal complement inhibitor F) Loop diuretic G) Cyclophosphamide H) Corticosteroid

RACP 2020a 55. EMQ Choose the best treatment option in the following scenarios: C3 glomerulopathy with 850mg protien excreted per day, normal renal function and blood pressure of 150/90 A) ACE Inhibitors B) Calcium Channel Blockers C) Vasopressin receptor, V2 antagonist D) Anti-CD20 antibody E) Terminal complement inhibitor F) Loop diuretic G) Cyclophosphamide H) Corticosteroid

RACP 2020a 62. 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

RACP 2020a 71. In the treatment of hyperkalaemia the mechanism of action of Calcium chloride is A) Membrane antagonism B) Increase urinary excretion of potassium C) Increased intracellular shift of potassium D) Reduced potassium absorption

RACP 2020a 78. What is the mechanism of action of Terlipressin? A) Splanchnic vasodilation B) Splanchnic vasoconstriction C) Systemic vasodilation D) Systemic vasoconstriction

RACP 2020 10. Which form of amyloidosis rarely affects kidney A) Amyloid A B) AL Amyloid C) TTR D) Apolipoprotein A1

RACP 202022. Young non-pregnant woman with a symptomatic UTI (dysuria, urinary frequency). No flank pain. Afebrile. Urine culture shows 300 WCC and fully sensitive E.Coli. What treatment should be initiated? A) Ciprofloxacin B) Gentamicin C) Ceftriaxone D) Trimethoprim

RACP 2019a Question 16 A 50 year old man with alcoholic cirrhosis represents with tense ascites 8 days following recent admission with acute variceal bleed. He was commenced on pantoprazole and lactulose. Bloods showed a creatinine of 240 micromol/L (90 micromol/L 8 days ago). LFTs <2xULN. Albumin 30 g/L. Diuretics have been withheld for 2 days and volume replaced with albumin 1g/kg but creatinine remains 242 micromol/L despite this. No nephrotoxic drugs, no proteinuria or microhaematuria. Renal US normal. Urine output 300mL/24hrs. Urine sodium <10mmol. What is the cause? A. ATN B. Hepatorenal syndrome C. IgA nephropathy D. Interstitial nephritis

RACP 2019a Question 34 Which drug is most likely to cause rebound hypertension when stopped abruptly after chronic use? A. Clonidine B. Prazosin C. Metoprolol D. Hydralazine

RACP 2019a Question 37 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

RACP 2019a Question 55 Dialysis disequilibrium syndrome refers to neurological symptoms and signs during or shortly after dialysis. The pathogenesis of dialysis disequilibrium is due to: A. Relative hypotension B. Cerebral oedema C. Uremic platelet dysfunction D. Aberrant calcium and phosphate metabolism

RACP 2019b Question 49 Where in the nephron does vasopressin act? A. Proximal convoluted tubule B. Distal convoluted tubule C. Cortical collecting duct D. Ascending loop of Henle

Answer C: Cortical collecting duct

RACP 2019b EMQ 67 and 68 For each question, please select the most appropriate option from the list below. A. Prorenin B. Prorenin receptor C. Renin D. Angiotensinogen E. Angiotensin I F. Angiotensin II G. Angiotensin converting enzyme H. Aldosterone Question 67 Synthesised in the liver, and a substrate for renin

RACP 2019bEMQ 68 Causes arterial vasoconstriction and sodium reabsorption in the proximal tubule A. Prorenin B. Prorenin receptor C. Renin D. Angiotensinogen E. Angiotensin I F. Angiotensin II G. Angiotensin converting enzyme H. Aldosterone

RACP 2018a 2. A 71-year-old male with hypertension, chronic obstructive pulmonary disease from cigarette smoking and previous coronary artery bypass grafting presents with a 3-day history of anuria and dyspnoea. He is taking ramipril, atorvastatin, amlodipine, clopidogrel and aspirin, amoxycillin, pantoprazole and inhaled corticosteroids. Blood pressure is 200/105 mmHg and an ECG shows previous anterior myocardial infarction. A renal ultrasound shows a 6 cm right kidney and an 11 cm left kidney. No urine is noted in the bladder. The creatinine is 900 μmol/L and the patient requires urgent haemodialysis for acute pulmonary oedema. What is the most likely diagnosis? A. Acute interstitial nephritis. B. Aortic dissection. C. Pyelonephritis. D. Renal thromboembolism. E. Urinary obstruction.

RACP 2018a 10.A 71-year-old woman with hypertension and a remote smoking history of 20 pack years is found to have abnormal kidney function on a routine blood test. Her current medication is enalapril 10 mg daily and amlodipine 10 mg daily and her last blood pressure was 138/86 mmHg. Her results are as follows: Normal values Serum creatinine 168 μmol/L [49–90] Estimated glomerular filtration rate (eGFR) 31 mL/min/1.73 m2 [90–130] Sodium (Na) 138 mmol/L [134–145] Potassium (K) 4.7 mmol/L [3.5–5.0] Haemoglobin (Hb) 116 g/L [120–160] Calcium (Ca) 2.45 mmol/L [2.20–2.55] Phosphate (PO4) 1.3 mmolL [0.78–1.43] Urine albumin:creatinine ratio (ACR) 11 mg/g [< 3.5] In addition to monitoring kidney function, what additional strategy should be the focus of her management? A. Dietary potassium restriction. B. Modification of cardiovascular risk. C. Planning for dialysis access. D. Reduction of proteinuria. E. Repletion of haematinics.

RACP 2018a 29. A 64-year-old man is receiving candesartan, hydrochlorothiazide and amlodipine at maximal doses for hypertension. A 24-hour blood pressure monitor shows the average BP to be 164/86 mmHg. The addition of which drug is likely to have the greatest effect in reducing the blood pressure? A. Hydralazine. B. Moxonidine. C. Perindopril. D. Prazosin. E. Spironolactone.

RACP 2018a 35. Which of the following is the strongest indication for kidney biopsy in a 65-year-old man with a 6-year history of type 2 diabetes mellitus and proteinuria (urine albumin:creatinine ratio of 250 g/mol creatinine)? A. An increase in serum creatinine from 90 to 170 μmol/L over 2 months. B. Declining estimated glomerular filtration rate (eGFR) of 10 mL/min over 1 year. C. Persistent microscopic haematuria. D. Positive anti-neutrophil cytoplasmic antibodies specific for myeloperoxidase. E. Positive antinuclear antibody in a titre of 1:640.

RACP 2018a 48. A 53-year-old woman with advanced CKD is found to have worsening anaemia. She has co-morbidities of gastro-oesophageal reflux, hypothyroidism and intermittent constipation. Her current medications include lisinopril 5 mg daily, atenolol 50 mg daily, pantoprazole 40 mg daily and thyroxine 100 mcg daily. Laboratory tests prior to her outpatient appointment are as follows: Normal values Haemoglobin 91 g/L [115–160] White cell count 5.1 × 109 /L [4.0–11.0] Platelets 301 × 109 /L [140–400] Iron 9 μmol/L [9–30] Transferrin 2.0 g/L [2.0–3.6] Transferrin saturation 9% [15–45] Ferritin 47 μg/L [10–200] C-reactive protein 3.1 mg/L [< 5.0] What is the best initial treatment for her anaemia? A. Erythropoietin. B. Intravenous iron. C. Oral iron. D. Packed red cell transfusion. E. Pentoxifylline.

Answer B IV iron

RACP 2018a 71. In a patient requiring urgent dialysis which of the following parameters would favour continuous renal replacement therapy (CRRT) rather than intermittent haemodialysis (IHD)? A. Active bleeding. B. Coagulopathy. C. Hyperkalaemia. D. Hypotension. E. Hypoxia.

RACP 2018b 105.In the evaluation of a patient with suspected kidney disease, the use of a urinary dipstick (Multi-stick) may fail to detect significant quantities of which of the following? A. Albumin. B. Erythrocytes. C. Leucocytes. D. Nitrites. E. Non-albumin protein.

Answer E Non albumin protein

RACP 2018b 133.Hepatic proprotein convertase subtilisin/kexin type 9 (PCSK9) impacts lipid metabolism. Which plasma lipid component is increased by PCSK9? A. Chylomicrons. B. High density lipoprotein. C. Intermediate density lipoprotein. D. Low density lipoprotein. E. Very low density lipoprotein.

RACP 2018b 149.Type 4 renal tubular acidosis is most commonly seen in which condition? A. Diabetic nephropathy. B. Interstitial nephritis. C. Pseudo hypoaldosteronism type 1. D. Sjögren's syndrome. E. Systemic lupus erythematosus.

Answer A Diabetic nephropathy