Nephrology Practice Questions

Q: Milk-Alkali syndrome may be caused by ingestion of

Calcium carbonate. **Explanation:** **Milk-Alkali Syndrome (MAS)** is a clinical triad of **hypercalcemia, metabolic alkalosis, and acute kidney injury (AKI)**. It is caused by the excessive ingestion of calcium and absorbable alkali. [1] **Why Calcium Carbonate is correct:** Calcium carbonate is the most common culprit because it provides both a high concentration of elemental calcium and a source of alkali (carbonate). 1. **Hypercalcemia:** Excessive calcium intake leads to increased intestinal absorption, causing hypercalcemia. This induces renal vasoconstriction and a "calcium-sensing receptor" mediated diuresis, leading to volume depletion. 2. **Alkalosis:** The carbonate component acts as a buffer. Hypercalcemia also inhibits the parathyroid hormone (PTH), which increases bicarbonate reabsorption in the proximal tubule, further worsening alkalosis. [1] 3. **Renal Failure:** The combination of volume depletion and hypercalcemic vasoconstriction leads to AKI and potential nephrocalcinosis. **Why other options are incorrect:** * **Magnesium sulfate:** Used primarily as an osmotic laxative or for eclampsia; it does not contain calcium or significant absorbable alkali. * **Aluminium trisilicate & Aluminium hydroxide:** These are non-absorbable antacids. While they can cause phosphate depletion, they do not lead to hypercalcemia or the classic MAS triad. [1] **High-Yield Clinical Pearls for NEET-PG:** * **Modern Etiology:** Historically caused by "Sippy’s diet" (milk and cream for peptic ulcers), it is now most commonly seen in women taking **calcium carbonate supplements for osteoporosis prevention**. * **PTH Levels:** In MAS, PTH is typically **suppressed** (unlike primary hyperparathyroidism). * **Lab Findings:** Hypercalcemia, hypocalciuria (due to alkalosis enhancing calcium reabsorption), and metabolic alkalosis. [1] * **Treatment:** Aggressive hydration with isotonic saline and discontinuation of the offending agents.

Q: Which condition can present both as nephritic syndrome and nephrotic syndrome?

Membranoproliferative glomerulonephritis. **Explanation:** **Membranoproliferative Glomerulonephritis (MPGN)** is the correct answer because it is a unique glomerular disease characterized by both basement membrane thickening (membranous feature) and mesangial cell proliferation (proliferative feature). This dual pathology allows it to present across a wide clinical spectrum. While it often presents with **nephrotic-range proteinuria**, the underlying inflammatory/proliferative process frequently causes **nephritic features** such as hematuria, hypertension, and azotemia. **Analysis of Options:** * **Minimal Change Disease (A):** This is the classic cause of "pure" nephrotic syndrome. It involves podocyte effacement without inflammation, meaning hematuria and hypertension are typically absent. * **Acute Proliferative Glomerulonephritis (B):** Also known as PSGN, this is the prototype for **nephritic syndrome**. While mild proteinuria can occur, it rarely reaches the massive levels required for nephrotic syndrome. * **Rapidly Progressive Glomerulonephritis (C):** This is an aggressive **nephritic** condition characterized by crescent formation and a rapid decline in GFR. It is not a primary cause of nephrotic syndrome. **NEET-PG High-Yield Pearls:** * **MPGN Morphology:** Look for "Tram-track" appearance or "double contouring" of the basement membrane on Silver stain due to mesangial interposition. * **Complement Levels:** MPGN is associated with **hypocomplementemia**. Type II MPGN (Dense Deposit Disease) is specifically linked to **C3 Nephritic Factor**. * **Other "Mixed" Presentations:** Besides MPGN, **Systemic Lupus Erythematosus (SLE)** and **Amyloidosis** (rarely) can also show overlapping nephritic-nephrotic features.

Q: A 29-year-old man is seen in follow-up 1 year post-kidney transplant. He is doing well clinically and the transplant is functioning well, with no recent episodes of rejection or changes to his immunosuppressive medications. Which of the following complications of transplantation is the most likely cause of death?

atherosclerotic disease. **Explanation:** The correct answer is **A. atherosclerotic disease**. **1. Why Atherosclerotic Disease is Correct:** Cardiovascular disease (CVD), primarily due to accelerated atherosclerosis, is the **leading cause of death** in patients following a solid organ transplant (especially kidney transplants). While the risk of rejection and infection is highest in the immediate post-operative period, long-term survival is dictated by cardiovascular health. Post-transplant patients have a high prevalence of traditional risk factors (hypertension, diabetes, dyslipidemia) which are often exacerbated by immunosuppressive medications: * **Corticosteroids:** Cause weight gain, hyperglycemia, and hypertension. * **Calcineurin Inhibitors (Cyclosporine/Tacrolimus):** Lead to hypertension, hyperlipidemia, and new-onset diabetes after transplant (NODAT). **2. Why the Other Options are Incorrect:** * **B. Opportunistic Infection:** While a major cause of morbidity and mortality in the first 6 months (due to peak immunosuppression), the risk stabilizes after one year [2]. It is the second most common cause of death, but lags behind CVD. * **C. Metabolic Bone Disease:** Common (e.g., osteopenia, avascular necrosis) due to steroid use and pre-existing renal osteodystrophy, but it is rarely a direct cause of death. * **D. Lung Cancer:** Transplant recipients have an increased risk of malignancies (especially Skin Cancer and Post-Transplant Lymphoproliferative Disorder - PTLD), but lung cancer is not the leading cause of mortality in this population [1]. [2]. **Clinical Pearls for NEET-PG:** * **Most common cause of death post-renal transplant:** Cardiovascular disease (Atherosclerosis). * **Most common malignancy post-transplant:** Squamous cell carcinoma of the skin [1]. * **Most common viral infection post-transplant:** Cytomegalovirus (CMV). * **NODAT (New-onset diabetes):** Most strongly associated with Tacrolimus [2].

Q: Hyperkalemia is caused by which of the following conditions?

Gordon's syndrome. **Explanation:** **Gordon's Syndrome (Pseudohypoaldosteronism Type II)** is the correct answer. It is a rare genetic disorder characterized by **hyperkalemia**, hypertension, and metabolic acidosis. The underlying pathophysiology involves a "gain-of-function" mutation in WNK kinases, leading to overactivity of the **Na-Cl cotransporter (NCC)** in the distal convoluted tubule. This increased sodium reabsorption limits sodium delivery to the distal collecting duct, thereby reducing potassium secretion (via ROMK channels), resulting in hyperkalemia despite normal renal function and aldosterone levels [1]. **Analysis of Incorrect Options:** * **Liddle’s Syndrome:** This is a "gain-of-function" mutation of the ENaC channels. It causes hypertension and metabolic alkalosis, but it leads to **hypokalemia** due to excessive sodium reabsorption coupled with increased potassium secretion. * **Bartter’s Syndrome:** This involves defects in the thick ascending limb (NKCC2/ROMK). It mimics loop diuretic use, leading to salt wasting, activation of the RAAS, and significant **hypokalemia**. * **Vomiting:** Gastric juice is rich in H+ and Cl-. Loss of gastric acid leads to metabolic alkalosis [1]. The resulting bicarbonaturia increases distal delivery of sodium, which promotes potassium excretion, causing **hypokalemia** [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Gordon’s Syndrome** is often called "Inverse Gitelman’s" because it affects the same transporter (NCC) but in the opposite direction. * **Treatment of Gordon’s:** Thiazide diuretics are highly effective as they directly inhibit the overactive NCC transporter. * **Mnemonic:** Remember that most tubular "syndromes" (Bartter, Gitelman, Liddle) cause **hypokalemia**; Gordon’s is the notable exception causing **hyperkalemia**.

Q: What is the GFR (mL/min per 1.73m2) for a patient in stage IV of chronic kidney disease?

15 - 29. **Explanation:** Chronic Kidney Disease (CKD) is defined by the presence of kidney damage or a decreased Glomerular Filtration Rate (GFR) of less than 60 mL/min/1.73m² for a duration of 3 months or more. The KDIGO (Kidney Disease: Improving Global Outcomes) classification stages CKD based on GFR levels: * **Stage I:** GFR ≥ 90 (Kidney damage with normal or high GFR) * **Stage II:** GFR 60–89 (Mildly decreased GFR) * **Stage III:** GFR 30–59 (Moderately decreased GFR; often subdivided into IIIa: 45–59 and IIIb: 30–44) * **Stage IV: GFR 15–29 (Severely decreased GFR)** * **Stage V:** GFR < 15 (Kidney failure; often referred to as End-Stage Renal Disease or ESRD) **Analysis of Options:** * **Option A (60–89):** Represents Stage II CKD. * **Option B (30–59):** Represents Stage III CKD. * **Option C (15–29):** **Correct.** This range signifies Stage IV, where patients often begin showing significant clinical symptoms and require preparation for renal replacement therapy (RRT). * **Option D (< 15):** Represents Stage V CKD, requiring dialysis or transplantation. **High-Yield Clinical Pearls for NEET-PG:** 1. **Stage IV Management:** This is the critical window for creating vascular access (AV fistula) in anticipation of hemodialysis. 2. **Most Common Cause:** Diabetes Mellitus is the leading cause of CKD worldwide, followed by Hypertension. 3. **Formulae:** The **MDRD** and **CKD-EPI** equations are preferred over Cockcroft-Gault for staging because they are adjusted for body surface area (1.73m²). 4. **Anemia in CKD:** Usually begins in Stage III due to decreased Erythropoietin production.

Q: Which of the following is NOT a feature of Chronic Renal Failure?

All of the above. Chronic Kidney Disease (CKD) or Chronic Renal Failure is a multisystem disorder resulting from a progressive decline in GFR [1]. The correct answer is **D (All of the above)** because all three listed features are classic manifestations of advanced renal failure. 1. **Impotence (Sexual Dysfunction):** This is highly prevalent in CKD patients due to multifactorial causes, including decreased testosterone levels, autonomic neuropathy, atherosclerosis, and side effects of antihypertensive medications. Hyperprolactinemia (due to decreased renal clearance) also contributes to erectile dysfunction and loss of libido [1]. 2. **Restless Legs Syndrome (RLS):** This is a common neuropsychiatric manifestation of uremia [1]. It is characterized by an irresistible urge to move the legs, usually associated with paresthesias. It often improves with dialysis or renal transplantation. 3. **Isosthenuria:** This refers to the kidney's inability to concentrate or dilute urine, resulting in a fixed urinary specific gravity (typically **1.010**, similar to plasma). This occurs due to the loss of the medullary osmotic gradient and tubular resistance to ADH. **Why other options are incorrect:** Since A, B, and C are all well-documented clinical features of Chronic Renal Failure, they cannot be excluded. Therefore, "All of the above" is the only logical choice. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of CKD:** Isosthenuria (loss of concentrating capacity) often manifests as nocturia. * **Most common cause of death in CKD:** Cardiovascular disease (not renal failure itself). * **Hematology:** Normocytic normochromic anemia due to Erythropoietin deficiency is a hallmark [1]. * **Skin:** "Uremic frost" (urea crystals on skin) and "Half-and-half nails" (Lindsay’s nails) are classic signs.

Q: Which of the following statements is FALSE regarding type 2 renal tubular acidosis?

Urine pH > 5.5. ### Explanation **Type 2 Renal Tubular Acidosis (RTA)**, also known as **Proximal RTA**, is characterized by a defect in the proximal convoluted tubule’s (PCT) ability to reabsorb filtered bicarbonate ($HCO_3^-$). #### Why Option B is the Correct (False) Statement: In Type 2 RTA, although the proximal tubule fails to reabsorb bicarbonate initially, the distal tubule remains functional. Once the plasma bicarbonate level drops below the "renal threshold" (typically 12–20 mEq/L), the distal nephron is capable of acidifying the urine normally. Therefore, in a steady state of chronic acidemia, the **urine pH is typically 5.5 is a hallmark of **Type 1 (Distal) RTA**, where the distal tubule cannot secrete $H^+$ ions. #### Analysis of Incorrect Options: * **Option A (Proximal tubule defect):** This is true. The primary pathology is the loss of carbonic anhydrase activity or sodium-bicarbonate cotransporters in the PCT. * **Option C (Normal anion gap):** This is true. All RTAs are characterized by a **Normal Anion Gap Metabolic Acidosis (NAGMA)**, as the loss of $HCO_3^-$ is compensated by an increase in serum Chloride ($Cl^-$), leading to hyperchloremia. * **Option D (Fanconi syndrome present):** This is true. Type 2 RTA is frequently associated with generalized proximal tubule dysfunction (Fanconi Syndrome), leading to phosphaturia, glycosuria, aminoaciduria, and uricosuria. #### High-Yield Clinical Pearls for NEET-PG: * **Type 1 RTA (Distal):** Inability to secrete $H^+$; Urine pH > 5.5; associated with hypokalemia and **nephrolithiasis** (calcium phosphate stones). * **Type 2 RTA (Proximal):** Inability to reabsorb $HCO_3^-$; Urine pH < 5.5 (eventually); associated with **osteomalacia/rickets**. * **Type 4 RTA (Hyperkalemic):** Associated with **Aldosterone deficiency or resistance**; the only RTA with **high serum potassium**. * **Mnemonic:** "Bi-**P**-ar-**T**-ite" — **P**roximal is Type **2**.

Question 1

Milk-Alkali syndrome may be caused by ingestion of

Accepted Answer

Calcium carbonate

Answer

Magnesium sulfate

Answer

Aluminium trisilicate

Answer

Aluminium hydroxide

Question 2

Which condition can present both as nephritic syndrome and nephrotic syndrome?

Accepted Answer

Membranoproliferative glomerulonephritis

Answer

Minimal change disease

Answer

Acute proliferative glomerulonephritis

Answer

Rapidly progressive glomerulonephritis

Question 3

A 29-year-old man is seen in follow-up 1 year post-kidney transplant. He is doing well clinically and the transplant is functioning well, with no recent episodes of rejection or changes to his immunosuppressive medications. Which of the following complications of transplantation is the most likely cause of death?

Accepted Answer

atherosclerotic disease

Answer

opportunistic infection

Answer

metabolic bone disease

Answer

lung cancer

Question 4

Hyperkalemia is caused by which of the following conditions?

Accepted Answer

Gordon's syndrome

Answer

Liddle's syndrome

Answer

Bater's syndrome

Answer

Vomiting

Question 5

What is the GFR (mL/min per 1.73m2) for a patient in stage IV of chronic kidney disease?

Accepted Answer

15 - 29

Answer

60 - 89

Answer

30 - 59

Answer

< 15

Question 6

For the medical condition of hepatic cirrhosis complicated by acute renal failure, select the associated acid-base disturbances.

Accepted Answer

Metabolic acidosis and respiratory alkalosis

Answer

Metabolic acidosis and respiratory acidosis

Answer

Metabolic alkalosis and respiratory acidosis

Answer

Metabolic alkalosis and respiratory alkalosis

Question 7

Which of the following is NOT a feature of Chronic Renal Failure?

Accepted Answer

All of the above

Answer

Impotence

Answer

Restless legs

Answer

Isothenuria

Question 8

A 42-year-old female presents with diazepam and alcohol overdose. She is comatose with a temperature of 34.5°C, BP of 100/80 mmHg, and creatinine of 2.4 mg/dL. Her AST is 500 IU/L and GGT is 35 IU/L. Urine dipstick showed 3+ for blood, but urine analysis was normal. Ultrasound abdomen was normal. What is the most likely diagnosis?

Accepted Answer

Rhabdomyolysis

Answer

Hypothermia

Answer

Alcoholic hallucinosis

Answer

Acute interstitial nephritis

Question 9

A 45-year-old patient on hemodialysis for one week has noted that his blood pressure is more difficult to control. He reports good compliance with his medications, which include erythropoietin, ferrous sulfate, vancomycin, and vitamin D. His blood pressure is 180/99 mm Hg. What is the most likely cause for the worsening control of his blood pressure?

Accepted Answer

Erythropoietin

Answer

Ferrous sulfate

Answer

Vancomycin

Answer

Vitamin D

Question 10

Which of the following statements is FALSE regarding type 2 renal tubular acidosis?

Accepted Answer

Urine pH > 5.5

Answer

Proximal tubule defect

Answer

Normal anion gap

Answer

Fanconi syndrome present

Nephrology — MCQs

Nephrology — MCQs

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