A 64-year-old diabetic woman with stage 4 CKD, on ramipril and spironolactone for heart failure, comes to casualty with generalised weakness. Serum potassium 7.4 mmol/L (repeat sample, no haemolysis). ECG shows tall peaked T waves, flattened P waves and a QRS of 140 ms. Which drug should be given first?

Oral sodium polystyrene sulfonate

IV regular insulin with dextrose

A 68-year-old man with hypertension takes ramipril and hydrochlorothiazide. During a hot week a local practitioner gives him diclofenac for knee pain. Ten days later his creatinine has risen from 1.1 to 2.5 mg/dL with a bland urine. How did diclofenac contribute to his AKI?

Afferent constriction by blocking prostaglandins

Crystal deposition within the tubules

Efferent dilatation by blocking angiotensin II

Direct necrosis of proximal tubular cells

AKI, CKD, glomerular disease and electrolytes

35 NEET-PG practice questions on AKI, CKD, glomerular disease and electrolytes, part of General Medicine. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 64-year-old diabetic woman with stage 4 CKD, on ramipril and spironolactone for heart failure, comes to casualty with generalised weakness. Serum potassium 7.4 mmol/L (repeat sample, no haemolysis). ECG shows tall peaked T waves, flattened P waves and a QRS of 140 ms. Which drug should be given first?
1. AIV calcium gluconate
2. BIV sodium bicarbonate
3. COral sodium polystyrene sulfonate
4. DIV regular insulin with dextrose
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Answer: A · IV calcium gluconate
A broadened QRS in severe hyperkalaemia warns of imminent ventricular fibrillation or asystole, so the first step is to protect the heart. IV calcium gluconate raises the threshold potential and stabilises the myocardial membrane within minutes, but it does not lower potassium and its effect wears off in about an hour. Insulin with dextrose (and nebulised salbutamol) is given next to shift potassium into cells, and potassium is then removed by binders, diuretics or dialysis. Ramipril and spironolactone must be stopped.
- B: Bicarbonate acts slowly and helps mainly in severe metabolic acidosis.
- C: Resins remove potassium over hours and play no part in the emergency.
- D: Insulin shifts potassium into cells but takes 15-30 minutes and does not protect the heart first.
Question 2 · Medium
A 68-year-old man with hypertension takes ramipril and hydrochlorothiazide. During a hot week a local practitioner gives him diclofenac for knee pain. Ten days later his creatinine has risen from 1.1 to 2.5 mg/dL with a bland urine. How did diclofenac contribute to his AKI?
1. ACrystal deposition within the tubules
2. BEfferent dilatation by blocking angiotensin II
3. CAfferent constriction by blocking prostaglandins
4. DDirect necrosis of proximal tubular cells
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Answer: C · Afferent constriction by blocking prostaglandins
When renal perfusion falls, GFR is held up by prostaglandin-mediated afferent dilatation and angiotensin II-mediated efferent constriction. NSAIDs remove the first, ACE inhibitors the second, and the diuretic lowers volume: the 'triple whammy' that causes haemodynamic AKI, especially in the elderly and in hot weather. Stopping the NSAID, holding the ACE inhibitor and diuretic, and restoring volume usually reverses it. Patients on these drugs should be told to avoid over-the-counter NSAIDs.
- A: Crystal nephropathy follows drugs such as acyclovir or methotrexate, not NSAIDs.
- B: Efferent dilatation is the action of ramipril, not diclofenac.
- D: NSAIDs cause haemodynamic AKI here, not direct tubular necrosis.
Question 3 · Medium
A 59-year-old man has a serum potassium of 6.8 mmol/L with peaked T waves. The casualty team discusses: 1. Insulin with glucose. 2. Calcium gluconate. 3. Nebulised salbutamol. 4. Sodium zirconium cyclosilicate. Which of these lower serum potassium by shifting it into cells?
1. A1, 2 and 3 only
2. B1, 3 and 4 only
3. C1 and 3 only
4. D1, 2, 3 and 4
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Answer: C · 1 and 3 only
Insulin and beta-2 agonists such as salbutamol stimulate the Na-K-ATPase and move potassium into cells within about 15-30 minutes, and their effects add up. Calcium gluconate stabilises the cardiac membrane but does not lower potassium. Sodium zirconium cyclosilicate is a gut binder that removes potassium from the body by exchanging it for sodium and hydrogen. Shifting is temporary, so removal (binders, diuretics or dialysis) must follow.
- A: Calcium protects the heart but does not change the potassium level.
- B: The binder removes potassium from the body rather than shifting it.
- D: Calcium and the binder do not act by shifting potassium into cells.
Question 4 · Easy
A 50-year-old man who drinks heavily is admitted with confusion and a serum sodium of 108 mmol/L. By the next morning his sodium is 124 mmol/L. Three days later he develops dysarthria, dysphagia and spastic weakness of all four limbs. What is the most likely cause?
1. AHyponatraemic cerebral oedema
2. BOsmotic demyelination syndrome
3. CHepatic encephalopathy
4. DWernicke encephalopathy
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Answer: B · Osmotic demyelination syndrome
In chronic hyponatraemia, brain cells lose organic osmolytes to avoid swelling; if sodium then rises quickly, they cannot regain them fast enough and shrink, damaging myelin, classically in the pons. Symptoms appear 2-6 days after the correction: dysarthria, dysphagia, quadriparesis and, at worst, a locked-in state. Alcohol use, malnutrition, hypokalaemia and liver disease raise the risk, so in such patients the rise should be kept to about 8 mmol/L in 24 hours. His rise of 16 mmol/L overnight was far too fast.
- A: Cerebral oedema occurs while sodium is low, not days after rapid correction.
- C: Hepatic encephalopathy causes confusion and asterixis, not pseudobulbar palsy with quadriparesis.
- D: Wernicke encephalopathy gives confusion, ophthalmoplegia and ataxia, not quadriparesis after correction.
Question 5 · Medium
A 19-year-old man is referred from an ENT clinic, where audiometry showed bilateral high-frequency sensorineural hearing loss, with persistent microscopic haematuria and proteinuria of 1.2 g/day. Slit-lamp examination shows anterior lenticonus. His maternal uncle started dialysis at 30. Which protein is defective in his most likely disease?
1. AType IV collagen
2. BType I collagen
3. CNephrin
4. DFibrillin-1
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Answer: A · Type IV collagen
Haematuria, sensorineural deafness and anterior lenticonus with kidney failure in maternal male relatives is Alport syndrome. Most cases are X-linked, from mutations in COL4A5, which codes the alpha-5 chain of type IV collagen; the same collagen network is found in the glomerular basement membrane, the cochlea and the lens capsule. Electron microscopy shows a thinned and split ('basket-weave') basement membrane. ACE inhibitors slow progression, and family members should be offered screening and genetic counselling.
- B: Type I collagen defects cause osteogenesis imperfecta, not nephritis with deafness.
- C: Nephrin mutations cause congenital nephrotic syndrome of the Finnish type in infancy.
- D: Fibrillin-1 defects cause Marfan syndrome, with lens dislocation rather than lenticonus.
Question 6 · Hard
A 55-year-old man who drinks 8-10 bottles of beer a day and eats little is admitted with confusion. Serum sodium 114 mmol/L, potassium 3.0 mmol/L, serum osmolality 238 mOsm/kg, urine osmolality 70 mOsm/kg and urine sodium 8 mmol/L. He is clinically euvolaemic. What explains his hyponatraemia?
1. ALow solute intake limiting free-water excretion
2. BPseudohyponatraemia from hyperlipidaemia
3. CInappropriate ADH secretion
4. DRenal sodium loss as with a thiazide
Answer and explanation in LearnFree account
Question 7 · Medium
A 22-year-old college student in Bengaluru notices cola-coloured urine on the second day of a sore throat with fever; it is his third such episode in two years. Between episodes his urine shows microscopic haematuria. BP 128/80 mmHg, creatinine normal, serum C3 normal. He has no hearing loss. What is the most likely diagnosis?
1. AIgA nephropathy
2. BPost-streptococcal glomerulonephritis
3. CAlport syndrome
4. DLupus nephritis
Answer and explanation in LearnFree account
Question 8 · Hard
A 52-year-old woman with falciparum malaria and anuric AKI is in the ICU. Her potassium was 7.2 mmol/L with a broad QRS. She received IV calcium gluconate twice, insulin with dextrose and nebulised salbutamol. Two hours later her potassium is 6.9 mmol/L, pH 7.12, bicarbonate 10 mmol/L, she remains anuric, and she has bilateral crackles with SpO2 90% on 4 L/min of oxygen. What is the definitive next step?
1. AUrgent haemodialysis
2. BIV furosemide 80 mg
3. CIV sodium bicarbonate infusion
4. DOral sodium polystyrene sulfonate
Answer and explanation in LearnFree account
Question 9 · Medium
A 40-year-old woman with essential thrombocythaemia (platelets 14 lakh/µL) has a serum potassium of 6.9 mmol/L on routine testing. She feels well, her ECG is normal and renal function is normal. What is the next best step?
1. AGive IV insulin with dextrose
2. BStart an oral potassium binder
3. CGive IV calcium gluconate now
4. DRepeat potassium in heparinised plasma
Answer and explanation in LearnFree account
Question 10 · Easy
A 55-year-old man on maintenance haemodialysis misses two sessions and comes to casualty feeling weak. His serum potassium is 6.6 mmol/L. Which ECG change is typically the first to appear as potassium rises?
1. AProminent U waves
2. BTall, peaked T waves
3. CWidened QRS complex
4. DProlonged PR interval
Answer and explanation in LearnFree account
Question 11 · Medium
A 74-year-old man is brought to casualty with lower abdominal discomfort and dribbling of urine for 2 days, after starting a cold remedy containing chlorpheniramine. He has had poor stream for years. The bladder is palpable up to the umbilicus. Creatinine is 2.6 mg/dL (baseline 1.1). What is the first step in management?
1. AStart tamsulosin and review tomorrow
2. BInsert a urethral catheter
3. CGet a CT urogram first
4. DGive an IV fluid bolus
Answer and explanation in LearnFree account
Question 12 · Medium
A 38-year-old man with nephrotic syndrome (urine protein 9 g/day, serum albumin 1.9 g/dL) develops sudden flank pain and haematuria. His resident lists these statements about nephrotic syndrome: 1. Urinary loss of antithrombin III promotes thrombosis. 2. Increased hepatic lipoprotein synthesis causes hyperlipidaemia. 3. Oedema results mainly from raised capillary hydrostatic pressure. 4. Serum C3 is typically raised. Which statements are correct?
1. A1 and 2 only
2. B2 and 4 only
3. C1, 2, 3 and 4
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 13 · Medium
A 52-year-old man has had progressive swelling of both legs for 2 months. Urine protein is 7.5 g/day with a bland sediment, serum albumin 2.1 g/dL, BP 130/84 mmHg, and complement is normal. Serum anti-phospholipase A2 receptor antibody is strongly positive. What is the most likely diagnosis?
1. APrimary membranous nephropathy
2. BFocal segmental glomerulosclerosis
3. CMinimal change disease
4. DMembranoproliferative GN
Answer and explanation in LearnFree account
Question 14 · Medium
A 45-year-old man with CKD G5, who has so far declined dialysis, comes with pleuritic chest pain relieved by sitting forward. There is a pericardial rub; BP is 138/86 mmHg and there is no pulsus paradoxus. Echocardiography shows a small effusion without tamponade. Urea 240 mg/dL, creatinine 11.2 mg/dL, potassium 5.2 mmol/L. What is the most appropriate treatment?
1. AHigh-dose NSAIDs with colchicine
2. BPericardiocentesis
3. COral prednisolone
4. DUrgent haemodialysis
Answer and explanation in LearnFree account
Question 15 · Hard
A 70-year-old man with heart failure on furosemide 80 mg/day has creatinine rising from 1.2 to 2.4 mg/dL over 4 days of poor oral intake. Urine sodium is 48 mmol/L and FENa 2.4%. Plasma urea is 120 mg/dL and urine urea 900 mg/dL; plasma creatinine 2.4 mg/dL and urine creatinine 80 mg/dL. What is his fractional excretion of urea, and what does it suggest?
1. AAbout 22%, indicating prerenal AKI
2. BAbout 22%, indicating tubular necrosis
3. CAbout 2.4%, indicating tubular necrosis
4. DAbout 22%, an indeterminate result
Answer and explanation in LearnFree account
Question 16 · Easy
A 58-year-old man with 18 years of type 2 diabetes and proliferative retinopathy has nephrotic-range proteinuria. A renal biopsy, done because of unexplained haematuria, shows rounded, PAS-positive nodules of mesangial matrix in many glomeruli. What are these lesions called?
1. AGlomerular crescents
2. BBasement membrane spikes
3. CWire-loop lesions
4. DKimmelstiel-Wilson nodules
Answer and explanation in LearnFree account
Question 17 · Medium
A 60-year-old man had prolonged hypotension during emergency surgery for a perforated duodenal ulcer. Two days later his creatinine has risen from 1.0 to 3.4 mg/dL even though BP and volume have been restored. Urine sodium is 62 mmol/L, FENa 3.1%, urine osmolality 290 mOsm/kg, and microscopy shows many muddy-brown granular casts. What is the most likely diagnosis?
1. APrerenal azotaemia
2. BRapidly progressive glomerulonephritis
3. CAcute interstitial nephritis
4. DAcute tubular necrosis
Answer and explanation in LearnFree account
Question 18 · Easy
A 72-year-old woman from a Chennai old-age home is admitted with 3 days of diarrhoea, dry mucosae and postural hypotension. Creatinine is 2.0 mg/dL (baseline 0.8) and urea 98 mg/dL; urine sodium is 8 mmol/L, FENa 0.4%, and the urine sediment is bland. What type of AKI is this?
1. APrerenal
2. BPostrenal
3. CAcute interstitial nephritis
4. DAcute tubular necrosis
Answer and explanation in LearnFree account
Question 19 · Medium
A 56-year-old woman with CKD G4 complains of fatigue. Haemoglobin is 8.6 g/dL, MCV 76 fL, serum ferritin 40 ng/mL and transferrin saturation 11%. Upper GI endoscopy and colonoscopy are normal. What is the next step for her anaemia?
1. AStart erythropoietin at once
2. BTransfuse to a haemoglobin of 12 g/dL
3. CGive oral folic acid alone
4. DReplete iron before considering an ESA
Answer and explanation in LearnFree account
Question 20 · Easy
A 59-year-old diabetic man attending the NCD clinic at a CHC has an eGFR of 38 mL/min/1.73 m² on two tests 4 months apart, and a urine albumin-creatinine ratio of 20 mg/g. In which KDIGO GFR category is he?
1. AG2
2. BG3b
3. CG3a
4. DG4
Answer and explanation in LearnFree account
Question 21 · Easy
A 4-year-old boy is brought to the paediatric OPD with puffiness around the eyes for a week and now swollen feet. BP is normal for his age. Urine shows 4+ protein with no RBCs; serum albumin 1.8 g/dL, cholesterol 380 mg/dL, and creatinine and C3 are normal. What is the next step in management?
1. AOral prednisolone without a biopsy
2. BIV cyclophosphamide pulses
3. COral enalapril alone
4. DRenal biopsy before any treatment
Answer and explanation in LearnFree account
Question 22 · Medium
A 26-year-old man who smokes has had haemoptysis for 4 days and is now passing little urine. Chest X-ray shows bilateral alveolar shadows, creatinine has risen from 1.0 to 4.8 mg/dL in a week, and urine shows RBC casts. Renal biopsy shows crescents in most glomeruli with linear IgG along the glomerular basement membrane; ANCA is negative. Along with steroids and cyclophosphamide, what treatment does he need?
1. AOral mycophenolate
2. BRituximab alone
3. CPlasma exchange
4. DIV immunoglobulin
Answer and explanation in LearnFree account
Question 23 · Medium
A 30-year-old construction worker is pulled out from under a collapsed wall after 5 hours. His right thigh is swollen and tense. His urine is reddish-brown, the dipstick is 3+ for blood, but microscopy shows no red cells. CK is 48,000 U/L, potassium 5.6 mmol/L and creatinine 1.9 mg/dL. What is the most important early measure to protect his kidneys?
1. ALarge-volume IV isotonic crystalloid
2. BFluid restriction to avoid overload
3. CIV mannitol without extra fluids
4. DIV furosemide to force a diuresis
Answer and explanation in LearnFree account
Question 24 · Hard
A 9-year-old boy from Nagpur was diagnosed with post-streptococcal glomerulonephritis after a sore throat. Three months later he still has haematuria, proteinuria of 1.8 g/day, BP 128/84 mmHg, a slightly raised creatinine and a persistently low C3 with normal C4. What is the next best step?
1. ARepeat C3 after 3 more months
2. BRenal biopsy
3. CReassure; PSGN resolves slowly
4. DStart penicillin prophylaxis
Answer and explanation in LearnFree account
Question 25 · Medium
After a road-traffic head injury, a 28-year-old man in the neurosurgery ICU passes 6 litres of urine a day. Serum sodium is 152 mmol/L, plasma osmolality 312 mOsm/kg and urine osmolality 110 mOsm/kg. After subcutaneous desmopressin, urine osmolality rises to 480 mOsm/kg. What is the diagnosis?
1. APrimary polydipsia
2. BCentral diabetes insipidus
3. COsmotic diuresis from mannitol
4. DNephrogenic diabetes insipidus
Answer and explanation in LearnFree account

10 more AKI, CKD, glomerular disease and electrolytes questions

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Study General Medicine

AKI, CKD, glomerular disease and electrolytes

A 68-year-old man with hypertension takes ramipril and hydrochlorothiazide. During a hot week a local practitioner gives him diclofenac for knee pain. Ten days later his creatinine has risen from 1.1 to 2.5 mg/dL with a bland urine. How did diclofenac contribute to his AKI?

A 59-year-old man has a serum potassium of 6.8 mmol/L with peaked T waves. The casualty team discusses: 1. Insulin with glucose. 2. Calcium gluconate. 3. Nebulised salbutamol. 4. Sodium zirconium cyclosilicate. Which of these lower serum potassium by shifting it into cells?

A 50-year-old man who drinks heavily is admitted with confusion and a serum sodium of 108 mmol/L. By the next morning his sodium is 124 mmol/L. Three days later he develops dysarthria, dysphagia and spastic weakness of all four limbs. What is the most likely cause?

A 55-year-old man who drinks 8-10 bottles of beer a day and eats little is admitted with confusion. Serum sodium 114 mmol/L, potassium 3.0 mmol/L, serum osmolality 238 mOsm/kg, urine osmolality 70 mOsm/kg and urine sodium 8 mmol/L. He is clinically euvolaemic. What explains his hyponatraemia?

A 40-year-old woman with essential thrombocythaemia (platelets 14 lakh/µL) has a serum potassium of 6.9 mmol/L on routine testing. She feels well, her ECG is normal and renal function is normal. What is the next best step?

A 55-year-old man on maintenance haemodialysis misses two sessions and comes to casualty feeling weak. His serum potassium is 6.6 mmol/L. Which ECG change is typically the first to appear as potassium rises?

A 52-year-old man has had progressive swelling of both legs for 2 months. Urine protein is 7.5 g/day with a bland sediment, serum albumin 2.1 g/dL, BP 130/84 mmHg, and complement is normal. Serum anti-phospholipase A2 receptor antibody is strongly positive. What is the most likely diagnosis?

A 58-year-old man with 18 years of type 2 diabetes and proliferative retinopathy has nephrotic-range proteinuria. A renal biopsy, done because of unexplained haematuria, shows rounded, PAS-positive nodules of mesangial matrix in many glomeruli. What are these lesions called?

A 72-year-old woman from a Chennai old-age home is admitted with 3 days of diarrhoea, dry mucosae and postural hypotension. Creatinine is 2.0 mg/dL (baseline 0.8) and urea 98 mg/dL; urine sodium is 8 mmol/L, FENa 0.4%, and the urine sediment is bland. What type of AKI is this?

A 56-year-old woman with CKD G4 complains of fatigue. Haemoglobin is 8.6 g/dL, MCV 76 fL, serum ferritin 40 ng/mL and transferrin saturation 11%. Upper GI endoscopy and colonoscopy are normal. What is the next step for her anaemia?

A 59-year-old diabetic man attending the NCD clinic at a CHC has an eGFR of 38 mL/min/1.73 m² on two tests 4 months apart, and a urine albumin-creatinine ratio of 20 mg/g. In which KDIGO GFR category is he?

A 4-year-old boy is brought to the paediatric OPD with puffiness around the eyes for a week and now swollen feet. BP is normal for his age. Urine shows 4+ protein with no RBCs; serum albumin 1.8 g/dL, cholesterol 380 mg/dL, and creatinine and C3 are normal. What is the next step in management?

A 9-year-old boy from Nagpur was diagnosed with post-streptococcal glomerulonephritis after a sore throat. Three months later he still has haematuria, proteinuria of 1.8 g/day, BP 128/84 mmHg, a slightly raised creatinine and a persistently low C3 with normal C4. What is the next best step?

After a road-traffic head injury, a 28-year-old man in the neurosurgery ICU passes 6 litres of urine a day. Serum sodium is 152 mmol/L, plasma osmolality 312 mOsm/kg and urine osmolality 110 mOsm/kg. After subcutaneous desmopressin, urine osmolality rises to 480 mOsm/kg. What is the diagnosis?