Renal medicine 10 Single Best Answer (SBA)
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1. A 65-year-old man with diabetes presents with fatigue and reduced urine output for 3 days. He was recently started on ibuprofen for knee pain. Blood tests show urea 14 mmol/L, creatinine 250 µmol/L (baseline 90 µmol/L), and potassium 6.1 mmol/L. What is the most likely mechanism of his AKI?
Answer: Inhibition of prostaglandin-mediated renal perfusion
NSAIDs decrease renal prostaglandin synthesis, especially affecting afferent arteriole dilation in hypoperfused kidneys, leading to AKI.
2. A 70-year-old woman with a history of heart failure presents with AKI. Her medications include furosemide, ramipril, and metformin. Which medication should be stopped immediately?
Answer: Metformin
In acute kidney injury, metformin poses a significant risk for lactic acidosis and should be discontinued.
3. A 60-year-old man with diabetes (on optimal treatment) has an eGFR of 48 mL/min/1.73m² and an albumin-to-creatinine ratio (ACR) of 80 mg/mmol. He denies haematuria. What is the most appropriate next step?
Answer: Routine nephrology referral
NICE guidelines recommend nephrology referral for ACR ≥70 mg/mmol, or more moderate ACR levels with progressive CKD or other complicating factors.
4. A 55-year-old smoker presents with painless macroscopic haematuria. What is the most appropriate next step?
Answer: 2WW referral for cystoscopy and imaging
Painless visible haematuria is a red flag for bladder cancer, and urgent referral ensures timely diagnosis and intervention.
5. A 45-year-old man presents with fever, perineal pain, and difficulty urinating. Examination reveals a tender, swollen prostate. What is the most appropriate next step?
Answer: Start empirical antibiotics for acute prostatitis
Acute prostatitis is managed with prompt empirical antibiotics, analgesia, and supportive care. Avoid vigorous prostate manipulation.
6. A 68-year-old man has a PSA level of 15 ng/mL. Digital rectal examination reveals a hard, irregular prostate. What is the most appropriate next step?
Answer: 2ww urology referral for MRI
Elevated PSA and suspicious DRE indicate possible prostate cancer; NICE guidance supports MRI before biopsy for accurate staging.
7. What is the most common complication of untreated muscle-invasive bladder cancer?
Answer: Local invasion into adjacent organs
Muscle-invasive bladder cancer, if untreated, can extend beyond the bladder into local tissues, causing severe morbidity.
8. A 70-year-old man with a long-term urinary catheter presents with abdominal discomfort and no urine output for 8 hours. What is the most appropriate first step?
Answer: Flush the catheter with normal saline
A blocked long-term catheter is often relieved by gentle irrigation. If unsuccessful, replacing the catheter or investigating further is next.
9. A 65-year-old woman with stage 4 CKD is started on erythropoiesis-stimulating agents (ESAs) for anaemia, such as Epoetin alfa (Epogen/Procrit). What is the most significant complication of ESA therapy?
Answer: Hypertension
ESA therapy can raise blood pressure, requiring close monitoring. Other effects include increased thrombotic risk if haematocrit rises too high.
10. A 50-year-old man presents with muscle pain and dark urine after prolonged immobilisation. Blood tests reveal creatine kinase of 20,000 U/L and creatinine 180 µmol/L. What is the most likely mechanism of AKI?
Answer: Tubular obstruction by myoglobin
Rhabdomyolysis releases large amounts of myoglobin, which accumulates in renal tubules, causing obstruction and acute kidney injury.
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