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

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)

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

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

91 g/L (130180)
7.2 109/L (4.011.0)
12 109/L (150400)

serum sodium
serum potassium
serum creatinine

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

899 mol/L (60110)

urine volume
ultrafiltration volume
Kt/V
creatinine clearance

220 mL/day
400 mL/day
1.28
42 L/week

What is the most appropriate management?

A
B
C
D
E

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

129 g/L (130180)

13.2 109/L (4.011.0)
222 109/L (150400)

serum sodium
serum potassium
serum creatinine
serum corrected calcium
serum phosphate
serum albumin

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)

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

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

141 mmol/L (137144)

4.1 mmol/L (3.54.9)
101 mol/L (60110)
14 g/L (3749)

urine protein:creatinine ratio

762 mg/mmol (<15)

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

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

89 g/L (115165)
13.6 109/L (4.011.0)
0.8 109/L (0.040.40)
389 109/L (150400)

serum creatinine

389 mol/L (60110)

serum C-reactive protein

293 mg/L (<10)

chest X-ray

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

92 mol/L (60110)
37 g/L (3749)

urinary protein:creatinine ratio

390 mg/mmol (<30)

renal biopsy histology

membranous nephropathy

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

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

130 mol/L (60110)

26 g/L (3749)

urinary albumin:creatinine ratio

496 mg/mmol (<3.5)

ultrasound scan of kidneys

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

176 mol/L (60110)

16.7 mmol/L (3.06.0)

urinary albumin:creatinine ratio

287 mg/mmol (<2.5)

ultrasound scan of kidneys

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

152 g/L (130180)

8.6 109/L (4.011.0)
475 109/L (150400)

serum sodium
serum potassium
serum urea
serum creatinine
serum creatinine (5 months previously)

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)

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

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

136 g/L (115165)

23.6 109/L (4.011.0)
18.4 109/L (1.57.0)

serum sodium
serum potassium
serum urea
serum creatinine

132 mmol/L (137144)

4.9 mmol/L (3.54.9)
14.7mmol/L (2.57.0)
212 mol/L (60110)

Which antibiotic should be included in her regimen?

A
B
C
D
E

cefuroxime
ciprofloxacin
piperacillin/tazobactam
rifampicin
vancomycin

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

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)

serum creatinine

305 mol/L (60110)

serum complement C3
serum complement C4

55 mg/dL (65190)
12 mg/dL (1550)

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

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

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)

chest X-ray

normal

What is the most appropriate investigation?

A
B
C
D
E

aspergillus precipitins
atypical serology
bronchoalveolar lavage
CT scan of chest
lung biopsy

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

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)

24-h urinary calcium

urinary pH

6.5 mmol (2.57.5)

7.0

What is the most likely diagnosis?

A
B
C
D
E

Bartters syndrome
cystinuria
distal renal tubular acidosis
hyporeninaemic hypoaldosteronism
proximal renal tubular acidosis

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)

5.6 mmol/L (2.57.0)

92 mol/L (60110)
>60 mL/min (>60)

urinalysis
urinary protein:creatinine ratio (clinic sample)
urinary protein:creatinine ratio (early morning)

protein 2+
103 mg/mmol (<30)
14 mg/mmol (<30)

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

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

258 mol/L (60110)

33 g/L (3749)

serum C-reactive protein

17 mg/L (<10)

24-h urinary total protein

2.4 g (<0.2)

What is the most likely renal diagnosis?

A
B
C
D
E

amyloidosis
analgesic nephropathy
hypertensive nephropathy
idiopathic membranous nephropathy
methotrexate nephrotoxicity

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

110 g/L (115165)

6.1 109/L (4.011.0)
234 109/L (150400)

serum urea
serum creatinine
serum albumin
random plasma glucose

24.0 mmol/L (2.57.0)

587 mol/L (60110)
30 g/L (3749)
7.2 mmol/L

pleural fluid:
total protein
glucose
lactate dehydrogenase

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

590 mol/L (60110)

24-h urinary total protein

3.9 g (<0.2)

ultrasound scan of kidneys

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

7.8 mmol/L (2.57.0)

116 mol/L (60110)

urinary protein:creatinine ratio

28 mg/mmol (<30)

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

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

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)

plasma parathyroid hormone

11.6 pmol/L (0.95.4)

blood tacrolimus

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

136 mmol/L (137144)

5.7 mmol/L (3.54.9)
24.0 mmol/L (2.57.0)
779 mol/L (60110)

serum complement C3
serum complement C4
serum immunoglobulin G
serum immunoglobulin A
serum immunoglobulin M

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

106 g/L (115165)

164 109/L (150400)

serum sodium
serum potassium
serum creatinine
serum albumin

143 mmol/L (137144)

4.4 mmol/L (3.54.9)
223 mol/L (60110)
19 g/L (3749)

24-h urinary total protein

7.8 g (<0.2)

What is the most likely diagnosis?

A
B
C
D
E

crescentic glomerulonephritis
gold-induced membranous nephropathy
interstitial nephritis
minimal change nephropathy
renal amyloid

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

178 mol/L (60110)

5.5 mmol/L

cerebrospinal fluid:
opening pressure
total protein
glucose
white cell count
lymphocyte count
neutrophil count

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)

What is the most likely diagnosis?

A
B
C
D
E

cerebral vasculitis
herpes simplex encephalitis
malignant infiltration of meninges
meningococcal meningitis
tuberculous meningitis

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

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)

24-h urinary total protein

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

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)

plasma parathyroid hormone

36 pmol/L (0.95.4)

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

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

143 mmol/L (137144)

2.9 mmol/L (3.54.9)
60 mol/L (60110)
0.70 mmol/L (0.751.05)

24-h urinary potassium

24-h urinary calcium

60 mmol
1.9 mmol (2.57.5)

What is the most likely diagnosis?

A
B
C
D
E

Bartters syndrome
chronic self-induced vomiting
diuretic abuse
Gitelmans syndrome
Liddles syndrome

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

108 g/L (130180)

pre-dialysis blood chemistry:

serum urea
serum creatinine
serum corrected calcium
serum phosphate
serum urate

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)

serum C-reactive protein

22 mg/L (<10)

plasma parathyroid hormone

45 pmol/L (0.95.4)

urea reduction ratio

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

88 mol/L (60110)

24-h urinary total protein

0.8 g (<0.2)

anti-double-stranded DNA antibodies (ELISA)

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

115 g/L (115165)

11.0 109/L (4.011.0)
0.70 109/L (0.040.40)

serum urea
serum creatinine

10.0 mmol/L (2.57.0)

156 mol/L (60110)

24-h urinary total protein

0.8 g (<0.2)

extractable nuclear antigen

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

110 g/L (115165)

4.0 109/L (4.011.0)
135 109/L (150400)
55 mm/1st h (<20)

serum urea
serum creatinine
serum creatine kinase

7.0 mmol/L (2.57.0)

144 mol/L (60110)
210 U/L (24170)

urinary protein:creatinine ratio

105 mg/mmol (<30)

serum complement C3
serum complement C4
serum C-reactive protein

74 mg/dL (65190)
22 mg/dL (1550)
42 mg/L (<10)

antinuclear antibodies
anti-La antibodies
anti-RNP antibodies
anti-Scl-70 antibodies
anti-Ro antibodies
anti-Sm antibodies

positive at 1:128 dilution

negative
negative
negative
positive
negative

What is the most likely diagnosis?

A
B
C
D
E

dermatomyositis
Sjgren's disease
systemic lupus erythematosus
systemic sclerosis
undifferentiated connective tissue disease

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

2.60 mmol/L (2.202.60)

1.67 mmol/L (0.81.4)

plasma parathyroid hormone

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

118 g/L (115165)

7.6 109/L (4.011.0)

serum urea
serum creatinine

3.0 mmol/L (2.57.0)

46 mol/L (60110)

serum C-reactive protein

8 mg/L (<10)

midstream urine microscopy:

white cells
culture

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

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

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

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)

urinary pH
urinary sodium
urinary osmolality

5.8
5 mmol/L (<10)
650 mosmol/kg (3501000)

serum cortisol (09.00 h)

650 nmol/L (200700)

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)

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

100 g/L (130180)

serum sodium
serum potassium
serum creatinine

133 mmol/L (137144)

6.4 mmol/L (3.54.9)
608 mol/L (60110)

ultrasound scan of kidneys

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

776 mol/L (60110)

serum C-reactive protein

226 mg/L (<10)

urinary albumin:creatinine ratio

136 mg/mmol (<3.5)

ultrasound scan of kidneys

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

2.35 mmol/L (2.202.60)

0.40 mmol/L (0.230.46)

24-h urinary calcium

24-h urinary urate
24-h urinary oxalate

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.