Nephrology Practice Questions

Q: Which of the following biomarkers is not typically involved in the diagnosis of acute kidney injury?

Micro RNA 122. Micro RNA 122 - **MicroRNA-122** is primarily a biomarker for **liver injury** [1] and not typically used in the diagnosis of **acute kidney injury (AKI)**. - Its expression is highly enriched in the liver and is released into circulation upon **hepatocyte damage**. *NGAL* - **Neutrophil gelatinase-associated lipocalin (NGAL)** is an early biomarker for **AKI**, found in both urine and plasma. - It rapidly increases in response to **renal tubular damage**, making it useful for early detection. *KIM 1* - **Kidney injury molecule-1 (KIM-1)** is a transmembrane protein expressed at very low levels in healthy kidneys but significantly upregulated in the **proximal tubular epithelial cells** during **AKI** [2]. - Its presence in urine is a strong indicator of **renal tubular injury**. *Cystatin C* - **Cystatin C** is a **glomerular filtration rate (GFR)** marker that increases in the blood earlier than creatinine in cases of **AKI**. - It is unaffected by muscle mass, age, or sex, making it a more reliable indicator of **renal function decline** in certain populations.

Q: Most common cause of hypernatremia.

Renal losses. ***Renal losses*** - **Renal losses** are a very common cause of hypernatremia, particularly when the kidneys cannot adequately reabsorb water, leading to increased free water excretion. [1] - This can be seen in conditions like **diabetes insipidus (central or nephrogenic)**, where there is either a deficiency of ADH or renal unresponsiveness to ADH, resulting in dilute urine and high serum sodium. [1] *Adipsic diabetes insipidus* - **Adipsic diabetes insipidus** is a rare form of central diabetes insipidus characterized by impaired thirst sensation. [2] - While it directly leads to profound hypernatremia, its **rarity** makes it an uncommon overall cause compared to other etiologies. *Carcinoid syndrome* - **Carcinoid syndrome** is caused by tumors that release excessive amounts of vasoactive substances, like serotonin. - It is primarily associated with symptoms like flushing, diarrhea, and bronchospasm, and **does not directly cause hypernatremia**. *Sweating* - **Sweating** causes loss of hypotonic fluid (more water than electrolytes), which can lead to hypernatremia if not adequately replaced. - While a contributing factor, severe hypernatremia specifically due to sweating alone is **less common** than that caused by renal free water losses, especially in the context of impaired thirst or access to water.

Q: Which of the following primary kidney diseases is NOT typically associated with nephrotic syndrome?

IgA nephropathy. ***IgA nephropathy*** - While it can cause **proteinuria**, it is more commonly associated with **hematuria** than nephrotic syndrome [1]. - It is characterized by **IgA-dominant immune complexes**, not primarily causing the massive protein loss typical in nephrotic syndrome [1]. *Membranous Glomerulopathy* - A leading cause of nephrotic syndrome, it presents with significant **proteinuria** and **edema** [1]. - Associated with the formation of **subepithelial immune complex deposits**, leading to nephrotic features [1]. *Minimal change disease* - The most common cause of nephrotic syndrome in children, leading to **massive proteinuria** [1]. - Characterized by **normal appearing glomeruli** on light microscopy and selective proteinuria [1]. *Focal segmental Glomerulosclerosis* - Also presents with **nephrotic syndrome**, causing significant **proteinuria** and renal impairment [1]. - Associated with focal, segmental sclerosis of the glomeruli seen on microscopy, contributing to nephrotic features [1].

Q: Chronic hemodialysis in ESRD patient is done

Thrice per week. ***Thrice per week*** - **Standard chronic hemodialysis** for **end-stage renal disease (ESRD)** patients is typically performed **three times per week** to adequately remove waste products and excess fluid. - This frequency is established to maintain a balance between effective treatment and the patient's quality of life, allowing for sufficient recovery time between sessions. *Once per week* - This frequency is generally **insufficient** for adequate solute and fluid removal in most ESRD patients, leading to **uremic symptoms** and complications. - Would likely result in **poor patient outcomes** due to accumulation of toxins and fluid overload. *Twice per week* - While sometimes considered for patients with **significant residual renal function** or those transitioning to another modality, it is **often inadequate** for long-term maintenance in most ESRD patients. - May lead to **suboptimal dialysis adequacy** and requires close monitoring for signs of under-dialysis. *Daily* - **Daily hemodialysis** (short daily or nocturnal daily) is an optimized regimen that can offer **better clearance** and **blood pressure control** [1] but is **not the standard chronic regimen**. - It imposes a **higher burden** on the patient's time and resources, and is typically reserved for specific clinical situations where standard thrice-weekly treatment is insufficient.

Q: ECG image showing U wave. A patient on furosemide and beta blocker presents with this ECG finding. What is the most likely diagnosis?

Hypokalemia (low potassium levels). ***Hypokalemia (low potassium levels)*** - The presence of **U waves** on an ECG, especially in a patient on **furosemide** (a loop diuretic known to cause potassium loss), is highly suggestive of **hypokalemia**. - **Furosemide** increases potassium excretion, and **low potassium levels** can lead to delayed repolarization and increased prominence of U waves. *Hypocalcemia (low calcium levels)* - **Hypocalcemia** primarily affects the **QT interval**, leading to its **prolongation** rather than the appearance of U waves. - While it can cause cardiac arrhythmias, U waves are not a characteristic ECG finding. *Hyperkalemia (high potassium levels)* - **Hyperkalemia** presents with distinct ECG changes such as **peaked T waves**, prolonged PR interval, and widening QRS complex, but not U waves. - The effects of **high potassium** are generally opposite to those seen in hypokalemia. *Hypercalcemia (high calcium levels)* - **Hypercalcemia** typically causes **shortening of the QT interval** and can lead to various arrhythmias. - It does not cause U waves; U waves are more specifically associated with potassium imbalances.

Q: A 48-year-old man presents with complaints of facial puffiness, frothy urine, and hypertension. He gives a history of infection with hepatitis B. Urine examination reveals microscopic hematuria. The histopathological image of the kidney biopsy shows a spike and dome pattern. What is the diagnosis of this condition?

Membranous nephropathy. ***Membranous nephropathy*** - The **spike and dome pattern** seen in the biopsy is characteristic of membranous nephropathy [1,5], which also explains the patient's **facial puffiness** and frothy urine due to nephrotic syndrome [2,4]. - The association with **hepatitis B** infection further supports this diagnosis, as HBV can lead to a secondary form of membranous nephropathy [4]. *Minimal change disease* - Typically presents with **edema** and **proteinuria**, but does not show a spike and dome pattern on biopsy [3]. - It is often associated with **children** and responds well to steroids, unlike the findings here [3]. *FSGS* - Presents with **nephrotic syndrome** and may show varying degrees of scarring on biopsy, but lacks the characteristic spike and dome appearance [3,5]. - FSGS can also be secondary to other conditions but is not typically linked with hepatitis B. *PSGN-associated disease* - Post-streptococcal glomerulonephritis (PSGN) usually results in **hematuria** and **hypertension** following a streptococcal infection, not hepatitis B [2]. - The histopathological findings would more likely show **proliferative changes** rather than a spike and dome pattern [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 921. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 915. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 927-928. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 919-921. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 531-532.

Q: A 40-year-old man with a known case of hypertension presented with multiple episodes of hematuria and loin pain. His elder brother passed away due to a stroke at the age of 40. What is the probable diagnosis based on the clinical presentation?

Autosomal dominant polycystic kidney disease. ***Autosomal dominant polycystic kidney disease*** - The patient's presentation with **pain**, **hematuria**, and **hypertension** is typical for **ADPKD**. The family history of a brother dying of a **stroke** at a young age suggests a genetic predisposition to vascular abnormalities, common in ADPKD. - **Cerebral aneurysms**, which can lead to stroke, are a known extranal manifestation of ADPKD, and early onset stroke in a sibling strengthens the diagnosis despite it not being the defining feature of ADPKD itself. *Renal cell carcinoma* - While **hematuria**, **loin pain**, and **hypertension** can be symptoms of renal cell carcinoma, the bilateral nature of the cysts seen in the image and the family history of **early stroke** make ADPKD a more probable diagnosis. - Renal cell carcinoma usually presents as a **unilateral** solid mass, not diffuse cystic changes in both kidneys. *Tuberculosis of the kidney* - Renal tuberculosis would present with symptoms like sterile pyuria, dysuria, and flank pain, but less commonly with the dramatic cystic changes and family history of stroke seen here. - The imaging would typically show cavitary lesions or hydronephrosis rather than widespread bilateral cysts. *Autosomal recessive polycystic kidney disease* - **ARPKD** typically presents in **infancy or childhood** with severe renal failure and liver involvement. - The patient's age (40 years) makes ARPKD highly unlikely, as individuals with this condition rarely survive into adulthood without significant medical intervention.

Q: A 51-year-old person came with a complaint of hematuria. On examination, he was normotensive and had pedal edema. Investigations revealed the patient had no glucosuria and had a creatinine value of 9mg%. Renal biopsy is as shown below. Which of the following investigations should be done to identify the etiology of the disease?

ANTI GBM antibodies. ***ANTI GBM antibodies*** - The presence of hematuria and renal failure suggests a possible **glomerulonephritis**, where **anti-GBM (Glomerular Basement Membrane) antibodies** would help confirm conditions like Goodpasture syndrome [2]. - This test specifically identifies **anti-GBM disease** [1,2], which is crucial in guiding management for this patient with suspected renal pathology [3]. *ANA* - **Antinuclear antibody (ANA)** testing is typically used for autoimmune diseases like **Systemic Lupus Erythematosus** but is less specific for glomerular diseases. - In this context, ANA would not specifically help in identifying the **etiology of renal failure** associated with hematuria. *Urine immunoelectrophoresis* - This test is primarily useful for detecting **light chains** in conditions like **multiple myeloma** and may not be relevant to general hematuria or renal failure. - It is not a direct test for **glomerular disease etiology** related to hematuria and edema. *HIV RNA* - While **HIV** can lead to renal complications, including **HIV-associated nephropathy**, this test is not the first line for etiological determination in this specific presentation. - Negative **HIV serology** doesn't rule out renal disease caused by other factors, making this test less relevant here. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 526-527. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 537-538. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 918-919.

Q: Which of the following is a cause of hypokalemic metabolic alkalosis with hypertension?

Liddle syndrome. ***Liddle syndrome*** - It is an **autosomal dominant** disorder characterized by a mutation in the **ENaC channel**, leading to increased sodium reabsorption and potassium excretion, thus causing **hypokalemia**, **metabolic alkalosis**, and **hypertension**. [1] - This condition mimics **primary hyperaldosteronism** but has **low plasma renin activity** and **low aldosterone levels**. [1] *Bartter syndrome* - This is a genetic disorder affecting the **Na-K-2Cl cotransporter** in the **thick ascending limb** of the loop of Henle, leading to **salt wasting** and compensatory **renin-angiotensin-aldosterone system activation**. - It presents with **hypokalemia**, **metabolic alkalosis**, but typically with **normal or low blood pressure**, not hypertension. *Gitelman syndrome* - This is an autosomal recessive disorder affecting the **thiazide-sensitive Na-Cl cotransporter** in the **distal convoluted tubule**. - It causes **hypokalemic metabolic alkalosis**, hypomagnesemia, and hypocalciuria, but patients are typically **normotensive** or **hypotensive**, distinguishing it from Liddle syndrome. *Renal tubular acidosis* - This is a group of disorders characterized by the **kidneys' inability to excrete acid** or **reabsorb bicarbonate**, leading to **metabolic acidosis**. [2] - While it can cause electrolyte abnormalities, hypokalemia is a feature of certain types (e.g., RTA type 1 and 2), but the defining feature is **metabolic acidosis**, not metabolic alkalosis, and it is not typically associated with hypertension from the primary tubular defect. [2]

Question 1

Which of the following biomarkers is not typically involved in the diagnosis of acute kidney injury?

Accepted Answer

Micro RNA 122

Answer

Cystatin C

Answer

NGAL

Answer

KIM 1

Question 2

Most common cause of hypernatremia.

Accepted Answer

Renal losses

Answer

Carcinoid syndrome

Answer

Adipsic diabetes insipidus

Answer

Sweating

Question 3

Which of the following primary kidney diseases is NOT typically associated with nephrotic syndrome?

Accepted Answer

IgA nephropathy

Answer

Minimal change disease

Answer

Focal segmental Glomerulosclerosis

Answer

Membranous Glomerulopathy

Question 4

Chronic hemodialysis in ESRD patient is done

Accepted Answer

Thrice per week

Answer

Once per week

Answer

Twice per week

Answer

Daily

Question 5

ECG image showing U wave. A patient on furosemide and beta blocker presents with this ECG finding. What is the most likely diagnosis?

Accepted Answer

Hypokalemia (low potassium levels)

Answer

Hypocalcemia (low calcium levels)

Answer

Hyperkalemia (high potassium levels)

Answer

Hypercalcemia (high calcium levels)

Question 6

A 48-year-old man presents with complaints of facial puffiness, frothy urine, and hypertension.    He gives a history of infection with hepatitis B. Urine examination reveals microscopic    hematuria. The histopathological image of the kidney biopsy shows a spike and dome pattern.    What is the diagnosis of this condition?

Accepted Answer

Membranous nephropathy

Answer

Minimal change disease

Answer

FSGS

Answer

Post-streptococcal glomerulonephritis (PSGN)

Question 7

A 40-year-old man with a known case of hypertension presented with multiple episodes of hematuria and loin pain. His elder brother passed away due to a stroke at the age of 40. What is the probable diagnosis based on the clinical presentation?

Accepted Answer

Autosomal dominant polycystic kidney disease

Answer

Renal cell carcinoma

Answer

Tuberculosis of the kidney

Answer

Autosomal recessive polycystic kidney disease

Question 8

What is the correct formula for calculating the Glomerular Filtration Rate (GFR)?

Accepted Answer

GFR (mL/min/1.73 m^2) = 186 x (Scr)^-1.154 x (Age)^-0.203 x (0.742 if female)

Answer

GFR (mL/min/1.73 m^2) = 175 x (Scr)^-1.254 x (Age)^-0.203 x (0.742 if female)

Answer

GFR (mL/min/1.73 m^2) = 175 x (Scr)^-1.154 x (Age)^-0.203 x (0.742 if female)

Answer

GFR (mL/min/1.73 m^2) = 175 x (Scr)^-1.154 x (Age)^-0.303 x (0.742 if female)

Question 9

A 51-year-old person came with a complaint of hematuria. On examination, he was normotensive and had pedal edema. Investigations revealed the patient had no glucosuria and had a creatinine value of 9mg%. Renal biopsy is as shown below. Which of the following investigations should be done to identify the etiology of the disease?

Accepted Answer

ANTI GBM antibodies

Answer

ANA

Answer

HIV RNA

Answer

Urine immunoelectrophoresis

Question 10

Which of the following is a cause of hypokalemic metabolic alkalosis with hypertension?

Accepted Answer

Liddle syndrome

Answer

Bartter syndrome

Answer

Gitelman syndrome

Answer

Renal tubular acidosis

Nephrology — MCQs

Nephrology — MCQs

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