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Quiz on Nephrology
1. Which of the following, antibiotics should be avoided for use in treatment of urinary tract infections in pregnancy ?
(3) Amoxicillin-clavulanic acid
2. A 76-year-old man with long-standing hypertension was admitted with increasing shortness of breath. His BP was 170/70 mmHg, heart rate 92 beats per minute, respiratory rate 28 per min, and pulse oximetry 96% on FiO2 0.4. A plain chest radiograph showed pulmonary edema and an echocardiogram showed a left ventricular ejection fraction of 60%. Serum creatinine was 0.9 mg/dl. Along with diuretic therapy, he was started on Ramipril 5 mg OD. During his in patient stay his serum creatinine progressively increased to 1.5 mg/dl over a period of 5 days. His BP at this stage was 145/80. What is the most appropriate next step ?
(1) Add a beta-blocker
(2) Add calcium channel blocker
(3) Add loop diuretics
(4) Stop Ramipril
3. Which of the following statements concerning angiotensin converting enzyme inhibitor therapy of unilateral renal artery stenosis is correct ?
(1) Would decrease the difference between renal vein renin levels between the stenotic and unaffected kidney.
(2) Would increase the GFR in the stenotic kidney.
(3) Will increase the sensitivity of nuclear medicine renal scan in identifying the presence of renal artery stenosis.
(4) Will decrease the GFR in the non-stenotic kidney.
4. Which of the following is not a dietary risk factor for primary hypertension ?
5. Which of the following trial report no beneficial effects of renal denervation in patients with resistant hypertension ?
(1) SPYRAL HTN-ON MED
(2) SPYRAL HTN-OFF MED
(3) SIMPLICITY HTN-3
(4) RADIANCE-HTN SOLO
6. A 3-year-old girl presented with febrile UTI. Culture is positive for E. coli. Which initial tests should be recommended for this patient ?
(1) USG abdoment+MCU
(2) USG abdomen+DMSA
(3) USG abdomentIVP
(4) CECT KUB
7. A 50-year-old woman is referred to you for evaluation of HTN, and you found that systolic BP in the right arm is 6 mmHg higher than the left arm. Her BP is 142/89 mmHg with a pulse rate of 72 beats/min. Femoral pulses are strong and present bilaterally. You repeated her BP 1 week later and found a similar difference in both arms. With regard to her inter-arm difference in BP and its management, which one of the following choices is CORRECT ?
(1) Obtain a Doppler ultrasound of both arms
(2) Obtain a 24-h ambulatory BP monitoring (ABPM)
(3) Order further tests for evaluation of coarctation of aorta
(4) No further evaluation of inter-arm BP difference
8. A 72-year-old man presented with postural dizziness. His BP is 150/102 mmHg. There are no sitting and standing BP changes, but a slight increase in pulse rate (12 beats/minutes) on standing is noticed and his both radial arteries are felt hardened. He is on Telmisarten 80 mg daily. He has no retinopathy or proteinuria, and chest X-ray is normal. Which one of the following is the MOST likely cause of his dizziness ?
(1) Autonomic insufficiency
(2) Essential hypertension
(4) Peripheral vascular disease
9. Which of the following drugs does NOT cause neurogenic orthostatic hypotension ?
10. Concerning renal transplant patients and pregnancy, which of the following statements is correct ?
(1) 10 year graft survival is lower in women who have a pregnancy than in women having no pregnancy.
(2) Prednisolone, azathioprine, Tacrolimus, and cyclosporine are all considered safe to use during pregnancy.
(3) Hypertension or a decline in renal function occurring before 28 weeks’ gestation does not adversely affect pregnancy outcome.
(4) Mycophenolate mofetil is safe to use provided the pregnant woman receives high-dose folic acid throughout pregnancy.
11. A 24-year-old woman who is being treated for eclampsia with acute kidney disease is found to have serum calcium of 7.6 mg/dL and a serum phosphate of 5.1 mg/dL with a serum albumin of 4.0 g/L. She has a BUN of 18 and a creatinine of 1.8 mg/dL. Which of the following is the likely cause of the hypocalcemia ?
(1) Renal failure
12. Which statement about unilateral renal agenesis is false ?
(1) It occurs in 1:10,000 births.
(2) Typically, there is no ureter.
(3) The fallopian tube may be absent in girls.
(4) Renal ultrasound is recommended in first-degree relatives.
13. Most patients with Dent disease have a mutation in which transporter ?
14. Which of the following is the most common risk factor for nephrolithiasis in autosomal dominant polycystic kidney disease ?
(1) Low urine citrate
(4) Renal tubular acidosis
15. The most common heritable cause of CKD is
(1) Alport’s disease
(2) Autosomal dominant polycystic kidney disease
(3) Fabry’s disease
(4) Medullary cystic disease
16. A 60-year-old female patient 6 months post kidney transplant is evaluated in routine follow-up. Physical exam is unremarkable. Laboratory studies reveal the following: creatinine 1.0 g/dL, calcium 10.8 mg/dL; phosphate 2.8 mg/dL; PTH 150 pg/mL. Which of the following statements about her condition is true ?
(1) Hyperparathyroidism is uncommon following a successful kidney transplant.
(2) She should be referred to an endocrine surgeon for parathyroidectomy.
(3) Cinacalcet may offer effective therapy for her hyperparathyroidism.
(4) Post-transplant hypercalcemia is not associated with increased mortality or graft loss.
17. A 27-year-old man presented with a 6 month history of polyuria and polydipsia and 3 weeks of worsening shortness of breath on exertion. He had also experienced recurrent episodes of excruciating pain in both feet but without any recent injury. On examination his BP was 164/84 mmHg, there were bibasal crepitations on auscultation of the chest and he had a number of abdominal telangiectasia. Investigations: serum creatinine 3.8 mg/dl, urinary protein: creatinine ratio 320 mg/mmol (<15). A renal biopsy was performed. Which of the following is most likely to be found on electron microscopy ?
(1) Mesangial electron dense deposits
(2) Thickened and duplicated GBM
(3) Subepithelial electron dense deposits
(4) Tubular reticular inclusion bodies
18. ADPKD type 1 is associated with a gene defect in:
(1) Chromosome 4
(2) Chromosome 8
(3) Chromosome 12
(4) Chromosome 16
19. A 30-year-old woman is referred to a nephrologist for proteinuria, hematuria, and elevation in serum creatinine level. She complained of eye pain and limping. She has a family history of glaucoma and proteinuria, but none on dialysis. Her serum creatinine is 3.6 mg/dL and serum ANA is negative. Her serum complement levels are normal. A 24-h urine collection reveals 3.6 g of proteinuria. The renal biopsy findings are as follows: Light microscopy : mild increase in mesangial matrix IF: unremarkable Electron microscopy : thickened BMs with irregular lucent areas and moth-eaten appearance Based upon the above information, which one of the following is the MOST likely diagnosis ?
(1) Immunotactoid glomerulopathy
(2) Membranous nephropathy
(3) Nail-patella syndrome
(4) Fabry’s disease
20. An HIV-infected individual is receiving antiviral therapy presented with AKI. The laboratory investigations showed reduced serum phosphate and uric acid along with glycosuria is noted. Which of the following is the most likely explanation for these abnormalities ?
21. A 52-year-old gentleman with diabetes presents with weight loss, fevers and dull persistent left loin pain. The general practitioner has been treating him for relapsing urinary tract infections with oral antibiotics. Computerized tomography scan shows a heterogeneous non-enhancing mass on the left kidney, which is hydronephrotic. The right kidney is normal. Renal biopsy shows lipid-laden macrophages with lymphocytes and polymorphonuclear leucocytes. What is the definitive treatment in this patient ?
(1) Intravenous antibiotics
(2) Left nephrectomy
(4) Antituberculous treatment
22. Which urine microscopy findings is pathagnomonic of acute pyelonephritis ?
(3) Leukocyte casts
(4) RBC casts
23. A 26-year-old male patient who is 9 months post-transplant undergoes kidney transplant biopsy because of an increase in serum creatinine from his baseline of 1.2 mg/dL to 1.6 mg/dL The biopsy shows prominent tubule-interstitial inflammation and SV40 positive inclusions seen throughout the cortex and medulla consistent with BK nephritis. His BK plasma PCR is 350,000 JU/ml. His current immunosuppression medication regimen consists of tacrolimus, MMF and prednisone. What is the most appropriate first step in his management ?
(1) Start monthly intravenous immunoglobulin (IVIG)
(2) Add oral levofloxacin.
(3) Start low dose cidofovir infusions every 2 weeks
(4) Stop MMF
24. Which of the following brain-dead donors does not meet the definition for an extended-criteria deceased donor ?
(1) A previously well 53-year-old with hypertension and a serum creatinine at donation of 1.7 mg/dl
(2) A 62-year-old with diabetes
(3) A 54-year-old with hypertension and death from a cerebrovascular accident
(4) A 58-year-old with hepatitis C
25. Which statement is not true regarding belatacept ?
(1) Belatacept, a high affinity CTLA4-Ig that blocks CD28-CD80/CD86 interactions.
(2) Compared to calcineurin inhibitors-based therapy belatacept-based therapy is associated with significantly more acute reversible cellular rejections.
(3) Belatacept should not be given to CMV seronegative recipients receiving a transplant from an CMV seropositive donor due to the high risk of developing PTLD.
(4) Belatacept has been associated with superior glomerular filtration rate as compared to calcineurin inhibitor-based treatments because of the absence of nephrotpxicity.
26. Which statement is not true regarding BENEFIT (Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial) trial ?
(1) This Phase III study assessed a more intensive (MI) or less intensive (LI) regimen of belatacept versus tacrolimus, in conjugation with steroids and MMF, in adults receiving a kidney transplant.
(2) Belatacept patients experienced a dose dependent higher incidence of acute cellular rejection.
(3) BENEFIT included patients 18 and older receiving a living donor or standard criteria deceased donor kidney transplant with an anticipated cold ischemia time of < 24 h. Recipients of extended criteria kidneys were excluded.
(4) Basiliximab induction was used in each treatment group.
27. The most common malignancy occurring after kidney transplantation is
(1) Non-melanoma skin cancer
(2) Kaposi’s sarcoma
(4) Breast cancer
28. The risk of recurrence in the allograft is LOWEST for which of the following primary renal diseases ?
(2) Focal and segmental glomerulosclerosis
(3) IgA nephropathy
(4) Lupus nephritis
29. The most common clinical syndrome associated with transplant renal artery stenosis consists of
(1) Microscopic hematuria and abdominal pain
(2) Slowly deteriorating kidney function and worsening hypertension
(3) Nephrotic syndrome
(4) Rapid deteriorating kidney function
30. 55 year male was having living related donor transplant. Procedure was smooth with normalization of renal profile. At day seven he developed severe pain in allograft area, sudden loss of urine output with blood in urine. What is most likely diagnosis ?
(1) Renal Artery thrombosis
(2) Renal Vein Thrombosis
(4) Acute Transplant rejection
31. A 30-year-old woman with diabetic nephropathy received a cadaveric renal allograft. On the third post- operative day her serum creatinine concentration was 1.8 mg/dL. She is being treated with cyclosporine and prednisone. On the sixth postoperative day she experiences a decrease in urine output from 1500 mL/d to 1000 mL/d; the serum creatinine concentration increases to 2.2 mg/dL. The best initial step in management would be to
(1) Decrease the dose of cyclosporine
(2) Obtain ultrasonography of the renal allograft
(3) Obtain a biopsy of the renal allograft
(4) Administer pulsed steroid therapy
32. A transplant patient on the Tacrolimust+ MMF for 5 years started on a health-food diet and over-the counter herbal products. The transplant center noted that his Tacrolimus levels have abruptly decreased to unacceptably low levels, putting him at risk for rejection. The nurse coordinator accused him of being noncompliant, but the patient insisted he was taking his medication as prescribed. What is your assessment ?
(1) This patient is taking Echinacea, which activates renal, tubular excretion of Tacrolimus.
(2) This patient is taking grapefruit extracts, which are preventing the absorption of his Tacrolimus.
(3) This patient is taking St. John’s Wort, which is increasing his cytochrome P450 system and accelerating the metabolism of his Tacrolimus.
(4) This patient is taking. creatine supplements, which increase the activity of P-glycoprotein, which leads to enhanced Tacrolimus excretion.
33. A 40-year-old woman is evaluated for kidney donation. All the pertinent tests are negative except for microscopic hematuria. She had menstrual cycle 15 days ago. Urine sediment shows six dysmorphic RBCs on phase contrast microscopy. Which one of the following tests you recommend for this donor ?
(1) CECT of the kidneys
(2) Renal biopsy
(3) Malignancy work-up
(4) Straight away refuse as potential donor.
34. A 60-year-old man with history of skin cancer received a cadaveric kidney transplant 10 years ago. His creatinine remains at 1.2 mg/dL. He is on tacrolimus and mycophenolate mofetil (MMF) 500 mg twice a day. In view of his history of skin cancer, which one of the following immunosuppressive agents is found to lower the incidence of skin cancer ?
35. A young adult female with end stage renal disease has been undergoing APD for the last four months. After five months of amenorrhea, she started her menstrual periods yesterday and last night, when she connected to the cycler, noted that the dialysate in the initial drain was pink in color. She reported to the dialysis unit the next day and the PD nurse performed several in-and-out exchanges and but the fluid remained pinkish-red. The PD fluid sample was 4 sent for cell count : 20 WBCs/mm3 and 800 RBCs/mm3 were present. Which ONE of the following represents the best plan of action in this patient ?
(1) Intraperitoneal heparin for the period of hemoperitoneum
(2) Intravaginal ultrasound to evaluate ectopic pregnancy.
(3) Antibiotic treatment.
(4) PD fluid cytology to exclude malignancy
36. Which of the following immune response is specific to organ transplantation ?
(1) Direct Allorecognization
(2) Indirect allorecognization
(3) Activation of adaptive immune response
(4) Activation of innate immune response.
37. A 28-year-old White female patient presents with nephrotic syndrome and is found to have class V membranous lupus on renal biopsy. Based on randomized controlled trials, which of the following medications has not been shown to be effective in treating this pattern of lupus nephritis ?
(1) Intravenous cyclophosphamide
(2) Oral MMF
(3) Oral cyclosporine
(4) Intravenous rituximab
38. A 68-year-old female on hemodialysis complained of progressive abdominal pain and bloating for 3 months. She was on CAPD for last 9 years and CAPD catheter was removed 8 months ago due to refractory fungal peritonitis. On examination she was afebrile with tight distended abdomen. Which finding is most likely to be seen on investigations ?
(1) CT evidence of visceral peritoneal calcification.
(2) Evidence of small bowel obstruction on skiagram
(3) Gram negative bacilli on diagnostic effluent culture.
(4) Transudative peritoneal effluent.
39. Which of the following is not an indication for combined liver-kidney transplantation ?
(1) Primary oxalosis.
(2) Alcoholic Cirrhosis with persistent GFR < 30 ml/min
(3) Mitochondrial disorders.
(4) aHUS due to factor H mutation.
40. Which of the following antibiotics is least likely to achieve therapeutic concentration in cyst fluid while treating urosepsis in ADPKD patient with CKD stage 3A ?
41. Linear deposition of IgG in IF renal biopsy slides is seen in all, except
(1) Diabetes mellitus
(2) Light chain disease
(3) Membranous nephropathy
(4) Fibrillary glomerulonephritis
42. A 59-year-old male with CKD stage G3A0 who started on sunitinib for renal cell carcinoma stage IV, now presented with new onset hypertension. His blood pressure is 164/90 mm Hg. There is no papilloedema, loin pain or any neurological deficit. His Serum creatinine remained stable, however 24 hour urine protein increased to 1200 mg from baseline value of 200 mg. Urine analysis showed I+ protein and absence of WBCs and RBCs. What should be appropriate management ?
(1) Add Ramipril.
(2) Discontinue Sunitinib
(3) Add Non-dihydropidine CCB.
(4) Doppler of bilateral renal vessels.
43. A 65-year-old woman (weight, 60 kg) is admitted to the intensive care unit with urosepsis and associated Escherichia coli bacteremia. Her course is complicated by respiratory failure due to acute lung injury and oligoanuric AKI (baseline serum creatinine level, 1.0 mg/dL, currently 5.0 mg/dL; urine output in the past 12 hours, 50 mL). In addition to antibiotics, she is receiving norepinephrine to achieve a mean arterial pressure of greater than 65 mm Hg and is mechanically ventilated, requiring a fraction of inspired oxygen of 40%. Her pH is 7.25, bicarbonate level of 18 mmol/L, and serum potassium level of 4.9 mmol/L. Her cumulative fluid balance since ICU admission is +16 L. The clinical team has elected to commence renal replacement therapy. Which of the following would not be compatible with an optimal strategy of renal replacement therapy ?
(1) Intermittent hemodialysis initial session of 4 hours, with planned ultrafiltration of 1 L
(2) Intermittent Hemodialysis initial session 4 hours, with planned ultrafiltration of 4 L
(3) Sustained low-efficiency dialysis (SLED): initial session, 8 hours; blood pump speed, 200 mL/min; planned ultrafiltration of 2 L.
(4) Continuous renal replacement therapy (CRRI): net fluid removal of 2 L over subsequent 24 hours
44. Which of the following is the most common sleep disorder in dialysis patients ?
(1) Increased sleep latency
(3) Restless leg syndrome
(4) Day time sleepiness
45. True statements regarding myeloma cast nephropathy :
1. Majority of casts are formed in distal tubules and collecting ducts.
2. There are minimal associated glomerular or vascular lesions.
3. Plasma exchange is the first line treatment of cast nephropathy.
4. Majority of free light chains are extracellularly distributed.
5. True incidence of cast nephropathy is unknown since majority of multiple myeloma patients do not undergo renal biopsy.