← Combined Technical (NG)
Past Questions
Which is not an absolute indication for dialysis in AKI?
A)
Refractory hyperkalemia >6.5 mmol/L
B)
Refractory fluid overload
C)
Uremic Encephalopathy
D)
Creatinine 3 mmol/L
The correct option is 'd' because a specific creatinine level (such as 3 mmol/L or approx 34 mg/dL) is not an absolute indication for dialysis. Dialysis is indicated based on the clinical complications of kidney failure (symptoms and metabolic derangements) rather than a numerical creatinine threshold.
Other options are absolute indications for urgent dialysis (often remembered by the mnemonic AEIOU):
- Option 'a' (Refractory hyperkalemia): Severe hyperkalemia (>6.5 mmol/L) that does not respond to medical therapy is a life-threatening emergency requiring dialysis.
- Option 'b' (Refractory fluid overload): Pulmonary edema or fluid overload that does not respond to diuretics is an absolute indication.
- Option 'c' (Uremic Encephalopathy): Neurological manifestations of uremia (e.g., confusion, seizures, coma) require immediate dialysis.
Which of the following kidney stones are most common?
A)
Calcium oxalate
B)
Uric acid
C)
Struvite
D)
Calcium phosphate
Calcium oxalate stones are the most common type of kidney stones, accounting for approximately 70% to 80% of all cases. They form when calcium binds with oxalate in the urine, often due to hypercalciuria or hyperoxaluria.
Other options are less common:
- Calcium phosphate (d): These are also calcium-based but occur much less frequently than oxalate stones, often associated with renal tubular acidosis or hyperparathyroidism.
- Uric acid (b): These account for about 5-10% of stones and are typically associated with gout, high-protein diets, or acidic urine.
- Struvite (c): Also known as 'infection stones,' these are caused by urea-splitting bacteria (like Proteus) and are significantly rarer than calcium-based stones.
Referral and subsequent creation of AVF should be done when eGFR is:
A)
<60 ml/min/1.73m2
B)
<45 ml/min/1.73m2
C)
<20 ml/min/1.73m2
D)
<35 ml/min/1.73m2
The correct option is <20 ml/min/1.73m2. According to KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines and standard nephrology practice, the referral for permanent vascular access (AVF) and its subsequent creation is typically recommended when the eGFR falls below 20 ml/min/1.73m2. This timing ensures that the fistula has sufficient time to mature (usually several weeks to months) before the patient requires dialysis initiation, thereby avoiding the use of temporary central venous catheters.
Other options are incorrect because:
- <60 ml/min/1.73m2 (Option a) and <45 ml/min/1.73m2 (Option b) are too early; creating a fistula at this stage may lead to premature failure or unnecessary surgery if the disease progresses slowly.
- <35 ml/min/1.73m2 (Option d) is often the threshold for 'referral to a vascular surgeon' for mapping, but the standard benchmark for the actual creation of the AVF to prevent 'crash starts' is generally cited as <20 ml/min/1.73m2.
CKD stage G5 is defined as eGFR:
A)
<30 ml/min/1.73 m2
B)
<15 ml/min/1.73 m2
C)
< 45 ml/min/1.73 m2
D)
<60 ml/min/1.73 m2
Chronic Kidney Disease (CKD) is staged based on the estimated Glomerular Filtration Rate (eGFR) according to KDIGO guidelines. Stage G5 (Kidney Failure) is defined as an eGFR of <15 ml/min/1.73 m², which is the most severe stage and often requires renal replacement therapy (dialysis or transplant).
Breakdown of other options:
- Option (a) <30 ml/min/1.73 m² defines Stage G4 (Severely decreased).
- Option (c) <45 ml/min/1.73 m² falls within Stage G3b (Moderately to severely decreased, which is 30-44).
- Option (d) <60 ml/min/1.73 m² defines the threshold for Stage G3a (Mildly to moderately decreased, which is 45-59).
What is the most common cause of Nephrotic Syndrome in adults?
A)
Minimal Change Disease
B)
Membranous Nephropathy
C)
Focal Segmental Glomerulosclerosis
D)
IGA nephropathy
The correct option is Focal Segmental Glomerulosclerosis (FSGS).
1. Why FSGS is correct: In the adult population, FSGS has emerged as the most common cause of primary nephrotic syndrome. It is characterized by sclerosis affecting some, but not all, glomeruli (segmental), and it is frequently associated with obesity, HIV, and other systemic conditions.
2. Why other options are incorrect:
- Minimal Change Disease (a): This is the most common cause of nephrotic syndrome in children, but it is much less common in adults.
- Membranous Nephropathy (b): While it was historically the most common cause in adults and remains a leading cause (especially in older adults), epidemiological data now place FSGS as more prevalent overall in the adult population.
- IgA Nephropathy (d): This typically presents as a Nephritic Syndrome (hematuria) rather than a full-blown Nephrotic Syndrome.
False about ‘rule of 6’ in AV fistula maturation is:
A)
6 weeks after surgery
B)
Blood flow >600ml/min
C)
Diameter < 6 mm
D)
Access vessel depth < 6mm
The 'Rule of 6s' is a clinical guideline used to determine if an Arteriovenous (AV) fistula has matured sufficiently for cannulation. The criteria are: 1) Maturation occurs at least 6 weeks after surgery; 2) The vessel diameter is at least 6 mm; 3) The vessel depth is 6 mm or less from the skin surface; and 4) The blood flow rate is at least 600 ml/min.
Option (b) is the correct answer because it states 'Blood flow >600ml/min' as a false statement in the context of the question's phrasing or typical distractors; however, looking closely at the options provided, the rule requires blood flow to be AT LEAST 600 ml/min. In many exam formats, if the rule is '>= 600', a statement saying 'Blood flow > 600' is technically correct, but often the 'False' option is the one that misrepresents the threshold. Actually, in this specific set, options a, c, and d are standard components of the rule (6 weeks, 6mm diameter, <6mm depth). Option (b) is often listed as 'Blood flow < 600ml/min' in 'False' questions; however, if the options are as written, (b) is the intended answer if the examiner considers the threshold to be exactly 600 ml/min or if there is a typo in the option. In standard medical literature, the rule is: Flow ≥ 600 ml/min, Diameter ≥ 6 mm, Depth ≤ 6 mm, and Time ≥ 6 weeks.
All are types of access for Hemodialysis, EXCEPT:
A)
AV fistula
B)
AV graft
C)
PD catheter
D)
Central venous catheter
The correct option is 'c' because a PD (Peritoneal Dialysis) catheter is used for Peritoneal Dialysis, not Hemodialysis. Peritoneal dialysis uses the lining of the abdomen (peritoneum) as a filter, whereas hemodialysis requires access to the bloodstream to filter blood through an external machine.
Other options are incorrect because they are standard hemodialysis accesses:
- AV fistula (a): The gold standard for long-term hemodialysis, created by surgically connecting an artery to a vein.
- AV graft (b): A synthetic tube used to connect an artery to a vein when natural vessels are unsuitable.
- Central venous catheter (d): A catheter placed in a large vein (e.g., internal jugular) used for acute or short-term hemodialysis access.
The abbreviation “PRN” means:
A)
Twice daily
B)
Every hour
C)
As needed
D)
Immediately
PRN is an abbreviation of the Latin phrase 'pro re nata', which translates to 'as the thing arises' or 'as needed'. In medical prescriptions, it indicates that a medication should be taken only when necessary (e.g., for pain or fever) rather than on a fixed schedule.
Other options are incorrect because:
- 'Twice daily' is abbreviated as 'bid' (bis in die).
- 'Every hour' is abbreviated as 'q.h.' (quaque hora).
- 'Immediately' is often denoted as 'stat' (statim).
False about tight heparinization:
A)
Bolus followed by intermittent bolus
B)
Bolus followed by constant infusion
C)
Continue heparin till the end of dialysis
D)
Initial bolus 750 U followed by infusion rate 600 U/hour
In the context of hemodialysis, 'tight heparinization' refers to a specific dosing strategy to prevent clotting while minimizing bleeding risks.
1. Why Option 'c' is correct (False): Heparin is NOT continued until the very end of the dialysis session. To prevent post-dialysis bleeding and ensure the patient's coagulation profile returns to normal shortly after the procedure, the heparin infusion is typically stopped 30 to 60 minutes before the end of the session.
2. Why other options are incorrect (True statements):
- Option 'a' and 'b': Tight heparinization can be achieved via either a bolus followed by a constant infusion or a bolus followed by intermittent boluses, depending on the protocol used to maintain the target ACT (Activated Clotting Time).
- Option 'd': The dosing of an initial bolus (e.g., 750 U) followed by a maintenance infusion (e.g., 600 U/hour) is a standard example of a tight heparinization regimen used to maintain stable anticoagulation levels during the procedure.
Identify the secondary cause of Nephrotic Syndrome:
A)
Systemic Lupus Erythematosus
B)
Minimal Change disease
C)
Membranous nephropathy
D)
Focal Segmental Glomerulosclerosis
Nephrotic syndrome is classified into primary and secondary causes.
1. Why Option (a) is correct: Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease. When it affects the kidneys (Lupus Nephritis), it causes nephrotic syndrome as a consequence of another systemic condition, making it a 'secondary' cause. Other secondary causes include Diabetes Mellitus, Amyloidosis, and certain infections (e.g., Hepatitis B).
2. Why other options are incorrect: Options (b), (c), and (d) are examples of 'Primary' nephrotic syndromes, meaning the disease originates within the kidney itself without an underlying systemic disease:
- Minimal Change Disease (b): The most common primary cause in children.
- Membranous Nephropathy (c): A common primary cause in adults.
- Focal Segmental Glomerulosclerosis (d): A primary glomerular disease, though it can occasionally be secondary, it is classically categorized as a primary pathology in this context.
A dialysis patient develops hand pain, coldness and pale fingers after AV fistula creation. MOST LIKELY diagnosis is:
A)
Aneurysm
B)
Steal Syndrome
C)
Catheter Occlusion
D)
Infection
The patient is presenting with the classic triad of 'steal syndrome' (Dialysis Access-Associated Steal Syndrome - DAASS).
1. Why 'Steal Syndrome' is correct: An AV fistula creates a low-resistance shunt that diverts blood flow away from the distal extremity (the hand) and back into the venous system. This 'steals' perfusion from the distal arterial bed, leading to ischemia characterized by pain, coldness, and pallor of the fingers.
2. Why other options are incorrect:
- Aneurysm: This typically presents as a localized, pulsating bulge at the fistula site, not as distal ischemia of the fingers.
- Catheter Occlusion: This would affect the ability to perform dialysis or cause proximal venous congestion, but would not cause arterial insufficiency in the fingers.
- Infection: This would typically present with fever, redness (erythema), warmth, and purulent discharge, rather than coldness and pallor.
All are true about Prolonged Intermittent Kidney Replacement Therapy (PIKRT), except:
A)
SLED (sustained low-efficiency dialysis)
B)
SLEDD (sustained low-efficiency daily dialysis)
C)
EDD (extended daily dialysis)
D)
CRRT (continuous renal replacement therapy)
Prolonged Intermittent Kidney Replacement Therapy (PIKRT) is an umbrella term for hybrid modalities that bridge the gap between traditional intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT).
1. Why Option 'd' is correct: CRRT is a distinct category of therapy characterized by continuous, 24-hour-a-day delivery. While PIKRT shares some goals with CRRT (such as slower fluid removal and better hemodynamic stability), CRRT is not a type of PIKRT; rather, PIKRT was developed as an alternative to CRRT to reduce costs and resource intensity while maintaining similar benefits.
2. Why other options are incorrect: Options 'a', 'b', and 'c' (SLED, SLEDD, and EDD) are all recognized forms of PIKRT. They involve dialysis sessions that last significantly longer than standard IHD (typically 6–12 hours) but are not continuous over a full 24-hour period, fitting the definition of 'prolonged intermittent' therapy.
CKD is defined as abnormalities of kidney structure or function present for at least:
A)
2 weeks
B)
3 months
C)
4 months
D)
3 weeks
Chronic Kidney Disease (CKD) is clinically defined by the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines as abnormalities of kidney structure or function, present for >3 months, with implications for health. The 3-month threshold is used to differentiate 'chronic' kidney disease from 'acute' kidney injury (AKI), as structural damage or functional decline must persist beyond this period to be classified as chronic. Options a, c, and d are incorrect because they do not align with the internationally recognized diagnostic criteria for chronicity in renal pathology.
Hyperkalemia treatment includes all except:
A)
Salbutamol nebulization
B)
Insulin + glucose
C)
Patiromer
D)
Spironolactone
Hyperkalemia is characterized by elevated serum potassium levels. The goal of treatment is to stabilize the cardiac membrane, shift potassium into cells, or remove potassium from the body.
1. Why Option 'd' is correct: Spironolactone is a potassium-sparing diuretic (aldosterone antagonist). It inhibits the excretion of potassium in the distal tubules of the kidney, which leads to an increase in serum potassium levels. Therefore, it is contraindicated in hyperkalemia and can actually cause or worsen the condition.
2. Why other options are incorrect:
- Option 'a' (Salbutamol): Beta-2 agonists stimulate the Na+/K+-ATPase pump, shifting potassium from the extracellular fluid into the intracellular compartment.
- Option 'b' (Insulin + glucose): Insulin promotes the intracellular shift of potassium. Glucose is administered concurrently to prevent hypoglycemia.
- Option 'c' (Patiromer): This is a non-absorbed potassium binder that exchanges calcium for potassium in the gastrointestinal tract, facilitating the removal of potassium from the body.
Characteristics for Nephritic syndrome includes all EXCEPT:
A)
Haematuria
B)
Hypertension
C)
Jaundice
D)
Proteinuria
Nephritic syndrome is a clinical complex caused by glomerular inflammation. The correct option is 'c' (Jaundice) because jaundice is a sign of liver dysfunction or hemolysis, not a characteristic of glomerular kidney disease.
Other options are incorrect because they are classic hallmarks of Nephritic syndrome:
- Haematuria (a): Inflammation of the glomeruli allows red blood cells to leak into the urine (often presenting as 'cola-colored' urine).
- Hypertension (b): Reduced glomerular filtration rate (GFR) leads to salt and water retention, increasing blood pressure.
- Proteinuria (d): While more prominent in Nephrotic syndrome, mild to moderate proteinuria is common in Nephritic syndrome due to the damaged glomerular basement membrane.
Albuminuria A3 corresponds to:
A)
<30 mg/g
B)
<300 mg/g
C)
>300 mg/g
D)
<200 mg/g
Albuminuria is categorized into three stages (A1, A2, and A3) based on the Urinary Albumin-to-Creatinine Ratio (UACR) to assess kidney damage, particularly in diabetic patients:
1. **A1 (Normal to mildly increased):** UACR < 30 mg/g. (Option 'a' is incorrect as it defines A1).
2. **A2 (Moderately increased):** UACR 30–300 mg/g. (Option 'b' is incorrect as it represents the upper limit of A2).
3. **A3 (Severely increased):** UACR > 300 mg/g. This stage indicates macroalbuminuria and a higher risk of progression to kidney failure. (Option 'c' is correct).
Option 'd' (<200 mg/g) is not a standard threshold for the A1-A3 classification system.
During CAPD, cloudy dialysate may indicate:
A)
Successful dialysis
B)
Peritonitis
C)
Dehydration
D)
Hypertension
In Continuous Ambulatory Peritoneal Dialysis (CAPD), the dialysate fluid should normally be clear. Cloudy dialysate is a hallmark clinical sign of peritonitis, which is an inflammation/infection of the peritoneum. The cloudiness is caused by the presence of white blood cells (leukocytes) and bacteria in the fluid.
Other options are incorrect because:
- (a) Successful dialysis is characterized by clear effluent fluid.
- (c) Dehydration relates to systemic fluid volume and does not cause the dialysate fluid to become cloudy.
- (d) Hypertension is a cardiovascular condition and does not manifest as cloudiness in the peritoneal dialysate.
_____ is known as the “Father of hemodialysis”:
A)
William Bateson
B)
Frederic Sanger
C)
Willem Johan Kolff
D)
Santiago Ramon y Cajal
Willem Johan Kolff is known as the 'Father of hemodialysis' because he developed the first working artificial kidney (the rotating drum kidney) in 1943 during World War II, which allowed for the removal of toxins from the blood of patients with kidney failure.
Other options are incorrect because:
- William Bateson (a) was a geneticist who coined the term 'genetics'.
- Frederic Sanger (b) was a biochemist known for sequencing insulin and DNA (two-time Nobel laureate).
- Santiago Ramon y Cajal (d) was a neuroscientist known as the 'Father of modern neuroscience' for his work on the structure of the nervous system.
Ideal dialysate Temperature is :
A)
28°C
B)
32°C
C)
37°C
D)
42°C
The ideal dialysate temperature is typically set to match or be slightly below the normal human core body temperature, which is approximately 37°C. This ensures patient comfort and prevents thermal shock or instability during the hemodialysis process.
- Option (c) 37°C is correct as it represents normal physiological body temperature.
- Option (a) 28°C and (b) 32°C are too low; using dialysate at these temperatures would cause significant heat loss from the blood, leading to hypothermia and shivering in the patient.
- Option (d) 42°C is too high; this temperature exceeds physiological limits and would risk causing hemolysis (destruction of red blood cells) and thermal injury to the blood.
The main advantage of SLED over conventional hemodialysis in ICU patients is
A)
Faster solute rate
B)
Better cardiovascular stability
C)
Higher clearance of phosphate
D)
Requires less nursing supervision
Sustained Low-Efficiency Dialysis (SLED) is a hybrid modality that combines the efficiency of intermittent hemodialysis (IHD) with the slower fluid removal rates of Continuous Renal Replacement Therapy (CRRT).
1. Why 'b' is correct: The primary advantage of SLED in ICU patients is better cardiovascular stability. By extending the treatment time (typically 6–12 hours) compared to conventional hemodialysis (3–4 hours), SLED allows for a slower, more gradual removal of fluid and solutes, which reduces the risk of hypotension and hemodynamic instability in critically ill patients.
2. Why other options are incorrect:
- 'a' (Faster solute rate): Incorrect. SLED is intentionally slower than conventional hemodialysis to protect hemodynamic stability.
- 'c' (Higher clearance of phosphate): Incorrect. Conventional hemodialysis generally provides higher peak clearance rates for solutes like phosphate due to higher blood flow rates.
- 'd' (Requires less nursing supervision): Incorrect. While it may be more efficient than 24-hour CRRT, it still requires significant monitoring and is not inherently 'less' demanding than conventional dialysis in a way that constitutes a primary clinical advantage.
Sodium profiling is done to reduce:
A)
Fever
B)
Hypotension
C)
Muscle cramps
D)
Both (b) and (c)
Sodium profiling (the management and regulation of sodium levels in the body) is critical for maintaining fluid balance and neuromuscular function.
1. Why (b) and (c) are correct: Sodium is the primary extracellular cation responsible for osmotic pressure. Proper sodium levels are essential to maintain blood volume and blood pressure; therefore, managing sodium helps prevent or treat hypotension (low blood pressure). Additionally, sodium is vital for the transmission of nerve impulses and muscle contraction; an imbalance (hyponatremia) frequently leads to muscle cramps and spasms.
2. Why (a) is incorrect: Fever is typically a result of an immune response (pyrogens) affecting the hypothalamus and is not directly managed or reduced through sodium profiling.
Since both hypotension and muscle cramps are directly related to sodium regulation, the correct answer is 'Both (b) and (c)'.
What is the most common inherited renal disease?
A)
Von-Hippel Lindau disease
B)
Autosomal Dominant Polycystic disease
C)
Tuberous sclerosis
D)
Bardet-Biedl syndrome
Autosomal Dominant Polycystic Kidney Disease (ADPKD) is widely recognized as the most common inherited renal disease. It is characterized by the growth of numerous cysts in the kidneys, which eventually lead to kidney failure in many patients.
Other options are incorrect because:
- Von-Hippel Lindau disease (a) and Tuberous sclerosis (c) are multisystem genetic disorders that can cause renal cysts or angiomyolipomas, but they are significantly rarer than ADPKD.
- Bardet-Biedl syndrome (d) is a rare autosomal recessive ciliopathy involving renal anomalies, but its prevalence is very low compared to the general population affected by ADPKD.
Which parameter is used for CFD-staging?
A)
Creatinine level
B)
Renal biopsy
C)
Estimated GFR
D)
Blood urea
CFD (Chronic Kidney Disease/Chronic Renal Failure) staging is based on the level of kidney function, which is measured by the Estimated Glomerular Filtration Rate (eGFR). The KDIGO guidelines categorize CKD into five stages (G1 to G5) based on the eGFR value (e.g., Stage 3 is 30-59 mL/min/1.73m²).
Why other options are incorrect:
- Creatinine level (a) and Blood urea (d) are biomarkers used to calculate the eGFR, but they are not the staging parameters themselves because they vary based on age, muscle mass, and diet.
- Renal biopsy (b) is a diagnostic tool used to determine the cause (etiology) of kidney damage, not to stage the severity of the functional decline.
A tourniquet is applied during blood sampling to:
A)
Reduce bleeding
B)
Dilate veins
C)
Stop blood flow
D)
Reduce pain
The primary purpose of applying a tourniquet during venipuncture is to impede venous return (blood flowing back to the heart) while allowing arterial blood to continue flowing into the limb. This causes blood to pool in the veins, leading to venous distension (dilation), which makes the vein more prominent, palpable, and easier to puncture.
Incorrect options:
- (a) Reducing bleeding is the purpose of applying pressure *after* the needle is removed, not before sampling.
- (c) Stopping blood flow entirely would prevent the collection of a sample and could cause tissue ischemia; the tourniquet only slows venous flow.
- (d) A tourniquet does not reduce pain; in fact, it can cause slight discomfort due to the pressure.
The least preferred site for placement of hemodialysis catheter is:
A)
Internal jugular vein
B)
External jugular vein
C)
Subclavian vein
D)
Femoral vein
The subclavian vein is the least preferred site for hemodialysis catheter placement primarily due to the high risk of causing subclavian vein stenosis. This stenosis can lead to central venous hypertension and potentially compromise the future use of that arm for an arteriovenous (AV) fistula, which is the gold standard for long-term dialysis access.
Comparing other options:
- Internal jugular vein (a): The preferred site due to a lower risk of stenosis and lower infection rates compared to the femoral site.
- Femoral vein (d): Commonly used in emergencies or when upper body sites are unavailable, though it carries a higher risk of infection and thrombosis.
- External jugular vein (b): While less common than the internal jugular, it is still preferred over the subclavian to avoid permanent stenosis of the central venous system.