Nephrology Practice Questions

Q: Sine wave pattern in an ECG is seen in which of the following conditions?

Hyperkalemia. ***Hyperkalemia*** - As **hyperkalemia** worsens, the ECG may show a loss of P waves, widening of the QRS complex, and tall, peaked T waves that merge with the QRS complex, creating a **sine wave pattern** [1]. - This pattern indicates severe electrical instability, often progressing to **ventricular fibrillation** [2] or **asystole** if not urgently treated. *Hypokalemia* - **Hypokalemia** typically manifests on ECG with U waves, T wave flattening or inversion, and prolongation of the QT interval [3]. - It does not cause a **sine wave pattern**, which is characteristic of severe hyperkalemia. *Hyponatremia* - While severe **hyponatremia** can affect cardiac function, it does not typically produce a specific **sine wave pattern** on the ECG [1]. - ECG changes in hyponatremia are often non-specific and may include bradycardia or arrhythmias due to altered nerve conduction. *Hypernatremia* - **Hypernatremia** can lead to various cardiac effects, but a **sine wave pattern** is not a characteristic ECG finding of this condition. - ECG changes in hypernatremia are often non-specific and are more related to volume status and associated electrolyte imbalances.

Q: Which of the following is NOT a feature of type 4A renal tubular acidosis?

Hypokalemia. Type 4 renal tubular acidosis (RTA) is characterized by **hyperkalemia**, not hypokalemia, due to impaired aldosterone function or renal tubular insensitivity to aldosterone [1]. The primary defect in Type 4 RTA is a disordered ammonia production and hydrogen ion secretion, aggravated by **hyperkalemia**, all of which impair kaliuresis and acid excretion. Type 4 RTA often occurs in the context of **mild to moderate chronic kidney disease** [3], as impaired GFR can contribute to aldosterone deficiency or resistance. While not the direct cause, renal impairment sets the stage for the specific tubular defects seen in Type 4 RTA [2]. A defining feature of type 4 RTA is **hyperkalemia**, resulting from either inadequate aldosterone production or tubular resistance to aldosterone's effects on potassium excretion. This leads to decreased potassium secretion in the principal cells of the collecting duct [1]. Type 4 RTA is frequently seen in patients with **diabetic nephropathy**, often termed **hyporeninemic hypoaldosteronism**. This condition involves damage to the juxtaglomerular apparatus, leading to reduced renin and subsequently reduced aldosterone levels [1].

Q: Metabolic complications in chronic renal failure include all of the following except:

Hypokalemia. ***Hypokalemia*** - Chronic renal failure primarily leads to an inability to excrete **potassium**, resulting in **hyperkalemia**, not hypokalemia. - While very specific conditions or medications in ESRD could rarely cause hypokalemia, it is not a typical metabolic complication of chronic kidney disease itself. *Hyperkalemia* - **Renal excretion** is the primary mechanism for potassium balance, and with kidney failure, this process is impaired. - This impaired excretion leads to an accumulation of **potassium** in the blood, causing hyperkalemia. *Hypocalcemia* - The failing kidneys are unable to convert **25-hydroxyvitamin D** to its active form, **1,25-dihydroxyvitamin D**, leading to reduced calcium absorption [1]. - Additionally, hyperphosphatemia (due to impaired phosphate excretion) can bind with calcium and also stimulates parathyroid hormone release, contributing to **hypocalcemia** [1]. *Hypophosphataemia* - Chronic renal failure typically causes **hyperphosphatemia** due to the kidneys' inability to adequately excrete phosphate [1]. - Only in specific and rare instances or aggressive phosphate binding therapy might hypophosphatemia occur, but it is not a characteristic metabolic complication of CKD [2].

Q: In glomerular disease, which substance is primarily excreted in urine?

Albumin. ***Albumin*** [1][2] - Commonly found in the urine during glomerular disease due to increased permeability of the **glomerular barrier** [1][2]. - Its presence is indicative of **nephrotic syndrome** [1][2], characterized by significant proteinuria [1]. *Heavy chain* - Not typically excreted in the urine; heavy chains are part of **Immunoglobulin molecules** and predominantly associated with **antibody responses**. - Their presence in urine can be a sign of specific disorders but is not a primary feature of glomerular disease. *Globulin* - While globulins can be present in urine, they do not represent the specific **proteinuria** typically seen in nephrotic syndrome like albumin does. - They encompass a broad category of proteins, often increased during inflammatory states rather than direct glomerular damage. *Light chain* - Light chains can be excreted in certain conditions, such as **multiple myeloma** [1][2], but are not the primary markers in general glomerular disease. - Their presence in urine is more specific to **Bence Jones proteinuria** [1][2] associated with malignancies rather than the typical scenarios in glomerular diseases.

Q: Pyuria is found in all except

Appendicular abscess. ***Appendicular abscess*** - An appendicular abscess is an **extraluminal collection of pus** originating from a ruptured appendix, usually contained within the peritoneum. - While it causes significant inflammation, it does not typically lead to **pyuria** because it is not directly associated with the urinary tract. *CA bladder* - **Carcinoma of the bladder** can lead to irritation and inflammation of the bladder lining. - This irritation can cause **hematuria** and, in some cases, an influx of white blood cells into the urine, resulting in **pyuria**. *Renal tuberculosis* - This is a form of **extrapulmonary tuberculosis** that affects the kidneys. - The infection directly within the renal parenchyma and urinary collecting system leads to significant **inflammation and pus formation**, causing **pyuria** [1]. *Vaginosis* - **Bacterial vaginosis** is an infection of the vagina [1]. - Due to the close anatomical proximity of the vagina and urethra, vaginal inflammation and discharge can result in **contamination of a urine sample** with white blood cells from the vagina, misinterpreted as pyuria [1].

Q: All of the following are decreased in nephrotic syndrome, except for:

Serum fibrinogen. ***Serum fibrinogen*** - **Fibrinogen** levels are generally **increased** in nephrotic syndrome due to compensatory hepatic synthesis triggered by the loss of other proteins and lipids, contributing to the hypercoagulable state. - The liver increases the production of various proteins, including clotting factors, in an attempt to maintain oncotic pressure, leading to elevated fibrinogen. *Serum transferrin* - **Transferrin** is a plasma protein responsible for iron transport and is significantly **decreased** in nephrotic syndrome due to its loss in the urine. - The urinary loss of transferrin can contribute to **iron-refractory microcytic anemia** seen in some nephrotic patients. *Serum albumin* - **Albumin** is the most abundant plasma protein and its severe **decrease** in nephrotic syndrome (hypoalbuminemia) is a hallmark of the condition due to massive urinary excretion [1]. - The low serum albumin is a primary cause of the characteristic **edema** in nephrotic syndrome due to reduced plasma oncotic pressure [2]. *Serum complement (C3)* - **Complement C3** levels are often **decreased** in nephrotic syndrome, particularly in glomerulonephritic causes like **post-streptococcal glomerulonephritis** or **membranoproliferative glomerulonephritis type 2**, where C3 is consumed [3]. - While not universally decreased in all nephrotic syndromes, significant urinary loss of C3 can occur, leading to reduced serum levels.

Q: In a case of autosomal dominant polycystic kidney disease, cysts are present in all of the following organs, except:

Lung. Cysts are generally not found in the lungs of patients with autosomal dominant polycystic kidney disease (ADPKD). - ADPKD primarily affects organs with epithelial linings derived from the mesonephric duct or related embryonic structures. ADPKD is a common autosomal dominant condition characterized by multiple renal cysts that enlarge over time, with mutations in PKD1 and PKD2 genes accounting for the majority of cases [1]. *Liver* - **Hepatic cysts** are the most common extrarenal manifestation of ADPKD, occurring in approximately 50-70% of patients. - Their prevalence and size tend to increase with age and female sex. *Pancreas* - **Pancreatic cysts** are also a recognized extrarenal manifestation of ADPKD, though less common than hepatic cysts. - They are typically asymptomatic but can occasionally cause symptoms. *Seminal vesicles* - **Seminal vesicle cysts** can occur in men with ADPKD, contributing to an increased risk of infertility or other reproductive issues. - They are often asymptomatic and found incidentally.

Q: What is the most likely diagnosis in a patient presenting with hypertension, proteinuria, and renal failure?

Wegener's granulomatosis. ***Wegener's granulomatosis*** - This condition, now known as **Granulomatosis with Polyangiitis (GPA)**, classically presents as a triad of **upper respiratory tract disease**, **lower respiratory tract disease**, and **renal disease** [1]. - The renal involvement often manifests as **glomerulonephritis**, leading to **hypertension**, **proteinuria**, and potentially rapid progression to **renal failure** [2]. *Mycosis fungoides* - This is a **cutaneous T-cell lymphoma** primarily affecting the skin, presenting with patches, plaques, and tumors. - It typically does not involve the kidneys in a manner that would cause **hypertension**, **proteinuria**, and **renal failure**. *Invasive aspergillosis* - This is a serious **fungal infection** most commonly seen in **immunocompromised individuals**, affecting the lungs and other organs. - While it can cause systemic illness, it does not typically present with the classic triad of **hypertension**, **proteinuria**, and **renal failure** as a primary finding. *Sarcoidosis* - This is a **multisystem inflammatory disease** characterized by the formation of **non-caseating granulomas** in various organs, most commonly the lungs and lymph nodes. - While renal involvement can occur, it's less common and doesn't typically present with the acute, severe combination of **hypertension**, **proteinuria**, and **renal failure** seen in GPA.

Q: Renal biopsy is indicated in which of the following conditions?

Nephrotic syndrome in adults. ***Nephrotic syndrome in adults*** - A **renal biopsy** is indicated in adults with **nephrotic syndrome** to identify the underlying glomerular pathology and guide treatment decisions, as different causes (e.g., focal segmental glomerulosclerosis, membranous nephropathy) require specific therapies [1]. - While other imaging or blood tests may suggest a diagnosis, a biopsy provides a **definitive histological diagnosis** of the specific kidney disease [2]. *Uncontrolled hypertension* - **Uncontrolled hypertension** is usually managed medically, and a renal biopsy is typically not indicated unless there is suspicion of a **secondary cause of hypertension** directly affecting the kidneys (e.g., renovascular disease) that cannot be diagnosed by less invasive means. - Imaging studies like **renal artery Doppler** or CT angiography are usually the first line to investigate renal causes of hypertension, not biopsy [3]. *Solitary kidney* - A **solitary kidney** itself does not typically warrant a renal biopsy unless there is evidence of **acute renal injury**, **proteinuria**, or **hematuria** with no clear cause, and thus a need to investigate the underlying pathology. - The presence of a solitary kidney is a **contraindication to biopsy** if the other kidney is healthy, due to the increased risk of complications (e.g., bleeding, infection) in the only functioning kidney. *Kidneys <60% predicted size* - **Small kidney size** (less than 60% predicted) often indicates **chronic kidney disease** with established scarring or atrophy, where a biopsy may not provide actionable information beyond what is already known. - In such cases, if a biopsy is performed, it is usually to assess for specific, treatable causes of rapid progression in a small, atrophic kidney, but is not a routine indication for small kidneys alone due to difficulty obtaining adequate tissue and increased risk.

Q: Immediate treatment for hyperkalemia with significant ECG changes is?

Calcium chloride. ***Calcium chloride*** - **Calcium** rapidly stabilizes the **cardiac membrane**, reducing the risk of arrhythmias from hyperkalemia [1]. - This is a critical **immediate intervention** for hyperkalemia with **ECG changes**, as it does not lower potassium levels but prevents their cardiotoxic effects [1]. *Calcium hydroxide* - This compound is primarily used as an **antacid** or in industrial applications, not for the treatment of **hyperkalemia** or for stabilizing cardiac membranes. - It does not possess the rapid **cardioprotective effects** necessary to counteract the immediate dangers of severe hyperkalemia. *K+ Binding Resin Enema* - **Potassium-binding resins** work by exchanging potassium for other ions in the gut, thereby **removing potassium** from the body. - While effective for lowering potassium, their **onset of action is slow** (hours), making them inappropriate for emergent treatment of hyperkalemia with significant ECG changes. *Calcium carbonate* - **Calcium carbonate** is mainly used as a **calcium supplement** or an **antacid**, and while it contains calcium, its parenteral administration is not standard for emergent hyperkalemia treatment. - **Calcium chloride** or **calcium gluconate** are the preferred forms for IV administration in hyperkalemia due to their rapid bioavailability and immediate membrane-stabilizing effects [1].

Question 1

Sine wave pattern in an ECG is seen in which of the following conditions?

Accepted Answer

Hyperkalemia

Answer

Hypokalemia

Answer

Hyponatremia

Answer

Hypernatremia

Question 2

Which of the following is NOT a feature of type 4A renal tubular acidosis?

Accepted Answer

Hypokalemia

Answer

Hyperkalemia

Answer

Occur in diabetic nephropathy

Answer

Mild renal failure

Question 3

Metabolic complications in chronic renal failure include all of the following except:

Accepted Answer

Hypokalemia

Answer

Hyperkalemia

Answer

Hypocalcemia

Answer

Hypophosphataemia

Question 4

In glomerular disease, which substance is primarily excreted in urine?

Accepted Answer

Albumin

Answer

Light chain

Answer

Heavy chain

Answer

Globulin

Question 5

Pyuria is found in all except

Accepted Answer

Appendicular abscess

Answer

Renal tuberculosis

Answer

Vaginosis

Answer

CA bladder

Question 6

All of the following are decreased in nephrotic syndrome, except for:

Accepted Answer

Serum fibrinogen

Answer

Serum complement (C3)

Answer

Serum albumin

Answer

Serum transferrin

Question 7

In a case of autosomal dominant polycystic kidney disease, cysts are present in all of the following organs, except:

Accepted Answer

Lung

Answer

Pancreas

Answer

Seminal vesicles

Answer

Liver

Question 8

What is the most likely diagnosis in a patient presenting with hypertension, proteinuria, and renal failure?

Accepted Answer

Wegener's granulomatosis

Answer

Mycosis fungoides

Answer

Invasive aspergillosis

Answer

Sarcoidosis

Question 9

Renal biopsy is indicated in which of the following conditions?

Accepted Answer

Nephrotic syndrome in adults

Answer

Uncontrolled hypertension

Answer

Solitary kidney

Answer

Kidneys <60% predicted size

Question 10

Immediate treatment for hyperkalemia with significant ECG changes is?

Accepted Answer

Calcium chloride

Answer

K+ Binding Resin Enema

Answer

Calcium carbonate

Answer

Calcium hydroxide

Nephrology — MCQs

Nephrology — MCQs

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