Nephrology Practice Questions

Q: Evaluating a patient with nephrotic syndrome, which symptom would indicate severe progression of the disease?

Severe edema. ***Severe edema*** - **Severe edema**, particularly **anasarca** (generalized body swelling), is a hallmark of severe nephrotic syndrome, indicating profound **hypoalbuminemia** due to massive urinary protein loss [1]. - The reduced intravascular oncotic pressure leads to fluid shifting into the interstitial space, causing significant and widespread swelling [1]. *Mild proteinuria* - While proteinuria is a diagnostic criterion for nephrotic syndrome, **mild proteinuria** does not indicate severe progression. - Severity is defined by **massive proteinuria** (typically >3.5 g/day in adults) [1]. *Hypertension* - **Hypertension** can be associated with nephrotic syndrome, particularly in cases with underlying renal disease or fluid overload. - However, it is not a direct measure of the severity of the nephrotic syndrome itself, but rather a complication or co-morbidity. *Hyperkalemia* - **Hyperkalemia** is more commonly associated with acute kidney injury or chronic kidney disease, where the kidneys cannot adequately excrete potassium [2]. - While nephrotic syndrome can sometimes lead to renal dysfunction, hyperkalemia is not a direct or primary indicator of the severity of the nephrotic syndrome's characteristic features (proteinuria, hypoalbuminemia, edema).

Q: Renal tubular acidosis with ABG value pH = 7.24 PO2=80; PaCO2= 36 Na = 131; HCO3 = 14 Cl= 90; BE = -13 Glucose = 135 the above ABG picture suggests –

Metabolic acidosis. The ABG shows a pH of 7.24, indicating **acidemia** [1]. The HCO3 is 14 mEq/L, which is significantly **low**, and the base excess (BE) is -13 [1]. The PaCO2 of 36 mmHg is within the normal range, indicating no significant primary respiratory derangement [2]. The overall picture is consistent with an uncompensated or partially compensated **metabolic acidosis** [1][2]. ***Metabolic acidosis*** - The **low pH (acidemia)**, **low bicarbonate (HCO3)**, and **negative base excess (BE)** are direct indicators of metabolic acidosis [1]. - The **PaCO2 within normal limits** or slightly decreased suggests either no respiratory compensation or insufficient compensation for the metabolic derangement [1][2]. *Respiratory acidosis* - This would present with a **low pH** and an **elevated PaCO2** as the primary defect, which is not seen here (PaCO2 is normal) [1]. - Bicarbonate would typically be normal or elevated if compensated, not significantly decreased. *Respiratory alkalosis* - This would be characterized by an **elevated pH** and a **low PaCO2**, which is the opposite of the findings in this ABG [1]. - HCO3 would be normal or low if compensated. *Metabolic alkalosis* - This would present with an **elevated pH** and an **elevated HCO3**, which contradicts the given ABG values (low pH and low HCO3) [2].

Q: 40 years old male complains of loin pain since 1 month. Patient's complaint of pain has severely increased over last 2 hours and pain now radiates from loin and to groin and anterior thigh and patient is writhing in bed for comfort. What is the most probable etiology?

Ureteric calculus. ***Ureteric calculus*** - The sudden onset of **severe, colicky loin pain radiating to the groin and anterior thigh**, causing the patient to writhe in bed, is highly characteristic of **ureteric colic** due to a calculus [1]. - This pain pattern is due to the obstruction and spasm of the ureter as it tries to pass the stone, with referred pain along the genitofemoral and ilioinguinal nerves [1]. *Bladder calculus* - A bladder calculus typically causes **suprapubic pain**, **dysuria**, **frequency**, and sometimes **hematuria**, but usually not severe, radiating loin-to-groin pain. - Pain from a bladder stone is often worse during micturition and can be relieved by changing position. *Vesicoureteric reflux* - **Vesicoureteric reflux (VUR)** is a backward flow of urine from the bladder to the ureters and kidneys, most commonly causing **recurrent UTIs** and potentially **renal scarring**. - It typically does not present with the acute, severe, radiating pain described, which is classic for an acute obstruction [2]. *Hydronephrosis* - **Hydronephrosis** refers to the swelling of the kidney due to a buildup of urine, often caused by obstruction, but it is a *consequence* rather than the primary etiology in this acute presentation [2]. - While a ureteric calculus can cause hydronephrosis, the term itself describes the *result* of the obstruction, not the acute event causing the severe pain [2].

Q: RIFLE criteria is used for diagnosis of

Acute kidney injury. ***Acute kidney injury*** - The **RIFLE criteria** (Risk, Injury, Failure, Loss, End-stage kidney disease) is a classification system specifically developed to define and stage **acute kidney injury (AKI)** based on changes in serum creatinine and/or urine output [1]. - It provides a standardized method for diagnosing AKI, allowing for consistent communication and research in nephrology. *Acute splenic injury* - **Splenic injury** is typically diagnosed based on **trauma history, imaging studies** (e.g., CT scan), and clinical signs like left upper quadrant pain and hypovolemia [2]. - There are no specific criteria like RIFLE for grading splenic injury, which is usually categorized by severity of laceration or hematoma [2]. *Acute liver injury* - **Acute liver injury** is diagnosed using criteria such as a rapid increase in **liver enzymes** (AST, ALT), **bilirubin**, and often signs of hepatic encephalopathy. - Classification systems for liver injury exist (e.g., King's College Criteria for acute liver failure), but RIFLE specifically pertains to kidney function. *Acute bowel injury* - **Acute bowel injury** (e.g., ischemic bowel, perforation) is diagnosed by **clinical presentation** (abdominal pain, signs of peritonitis), **imaging** (X-ray, CT scan), and sometimes **endoscopy**. - There are no standardized staging criteria like RIFLE for acute bowel injury.

Q: In a patient with nephrotic syndrome, which antibody is decreased?

IgG. ***IgG*** - In **nephrotic syndrome**, the kidneys' glomerular basement membrane becomes highly permeable, leading to a significant loss of plasma proteins into the urine [1]. - **IgG** is the smallest and most abundant immunoglobulin, making it particularly susceptible to urinary loss due to its size, leading to decreased serum levels. *IgE* - **IgE** levels are not typically decreased in nephrotic syndrome; its primary role is in allergic reactions and parasite defense, and it is not significantly lost in urine. - While other proteins are lost, the relatively low concentration and functional role of IgE mean its depletion is not a characteristic feature of nephrotic syndrome. *IgM* - **IgM** is a large pentameric antibody and, due to its substantial size, it is generally retained in the bloodstream even when the glomerular filtration barrier is compromised in nephrotic syndrome [1]. - Its large molecular weight makes it less likely to be filtered and excreted in the urine compared to smaller proteins like albumin and IgG [2]. *IgA* - **IgA** exists as a monomer in serum and as a dimer in mucosal secretions. While smaller than IgM, it is still larger than IgG and is not characteristically decreased in nephrotic syndrome due to urinary loss. - Decreased IgA levels are more commonly associated with selective IgA deficiency, a primary immunodeficiency, rather than the non-selective protein loss of nephrotic syndrome.

Q: What is oliguria?

Excretion of less than 500 ml in 24 hrs. ***Excretion of less than 500 ml in 24 hrs*** - **Oliguria** is clinically defined as a urine output of less than **500 ml over a 24-hour period** in adults. [1] - This threshold is significant because it is generally considered the minimum urine volume required to excrete the daily obligatory solute load, preventing **azotemia**. *Excretion of less than 300 ml in 24 hrs* - While a very low urine output, this volume typically falls under the definition of **anuria** or severe oliguria, which is less than 100 ml/24 hours, or very close to it. [1] - It indicates a more profound impairment of kidney function than the standard definition of oliguria. *Excretion of less than 300 ml in 12 hrs* - This statement refers to a shorter time frame (12 hours) and does not align with the standard 24-hour definition used for **oliguria**. - A proportional output over 24 hours would be 600 ml, which is above the threshold for oliguria. *Excretion of less than 100 ml in 24 hrs* - This urine output level is specifically defined as **anuria**, indicating almost complete cessation of urine production. [1] - Anuria represents a more severe state of renal dysfunction compared to oliguria.

Q: Which of the following is a clinical abnormality of uremia?

All of the options. ***All of the options*** - **Uremia** is a syndrome caused by the accumulation of **nitrogenous waste products** and other toxins in the blood due to failing kidneys. All listed options are recognized clinical abnormalities that can manifest in patients with uremia. [1] - This option correctly identifies that uremia can lead to a broad spectrum of clinical manifestations, including metabolic derangements like **hyperphosphatemia**, dermatological signs like **uremic frost**, and gastrointestinal issues like **peptic ulcers**. *Hyperphosphatemia* - **Hyperphosphatemia** is a common electrolyte imbalance in uremia because the kidneys are unable to adequately excrete phosphate. - Elevated phosphate levels contribute to **renal osteodystrophy** and metabolic bone disease in patients with chronic kidney disease. *Uremic frost* - **Uremic frost** is a dermatological manifestation of severe uremia, characterized by the deposition of **urea crystals** on the skin, particularly on the face and neck. - It occurs when urea concentrations in sweat exceed its solubility, leading to crystallization as sweat evaporates. *Peptic ulcer* - **Peptic ulcers** are more common in patients with uremia due to a combination of factors, including increased gastrin levels from impaired renal clearance, impaired mucosal defense, and increased acid secretion. [1] - The gastrointestinal system is significantly affected by uremia, leading to a variety of symptoms such as nausea, vomiting, and gastrointestinal bleeding. [1]

Q: Decrease in plasma osmotic pressure is cause of edema in?

Nephrotic syndrome. ***Nephrotic syndrome*** [2] - Characterized by **massive proteinuria**, leading to a significant decrease in plasma albumin levels which reduces plasma osmotic pressure [2]. - The resultant decrease in oncotic pressure causes **edema**, particularly in the periorbital and lower extremity regions [1][2]. *CHF* - Congestive heart failure (CHF) typically leads to **increased hydrostatic pressure** due to impaired cardiac output, not decreased plasma osmotic pressure. - Edema in CHF is more related to **fluid overload** rather than a decrease in protein levels. *DVT* - Deep vein thrombosis (DVT) causes localized edema due to **venous obstruction**, leading to increased hydrostatic pressure in the affected limb. - It does not primarily affect plasma osmotic pressure, instead causing **unilateral edema**. *None* - This does not provide a pathological condition associated with decreased plasma osmotic pressure causing edema. - There are known conditions, like **nephrotic syndrome**, that directly link decreased osmotic pressure to edema formation [1][2].

Q: Among the following, which is the most characteristic urinary finding in chronic renal failure (CRF)?

Broad casts in urine. ***Broad casts in urine*** [3] - **Broad casts** are pathognomonic for **chronic renal failure (CRF)** and signify irreversible nephron loss because they are formed in dilated tubules that have undergone compensatory hypertrophy. - They are composed of cellular debris and Tamm-Horsfall protein and indicate severe and long-standing renal parenchymal damage. *Elevated blood urea* - While elevated blood urea, or **azotemia**, is characteristic of CRF, it is a blood chemistry finding, not a urinary finding [3], [4]. - It reflects impaired glomerular filtration and accumulation of nitrogenous waste products. *Bleeding diathesis* - **Bleeding diathesis** is a common complication of CRF due to uremia-induced platelet dysfunction, but it is a systemic clinical manifestation, not a urinary finding [1]. - It manifests as easy bruising, epistaxis, or prolonged bleeding. *Proteinuria* - **Proteinuria** is a common finding in many forms of kidney disease, including CRF, but it is not the most *characteristic* finding specifically for the **chronicity** and severity of CRF [2]. - Its presence indicates glomerular or tubular injury, but broad casts offer more specific evidence of advanced, irreversible damage.

Q: What is the most common renal manifestation associated with leprosy?

Membranous glomerulonephritis. ***Membranous glomerulonephritis*** - **Membranous glomerulonephritis** is the most frequently reported renal lesion in leprosy, often associated with a **lepromatous form** of the disease. [2] - This is due to the deposition of **immune complexes** containing *Mycobacterium leprae* antigens in the glomerular basement membrane. [2] *Acute glomerulonephritis* - While possible in some infections, **acute glomerulonephritis** is not specifically or most commonly linked to leprosy. - It’s often characterized by **abrupt onset** of hematuria, proteinuria, and renal dysfunction. [1] *Membranoproliferative glomerulonephritis* - **Membranoproliferative glomerulonephritis** is a less common renal manifestation in leprosy. - It results from immune complex deposition causing mesangial and endothelial cell proliferation, often associated with other chronic infections but less so with leprosy specifically. [3] *Mesangioproliferative glomerulonephritis* - **Mesangioproliferative glomerulonephritis** involves proliferation of mesangial cells and can be seen in various conditions. - However, it is not the dominant or most common renal finding in patients with leprosy, which primarily involves subepithelial immune complex deposition.

Question 1

Evaluating a patient with nephrotic syndrome, which symptom would indicate severe progression of the disease?

Accepted Answer

Severe edema

Answer

Mild proteinuria

Answer

Hyperkalemia

Answer

Hypertension

Question 2

Renal tubular acidosis with ABG value pH = 7.24 PO2=80; PaCO2= 36 Na = 131; HCO3 = 14 Cl= 90; BE = -13 Glucose = 135 the above ABG picture suggests –

Accepted Answer

Metabolic acidosis

Answer

Respiratory alkalosis

Answer

Metabolic alkalosis

Answer

Respiratory acidosis

Question 3

40 years old male complains of loin pain since 1 month. Patient's complaint of pain has severely increased over last 2 hours and pain now radiates from loin and to groin and anterior thigh and patient is writhing in bed for comfort. What is the most probable etiology?

Accepted Answer

Ureteric calculus

Answer

Bladder calculus

Answer

Vesico ureteric reflux

Answer

Hydronephrosis

Question 4

RIFLE criteria is used for diagnosis of

Accepted Answer

Acute kidney injury

Answer

Acute splenic injury

Answer

Acute liver injury

Answer

Acute bowel injury

Question 5

In a patient with nephrotic syndrome, which antibody is decreased?

Accepted Answer

IgG

Answer

IgE

Answer

IgM

Answer

IgA

Question 6

What is oliguria?

Accepted Answer

Excretion of less than 500 ml in 24 hrs

Answer

Excretion of less than 300 ml in 24 hrs

Answer

Excretion of less than 300 ml in 12 hrs

Answer

Excretion of less than 100 ml in 24 hrs

Question 7

Which of the following is a clinical abnormality of uremia?

Accepted Answer

All of the options

Answer

Hyperphosphatemia

Answer

Uremic frost

Answer

Peptic ulcer

Question 8

Decrease in plasma osmotic pressure is cause of edema in?

Accepted Answer

Nephrotic syndrome

Answer

CHF

Answer

DVT

Answer

None of the options

Question 9

Among the following, which is the most characteristic urinary finding in chronic renal failure (CRF)?

Accepted Answer

Broad casts in urine

Answer

Elevated blood urea

Answer

Bleeding diathesis

Answer

Proteinuria

Question 10

What is the most common renal manifestation associated with leprosy?

Accepted Answer

Membranous glomerulonephritis

Answer

Acute glomerulonephritis

Answer

Membranoproliferative glomerulonephritis

Answer

Mesangioproliferative glomerulonephritis

Nephrology — MCQs

Nephrology — MCQs

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