DHA Nephrology Exam 2023

DHA Nephrology Exam 2023

For those planning to exam DHA Nephrology specialist..

3500 MCQs

Updated

Enough to pass exam

Questions Samples :

Question 1
A 54-year-old woman with a history membranous glomerulonephritis secondary to systemic lupus erythematous
is admitted to hospital. Her previous stable renal function has deteriorated rapidly. The following blood tests were obtained:
Na+ 139 mmol/l
K+ 5.8 mmol/l
Urea 44 mmol/l
Creatinine 867 μmol/l
Albumin 17 g/l
ESR 49 mm/hr
Urinary protein 14 g/24 hours
Urine dipstick protein +++
blood ++

What has likely caused the sudden deterioration in renal function?
A. Exacerbation of SLE
B. Renal vein thrombosis **
C. Bilateral hydronephrosis
D. Acute interstitial nephritis
E. Analgesic nephropathy

Nephrotic syndrome predisposes to thrombotic episodes, possibly due to loss of antithrombin III.
These commonly occur in the renal veins and may be bilateral. Common symptoms include loin pain and
haematuria.
A greater rise in the ESR would be expected if the renal failure was due to an exacerbation of SLE.

Nephrotic syndrome: complications

Complications
􀁸􀁸increased risk of infection due to urinary immunoglobulin loss
􀁸􀁸increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine
􀁸􀁸hyperlipidaemia
􀁸􀁸hypocalcaemia (vitamin D and binding protein lost in urine)
􀁸􀁸acute renal failure

Question 2
A 25-year-old man has a renal biopsy due to worsening renal function. This reveals linear IgG deposits along the basement membrane. What is the most likely diagnosis?
A. Systemic lupus erythematous
B. IgA nephropathy
C. Minimal change disease
D. Post-streptococcal glomerulonephritis
E. Goodpasture’s syndrome **

Goodpasture’s syndrome
􀁸􀁸IgG deposits on renal biopsy
􀁸􀁸anti-GBM antibodies

These changes are characteristic of Goodpasture’s syndrome.

Goodpasture’s syndrome
Goodpasture’s syndrome is rare condition associated with both pulmonary haemorrhage and rapidly progressive
glomerulonephritis. It is caused by anti-glomerular basement membrane (anti-GBM) antibodies against type IV collagen.

Goodpasture’s syndrome is more common in men (sex ratio 2:1) and has a bimodal age distribution (peaks in 20-30 and 60-70 age bracket). It is associated with HLA DR2.

Features
􀁸􀁸pulmonary haemorrhage
􀁸􀁸followed by rapidly progressive glomerulonephritis

Factors which increase likelihood of pulmonary haemorrhage
􀁸􀁸smoking
􀁸􀁸lower respiratory tract infection
􀁸􀁸pulmonary oedema
􀁸􀁸inhalation of hydrocarbons
􀁸􀁸young males

Investigations
􀁸􀁸renal biopsy: linear IgG deposits along basement membrane
􀁸􀁸raised transfer factor secondary to pulmonary haemorrhages

Management
􀁸􀁸plasma exchange
􀁸􀁸steroids
􀁸􀁸cyclophosphamide

Question 3
A 65-year-old female with a 20 year history of rheumatoid arthritis is referred to the acute medical unit with bilateral leg oedema. The following results are obtained:
Urea 11.2 mmol/l
Creatinine 205 μmol/l
Albumin 26 g/l
Bilirubin 12 mmol/l
ALP 120 IU/l
Urine protein 6.2 g/24 hours

Which investigation is most likely to lead to the correct diagnosis?
A. CT abdomen
B. Plasma magnesium
C. Intravenous urogram
D. Rectal biopsy **
E. Renal angiogram

This rather odd question fooled most candidates when it appeared. The chronic inflammatory process (rheumatoid) predisposes to amyloidosis which in turn can cause nephrotic syndrome.
Rectal biopsy is an (infrequent) test done to look for amyloidosis.

Rheumatoid drugs such as gold may cause nephrotic syndrome but none of the other options point to this as an
answer

Amyloidosis:

types
AL amyloid
􀁸􀁸L for immunoglobulin Light chain fragment
􀁸􀁸due to myeloma, Waldenstrom’s, MGUS
􀁸􀁸features include: cardiac and neurological involvement, macroglossia, periorbital eccymoses AA amyloid
􀁸􀁸A for precursor serum amyloid A protein, an acute phase reactant
􀁸􀁸seen in chronic infection/inflammation
􀁸􀁸e.g. TB, bronchiectasis, rheumatoid arthritis
􀁸􀁸features: renal involvement most common feature
Beta-2 microglobulin amyloidosis
􀁸􀁸precursor protein is beta-2 microglobulin, part of the major histocompatibility complex
􀁸􀁸associated with patients on renal dialysis

Question 4
Which one of the following types of glomerulonephritis is most characteristically associated with partial lipodystrophy?
A. Minimal change disease
B. Diffuse proliferative glomerulonephritis
C. Mesangiocapillary glomerulonephritis **
D. Membranous glomerulonephritis
E. Rapidly progressive glomerulonephritis

Mesangiocapillary glomerulonephritis (membranoproliferative)
􀁸􀁸type 1: cryoglobulinaemia, hepatitis C
􀁸􀁸type 2: partial lipodystrophy

Type 2 mesangiocapillary glomerulonephritis is associated with partial lipodystrophy. Type 1 is seen in association with hepatitis C and cryoglobulinaemia Mesangiocapillary glomerulonephritis is sometimes referred to as membranoproliferative glomerulonephritis
Glomerulonephritides
Knowing a few key facts is the best way to approach the difficult subject of glomerulonephritis:

Membranous glomerulonephritis
􀁸􀁸presentation: proteinuria / nephrotic syndrome / chronic kidney disease
􀁸􀁸cause: infections, rheumatoid drugs, malignancy
􀁸􀁸1/3 resolve, 1/3 respond to cytotoxics, 1/3 develop chronic kidney disease IgA nephropathy – aka Berger’s disease, mesangioproliferative GN
􀁸􀁸typically young adult with haematuria following an URTI

Diffuse proliferative glomerulonephritis
􀁸􀁸classical post-streptococcal glomerulonephritis in child
􀁸􀁸presents as nephritic syndrome / acute kidney injury
􀁸􀁸most common form of renal disease in SLE

Minimal change disease
􀁸􀁸typically a child with nephrotic syndrome (accounts for 80%)
􀁸􀁸causes: Hodgkin’s, NSAIDs
􀁸􀁸good response to steroids

Focal segmental glomerulosclerosis
􀁸􀁸may be idiopathic or secondary to HIV, heroin
􀁸􀁸presentation: proteinuria / nephrotic syndrome / chronic kidney disease

Rapidly progressive glomerulonephritis – aka crescentic glomerulonephritis
􀁸􀁸rapid onset, often presenting as acute kidney injury
􀁸􀁸causes include Goodpasture’s, ANCA positive vasculitis

Mesangiocapillary glomerulonephritis (membranoproliferative)
􀁸􀁸type 1: cryoglobulinaemia, hepatitis C
􀁸􀁸type 2: partial lipodystrophy

Question 5
A 67-year-old woman presents for review due to ankle swelling. She has a history of rheumatoid arthritis which was diagnosed when she was 24 years old and a 8 year history of type 2 diabetes mellitus. Her current medication includes metformin and methotrexate. On examination she has bilateral pitting lower limb oedema. A 24 hour urine collection is reported as follows:
24 hr urinary protein 4.8g
What is the most likely cause of her leg oedema?
A. Diabetic nephropathy
B. Nephrotic syndrome secondary to methotrexate
C. Dilated cardiomyopathy secondary to methotrexate
D. Amyloidosis **
E. Protein-losing enteropathy secondary to metformin

This patient has developed nephrotic syndrome secondary to amyloidosis, a recognised complication of inflammatory conditions such as rheumatoid arthritis. Methotrexate is not a common cause of nephritic syndrome. Diabetic nephropathy often presents as nephrotic syndrome but typically develops at least 15 years after onset.

Nephrotic syndrome:

causes
Primary glomerulonephritis accounts for around 80% of cases
􀁸􀁸minimal change glomerulonephritis (causes 80% in children, 30% in adults)
􀁸􀁸membranous glomerulonephritis
􀁸􀁸focal segmental glomerulosclerosis
􀁸􀁸membranoproliferative glomerulonephritis

Systemic disease (about 20%)
􀁸􀁸diabetes mellitus
􀁸􀁸systemic lupus erythematosus
􀁸􀁸amyloidosis

Drugs
􀁸􀁸gold (sodium aurothiomalate), penicillamine

Others
􀁸􀁸congenital
􀁸􀁸neoplasia: carcinoma, lymphoma, leukaemia, myeloma
􀁸􀁸infection: bacterial endocarditis, hepatitis B, malaria