1. CHRONIC KIDNEY DISEASE and
RENAL REPLACEMENT THERAPY
Dr.A.MAGESH MD
SENIOR ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL MEDICINE
THANJAVUR MEDICAL COLLEGE
2. 1.Which of the following is the main principle of Dialysis?
A.Diffusion
B. Osmosis
C. Ultrafiltration
D. All of the above
3. ANAWER – D : All of the Above
• Dialysis works on the
principles of
the diffusion of solutes
and ultrafiltration of fluid
across a semi-
permeable membrane.
Diffusion is a property of
substances in water;
substances in water tend
to move from an area of
high concentration to an
area of low
concentration
4. 2. Which of the following can be the side effect of the
Haemodialysis?
A. Nausea
B. Cramps
C. Weakness
D. All of the above
5. ANSWER D : All of the Above
• There are many side effects of Haemodialysis such as Nausea,
Cramps, Weakness, anxiety, blurred vision and more.
• Haemodialysis aids in the control of blood pressure and the
balance of essential minerals in the blood, like
sodium, potassium, and calcium.
• Weakness and Cramps due to mineral
loss(Hypomagnesemia/Hypokalemia)
6. 3. Which of the following is the access for the treatment which is
used in the Peritoneal Dialysis?
A. Graft
B.Catheter
C. Dialysis Machine
D. Fistula
7. ANSWER B : CATHETER
• Peritoneal dialysis can only be
done with the Peritoneal
Dialysis Catheter. A PD
catheter is a thin, flexible, tube
of the size of a straw which is
surgically implanted in your
lower belly. When not in use, a
tiny portion of tubing is left
outside the body and can be
covered.
8. 4. What is the composition of the membrane that is used in
Dialysis?
A.Polyvinyl Chloride
B. Polyethylene
C. Cellulose
D. None of the above
9. ANSWER D - Cellulose
• Cellulose is a readily available
substance that is harmless to the
blood and body.
• It is inexpensive, and its strength
may be enhanced with some
manipulation.
• It has an excellent pore size,
which is small enough to halt
blood cells but large enough to
allow waste materials to flow
through.
10. 5.Modifiable risk factors for CKD include:
A. Diabetes
B. Hypertension
C. History of AKI
D. Frequent NSAID use
E. All of the above
12. 6. Renal replacement therapy should be considered if the
patient is experiencing:
• a. Hyperkalemia
• b. Metabolic acidosis
• c. Fluid Overload
• d. All of the above
13. ANSWER D: All of the Above
• Dialysis can help regulate potassium, acid/base balance
and fluid. Whenthe kidneys can no longer
balance, renal replacementtherapy should be
considered
14. 7. Which of the following is an indication for urgent hemodialysis in a
patient with AKI who has just presented to ED?
• a) Serum creatinine of 1020 umol/L
• b) K of 6.7
• c) Serum HCO3 18 mM
• d) Pericardial rub
• e) Urea of 66 mM
15. ANSWER D : Pericardial rub
K of 6.7 deserves medical management and ONLY if that fails could
justify dialysis.
Indications for urgent dialysis (my rule of Ps)
1. Low pH (refractory to medical management)
2. High potassium (refractory to medical management)
3. Pulmonary oedema (refractory to medical management)
4. Pericarditis/pericardial effusion
5. Symptoms of uraemia
16. 8. Dialysis related amyloidosis (DRA) classically presents with:
• a)Heart failure
• b) Back pain
• c)Autonomic neuropathy
• d)Peripheral neuropathy
• e)Shoulder pain
17. ANSWER E : Shoulder Pain (Amyloid
Deposition)
• DRA is almost exclusively seen in patients on dialysis. Few points to remember:
• Tissue deposition of amyloid, particularly in bone, articular cartilage, synovium,
muscle, tendons, and ligaments
• Amyloid protein in DRA is derived primarily from beta2-microglobulin (beta2-m)
• With the use of high-flux membranes that provide better clearance of beta2-m,
less common now
• Present with shoulder pain or carpal tunnel syndrome
• X-rays show multiple bone cysts that enlarge over time
• Treatment: optimization of dialysis with high-flux biocompatible membranes
• (transplant definite cure
18. 9. Which among the following vaccines is contraindicated in patients
with CKD?
• a) Pneumococcal conjugate vaccine
• b) Varicella vaccine
• c) Injectable polio vaccine
• d) Live attenuated Influenza vaccine
19. ANSWER E :Live attenuated Influenza vaccine
• As a rule, live vaccines are contraindicated in CKD, whereas
inactivated and subunit vaccines can be given. However, MMR and
varicella vaccines are attenuated viral vaccines and can be given in
CKD unless the patient is on concomitant immunosuppressive therapy
• All CKD patients should receive annual vaccinations with inactivated
influenza vaccine.
• NOTE- Hepatitis B vaccine in ESRD:
• Reduced efficacy- Compared with a response rate of >90 percent in
• patients without renal failure, only 50 to 60 percent of those with
ESKD develop antibodies following HBV vaccination.
20. 10. The presence of which of the following for a period of three months
does not lead to the diagnosis of chronic kidney disease?
• a) 24-hour urinary albumin excretion of 30 mg
• b) Persistent presence of leucocytes in urine
• c) Red blood cell casts in the urine
• d) Kidney transplantation
• e) Enlarged kidneys with more than 10 cysts in each kidney
21. ANSWER B : Persistence presence of
Leucocytes in Urine
• While persistent white cell casts in the urine for more than 3 months is
considered
• a criterion for chronic kidney disease (CKD) due to the association with chronic
tubulo-interstitial disease, presence of white cells in urine persistently does not
lead to the diagnosis of CKD.
• CKD is defined as abnormalities of kidney structure or function, present for > 3
months, irrespective of the cause
• Diagnosis: GFR is < 60 ml/ min/ 1.73m2 and/ or the following markers of kidney
damage are present for > 3 months:
• Albuminuria: 24-hour urinary albumin excretion of 30 mg/day or higher, or urine
• albumin- creatinine ratio (ACR) of 30 mg/g (or 3.4 mg/mmol) or higher
• Urinary sediment abnormalities: Red or white blood cell casts may indicate the
presence of glomerular injury or tubular inflammation
22. 11. It is thought that the initial event that triggers the development of
Mineral Bone Disease in CKD is:
• a) Hyperparathyroidism
• b) Low serum calcium
• c) Hyperphosphatemia
• d) Low potassium
• e) High potassium
23. ANSWER C : Hyperphosphatemia
• Pathophysiology of bone and mineral disorder in CKD involves the
following:
1. Phosphate retention ( starts when GFR < 70 ml/min )- first step
2. Decreased serum calcium
3. Decreased 1,25-dihydroxyvitamin D (calcitriol) concentration
4. Increased fibroblast growth factor 23 (FGF-23) concentration leading to
5. decreased calcitriol production ( inhibits 1-alpha hydroxylation of vit.D)
6. Repression of calcium-sensing receptors (CaSRs) in the parathyroid gland
7. Decreased expression of FGF 23 receptor 1 and co-receptor klotho in the
hyperplastic parathyroid gland causes inability of FGF 23 to suppress PTH
as would normally do
24. 12. Which part of the renal tubule is impermeable to water?
• a) Proximal convoluted tubule
• b) Distal convoluted tubule
• c) Cortical duct
• d) Descending limb of loop of Henle
• e) Ascending limb of loop of Henle
25. ANSWER E – Ascending Limb of loop of Henle
• That is the basis of the counter-current mechanism and generation of
the interstitial osmotic gradient which enables ADH to do its job.
26. 13. Macula densa is the specialized region in the
• A. Proximal Convoluted Tubule (PCT)
B. Thick Ascending limb of Loop of Henle
C. Distal Convoluted Tubule (DCT)
D. Collecting duct
27. ANSWER B – Thick Ascending Limb of Loop of
Henle
• The macula densa is an area of closely packed
specialized cells lining the wall of the thick ascending limb of
Henle (TALH) at the point of return of the nephron to the
vascular pole of its parent glomerulus glomerular vascular pole.
• Cells of the macula densa are sensitive to the ionic content and
water volume of the fluid in the TALH, producing molecular
signals that promote renin secretion by other cells of
the juxtaglomerular apparatus.[1] The release of renin is an
essential component of the renin-angiotensin-aldosterone
system (RAAS)
28. 14. Vascular manifestations of ADPKD include
• A. Intracranial aneurysm
B. Coronary artery aneurysm
C. Thoracic aortic dissections
D. All of the above
30. 15. Which of the following feature is not a part of Lithium
nephrotoxicity ?
• A. Nephrogenic DI
B. Incomplete distal RTA (Renal Tubular Acidosis)
C. Hypocalcemia
D. Chronic Tubulo interstitial Nephropathy
31. ANSWER C - Hypocalcemia
• Lithium is widely used in the therapy of bipolar disorder.
• Its toxicity includes
1. urinary concentration deficit and
2. renal tubular acidosis,
3. tubulointerstitial nephritis which complicates with chronic kidney
disease
4. hypercalcemia.
• The most common adverse effect is diabetes insipidus, which occurs
in 20-40% of patients some weeks after initiation of treatment.
32. 16.Identify the wrong statement about Dialysis associated
Amyloidosis.
• A. Beta 2 Microglobulin is the amyloid precursor protein in dialysis
associated amyloidosis
B. Eprodisate is the specific treatment for this condition
C. Carpal tunnel syndrome is often the first symptom
D. Renal transplant may lead to symptomatic improvement
33. ANSWER B – Eprodisate is the specific
treatment
• Eprosidate – Antifibril Drug ( Interfere with formation of GAG( Newer
drug – Failed In phase 3 trial)
• choices for first-line treatment of systemic light-chain (AL) amyloidosis
are autologous stem cell transplantation (ASCT) and combination
chemotherapy.
34. 17. Indications for parathyroidectomy in Chronic kidney disease is all
EXCEPT
• A. Persistent elevation of PTH more than 800 pg/ml in spite of
aggressive treatment with calcimimetics and Vitamin D analogues
B. Uncontrolled hypercalcemia and hyperphosphatemia
C. High levels of bone biomarkers (bone-specific ALP, TRAP5b)
D. Adynamic bone disease on bone biopsy
35. ANSWER D – Aynamic Bone Disease (Not a
Indication)
36. 18. Risk factor and triggering factors in nephrogenic systemic fibrosis
caused by Gadolinium-based contrast agent in CKD are all EXCEPT
• A. Haemodialysis
B. Peritoneal dialysis
C. High dose erythropoietin therapy
D. Elevated serum phosphorous
37. ANSWER A : Hemodialysis(Not a Trigger
Factor)
• Nephrogenic systemic fibrosis
is a progressive multiorgan
fibrosing condition mainly
caused by patients' exposure
to gadolinium-based contrast
agents used in magnetic
resonance imaging. This
condition is primarily
characterized by thickening of
the skin and subcutaneous
tissue in addition to systemic
manifestations
38. 19. Gittleman syndrome is characterized by all EXCEPT
• A. Metabolic alkalosis
B. Hypocalcemia
C. Hypokalemia
D. Sodium wasting
42. 22.Which cause of nephrotic syndrome have highest incidence of
renal vein thrombosis, pulmonary embolism and deep vein
thrombosis ?
• A. Minimal change disease
B. FSGS
C. Membranous Glomerulopathy
D. Diabetic nephropathy
43. ANSWER C : Membranous Glomerulopathy
(Most Common cause)
44. 23. The most common cause of medullary nephrocalcinosis is
• A. Sarcoidosis
B. Hypervitaminosis D
C. Primary hyperparathyroidism
D. Renal tubular acidosis
45. ANSWER C : Primary Hyperparathyroidism
• Nephrocalcinosis refers to generalized calcium deposition in the
kidney and does not include the focal calcium deposition associated
with focal renal injury.
• It is caused by diseases that cause hypercalcemia,
hyperphosphatemia, hypercalciuria, hyperphosphaturia, and
hyperoxaluria.
• Calcium phosphate crystal formation occurs in alkaline urine pH. It
has associations with many diseases which operate through the
underlying mechanisms.
46. 24 . Which of the following variable is NOT USED to estimate kidney
function from Plasma Creatinine in four-variable MDRD (Modification
of Diet in Renal Disease) equation ?
• A. Age
B. Sex
C. Race
D. Weight
48. 21.Combined liver-kidney transplantation is the best option for
• A. Secondary hyperoxaluria
B. Secondary IgA Nephropathy
C. IgA Nephropathy
D. Primary Oxalosis
49. ANSWER D : Primary Oxalosis
• Combined liver and kidney transplantation (CLKT) is indicated for
patients with failure of both organs, or for the replacement of
genetic defect in the liver in the presence of advanced or end-stage
chronic kidney disease.
50. 25.How many times a week dialysis must be done?
a) Every day
b) Once a week
c) Twice a day
d) Thrice a week
