Vascular Diseases of the Kidney — MCQs
All are seen in Nephrotic syndrome except
In the context of bilateral renal artery stenosis, which antihypertensive drug is considered contraindicated?
What is the most likely diagnosis in a patient presenting with hypertension, proteinuria, and renal failure?
In shigella dysentery associated hemolytic uremic syndrome, the false statement is ?
Most common cause of persistent hypertension in a child with intrinsic renal disease is -
Thrombotic thrombocytopenic purpura is a syndrome characterized by which of the following?
All the following are features of Polycystic disease of kidneys EXCEPT:
IgA nephropathy is not associated with which of the following?
A 7 year old boy presented with generalized edema. Urine examination revealed marked albuminuria. Serum biochemical examinations showed hypoalbuminemia with hyperlipidemia. Kidney biopsy was undertaken. On light microscopic examination, the kidney appeared normal. Electron microscopic examination is most likely to reveal
Irregular scarred kidney with pelvic dilatation is seen with?
Vascular Diseases of the Kidney Indian Medical PG Practice Questions and MCQs
Question 1: All are seen in Nephrotic syndrome except
- A. Atherosclerosis
- B. Thrombo-embolism
- C. Lipiduria
- D. Increased protein C levels (Correct Answer)
Explanation: ***Increased protein C levels*** - In **nephrotic syndrome**, there is an **increased urinary loss of anticoagulant proteins**, including **Protein C** and **Protein S**, leading to a state of **hypercoagulability**. [1] - Therefore, **Protein C levels are decreased**, not increased, making this the exception. *Atherosclerosis* - **Hyperlipidemia**, a hallmark of nephrotic syndrome, contributes significantly to **accelerated atherosclerosis** due to dysregulation of lipid metabolism. - The increased levels of **LDL cholesterol** and other lipoproteins promote plaque formation and arterial stiffening. *Thrombo-embolism* - Patients with nephrotic syndrome are at a significantly **increased risk of thromboembolic events**, such as deep vein thrombosis and pulmonary embolism, due to a **hypercoagulable state**. - This state results from the **urinary loss of anticoagulant proteins** (e.g., antithrombin III, Protein C, Protein S) and increased levels of procoagulant factors (e.g., fibrinogen, factor V, factor VIII). *Lipiduria* - **Lipiduria**, the presence of lipids in the urine, is a characteristic feature of nephrotic syndrome, often manifested as **oval fat bodies** and **fatty casts**. [1] - This occurs due to the increased glomerular permeability that allows lipoproteins to filter into the urine. [1]
Question 2: In the context of bilateral renal artery stenosis, which antihypertensive drug is considered contraindicated?
- A. Beta-blockers
- B. Calcium channel blockers
- C. ACE inhibitors (Correct Answer)
- D. Diuretics
Explanation: ***ACE inhibitors*** - In bilateral renal artery stenosis, ACE inhibitors can precipitate **acute kidney injury** by severely reducing **glomerular filtration pressure**, as both kidneys rely on **angiotensin II** for maintaining this pressure [1]. - They inhibit the production of **angiotensin II**, leading to **efferent arteriolar dilation** and a drop in glomerular hydrostatic pressure, which is critical for filtration in stenosed kidneys [2]. *Beta-blockers* - Beta-blockers are generally considered safe and effective in treating hypertension associated with renal artery stenosis, as they do not directly interfere with **renal autoregulation** in the same critical way as ACE inhibitors. - They lower blood pressure by reducing **cardiac output** and inhibiting renin release but do not acutely compromise **glomerular filtration** in the presence of stenosis. *Calcium channel blockers* - Calcium channel blockers are safe to use in bilateral renal artery stenosis and are often effective in controlling blood pressure. - They dilate **afferent arterioles**, which can actually help maintain or improve **glomerular filtration rate** by increasing blood flow to the glomerulus. *Diuretics* - Diuretics can be used cautiously in renal artery stenosis to manage blood pressure and fluid overload. - However, aggressive diuresis can lead to intravascular volume depletion, which might exacerbate **renal hypoperfusion** in already stenosed kidneys.
Question 3: What is the most likely diagnosis in a patient presenting with hypertension, proteinuria, and renal failure?
- A. Mycosis fungoides
- B. Wegener's granulomatosis (Correct Answer)
- C. Invasive aspergillosis
- D. Sarcoidosis
Explanation: ***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.
Question 4: In shigella dysentery associated hemolytic uremic syndrome, the false statement is ?
- A. Hepatic failure (Correct Answer)
- B. Leucocytosis
- C. Thrombotic angiopathy
- D. Neurological abnormalities
Explanation: Detailed assessment of the complications of Hemolytic Uremic Syndrome (HUS) following Shigella infection shows that hepatic failure is not a characteristic component. ***Hepatic failure*** - **Hepatic failure** is not a typical hallmark or direct complication of **Shiga toxin-producing E. coli (STEC) HUS**, which primarily targets the kidneys. - The primary organs affected in **HUS** are the **kidneys (acute kidney injury)**, brain (neurological symptoms), and hematopoietic system (thrombocytopenia, microangiopathic hemolytic anemia) [2]. *Leucocytosis* - **Leucocytosis** (elevated white blood cell count) is a common finding in **Shigella dysentery**, reflecting the systemic inflammatory response to the infection. - It can be a predictive marker for the severity of **HUS** development in patients with **STEC** infection. *Thrombotic angiopathy* - **Thrombotic angiopathy** is the underlying pathological process in **HUS**, characterized by **microvascular thrombosis** and **endothelial damage** [1]. - These microthrombi lead to **thrombocytopenia**, **microangiopathic hemolytic anemia**, and **ischemic organ damage**, particularly in the kidneys [1], [2]. *Neurological abnormalities* - **Neurological abnormalities** such as seizures, altered mental status, and strokes can occur in a significant proportion of **HUS** patients. - These complications are due to **cerebral microthrombosis** and **endothelial damage** in the brain, affecting blood flow and neuronal function.
Question 5: Most common cause of persistent hypertension in a child with intrinsic renal disease is -
- A. CGN (Correct Answer)
- B. Obstructive uropathy
- C. Renal tumor
- D. Chronic Pyelonephritis
Explanation: ***CGN*** - **Chronic glomerulonephritis (CGN)** is a leading cause of persistent hypertension in children with intrinsic renal disease due to widespread glomerular damage leading to **renin-angiotensin-aldosterone system** activation and fluid retention. - The damaged kidneys are unable to filter waste and regulate blood pressure effectively, contributing to sustained hypertension. *Chronic Pyelonephritis* - While chronic pyelonephritis can cause hypertension, it is typically due to **scarring and inflammation** affecting renal function. - However, it is not as common a cause of persistent hypertension as CGN in children with intrinsic renal disease. *Obstructive uropathy* - **Obstructive uropathy** is classified as a **post-renal (obstructive) disorder** rather than intrinsic renal disease, though it can lead to secondary renal parenchymal damage. - It can cause hypertension through renal parenchymal damage and **renin release** due to increased pressure, but it is not a primary intrinsic renal disease. *Renal tumor* - **Renal tumors**, such as Wilms' tumor, can cause hypertension through **compression of renal arteries** or increased renin production. - While a significant cause of hypertension, it is generally less common than CGN as a cause of persistent hypertension in children with *intrinsic renal disease* overall.
Question 6: Thrombotic thrombocytopenic purpura is a syndrome characterized by which of the following?
- A. Thrombocytopenia, anemia, neurological abnormalities, progressive renal failure and fever (Correct Answer)
- B. Thrombocytopenia, anemia, neurological abnormalities, progressive hepatic failure and fever
- C. Thrombocytopenia, normal anemia, neurological abnormalities, progressive renal failure and fever
- D. Thrombocytopenia, anemia, no neurological abnormalities, progressive renal failure and fever
Explanation: ***Thrombocytopenia, anemia, neurological abnormalities, progressive renal failure and fever*** - Thrombotic thrombocytopenic purpura is characterized by **thrombocytopenia** and **microangiopathic hemolytic anemia**, along with neurological and renal complications [1][2]. - The presence of **fever** and other systemic symptoms is consistent with this **thrombotic microangiopathy** syndrome [1]. *Thrombocytosis, anemia, neurologic abnormalities, progressive renal failure and fever* - This option incorrectly lists **thrombocytosis** rather than **thrombocytopenia**, which is a hallmark of thrombotic thrombocytopenic purpura (TTP) [1]. - While it includes anemia, the absence of thrombocytopenia makes it inconsistent with TTP's classic presentation [2]. *Thrombocytopenia, anemia, neurologic abnormalities, progressive hepatic failure and fever* - Although it correctly states **thrombocytopenia** and **anemia**, it incorrectly identifies **progressive hepatic failure** instead of **renal failure**, which is a key feature of TTP [1]. - The presence of neurological abnormalities and fever does align with TTP; however, the hepatic failure aspect is misleading. *Thrombocytosis, anemia neurologic abnormalities, progressive renal failure and fever* - Again, this option incorrectly notes **thrombocytosis**, contradicting the characteristic finding of **thrombocytopenia** found in TTP [1]. - While other features align with TTP's clinical picture, the thrombocytosis excludes this option from being correct [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 947-948. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 667-668.
Question 7: All the following are features of Polycystic disease of kidneys EXCEPT:
- A. Erythrocytosis (Correct Answer)
- B. Renal failure
- C. Haematuria
- D. Hypertension
Explanation: ***Erythrocytosis*** - While other renal conditions like **renal cell carcinoma** can cause erythrocytosis due to increased **erythropoietin** production, it is generally **not a typical feature** of Polycystic Kidney Disease (PKD). - Patients with PKD usually have **normal or even low erythropoietin levels** despite compromised kidney function, and anemia is more common, particularly as **renal failure progresses**. *Renal failure* - **Progressive cyst growth** leads to replacement of normal kidney parenchyma, inevitably culminating in **end-stage renal disease** [1] in the majority of patients. - This is a hallmark feature, often necessitating **dialysis or transplant** later in life for individuals with autosomal dominant polycystic kidney disease (ADPKD) [2]. *Haematuria* - **Gross or microscopic hematuria** is a common symptom in PKD, often resulting from **cyst rupture** [1], bleeding into a cyst, or the passage of a calculus due to urinary stasis. - It can be a presenting symptom and can cause significant pain and anxiety for patients. *Hypertension* - **Hypertension** is an early and frequent complication of PKD, often preceding any significant decline in glomerular filtration rate. - It is primarily caused by activation of the **renin-angiotensin-aldosterone system (RAAS)** [3] due to arterial compression and ischemia from expanding cysts. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 951-955. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 544-545. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 520-521.
Question 8: IgA nephropathy is not associated with which of the following?
- A. Focal mesangial proliferation
- B. Gross hematuria concurrent with upper respiratory infection
- C. Immunofluorescence deposits contain IgA and IgG
- D. Decreased complement level (Correct Answer)
Explanation: ***Decreased complement level*** - IgA nephropathy is typically associated with **normal serum complement levels** (C3 and C4), which is an important distinguishing feature. - Unlike post-streptococcal glomerulonephritis or lupus nephritis where complement levels are **low/decreased**, IgA nephropathy does not cause systemic complement consumption. - While complement activation does occur locally in the glomerulus (via lectin and alternative pathways), it does not lead to a decrease in serum complement levels. *Focal mesangial proliferation* - This is a **common histological finding** in IgA nephropathy, reflecting the proliferative response to IgA deposition in the mesangium. - The mesangial cells proliferate in an attempt to clear the immune deposits. *Gross hematuria concurrent with upper respiratory infection* - This is a **classic clinical presentation** of IgA nephropathy, often referred to as **synpharyngitic hematuria**. - The episode of gross hematuria typically occurs **within 1-2 days** of the onset of an upper respiratory tract infection, distinguishing it from post-streptococcal glomerulonephritis where hematuria appears 1-3 weeks later. *Immunofluorescence deposits contain IgA and IgG* - The defining feature of IgA nephropathy on immunofluorescence is the **predominant deposition of IgA**, often accompanied by C3. - While IgA is the primary immunoglobulin, **IgG and IgM can also be present** in variable amounts, but IgA must be the dominant or co-dominant immunoglobulin for the diagnosis.
Question 9: A 7 year old boy presented with generalized edema. Urine examination revealed marked albuminuria. Serum biochemical examinations showed hypoalbuminemia with hyperlipidemia. Kidney biopsy was undertaken. On light microscopic examination, the kidney appeared normal. Electron microscopic examination is most likely to reveal
- A. Rarefaction of glomerular basement membrane
- B. Fusion of foot processes of the glomerular epithelial cells (Correct Answer)
- C. Deposition of electron dense material in the basement membrane
- D. Thin basement membrane
Explanation: ***Fusion of foot processes of the glomerular epithelial cells*** - The clinical presentation of generalized edema, marked albuminuria, hypoalbuminemia, and hyperlipidemia in a young child strongly indicates **minimal change disease** (MCD), which is the most common cause of **nephrotic syndrome** in children [1]. - While light microscopy is normal in MCD, electron microscopy characteristically reveals **effacement or fusion of the foot processes** of the podocytes, which leads to increased glomerular permeability to proteins [1]. *Rarefaction of glomerular basement membrane* - **Rarefaction** or thinning of the glomerular basement membrane is associated with **Alport syndrome** or diseases causing basement membrane injury, which typically present with progressive kidney disease and hematuria. - This finding is not characteristic of minimal change disease or the nephrotic syndrome described. *Deposition of electron dense material in the basement membrane* - The deposition of **electron-dense material** within the glomerular basement membrane is characteristic of immune complex-mediated diseases like **membranoproliferative glomerulonephritis** (MPGN) or **post-infectious glomerulonephritis**. - These conditions often present with hematuria and are not typically associated with normal light microscopy in the context of nephrotic syndrome. *Thin basement membrane* - A **thin basement membrane** is a defining feature of **thin basement membrane disease** (also known as benign familial hematuria). - This condition is primarily associated with **microscopic hematuria** and does not typically cause nephrotic range proteinuria or generalized edema. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 922-923.
Question 10: Irregular scarred kidney with pelvic dilatation is seen with?
- A. Chronic pyelonephritis (Correct Answer)
- B. Polycystic kidney
- C. Renal artery stenosis
- D. Tuberculosis of kidney
Explanation: ***Chronic pyelonephritis*** - Characterized by irregular scarring of the kidney and often leads to **pelvic dilatation** due to recurrent infections and obstruction [1]. - The damage from inflammation results in **cortical scarring** and can affect kidney function significantly over time [1]. *Renal artery stenosis* - Typically presents with **hypertension** and may lead to ischemic atrophy, but does not cause significant **pelvic dilatation**. - The kidney appears small and often asymmetric, but not typically irregular and scarred. *Tuberculosis of kidney* - Can cause damage to the kidney, but usually leads to **caseating granulomas** and can cause abscesses, not specifically irregular scarring with pelvic dilation. - Often presents with systemic symptoms such as fever and night sweats, along with hematuria. *Polycystic kidney* - Characterized by multiple cysts in both kidneys leading to enlarged kidneys, but does not typically present as **irregularly scarred kidneys**. - Usually associated with **hemodynamic issues** and hypertension but not pelvic dilatation in the sense of scarring or fibrosis. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 937-939.
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