Nephrology Practice Questions

Q: Most sensitive early marker for diabetic nephropathy?

Microalbuminuria. ***Microalbuminuria*** - **Microalbuminuria** refers to the presence of abnormally high levels of **albumin** in the urine, typically between 30 and 300 mg/day [1]. - It's considered the **earliest detectable sign** of **diabetic nephropathy**, reflecting initial glomerular damage before overt proteinuria or changes in kidney function occur [2]. *Increased serum creatinine* - An increase in **serum creatinine** usually indicates a more significant decline in **glomerular filtration rate (GFR)**, suggesting later stages of kidney damage [2]. - It is not an early marker as it rises only after substantial kidney function has been lost. *Proteinuria >500mg/day* - **Overt proteinuria** (macroalbuminuria), often defined as albumin excretion exceeding 300 mg/day (or 500 mg/day in some classifications), represents a more advanced stage of kidney disease [2]. - This level of protein excretion occurs after microalbuminuria has been established and signifies further progression of renal damage. *Decreased GFR* - A **decreased GFR** (glomerular filtration rate) indicates reduced kidney function and is a later manifestation of **diabetic nephropathy** [2]. - Early stages of nephropathy often involve normal or even increased GFR before a significant decline is observed.

Q: A hypertensive diabetic patient with microalbuminuria should receive:

Losartan. ***Losartan*** - **Losartan** is an **Angiotensin Receptor Blocker (ARB)**, which is a preferred treatment for hypertension in diabetic patients with microalbuminuria due to its **renoprotective effects**. - ARBs work by blocking the effects of **angiotensin II**, leading to **vasodilation** and a reduction in **glomerular hypertension**, thereby slowing the progression of diabetic nephropathy [2]. *Clonidine* - **Clonidine** is a centrally acting alpha-2 agonist, which can be used for hypertension but is not a first-line agent, especially in diabetic patients with microalbuminuria. - It is associated with side effects such as **sedation** and **rebound hypertension** if discontinued abruptly, and lacks the specific renoprotective benefits of ARBs. *Metoprolol* - **Metoprolol** is a **beta-blocker** that can be used for hypertension but is generally not the first choice for diabetic patients with microalbuminuria due to lack of specific renoprotective effects seen with ARBs [1]. - Beta-blockers can **mask symptoms of hypoglycemia** in diabetic patients and may also worsen **insulin resistance** in some individuals. *Amlodipine* - **Amlodipine** is a **calcium channel blocker** that is effective in lowering blood pressure but does not offer the same **renoprotective benefits** as ARBs in diabetic patients with microalbuminuria. - While safe for use in diabetics, it does not specifically address the underlying **glomerular hyperfiltration** associated with early diabetic kidney disease.

Q: A patient of CKD has presented with protracted vomiting. ABG shows pH = 7.40, pCO2 = 40 mm Hg, HCO3 = 24 mEq/L, Na = 145 mEq/L, Chloride = 100 mEq/L. What is the observation?

High anion gap metabolic acidosis and metabolic alkalosis. ***High anion gap metabolic acidosis and metabolic alkalosis*** - The **calculated anion gap** is 145 - (100 + 24) = 21, which is elevated (normal 8-12), indicating a **high anion gap metabolic acidosis**. [1] - The **ΔΔ ratio (ΔAG / ΔHCO3)** is (21-12) / (24-24) = 9/0, which is indeterminate but given the **normal pH and Bicarbonate**, a co-existing metabolic alkalosis that is compensating for the acidosis is likely. [1] *Normal anion gap metabolic acidosis* - This would be characterized by a **normal anion gap** (8-12 mEq/L), which is not the case here (elevated to 21 mEq/L). [1] - Normal anion gap acidosis usually involves **loss of bicarbonate** or **addition of chloride**, leading to hyperchloremia. *No acid base abnormality* - While the **pH and HCO3** are within the normal range, the elevated anion gap indicates an underlying acid-base disturbance. [1] - A comprehensive assessment, including anion gap calculation, reveals an abnormality **despite normal pH**. [1] *High anion gap metabolic acidosis* - Although there is a **high anion gap metabolic acidosis**, the **normal pH and bicarbonate** suggest a second primary acid-base disorder. [1] - In an isolated high anion gap metabolic acidosis, the pH and bicarbonate would typically be **lower than normal**.

Q: Which finding is typical of hyperkalemia on ECG?

Peaked T waves. ***Peaked T waves*** - **Peaked T waves**, characterized by being tall, narrow, and symmetric, are an early and classic sign of **hyperkalemia** on an ECG [1]. - This occurs due to the effect of high extracellular potassium on myocardial repolarization, specifically shortening the **action potential duration**, which is manifested as altered repolarization on the ECG [1]. *Q waves* - **Q waves** on an ECG are commonly associated with **myocardial infarction** (heart attack), indicating necrotic myocardium. - They are not a typical direct finding of **hyperkalemia**, although other severe ECG changes from hyperkalemia can mimic cardiac ischemia. *Flattened P waves* - **Flattened P waves**, and eventually their disappearance, are characteristic of later stages of **hyperkalemia** as potassium levels rise significantly [1]. - This reflects impaired atrial depolarization (atrial paralysis), but **peaked T waves** are generally an earlier and more specific initial indicator [1]. *ST elevation* - **ST elevation** is primarily a hallmark of **acute myocardial infarction** or **pericarditis**, signifying myocardial injury or inflammation. - While extreme hyperkalemia can lead to a "sine wave" pattern and wide QRS complexes that might superficially resemble ST elevation, it is not a direct or typical finding.

Q: History of fever and sore throat. Patient is on antibiotics. Blood shows eosinophilia and urine shows WBC cast. Diagnosis?

Interstitial nephritis. ***Interstitial nephritis*** - The combination of **fever**, **eosinophilia**, and **WBC casts** [1] in the context of **antibiotic use** strongly suggests **acute interstitial nephritis (AIN)** [3]. - AIN is often an **allergic reaction to drugs** (like antibiotics, NSAIDs) leading to inflammation of the renal interstitium [1], [3]. *Lupus nephritis* - While Lupus nephritis affects the kidneys and can cause inflammation, it is typically associated with **immune complex deposition** and often presents with features of systemic lupus erythematosus [3], which are not described here. - **Eosinophilia** and **WBC casts** are not characteristic diagnostic features of lupus nephritis; **red blood cell casts** and **proteinuria** are more common. *Chronic Glomerulonephritis* - This condition involves long-term damage to the glomeruli, often leading to **proteinuria**, **hematuria**, and **hypertension**. - It does not typically present with **fever** or marked **eosinophilia**, and while red cell casts can occur, WBC casts are less indicative. *Chronic Pyelonephritis* - This is a long-standing **bacterial infection of the kidney** and renal pelvis, often leading to scarring. - While WBC casts can be present due to infection, **fever is usually acute**, and **eosinophilia is not a typical finding** unless it's related to a complication or a different underlying process [2].

Q: Which of the following is NOT a feature of nephrotic syndrome?

Hematuria. ### Original Explanation ***Hematuria*** - **Hematuria** is a characteristic feature of **nephritic syndrome**, which involves glomerular inflammation and damage leading to blood in the urine [1]. - In contrast, **nephrotic syndrome** is primarily characterized by increased glomerular permeability to protein, not red blood cells, resulting in significant **proteinuria** [1]. *Edema* - **Edema** is a hallmark of nephrotic syndrome, resulting from severe **hypoalbuminemia** that reduces plasma oncotic pressure [2]. - This leads to fluid extravasation into the interstitial spaces, causing generalized swelling. *Hypoalbuminemia* - **Hypoalbuminemia** is a defining feature of nephrotic syndrome, caused by excessive urinary loss of albumin due to widespread glomerular damage [2]. - Reduced serum albumin levels contribute to the characteristic edema and increased lipid synthesis by the liver. *Proteinuria* - **Proteinuria**, specifically *massive proteinuria* (>3.5 g/day in adults), is the cardinal feature of nephrotic syndrome [1], [2]. - It signifies significant damage to the glomerular filtration barrier, allowing large amounts of protein to leak into the urine.

Q: All of the following are indications for hemodialysis in acute kidney injury, EXCEPT:

Hypertension. ***Hypertension*** - While hypertension can be a complication of **acute kidney injury (AKI)**, it is generally managed with **antihypertensive medications** and **fluid removal**, and does not by itself necessitate urgent hemodialysis unless it is severe and refractory, alongside other uremic symptoms. - Hemodialysis primarily addresses life-threatening electrolyte imbalances, fluid overload, and uremic symptoms. [2] *Severe metabolic acidosis* - **Severe metabolic acidosis (pH 6.5 mEq/L)**, especially when refractory to medical management (e.g., insulin, glucose, calcium gluconate), is a major indication for hemodialysis. [1] - Hemodialysis is highly effective at rapidly lowering potassium levels, which is crucial to prevent cardiac arrhythmias. [1] *Pulmonary edema* - **Severe fluid overload** leading to **pulmonary edema** that is refractory to diuretic therapy is a strong indication for hemodialysis in AKI. [2] - Hemodialysis can efficiently remove excess fluid, thereby alleviating respiratory distress and improving oxygenation.

Q: A 58-year-old man with a history of smoking presents with hematuria. What is the most likely diagnosis?

Bladder cancer. ***Bladder cancer*** - **Smoking** is the strongest risk factor for bladder cancer, and **painless hematuria** is its most common presenting symptom [1]. - The combination of a long-term smoker and gross hematuria makes this the most concerning diagnosis [1]. *Renal cyst* - **Renal cysts** are typically asymptomatic and rarely cause gross hematuria unless they are large, complicated, or rupture. - While common, they are less likely to be the cause of hematuria in a smoker without other symptoms. *Pyelonephritis* - **Pyelonephritis** is an upper urinary tract infection characterized by fever, flank pain, dysuria, and often microscopic hematuria, but gross hematuria is less common. - This patient presents with hematuria without signs of infection. *Prostate cancer* - **Prostate cancer** usually presents with urinary obstructive symptoms (e.g., hesitancy, weak stream, nocturia) or is found incidentally on screening. - While microscopic hematuria can occur, gross hematuria as the sole presenting symptom is rare.

Q: Which of the following is TRUE about Nephrotic Syndrome?

Causes hyperlipidemia. ***Causes hyperlipidemia*** - **Nephrotic syndrome** leads to increased hepatic synthesis of lipoproteins in response to **hypoalbuminemia**, resulting in **hyperlipidemia** [3]. - This is a compensatory mechanism where the liver, trying to produce more albumin, also increases the production of other proteins, including lipoproteins. *Causes decreased risk of thrombosis* - **Nephrotic syndrome** actually causes an **increased risk of thrombosis** due to the urinary loss of anticoagulant proteins like **antithrombin III**, and increased levels of procoagulant factors [3]. - The combination of **hypercoagulability** and potential for vascular stasis significantly elevates thrombotic risk, especially deep vein thrombosis and renal vein thrombosis. *Is primarily characterized by decreased GFR* - While **glomerular filtration rate (GFR)** can be affected in some cases, the primary characteristic of **nephrotic syndrome** is massive **proteinuria** (typically >3.5 g/day), leading to **hypoalbuminemia**, **edema**, and **hyperlipidemia** [2], [3]. - A significant decrease in GFR is more characteristic of **nephritic syndrome** or advanced kidney disease, although some nephrotic conditions can progress to impact GFR [2]. *Commonly presents with hematuria* - **Hematuria** is a hallmark feature of **nephritic syndrome**, which involves glomerular inflammation and damage to the filtering barrier, allowing red blood cells to pass into the urine [1], [2]. - **Nephrotic syndrome**, in contrast, primarily involves a derangement of the glomerular basement membrane that selectively allows protein to pass, making **hematuria** an atypical or minor finding unless there is an overlap with nephritic features [2].

Question 1

Most sensitive early marker for diabetic nephropathy?

Accepted Answer

Microalbuminuria

Answer

Increased serum creatinine

Answer

Proteinuria >500mg/day

Answer

Decreased GFR

Question 2

A hypertensive diabetic patient with microalbuminuria should receive:

Accepted Answer

Losartan

Answer

Clonidine

Answer

Metoprolol

Answer

Amlodipine

Question 3

A patient of CKD has presented with protracted vomiting. ABG shows pH = 7.40, pCO2 = 40 mm Hg, HCO3 = 24 mEq/L, Na = 145 mEq/L, Chloride = 100 mEq/L. What is the observation?

Accepted Answer

High anion gap metabolic acidosis and metabolic alkalosis

Answer

Normal anion gap metabolic acidosis

Answer

No acid base abnormality

Answer

High anion gap metabolic acidosis

Question 4

Which finding is typical of hyperkalemia on ECG?

Accepted Answer

Peaked T waves

Answer

Q waves

Answer

Flattened P waves

Answer

ST elevation

Question 5

History of fever and sore throat. Patient is on antibiotics. Blood shows eosinophilia and urine shows WBC cast. Diagnosis?

Accepted Answer

Interstitial nephritis

Answer

Lupus nephritis

Answer

Chronic Glomerulonephritis

Answer

Chronic Pyelonephritis

Question 6

Which of the following is NOT a feature of nephrotic syndrome?

Accepted Answer

Hematuria

Answer

Edema

Answer

Hypoalbuminemia

Answer

Proteinuria

Question 7

Assertion: In a patient with chronic kidney disease (CKD) and metabolic acidosis, sodium bicarbonate should be initiated to correct acidosis.
Reason: Sodium bicarbonate therapy reduces the progression of kidney disease by decreasing tubular injury and slowing fibrosis.

Accepted Answer

Both Assertion and Reason are true, but Reason is NOT the correct explanation of Assertion

Answer

Assertion is false, but Reason is true

Answer

Both Assertion and Reason are true, and Reason is the correct explanation of Assertion

Answer

Assertion is true, but Reason is false

Question 8

All of the following are indications for hemodialysis in acute kidney injury, EXCEPT:

Accepted Answer

Hypertension

Answer

Severe metabolic acidosis

Answer

Hyperkalemia

Answer

Pulmonary edema

Question 9

A 58-year-old man with a history of smoking presents with hematuria. What is the most likely diagnosis?

Accepted Answer

Bladder cancer

Answer

Renal cyst

Answer

Pyelonephritis

Answer

Prostate cancer

Question 10

Which of the following is TRUE about Nephrotic Syndrome?

Accepted Answer

Causes hyperlipidemia

Answer

Causes decreased risk of thrombosis

Answer

Is primarily characterized by decreased GFR

Answer

Commonly presents with hematuria

Nephrology — MCQs

Nephrology — MCQs

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