Specialty Certificate in Nephrology Sample Questions

Questions 1 to 10 were written by the Nephrology question-writing team and reviewed by the Nephrology Examination Board as examples of the kind of questions used in the Nephrology Specialty Certificate Examination. Questions 11 to 50 were similarly written and reviewed but, in addition, have already been used in a Nephrology Specialty Certificate Examination the percentage of candidates answering each question correctly is given.

Question 1 A 66-year-old woman who had been undergoing regular haemodialysis for 2 years suffered repeated episodes of hypotension during dialysis. She usually arrived for dialysis approximately 1.5 kg over her dry weight and, during the second hour of each dialysis, her blood pressure fell to <80 mmHg systolic. She was otherwise well and was taking no antihypertensive drugs. She had no oedema. Investigations (performed before a mid-week dialysis session): serum sodium serum potassium serum corrected calcium serum phosphate serum albumin What intervention is most likely to be helpful? A B C D E intradialytic parenteral nutrition low calcium dialysate perform dialysis but not ultrafiltration at start of dialysis sessions reduce sodium concentration in dialysate at start of dialysis sessions reduce temperature of dialysate 134 mmol/L (137144) 4.3 mmol/L (3.54.9) 2.50 mmol/L (2.202.60) 1.4 mmol/L (0.81.4) 31 g/L (3749)

Question 2 A 56-year-old man complained of bruising over his arms. He had presented with acute renal failure because of interstitial nephritis 2 weeks previously, and had initially been treated with continuous haemofiltration in the intensive care unit for 10 days before being switched to haemodialysis three times per week. He was taking prednisolone 40 mg daily and omeprazole 20 mg daily. Investigations: haemoglobin white cell count platelet count serum sodium serum potassium serum creatinine 91 g/L (130180) 7.2 109/L (4.011.0) 12 109/L (150400) 134 mmol/L (137144) 4.3 mmol/L (3.54.9) 513 mol/L (60110)

A diagnosis of heparin-induced thrombocytopenia was made. What anticoagulation should be used now for his dialysis? A B C D E aspirin danaparoid enoxaparin intravenous citrate minimal heparin with only a heparin flush of the dialysis circuit

Question 3 A 31-year-old man was reviewed at a routine clinic visit having been undergoing continuous ambulatory peritoneal dialysis for 6 months. He felt well, had no specific complaints, and was clinically euvolaemic. He was using 4 1.5 L dextrose 1.36% exchanges. Investigations: serum creatinine urine volume ultrafiltration volume Kt/V creatinine clearance What is the most appropriate management?
A B C D E

899 mol/L (60110) 220 mL/day 400 mL/day 1.28 42 L/week

change nocturnal exchange to icodextrin increase volume of exchanges to 2 L no change to dialysis regimen reduce to 3 1.5 L exchanges start oral furosemide 500 mg daily

Question 4 A 62-year-old man with diabetic nephropathy, who had been undergoing dialysis for 9 months, received a kidney transplant from his wife. Immunosuppressive therapy comprised basiliximab, prednisolone and tacrolimus. The operation was uneventful, and in the first 24 hours postoperatively he passed 3.5 L of urine. Thirty-six hours after the operation he was noted to have a falling urine output, with volumes of 60, 50 and 30 mL urine per hour for the previous 3 hours. On examination, he had no oedema, his pulse was 88 beats per minute, his blood pressure was 110/62 mmHg and central venous pressure was +4 cmH2O. Investigations: haemoglobin white cell count platelet count serum sodium serum potassium serum creatinine serum corrected calcium serum phosphate serum albumin ultrasound and Doppler scan of transplant kidney normal appearance, normal resistive index, normal flow in renal artery and vein What is the most appropriate management? A B C D E human albumin solution 1 L over 2 h intravenous dopamine 3 g/kg/min intravenous methylprednisolone 500 mg plasma exchange 50 mL/kg sodium chloride 0.9% 1 L over 2 h 129 g/L (130180) 13.2 109/L (4.011.0) 222 109/L (150400) 141 mmol/L (137144) 5.1 mmol/L (3.54.9) 330 mol/L (60110) 2.10 mmol/L (2.202.60) 0.7 mmol/L (0.81.4) 31 g/L (3749)

Question 5 A 22-year-old man presented with a 2-week history of bilateral ankle swelling and mild ankle pain. He had no past medical history and was taking no medication. He worked as a shop assistant, and neither smoked nor used recreational drugs. On examination, his blood pressure was 110/55 mmHg, and he had pitting oedema to midcalf. His chest and abdomen were normal. He had small lymph nodes palpable in his groins. Urinalysis showed protein 4+, blood 2+.

Investigations: serum sodium serum potassium serum creatinine serum albumin urine protein:creatinine ratio What investigation is likely to be most useful? A B C D E anti-neutrophil cytoplasmic antibody antinuclear antibody EpsteinBarr virus serology protein electrophoresis serum cryoglobulins 141 mmol/L (137144) 4.1 mmol/L (3.54.9) 101 mol/L (60110) 14 g/L (3749) 762 mg/mmol (<15)

Question 6 A 63-year-old woman presented with a 3-day history of haemoptysis. She also had a 4month history of lethargy and weight loss of 3 kg. On examination, she appeared pale and had bilateral red eyes, but there were no other abnormalities. Urinalysis showed protein 2+, blood 3+. Investigations: haemoglobin white cell count eosinophil count platelet count serum creatinine serum C-reactive protein chest X-ray 89 g/L (115165) 13.6 109/L (4.011.0) 0.8 109/L (0.040.40) 389 109/L (150400) 389 mol/L (60110) 293 mg/L (<10) bilateral patchy shadowing in lower zones

What is the most likely diagnosis? A B C D E anti-glomerular basement membrane disease ChurgStrauss syndrome systemic lupus erythematosus tubulointerstitial nephritis with uveitis Wegeners granulomatosis

Question 7 A 62-year-old man was found to have proteinuria on routine testing. He had a 3-year history of exertional angina but his symptoms had been well controlled since he had been taking atenolol 50 mg daily and amlodipine 10 mg daily. On examination, his blood pressure was 129/76 mmHg, his jugular venous pressure was not raised, and he had mild ankle oedema, but his chest was clear. Urinalysis showed protein 4+, blood 1+.

Investigations: serum creatinine serum albumin urinary protein:creatinine ratio renal biopsy histology What is the most appropriate treatment? A B C D E ciclosporin cyclophosphamide and high-dose corticosteroids during alternate months for 6 months furosemide high-dose oral prednisolone ramipril 92 mol/L (60110) 37 g/L (3749) 390 mg/mmol (<30) membranous nephropathy

Question 8 A 56-year-old woman presented with swollen ankles. She had a 3-year history of back, knee and ankle pains for which she was taking ibuprofen 400 mg three times daily. There was no other significant past medical history and she was taking no other regular medication. On examination, she was obese, her blood pressure was 164/84 mmHg and there was bilateral pitting oedema of the ankles, but there were no other abnormalities. Urinalysis showed protein 4+. Investigations: serum creatinine serum albumin urinary albumin:creatinine ratio ultrasound scan of kidneys 130 mol/L (60110) 26 g/L (3749) 496 mg/mmol (<3.5) normal

A renal biopsy was performed with difficulty because of her build. Renal tissue was present only in the sample sent for immunofluorescence (IF). The result of IF for IgG is shown (see image). IF for complement C3 yielded a similar result. IF for other immunoglobulins and complement components was negative. What is the most likely diagnosis? A B C D E focal and segmental glomerulosclerosis idiopathic membranous nephropathy interstitial nephritis mesangiocapillary glomerulonephritis type 1 systemic lupus erythematosus

Image for Question 8

Question 9 A 53-year-old man presented to his general practitioner with a right inguinal hernia. He had a 6-year history of hypertension that had been initially treated with atenolol but he had neither visited a doctor nor taken any medication for 3 years. There was no other significant medical history. He smoked 30 cigarettes per day. On examination, his blood pressure was 176/96 mmHg, his heart sounds were normal and his chest was clear. The abdomen was normal. Fundoscopy revealed bilateral dot haemorrhages, microaneurysms and hard exudates. Urinalysis showed protein 4+, blood 2+. Investigations serum creatinine fasting plasma glucose urinary albumin:creatinine ratio ultrasound scan of kidneys 176 mol/L (60110) 16.7 mmol/L (3.06.0) 287 mg/mmol (<2.5) normal appearances, left kidney 10.4 cm, right kidney 11.2 cm

What is the most likely diagnosis? A B C D E diabetic nephropathy focal and segmental glomerulosclerosis hypertensive nephropathy idiopathic membranous nephropathy ischaemic nephropathy

Question 10 A 21-year-old man presented with progressive deafness and was found to have bilateral high-tone hearing loss. Further investigations revealed chronic kidney disease stage 5. No family history was available as he had been adopted as a baby. What eye abnormality is most likely to be present? A B C D E anterior lenticonus corneal deposits lens dislocation optic atrophy retinitis pigmentosa

Question 11 A 52-year-old man presented with a 4-week history of nausea, anorexia, fever, bilateral flank pains and polyuria. There was a past history of asthma and gastro-oesophageal reflux disease. His medication comprised omeprazole and a compound, over-the-counter analgesic (paracetamol 500 mg/aspirin 300 mg/caffeine per tablet) for flank pain. On examination, his pulse was 72 beats per minute and his blood pressure was 128/81 mmHg. There were no palpable abdominal masses. Urinalysis showed blood trace. Investigations: haemoglobin white cell count platelet count serum sodium serum potassium serum urea serum creatinine serum creatinine (5 months previously) What is the most likely diagnosis? A B C D E acute interstitial nephritis acute papillary necrosis acute tubular necrosis ChurgStrauss syndrome urinary tract obstruction 152 g/L (130180) 8.6 109/L (4.011.0) 475 109/L (150400) 141 mmol/L (137144) 5.2 mmol/L (3.54.9) 16.5 mmol/L (2.57.0) 223 mol/L (60110) 86 mol/L (60110)

Question 12 A 26-year-old woman with spina bifida had become increasingly confused over the preceding 12 hours. Her past medical history included recurrent urinary tract infections and anaphylaxis secondary to penicillin. MRSA had been cultured from her urine during her previous two admissions. On examination, her temperature was 38.9C, her pulse was 112 beats per minute and her blood pressure was 90/56 mmHg. Her Glasgow coma score was 10. Urinalysis showed leucocytes and erythrocytes. Investigations: haemoglobin white cell count neutrophil count serum sodium serum potassium serum urea serum creatinine Which antibiotic should be included in her regimen? A B C D E cefuroxime ciprofloxacin piperacillin/tazobactam rifampicin vancomycin 136 g/L (115165) 23.6 109/L (4.011.0) 18.4 109/L (1.57.0) 132 mmol/L (137144) 4.9 mmol/L (3.54.9) 14.7mmol/L (2.57.0) 212 mol/L (60110)

Question 13 A 74-year-old man presented with acute renal failure. He had a past medical history of hypertension, ischaemic heart disease and type 2 diabetes mellitus. He smoked 25 cigarettes a day. He had recently been found to be in atrial fibrillation and anticoagulation with warfarin was started. Shortly before presentation he had developed lower abdominal pain, associated with watery diarrhoea that had become blood-stained. On examination, he was afebrile, his pulse was 104 beats per minute and irregularly irregular, his blood pressure was 176/94 mmHg, and he was euvolaemic. He had abdominal tenderness below the umbilicus without guarding or rebound. No abdominal masses were palpable. A purpuric rash was noted on his feet, legs and buttocks. His peripheral pulses were absent below the knees bilaterally. Urinalysis showed blood 2+, protein 2+. Investigations: haemoglobin white cell count neutrophil count lymphocyte count eosinophil count platelet count erythrocyte sedimentation rate serum creatinine serum complement C3 serum complement C4 What is the most likely cause of acute renal failure? A B C D E acute interstitial nephritis aortic dissection athero-embolic renal disease cryoglobulinaemia HenochSchnlein purpura 106 g/L (130180) 22 109/L (4.011.0) 18.0 109/L (1.57.0) 3.1 109/L (1.54.0) 0.9 109/L (0.040.40) 164 109/L (150400) 75 mm/1st h (<20) 305 mol/L (60110) 55 mg/dL (65190) 12 mg/dL (1550)

Question 14 A 54-year-old man was admitted to hospital with a 2-day history of increasing shortness of breath, 6 months after a renal transplant. One month earlier, he had sustained a single episode of severe acute vascular rejection treated with methylprednisolone and antithymocyte globulin. Following this episode he was converted from tacrolimus to sirolimus, and continued mycophenolate mofetil and prednisolone. He was a non-smoker and worked as farm worker. He had a past medical history of asthma. Investigations: arterial blood gases, breathing air PO2 PCO2 pH H+ bicarbonate oxygen saturation chest X-ray What is the most appropriate investigation? A B C D E aspergillus precipitins atypical serology bronchoalveolar lavage CT scan of chest lung biopsy

9.2 kPa (11.312.6) 3.2 kPa (4.76.0) 7.40 (7.357.45) 40 nmol/L (3545) 21 mmol/L (2129) 89% (9499) normal

Question 15 A 50-year-old woman was referred with a 6-month history of myalgia and arthralgia. She had a history of recurrent renal stones and was undergoing intermittent lithotripsy. Her grandmother and father had experienced renal problems. On examination, she had generalised muscle weakness but her tendon reflexes, plantar responses and sensory examination were normal. Investigations: serum sodium serum potassium serum chloride serum bicarbonate serum creatinine serum corrected calcium 24-h urinary calcium urinary pH What is the most likely diagnosis? A B C D E Bartters syndrome cystinuria distal renal tubular acidosis hyporeninaemic hypoaldosteronism proximal renal tubular acidosis 140 mmol/L (137144) 2.9 mmol/L (3.54.9) 118 mmol/L (95107) 16 mmol/L (2028) 185 mol/L (60110) 2.05 mmol/L (2.202.60) 6.5 mmol (2.57.5) 7.0

Question 16 A 28-year-old man was found to have protein 2+ on a routine urinalysis done during a life insurance medical. His general practitioner confirmed this and referred him to the outpatient clinic. There had been a similar finding at his occupational health screen when he started at university. He had undergone further tests at the time and had been told there was nothing to worry about. Physical examination was normal and his blood pressure was 118/76 mmHg. Investigations: serum urea serum creatinine estimated glomerular filtration rate (MDRD) urinalysis urinary protein:creatinine ratio (clinic sample) urinary protein:creatinine ratio (early morning) How should the patient be advised? A B C D E he can be reassured that he is at no increased risk of developing renal disease he needs blood tests to exclude renal inflammation he needs regular blood tests because he is at risk of worsening renal function he should be started on an ACE inhibitor he should have a renal biopsy to find out the cause of his proteinuria 5.6 mmol/L (2.57.0) 92 mol/L (60110) >60 mL/min (>60) protein 2+ 103 mg/mmol (<30) 14 mg/mmol (<30)

Question 17 A 54-year-old man presented after an episode of central chest pain lasting 60 minutes, which was unrelieved by sublingual nitrate spray and required opioid analgesia. He had end-stage kidney disease secondary to polycystic kidney disease and he had been dialysis-dependent for 3 years. On examination, his pulse was 110 beats per minute and his blood pressure was 120/66 mmHg. He had no signs of heart failure and no pericardial rub. Investigation: ECG ST segment depression in leads V1 to V6

Which serum indicator is most specific for the diagnosis of acute coronary syndrome in this man? A B C D E brain natriuretic peptide creatine kinase creatine kinase MB fraction troponin I troponin T

Question 18 A 48-year-old woman presented with acute graft dysfunction 3 weeks after renal transplantation. At the time of presentation her maintenance immunosuppressive therapy consisted of trough-level-controlled ciclosporin, azathioprine 100 mg once a day and prednisolone 20 mg once a day. Acute cellular rejection was diagnosed on transplant biopsy. Despite treatment with pulsed methylprednisolone, there was continued deterioration in function and she underwent a second renal biopsy 6 days later (see image). What is the most appropriate next step in management? A B C D E anti-T-lymphocyte globulin further pulsed methylprednisolone intravenous valganciclovir stop azathioprine and start mycophenolate mofetil stop ciclosporin and start tacrolimus

Image for Question 18

Question 19 A 78-year-old man presented with a 2-week history of ankle swelling and headache. He had a 4-year history of rheumatoid arthritis. His medication, which had remained unaltered for 3 years, comprised methotrexate 10 mg weekly, folic acid 5 mg daily and diclofenac 75 mg daily. On examination, his blood pressure was 188/122 mmHg and he had bilateral ankle oedema. There were chronic changes of rheumatoid arthritis in the hands but no evidence of active synovitis. Examination of the optic fundi showed grade 3 hypertensive retinopathy. Investigations: serum creatinine serum albumin serum C-reactive protein 24-h urinary total protein What is the most likely renal diagnosis? A B C D E amyloidosis analgesic nephropathy hypertensive nephropathy idiopathic membranous nephropathy methotrexate nephrotoxicity 258 mol/L (60110) 33 g/L (3749) 17 mg/L (<10) 2.4 g (<0.2)

Question 20 A 71-year-old man with IgA nephropathy was reviewed in the renal clinic. He complained of pain in the right big toe of recent onset. His renal function was stable and he was otherwise well. He was taking perindopril, amlodipine and thyroxine. On examination, he had swelling and erythema over the distal joint of the toe. He was afebrile and did not look acutely ill. His body mass index was 32 kg/m2 (1825). Investigations: serum creatinine serum urate A clinical diagnosis of gout was made. What is the most appropriate treatment? A B C D E allopurinol colchicine diclofenac prednisolone probenecid 245 mol/L (60110) 0.68 mmol/L (0.230.46)

Question: 21 A 67-year-old woman presented with a 2-day history of increasing shortness of breath. She had suffered a persistent cough for the previous 3 weeks and had lost 3 kg in weight. She had been undergoing continuous ambulatory peritoneal dialysis (CAPD) for 3 months using 2.5 L exchanges. She had a past medical history of diabetes mellitus, ischaemic heart disease and previous tuberculosis. On examination, she was breathless on minimal exertion. Her blood pressure was 146/90 mmHg and her jugular venous pressure was visible at 4 cm above the sternal angle. There was reduced air entry at the right base and this area was dull to percussion. She had mild ankle oedema. Investigations: haemoglobin white cell count platelet count serum urea serum creatinine serum albumin random plasma glucose pleural fluid: total protein glucose lactate dehydrogenase 110 g/L (115165) 6.1 109/L (4.011.0) 234 109/L (150400) 24.0 mmol/L (2.57.0) 587 mol/L (60110) 30 g/L (3749) 7.2 mmol/L

20 g/L 17 mmol/L 100 IU/L

What is the most likely cause of her shortness of breath? A B C D E cardiac failure fluid overload mesothelioma pleuroperitoneal leak pulmonary tuberculosis

Question: 22 A 23-year-old woman presented with a 2-month history of lethargy. She had no other symptoms and there was no other past medical history. Her mother confirmed that she had been healthy as a child. On examination, her blood pressure was 178/110 mmHg and she had grade II hypertensive retinopathy but there were no other abnormalities. Urinalysis showed protein 4+, blood 3+. Investigations: serum creatinine 24-h urinary total protein ultrasound scan of kidneys 590 mol/L (60110) 3.9 g (<0.2) right kidney 6 cm, irregular outline; left kidney 7 cm, irregular outline

What is the most likely diagnosis? A B C D E chronic glomerulonephritis congenital renal dysplasia fibromuscular dysplasia of the renal arteries hypertensive nephropathy reflux nephropathy

Question: 23 A 22-year-old woman attended for outpatient review and requested advice about family planning. She had end-stage renal failure secondary to renal dysplasia, and had undergone pre-emptive transplantation 6 months previously. She had gained 6 kg in weight since her transplant and had not had any infections or episodes of rejection. Her current treatment comprised low-dose prednisolone, and tacrolimus titrated against trough levels. Examination was normal. Her blood pressure was 142/78 mmHg. Investigations: serum urea serum creatinine urinary protein:creatinine ratio What is the most appropriate advice? A B C D E attempt to conceive without delay avoid pregnancy because of risks to the fetus delay conception for 6 months introduce antihypertensive therapy before conception substitute mycophenolate for tacrolimus before conception 7.8 mmol/L (2.57.0) 116 mol/L (60110) 28 mg/mmol (<30)

Question: 24 An 87-year-old woman, who had been undergoing regular haemodialysis for 14 years, developed infection in her arteriovenous fistula and infective endocarditis. The endocarditis was successfully treated with 6 weeks of intravenous antibiotics but she then developed Clostridium difficile diarrhoea. This persisted for over 6 weeks, during which time she had become malnourished and required nasogastric tube feeding. She had also developed sacral and heel pressure sores. She asked the nurses if she could stop dialysis but her family did not wish her to stop. What is the most appropriate next action? A B C D E continue to dialyse her as long as the relatives wish it explore further with her the reasons behind her decision obtain a formal psychiatric assessment obtain legal advice stop dialysis

Question: 25 A 47-year-old man, with end-stage renal failure secondary to polycystic kidney disease, underwent successful renal transplantation. Routine immunosuppression included tacrolimus, mycophenolate mofetil and prednisolone. At review 8 weeks later, he was feeling well apart from some lethargy and a poor sleep pattern. On examination, he had a fine tremor of his hands and his blood pressure was 126/80 mmHg. The renal graft was non-tender to palpation. Urinalysis revealed protein 2+. Investigations: serum potassium serum urea serum creatinine serum corrected calcium serum albumin serum phosphate serum alkaline phosphatase plasma parathyroid hormone blood tacrolimus 4.4 mmol/L (3.54.9) 5.9 mmol/L (2.57.0) 104 mol/L (60110) 2.56 mmol/L (2.202.60) 34 g/L (3749) 0.56 mmol/L (0.81.4) 187 U/L (45105) 11.6 pmol/L (0.95.4) 11.2 g/L (812)

What is the most likely cause of the hypophosphataemia? A B C D E Fanconis syndrome hyperparathyroidism malnutrition mycophenolate mofetil tacrolimus toxicity

Question: 26 A 64-year-old woman presented with a 4-week history of intermittent pain and numbness in her left hand. She had noticed that her hand became pale at times, particularly in the cold. She had long-standing type 2 diabetes mellitus and mild leg claudication, and had started haemodialysis via a left brachial fistula 2 months previously. The symptoms in her left hand were worse during dialysis. On examination, the left hand was paler than the right but all pulses were present and equal. The brachial fistula was working well. Pain and fine touch sensation were reduced in the thumb and first two fingers of the left hand. What is the most likely diagnosis? A B C D E carpal tunnel syndrome cervical spondylosis diabetic neuropathy reflex sympathetic dystrophy steal syndrome

Question: 27 A 50-year-old woman presented to her general practitioner with a 3-week history of malaise and oliguria. On examination, her blood pressure was 150/98 mmHg, her jugular venous pressure was elevated to 6 cm and she had a soft pericardial friction rub audible over the precordium. She had bilateral pitting oedema to the knees. Urinalysis showed blood 2+, protein 2+. Investigations: serum sodium serum potassium serum urea serum creatinine serum complement C3 serum complement C4 serum immunoglobulin G serum immunoglobulin A serum immunoglobulin M 136 mmol/L (137144) 5.7 mmol/L (3.54.9) 24.0 mmol/L (2.57.0) 779 mol/L (60110) 46 mg/dL (65190) 20 mg/dL (1550) 6.8 g/L (6.013.0) 4.3 g/L (0.83.0) 1.2 g/L (0.42.5)

anti-double-stranded DNA antibodies (ELISA) 35 U/mL (<73) anti-glomerular basement membrane antibodies negative anti-neutrophil cytoplasmic antibodies negative What is the most likely diagnosis? A B C D E focal segmental glomerulosclerosis IgA nephropathy infective endocarditis membranous glomerulonephritis renal limited vasculitis

Question: 28 A 65-year-old woman with a 30-year history of rheumatoid arthritis presented with a 6week history of progressive ankle oedema. She had been treated with regular gold injections for 5 years, but these had been stopped 9 months previously. She had also been taking diclofenac for the past 2 years. On examination, she had pitting oedema to her knees and a sacral pad. Investigations: haemoglobin platelet count serum sodium serum potassium serum creatinine serum albumin 24-h urinary total protein What is the most likely diagnosis? A B C D E crescentic glomerulonephritis gold-induced membranous nephropathy interstitial nephritis minimal change nephropathy renal amyloid 106 g/L (115165) 164 109/L (150400) 143 mmol/L (137144) 4.4 mmol/L (3.54.9) 223 mol/L (60110) 19 g/L (3749) 7.8 g (<0.2)

Question: 29 A 65-year-old man with acute renal failure secondary to Wegeners granulomatosis was treated with 3 months of oral cyclophosphamide and decreasing doses of oral prednisolone. He achieved good symptomatic relief with moderate recovery of renal function. He was admitted to hospital with a 3-week history of headache and confusion. Investigations: serum creatinine random plasma glucose cerebrospinal fluid: opening pressure total protein glucose white cell count lymphocyte count neutrophil count What is the most likely diagnosis? A B C D E cerebral vasculitis herpes simplex encephalitis malignant infiltration of meninges meningococcal meningitis tuberculous meningitis 178 mol/L (60110) 5.5 mmol/L

250 mmH20 (50180) 2.10 g/L (0.150.45) 1.2 mmol/L (3.34.4) 24/L ( 5) 22/L ( 3.5) 2 (0)

Question: 30 A 78-year-old woman presented with shortness of breath and oedema. She had felt generally unwell for the last few weeks with increasing tiredness, loss of appetite and abdominal discomfort. Her serum creatinine was 105 mol/L (60110). She was treated with intravenous furosemide at doses up to 120 mg twice a day, but there was no improvement in her symptoms and her renal function deteriorated. On examination, her blood pressure was 125/65 mmHg and her jugular venous pressure was not elevated. She had oedema to the thigh. Auscultation of the chest revealed dullness to percussion on the left. Investigations: serum sodium serum potassium serum urea serum creatinine serum albumin 24-h urinary total protein 128 mmol/L (137144) 3.2 mmol/L (3.54.9) 31.5 mmol/L (2.57.0) 351 mol/L (60110) 15 g/L (3749) 15.8 g (<0.2)

What is the most appropriate next step in management? A B C D E increase dose of furosemide intravenous sodium chloride 0.9% start enalapril start metolazone ultrafiltration

Question: 31 A 48-year-old Caucasian man with chronic foot pain presented with acute, severe and generalised pain. On examination, he was of normal build. He had mild visual impairment. There were multiple angiokeratomas on his lower abdomen and buttocks. Urinalysis showed protein 3+. Investigations: serum sodium serum potassium serum urea serum creatinine 137 mmol/L (137144) 4.6 mmol/L (3.54.9) 8.7 mmol/L (2.57.0) 178 mol/L (60110)

A diagnosis of AndersonFabry disease was confirmed by renal biopsy. Which electron microscopic appearances are most consistent with this diagnosis? A B C D E capillary lumina filled with a meshwork of membranes and amorphous deposits concentric lamellar inclusions in lysosomes of endothelial and epithelial cells diffuse crystal deposition foam cells packed with fibrillary material oligo-fibrillary sub-epithelial electron dense deposits

Question: 32 A 60-year-old woman developed atrial fibrillation and was treated with warfarin. Four weeks later, she presented with painful discolouration of lower limb extremities (see image) and acute renal failure. Her renal function had previously been normal. What is the most likely diagnosis? A B C D E cholesterol embolisation cryoglobulinaemia HenochSchnlein purpura IgA nephropathy systemic small vessel vasculitis

Image for Question 32

Question: 33 A 55-year-old man with end-stage renal disease, who had been undergoing haemodialysis for 3 years, complained of generalised muscle stiffness and pain in his lower back. He had lost 4 kg in weight over the previous 4 months. Clinical examination was unremarkable. Investigations: serum urea serum creatinine serum corrected calcium serum phosphate serum total protein serum albumin serum alkaline phosphatase serum aluminium plasma parathyroid hormone What is the most likely bone abnormality? A B C D E decreased bone mineralisation decreased osteoblast activity disrupted continuity of the trabeculae increased osteoclast activity thin osteoid seams 32 mmol/L (2.57.0) 1208 mol/L (60110) 2.30 mmol/L (2.202.60) 3.1 mmol/L (0.81.4) 75 g/L (6176) 39 g/L (3749) 167 U/L (45105) 3 g/L (<10) 36 pmol/L (0.95.4)

Question: 34 A 32-year-old woman with a history of psychotic illness was referred for evaluation of asymptomatic hypokalaemia. On examination, she was overweight, with a blood pressure of 105/68 mmHg. Investigations: serum sodium serum potassium serum creatinine serum magnesium 24-h urinary potassium 24-h urinary calcium What is the most likely diagnosis? A B C D E Bartters syndrome chronic self-induced vomiting diuretic abuse Gitelmans syndrome Liddles syndrome 143 mmol/L (137144) 2.9 mmol/L (3.54.9) 60 mol/L (60110) 0.70 mmol/L (0.751.05) 60 mmol 1.9 mmol (2.57.5)

Question: 35 A 49-year-old man was reviewed in the dialysis clinic. He complained of stiffness and pain in his shoulders, knees and elbows. The pain was worse at night and after dialysis. He had noticed that his fistula was bleeding for longer than previously after removal of the dialysis needles. He had presented with end-stage renal failure caused by IgA nephropathy 15 years previously. He was dialysing with a low-flux polysulphone dialyser through a left radiocephalic arteriovenous fistula. On examination, he had small effusions in both knees and reduced abduction and external rotation in the shoulders Investigations: haemoglobin pre-dialysis blood chemistry: serum urea serum creatinine serum corrected calcium serum phosphate serum urate serum C-reactive protein plasma parathyroid hormone urea reduction ratio 108 g/L (130180)

38.0 mmol/L (2.57.0) 640 mol/L (60110) 2.55 mmol/L (2.202.60) 2.02 mmol/L (0.81.4) 0.48 mmol/L (0.230.46) 22 mg/L (<10) 45 pmol/L (0.95.4) 69%

What is the most likely explanation for his symptoms? A B C D E

2-microglobulin amyloidosis hyperparathyroidism inadequate dialysis light-chain amyloidosis pseudogout

Question: 36 A 26-year-old woman presented with a facial rash and arthralgia. Her blood pressure was 116/66 mmHg. Urinalysis showed blood 2+, protein 2+. Investigations: serum creatinine 24-h urinary total protein anti-double-stranded DNA antibodies (ELISA) 88 mol/L (60110) 0.8 g (<0.2) 229 U/mL (<73)

A diagnosis of systemic lupus erythematosus was made and she was treated with prednisolone 60 mg daily and azathioprine 2 mg/kg/day. On the same day, a renal biopsy was performed that showed class II lupus nephritis. What is the most appropriate further management? A B C D E add ciclosporin add intravenous methylprednisolone 1 g for 3 days no change stop azathioprine, start cyclophosphamide stop azathioprine, start mycophenolate mofetil

Question: 37 A 29-year-old woman presented with a 5-day history of generalised weakness. During the preceding 6 months, she had suffered from intermittent nausea and vomiting, and recurrent abdominal pain. She had been taking the oral contraceptive pill for about a year. On examination, her blood pressure fell from 144/94 mmHg supine to 120/84 mmHg standing. There was generalised muscle weakness affecting her limbs. Urinalysis was negative. Investigations: serum sodium serum potassium serum bicarbonate serum urea serum creatinine What is the most likely diagnosis? A B C D E acute intermittent porphyria Addisons disease GuillainBarr syndrome rhabdomyolysis systemic vasculitis 123 mmol/L (137144) 3.6 mmol/L (3.54.9) 28 mmol/L (2028) 10.9 mmol/L (2.57.0) 120 mol/L (60110)

Question: 38 A 64-year-old man undergoing maintenance haemodialysis was reviewed. He had suffered a myocardial infarction 9 months earlier. His medication comprised alfacalcidol 0.25 micrograms once daily, calcium carbonate 500 mg three times daily, ramipril 5 mg once daily, simvastatin 10 mg at night and subcutaneous epoetin beta 3000 units twice weekly. Investigations: haemoglobin white cell count platelet count serum ferritin 96 g/L (130180) 6.7 109/L (4.011.0) 175 109/L (150400) 185 g/L (15300)

What is the most appropriate next management step? A B C D E blood transfusion change epoetin beta to darbepoetin increase dose of epoetin beta intravenous iron stop ramipril

Question: 39 A 33-year-old woman had two children with cystinosis from her first marriage. She was planning to re-marry and asked what the likelihood was of any children by her new partner developing or carrying the disease. What is the most appropriate response? A B C D E 50% of all children will be affected 50% of all children will be carriers all female children will be carriers all male children will be affected no female children will be affected

Question: 40 A 20-year-old woman presented to an ophthalmologist with bilateral, painful red eyes that improved with a topical corticosteroid. Two months later, she presented to the outpatient clinic with renal impairment and proteinuria. In addition she complained of arthralgia, myalgia and lethargy. Urinalysis showed protein 2+. Investigations: haemoglobin white cell count eosinophil count serum urea serum creatinine 24-h urinary total protein extractable nuclear antigen 115 g/L (115165) 11.0 109/L (4.011.0) 0.70 109/L (0.040.40) 10.0 mmol/L (2.57.0) 156 mol/L (60110) 0.8 g (<0.2) negative

Renal histology showed normal glomeruli. Interstitial oedema with a lymphocytic infiltrate was noted. The occasional granuloma and eosinophils were seen. What is the most likely diagnosis? A B C D E Behets disease sarcoidosis Sjgrens syndrome systemic lupus erythematosus Wegeners granulomatosis

Question: 41 A 37-year-old woman presented with acute renal failure and pulmonary haemorrhage resulting from anti-neutrophil cytoplasmic antibody-positive vasculitis, and was treated with immunosuppression, dialysis and plasma exchange. Three months later, the vasculitis was not clinically active and she had recovered sufficient renal function to cease dialysis. What is the most likely mode of action of plasma exchange in this patient? A B C D E anti-inflammatory effects of replacement plasma removal of activated complement removal of inflammatory cytokines removal of pathogenic antibodies replenishment of normal immunoglobulins

Question: 42 A 37-year-old woman with a 4-year history of Raynauds phenomenon, arthralgia, weight loss, muscle tenderness and intermittent malaise was referred by her general practitioner. On examination, she had indurated thickening of the skin distal to the metacarpophalangeal joints. There was no active synovitis, rash or nail abnormalities. Her blood pressure was 158/94 mmHg. She weighed 48 kg. Investigations: haemoglobin white cell count platelet count erythrocyte sedimentation rate serum urea serum creatinine serum creatine kinase urinary protein:creatinine ratio serum complement C3 serum complement C4 serum C-reactive protein antinuclear antibodies anti-La antibodies anti-RNP antibodies anti-Scl-70 antibodies anti-Ro antibodies anti-Sm antibodies What is the most likely diagnosis? A B C D E dermatomyositis Sjgren's disease systemic lupus erythematosus systemic sclerosis undifferentiated connective tissue disease 110 g/L (115165) 4.0 109/L (4.011.0) 135 109/L (150400) 55 mm/1st h (<20) 7.0 mmol/L (2.57.0) 144 mol/L (60110) 210 U/L (24170) 105 mg/mmol (<30) 74 mg/dL (65190) 22 mg/dL (1550) 42 mg/L (<10) positive at 1:128 dilution negative negative negative positive negative

Question: 43 A 50-year-old man who was undergoing maintenance haemodialysis was reviewed. His medication comprised alfacalcidol 0.25 micrograms daily, calcium carbonate 500 mg three times daily, ramipril 5 mg daily and simvastatin 10 mg daily. The dialysate calcium concentration was 1.25 mmol/L. Investigations: serum corrected calcium serum phosphate plasma parathyroid hormone 2.60 mmol/L (2.202.60) 1.67 mmol/L (0.81.4) 28.0 pmol/L (0.95.4)

What is the most appropriate next management step? A B C D E change calcium carbonate to sevelamer dialyse against lower calcium dialysate no change omit alfacalcidol prescribe cinacalcet

Question: 44 A 27-year-old woman presented with fatigue and intermittent pyrexia, 10 months after a renal transplant for end-stage renal failure. Her kidney injury had resulted from treatment with ciclosporin, which she had been given after an earlier heartlung transplant performed because of cystic fibrosis. Immunosuppression comprised prednisolone, ciclosporin and azathioprine after basiliximab induction. Her serum creatinine concentration was found to have risen from 120 mol/L to 150 mol/L (60110) and a renal biopsy was performed. The renal biopsy showed no evidence of cellular or humoral rejection. The architecture was preserved, but there was a T-cell and plasma-cell infiltrate, with a prominent immunoblastic proliferation. The immunoblasts showed evidence of EpsteinBarr virus (EBV) infection with positivity for EBV LMP-1. What is the most appropriate next step in management? A B C D E reduce immunosuppression start antiviral therapy start cytotoxic chemotherapy start rituximab stop immunosuppression

Question: 45 A 22-year-old woman was admitted by the obstetric service in the 30th week of her first pregnancy. She had been treated with antibiotics for dysuria at 12 weeks. On admission, she complained of dysuria and suprapubic discomfort. General examination was normal. Her temperature was 36.8C, her pulse was 78 beats per minute and her blood pressure was 104/62 mmHg. There was no peripheral oedema and fundal height was appropriate. Investigations: haemoglobin white cell count serum urea serum creatinine serum C-reactive protein midstream urine microscopy: white cells culture 118 g/L (115165) 7.6 109/L (4.011.0) 3.0 mmol/L (2.57.0) 46 mol/L (60110) 8 mg/L (<10)

>50/L (<10) >105 E. coli per mL, sensitive to amoxicillin, ciprofloxacin, trimethoprim minimal right hydronephrosis

ultrasound scan of renal tract What investigation is most appropriate? A B C D E DTPA isotope renography monthly midstream urine cultures MR urography retrograde pyelography urodynamic study

Question: 46 A 70-year-old man with hypertension was admitted with a 7-day history of worsening confusion. His wife reported a 13-kg weight loss, anorexia and vomiting after food over a 6-month period. On examination, he had reduced skin turgor. His blood pressure was 120/75 mmHg and his respiratory rate was 12 breaths per minute. His Glasgow coma score was 12. Investigations: serum sodium serum potassium serum chloride serum bicarbonate serum urea serum creatinine plasma osmolality urinary pH urinary sodium urinary osmolality serum cortisol (09.00 h) What is the most likely diagnosis? A B C D E Addisonian crisis Bartters syndrome distal renal tubular acidosis pyloric stenosis syndrome of inappropriate antidiuretic hormone secretion (SIADH) 128 mmol/L (137144) 2.5 mmol/L (3.54.9) 75 mmol/L (95107) 48 mmol/L (2028) 34.0 mmol/L (2.57.0) 200 mol/L (60110) 300 mosmol/kg (278300) 5.8 5 mmol/L (<10) 650 mosmol/kg (3501000) 650 nmol/L (200700)

Question: 47 A 78-year-old man presented with a 3-month history of malaise. On examination, his blood pressure was 135/72 mmHg. Investigations: haemoglobin serum sodium serum potassium serum creatinine ultrasound scan of kidneys 100 g/L (130180) 133 mmol/L (137144) 6.4 mmol/L (3.54.9) 608 mol/L (60110) grossly hydronephrotic right kidney with thin cortex; left kidney with moderate hydronephrosis but otherwise normal appearance

What is the most appropriate next step in management? A B C D E percutaneous nephrostomy of the left kidney percutaneous nephrostomy of the right kidney retrograde ureteric stent on the left retrograde ureteric stent on the right urgent dialysis

Question: 48 A 68-year-old man who was undergoing home haemodialysis wanted to reduce his dialysis hours. On examination, the fistula had a modest thrill and bruit. Arterial and venous needling sites were separated by about 10 cm. There were no other significant findings. The most recent urea reduction ratio (URR) was 76%. His wife reported she had taken the post-dialysis blood sample immediately at the end of dialysis. What is the most appropriate next step? A B C D E measure access recirculation with a potassium-based dilutional measurement measure access recirculation with a two-needle urea-based measurement measure URR with post-dialysis urea by slowing blood flow to 100 mL/min for 10 s measure URR with post-dialysis urea by stopping blood flow for 5 s measure URR with post-dialysis urea by stopping dialysate flow for 5 min

Question: 49 A 33-year-old woman presented with a 1-week history of malaise and a 3-day history of a rash on her legs. She had no significant past medical history and was taking no regular medication. Examination was normal except for a palpable purpuric rash over her lower legs. Urinalysis showed blood 3+, protein 3+. Investigations: serum creatinine serum C-reactive protein urinary albumin:creatinine ratio ultrasound scan of kidneys 776 mol/L (60110) 226 mg/L (<10) 136 mg/mmol (<3.5) normal

A renal biopsy was performed. The light microscopic appearance of a typical glomerulus is shown (see image A). Immunofluorescence (IF) for IgA is shown (see image B); a similar pattern was seen for IgG and complement C3. IF for other immunoglobulins and complement components was negative. What is the most likely diagnosis? A B C D E cryoglobulinaemia HenochSchnlein purpura microscopic polyangiitis polyarteritis nodosa systemic lupus erythematosus

Question: 50 A 55-year-old man presented with left ureteric colic. He later passed a stone and analysis showed it to be composed of calcium oxalate. He had experienced no previous symptomatic nephrolithiasis and had no other past medical history. Investigations: serum corrected calcium serum urate 24-h urinary calcium 24-h urinary urate 24-h urinary oxalate 2.35 mmol/L (2.202.60) 0.40 mmol/L (0.230.46) 8.5 mmol (2.57.5) 1.6 mmol (<3.6) 0.3 mmol (0.140.46)

What is the most appropriate way to prevent further stone formation? A B C D E alkalinisation of the urine restriction of dietary calcium restriction of dietary oxalate restriction of dietary protein restriction of dietary sodium

Answers and Comments

1. Answer: E Comment: Reduced dialysate temperature has been shown to reduce the incidence of intradialytic hypotension. Option A has not been shown to be beneficial. Options B, C and D may worsen the problem. 2. Answer: B Comment: This is severe heparin-induced thrombocytopenia (HIT) and heparin in any form should be avoided, so C & E are incorrect. Aspirin is not effective. Regional but not intravenous citrate might be used. Danaparoid is a non-heparin anticoagulant, which can be used in patients with HIT. Anticoagulant-free haemodialysis might be tried but is not given as an option. 3. Answer: B Comment: He is underdialysed by all criteria. Only B will significantly increase dialysis dose. 4. Answer: E Comment: This patient is hypovolaemic because of polyuria from the transplant kidney. Intravenous sodium chloride is the most appropriate treatment. 5. Answer: B Comment: This man has nephrotic syndrome. Given the ankle pain and lymphadenopathy, it would be reasonable to screen for systemic lupus erythematosus. Options A, C, D and E are very unlikely to be helpful. 6. Answer: E Comment: This presentation is consistent with a pulmonary renal syndrome due to Wegeners granulomatosis. Eye abnormalities, particularly conjunctivitis, and a mild eosinophilia are common in Wegeners granulomatosis. The extra-renal features make anti-glomerular basement membrane disease less likely. The clinical features are not consistent with tubulointerstitial nephritis with uveitis, ChurgStrauss syndrome or systemic lupus erythematosus.

7. Answer: E Comment: Although he has idiopathic membranous nephropathy (IMN) with heavy proteinuria, he does not have nephrotic syndrome and, in the UK, it would be usual practice to treat conservatively with a regimen including an ACE inhibitor for at least 6 months before considering specific therapy. The mild ankle oedema has probably been caused by amlodipine and does not require treatment with furosemide. Prednisolone alone is not an effective treatment for IMN. 8. Answer: B Comment: The image shows the typical granular pattern of deposition of immunoglobulin G (IgG) (and complement C3) of membranous nephropathy. A similar pattern for complement C3, but not usually for IgG, can occur in mesangiocapillary glomerulonephritis type 1 but the clinical features make this much less likely. In membranous lupus nephritis, IF for other immunoglobulins and complement components is positive and, in the other two options, IF is usually negative or non-specific. 9. Answer: A Comment: This man has type 2 diabetes mellitus that is newly diagnosed but has clearly been present for some time as he has diabetic retinopathy. He has heavy proteinuria and diabetic nephropathy is the most likely renal diagnosis. In type 2 diabetes mellitus, unlike in type 1, diabetic nephropathy may be present when the diagnosis of diabetes is first made. 10. Answer: A Comment: This man has Alports syndrome. Of the options given, anterior lenticonus is the most common eye abnormality, occurring in about 25% of adult males with Alports syndrome. A retinopathy is present in over 80% of affected adult males but this is not listed as an option. 11. Answer: A Comment: This patient is most likely to have an acute interstitial nephritis caused by omeprazole. Acute papillary necrosis is much less likely and would have to have been bilateral to cause the serum creatinine to rise to 223 mol/L. There is no clear precipitant for acute tubular necrosis. The history of asthma and the constitutional symptoms raise the possibility of ChurgStrauss syndrome but this would cause proteinuria and haematuria. Urinary tract obstruction, in this context, would not produce all the symptoms described.

39% of candidates answered this question correctly. 12. Answer: E Comment: This patient may have septicaemia as a result of the MRSA urinary tract infection so a glycopeptide antibiotic (in this case vancomycin) should be included in her regimen. 85% of candidates answered this question correctly. 13. Answer: C Comment: This man with vascular disease is likely to have developed athero-embolic renal disease related to starting warfarin. The combination of eosinophilia and hypocomplementaemia makes acute interstitial nephritis, aortic dissection and HenochSchnlein purpura unlikely. Cryoglobulinaemia is very uncommon in this context. 73% of candidates answered this question correctly. 14. Answer: C Comment: The combination of breathlessness and hypoxia with a clear chest X-ray in this setting raise the suspicion of Pneumocystis jirovecii pneumonia, so bronchoalveolar lavage is the most appropriate investigation of the options given. 39% of candidates answered this question correctly. 15. Answer: C Comment: This patient has distal renal tubular acidosis. None of the other options can account for all the clinical and biochemical features. 58% of candidates answered this question correctly. 16. Answer: A Comment: This man has orthostatic proteinuria, which is not associated with an increased risk of developing renal disease. 88% of candidates answered this question correctly. 17. Answer: D

Comment: For reasons that are still not clear, serum troponin T is raised in many patients on dialysis without acute coronary syndrome (2082% depending on the cut-off used). Troponin I is elevated in only 0.46% of stable dialysis patients and is the most specific marker for acute coronary syndrome in this setting. 70% of candidates answered this question correctly. 18. Answer: A Comment: The image shows severe vascular rejection for which administration of an anti-Tlymphocyte globulin is the most appropriate next step. 85% of candidates answered this question correctly. 19. Answer: C Comment: This man is most likely to have hypertensive nephropathy related to malignant hypertension. The history of rheumatoid arthritis and non-steroid anti-inflammatory drug use is too short for amyloidosis or analgesic nephropathy to be likely. Idiopathic membranous nephropathy is very rarely associated with malignant hypertension. Methotrexate may cause a crystal nephropathy (when given in high doses) but does not cause either malignant hypertension or heavy proteinuria. 64% of candidates answered this question correctly. 20. Answer: B Comment: This man has acute gout. Allopurinol should not be started during an acute attack. Diclofenac and probenecid are inappropriate because of his impaired renal function. Although prednisolone would probably be an effective treatment, it is most appropriate to try low-dose colchicine first. 64% of candidates answered this question correctly. 21. Answer: D 73% of candidates answered this question correctly.

22. Answer: E 58% of candidates answered this question correctly.

23. Answer: C 91% of candidates answered this question correctly.

24. Answer: B 94% of candidates answered this question correctly.

25. Answer: B 42% of candidates answered this question correctly.

26. Answer: E 85% of candidates answered this question correctly.

27. Answer: C 58% of candidates answered this question correctly.

28. Answer: E 49% of candidates answered this question correctly.

29. Answer: E 82% of candidates answered this question correctly.

30. Answer: E 58% of candidates answered this question correctly.

31. Answer: B 76% of candidates answered this question correctly.

32. Answer: A 97% of candidates answered this question correctly.

33. Answer: D

58% of candidates answered this question correctly

34. Answer: D 49% of candidates answered this question correctly.

35. Answer: A 88% of candidates answered this question correctly.

36. Answer: C 91% of candidates answered this question correctly.

37. Answer: A 64% of candidates answered this question correctly.

38. Answer: D 70% of candidates answered this question correctly.

39. Answer: B 58% of candidates answered this question correctly.

40. Answer: B 79% of candidates answered this question correctly.

41. Answer: D 61% of candidates answered this question correctly.

42. Answer: D 44% of candidates answered this question correctly.

43. Answer: A 58% of candidates answered this question correctly.

44. Answer: A 82% of candidates answered this question correctly.

45. Answer: B 91% of candidates answered this question correctly.

46. Answer: D 94% of candidates answered this question correctly.

47. Answer: A 70% of candidates answered this question correctly.

48. Answer: E 42% of candidates answered this question correctly.

49. Answer: B 66% of candidates answered this question correctly.

50. Answer: E 33% of candidates answered this question correctly.