Nephrology Practice Questions

Q: The hand of a patient of Gitelman syndrome shows?

Tetany. ***Tetany*** - **Gitelman syndrome** is characterized by renal salt wasting and **hypokalemia**, often accompanied by **hypomagnesemia** and **hypocalciuria**. - **Hypomagnesemia** and **hypokalemia** can lead to neuromuscular hyperexcitability, manifesting as **tetany**, which includes carpopedal spasm as seen in the image. *Tri-radiate hand* - A tri-radiate hand refers to a deformity where the hand has three, rather than five, digits, often associated with specific genetic conditions affecting limb development. - This condition is congenital and is not a feature of Gitelman syndrome. *Rhizomelic dwarfism* - This is a type of dwarfism characterized by the **shortening of the proximal limb segments**, such as the humerus and femur. - This is a skeletal dysplasia and is not a manifestation of Gitelman syndrome, which primarily affects renal tubular function. *Syndactyly* - **Syndactyly** is the condition where two or more fingers or toes are **fused together**. - This is a congenital malformation and is not associated with Gitelman syndrome, which is a renal tubular disorder.

Q: Hemodialysis is being performed on a patient of ESRD. Central dialysis catheter is placed at which site?

Right internal jugular vein. ***Right internal jugular vein*** - The **right internal jugular vein** is the preferred site for a central dialysis catheter due to its **straight course** to the superior vena cava, which minimizes the risk of vessel erosion, kinking, and malposition. - Its accessibility and lower risk for pneumothorax compared to subclavian approaches make it a safer and more effective choice for long-term catheterization for hemodialysis. *Left internal jugular vein* - The **left internal jugular vein** involves a **more acute angle** as it joins the superior vena cava, increasing the risk of catheter kinking and venous stenosis. - This anatomical difference makes it a less ideal primary choice compared to the right side, although it can be used if the right side is inaccessible or thrombosed. *Right subclavian vein* - Catheterization of the **subclavian vein** carries a higher risk of **pneumothorax** and **subclavian vein stenosis**, which can compromise future arteriovenous fistula creation in that arm. - For these reasons, subclavian vein access is generally avoided for long-term dialysis access. *Right subclavian artery* - The subclavian artery is an **artery**, not a vein, and central dialysis catheters must be placed in a **vein** for hemodialysis access. - Accidental arterial puncture during central line placement is a significant complication, leading to potential **hemorrhage** or hematoma, and is never an intended site for dialysis catheter insertion.

Q: A 60-year-old hypertensive patient was showing poor response to three classes of antihypertensive drugs (ACE inhibitors, CCB and diuretics). Renal CT angiography was performed. What is the diagnosis?

Renal artery stenosis. ***Renal artery stenosis*** - The image shows a **narrowing (stenosis)** of the right renal artery (indicated by the white arrow), which is consistent with the clinical presentation of **resistant hypertension** in a 60-year-old patient. - **Renal artery stenosis** leads to decreased blood flow to the kidney, activating the **renin-angiotensin-aldosterone system** and causing refractory hypertension. *Autosomal dominant polycystic kidneys* - This condition presents with numerous **cysts** in both kidneys, leading to their enlargement and impaired function, which would appear as multiple fluid-filled sacs on CT angiography, not arterial narrowing. - While ADPKD can cause hypertension, it is due to renal parenchymal disease and cyst growth, not primarily a focal arterial narrowing as seen. *Polyarteritis Nodosa* - This is a form of **vasculitis** that can affect medium-sized arteries, including renal arteries, causing **microaneurysms** and infarctions, but typically not a single, focal stenosis as depicted. - PAN is a systemic disease with other clinical features like fever, weight loss, and skin lesions, which are not mentioned. *Duplication of collecting duct* - This is a congenital anomaly affecting the **urinary collecting system**, not the renal vasculature. - It would involve two ureters draining a single kidney or a bifid collecting system, and would not explain resistant hypertension or the arterial narrowing seen.

Q: Most common cardiovascular association of this disease leading to mortality is:

Aortic root dilatation. ***Aortic root dilatation*** - The image provided shows a **gross specimen of a polycystic kidney**, indicating **Autosomal Dominant Polycystic Kidney Disease (ADPKD)**. - While hypertension is very common in ADPKD, **aortic root dilatation** and subsequent complications like **aortic dissection** are major causes of mortality, often linked to collagen defects associated with ADPKD. *Mitral valve prolapse* - While **mitral valve prolapse** can occur in ADPKD, it is generally less severe and less frequently a direct cause of mortality compared to other cardiovascular complications. - Its presence is often an incidental finding and rarely leads to life-threatening complications. *Hypertension and its complications* - **Hypertension** is extremely common in ADPKD and is a significant contributor to morbidity. - However, the direct cause of mortality from cardiovascular events in ADPKD is often secondary to structural abnormalities like **aortic root dilatation**, rather than hypertension itself being the ultimate cause of death. *Mitral regurgitation* - **Mitral regurgitation** can occur in ADPKD, often as a consequence of mitral valve prolapse. - Similar to mitral valve prolapse, it is typically not the most common **cardiovascular association leading to mortality** in ADPKD, which is more often related to great vessel abnormalities.

Q: A patient of ESRD is scheduled for hemodialysis. He complains of palpitations. Which of the following findings are seen on ECG?

Short QT with tall tented T waves. ***Short QT with tall tented T waves*** - This ECG demonstrates key features of **hyperkalemia**: **tall, peaked T waves** (often described as "tented"), a **shortened QT interval**, widening of the QRS complex, and diminished or absent P waves. - The patient's history of **ESRD** and complaints of **palpitations** suggest a likely underlying electrolyte imbalance, with hyperkalemia being a common and dangerous complication. *Prolonged QT with tall tented T waves* - While hyperkalemia causes **tall, tented T waves**, it typically **shortens the QT interval**, not prolongs it, due to accelerated repolarization. - A prolonged QT interval is more characteristic of conditions like hypokalemia or drug-induced arrhythmia, not hyperkalemia. *Ventricular fibrillation* - **Ventricular fibrillation** is characterized by chaotic, irregular electrical activity with no discernible P waves, QRS complexes, or T waves, resulting in cardiac arrest. - The ECG shows organized, albeit abnormal, QRS complexes and tall T waves, which is not consistent with ventricular fibrillation. *Ventricular tachycardia* - **Ventricular tachycardia** typically presents with a wide QRS complex tachycardia, often with a regular rhythm, and may or may not show P waves. - While the QRS is wide, the presence of distinct, tall, tented T waves and a clear, albeit abnormal, rhythm pattern is more indicative of the extreme effects of hyperkalemia than a pure ventricular tachyarrhythmia.

Q: A 30-year-old lady with crush injury was admitted to the casualty. Her urobag shows 100 mL red color urine. ECG is shown below. All are indicated for this patient except?

Furosemide drip. ***Furosemide drip*** - The patient has evidence of **rhabdomyolysis** (crush injury, red urine) and ECG changes consistent with **hyperkalemia** (tall peaked T waves). In this context, furosemide is generally **not indicated** because the patient is likely oliguric or anuric due to acute kidney injury from rhabdomyolysis. - Furosemide can worsen kidney injury in settings of **volume depletion** or acute tubular necrosis, and its use in hyperkalemia without adequate urine output is not effective and can exacerbate electrolyte imbalances. *Magnesium sulfate* - This patient, having suffered a crush injury, is at high risk for **hypomagnesemia**, which can occur due to cellular efflux and renal wasting, especially when other electrolytes are also deranged. - While not directly treating hyperkalemia, magnesium is crucial for cardiac stability and preventing **arrhythmias**, particularly in the presence of other electrolyte abnormalities. *Calcium chloride* - The ECG shows significant **peaked T waves**, highly suggestive of severe hyperkalemia, which is a life-threatening condition. - **Calcium chloride** (or calcium gluconate) is indicated to **stabilize myocardial cell membranes** and reduce the risk of life-threatening arrhythmias, it does not lower potassium levels but counteracts its cardiac effects. *Hemodialysis* - Given the patient's crush injury, likely **rhabdomyolysis**, and severe hyperkalemia evident on the ECG, **hemodialysis** is an absolute indication if medical management fails or the hyperkalemia is refractory. - It is the most effective way to rapidly remove excess potassium and address other metabolic derangements, such as **uremia** and **fluid overload**, that may arise from acute kidney injury.

Q: Which of the following findings in a patient are suggestive of acute nephritis? I. Hematuria II. Oliguria III. Reduced size of both kidneys IV. Edema Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - **Hematuria**, **oliguria**, and **edema** are classic signs of acute nephritis, indicating inflammation and impaired kidney function [1]. - Oliguria results from reduced **glomerular filtration**, while edema is due to fluid retention secondary to kidney dysfunction. *I and II only* - This option is incomplete as **edema** is also a significant finding in acute nephritis due to fluid overload from impaired renal excretion. - While hematuria and oliguria are key, omitting edema overlooks a critical systemic manifestation. *I and III* - **Reduced size of both kidneys** (III) is typically associated with **chronic kidney disease** [1], not the acute inflammation seen in acute nephritis. - Acute nephritis usually presents with **normal or enlarged kidneys** due to inflammation and swelling. *III and IV* - This option incorrectly includes **reduced kidney size**, which is characteristic of chronic, not acute, kidney disease. - While edema (IV) is present in acute nephritis, the presence of hematuria and oliguria is also crucial for diagnosis.

Q: Which one of the following hereditary tubulo-interstitial kidney diseases has an autosomal recessive mode of inheritance?

Nephronophthisis. ***Nephronophthisis*** - This is a group of **autosomal recessive** disorders characterized by tubulointerstitial nephritis, renal cysts, and progression to **end-stage renal disease (ESRD)**, often in childhood or adolescence [1]. - It is the most common genetic cause of ESRD in children, with classic features including **polydipsia, polyuria**, and anemia [1]. *Juvenile hyperuricaemic nephropathy* - This condition is typically inherited in an **autosomal dominant** pattern. - It is characterized by early-onset hyperuricemia, gout, and progressive renal insufficiency due to changes in **urate transport**. *Medullary cystic kidney disease type 1* - Previously known as **medullary cystic kidney disease**, this is now often referred to as **Autosomal Dominant Tubulointerstitial Kidney Disease (ADTKD)**. - It is caused by mutations in the **UMOD gene** (encoding uromodulin) and is inherited in an **autosomal dominant** fashion [1]. *Medullary cystic kidney disease type 2* - Also categorized under **ADTKD**, this form is caused by mutations in the **REN gene** (encoding renin). - Like type 1, it follows an **autosomal dominant** inheritance pattern leading to progressive chronic kidney disease.

Q: Kidney damage and Glomerular Filtration Rate (GFR) value between 15-29 mL / min / 1.73 m^2 are found in which stage of Chronic Kidney Disease?

Stage 4 (severe). ***Stage 4 (severe)*** - **Stage 4 Chronic Kidney Disease (CKD)** is defined by a **Glomerular Filtration Rate (GFR)** in the range of **15-29 mL/min/1.73 m²** [1]. - At this stage, significant kidney damage is present, indicating **severe reduction in kidney function** with increased risk of complications. *Stage 3A (mild to moderate)* - **Stage 3A CKD** is characterized by a **GFR** between **45-59 mL/min/1.73 m²**, which is a milder reduction compared to the GFR given in the question [1]. - This stage represents a **mild to moderate decrease** in kidney function, falling above the severe range. *Stage 2 (mild)* - **Stage 2 CKD** involves a **GFR** between **60-89 mL/min/1.73 m²**, which is a mild reduction in GFR but typically with persistent kidney damage. - This GFR range is significantly higher than the 15-29 mL/min/1.73 m² specified in the question, representing **earlier kidney dysfunction**. *Stage 5 (kidney failure)* - **Stage 5 CKD** is defined by a **GFR** of **less than 15 mL/min/1.73 m²**, indicating **kidney failure** requiring dialysis or kidney transplant [1]. - The given GFR range of 15-29 mL/min/1.73 m² is higher than that of Stage 5, although it is still considered a **very advanced stage of CKD**.

Question 1

All are true about the condition shown in the above figure except:

Accepted Answer

Seen with polyarteritis nodosa

Answer

Failure to achieve BP control with optimal medical therapy needs angioplasty

Answer

Decline in GFR while on ACE inhibitors needs angioplasty

Answer

Secondary cause of hypertension

Question 2

The hand of a patient of Gitelman syndrome shows?

Accepted Answer

Tetany

Answer

Tri-radiate hand

Answer

Rhizomelic dwarfism

Answer

Syndactyly

Question 3

Hemodialysis is being performed on a patient of ESRD. Central dialysis catheter is placed at which site?

Accepted Answer

Right internal jugular vein

Answer

Left internal jugular vein

Answer

Right subclavian vein

Answer

Right subclavian artery

Question 4

A 60-year-old hypertensive patient was showing poor response to three classes of antihypertensive drugs (ACE inhibitors, CCB and diuretics). Renal CT angiography was performed. What is the diagnosis?

Accepted Answer

Renal artery stenosis

Answer

Autosomal dominant polycystic kidneys

Answer

Polyarteritis Nodosa

Answer

Duplication of collecting duct

Question 5

Most common cardiovascular association of this disease leading to mortality is:

Accepted Answer

Aortic root dilatation

Answer

Mitral valve prolapse

Answer

Hypertension and its complications

Answer

Mitral regurgitation

Question 6

A patient of ESRD is scheduled for hemodialysis. He complains of palpitations. Which of the following findings are seen on ECG?

Accepted Answer

Short QT with tall tented T waves

Answer

Prolonged QT with tall tented T waves

Answer

Ventricular fibrillation

Answer

Ventricular tachycardia

Question 7

A 30-year-old lady with crush injury was admitted to the casualty. Her urobag shows 100 mL red color urine. ECG is shown below. All are indicated for this patient except?

Accepted Answer

Furosemide drip

Answer

Magnesium sulfate

Answer

Calcium chloride

Answer

Hemodialysis

Question 8

Which of the following findings in a patient are suggestive of acute nephritis?
I. Hematuria
II. Oliguria
III. Reduced size of both kidneys
IV. Edema

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

I and II only

Answer

I and III

Answer

III and IV

Question 9

Which one of the following hereditary tubulo-interstitial kidney diseases has an autosomal recessive mode of inheritance?

Accepted Answer

Nephronophthisis

Answer

Juvenile hyperuricaemic nephropathy

Answer

Medullary cystic kidney disease type 1

Answer

Medullary cystic kidney disease type 2

Question 10

Kidney damage and Glomerular Filtration Rate (GFR) value between 15-29 mL / min / 1.73 m^2 are found in which stage of Chronic Kidney Disease?

Accepted Answer

Stage 4 (severe)

Answer

Stage 3A (mild to moderate)

Answer

Stage 2 (mild)

Answer

Stage 5 (kidney failure)

Nephrology — MCQs

Nephrology — MCQs

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