Nephrology Prometric exam questions with answers

1. Question 1Acute Kidney Injurymedium

   An oliguric patient has urine sodium 10 mmol/L, plasma sodium 140 mmol/L, urine creatinine 8000 µmol/L and plasma creatinine 200 µmol/L. What is the FENa and its usual interpretation?

   1. A0.18%, suggesting prerenal azotemia
   2. B1.8%, suggesting tubular necrosis
   3. C0.18%, suggesting tubular necrosis
   4. D1.8%, suggesting prerenal azotemia
   Show answer and explanation▾

   Answer: A. 0.18%, suggesting prerenal azotemia

   FENa = (UNa x PCr)/(PNa x UCr) x 100 = (10 x 200)/(140 x 8000) x 100 = 0.18%. A value below 1% suggests intact tubular sodium reabsorption, as in prerenal states; above 2% suggests tubular injury.

2. Question 2Chronic Kidney Disease and Complicationshard

   In an adult on hemodialysis with raised phosphate, which approach is consistent with current KDIGO CKD-MBD guidance?

   1. ATarget a normal PTH with high-dose calcitriol
   2. BUse calcium carbonate to raise calcium to high-normal
   3. CAvoid any dietary phosphate counselling
   4. DRestrict the dose of calcium-based phosphate binders
   Show answer and explanation▾

   Answer: D. Restrict the dose of calcium-based phosphate binders

   KDIGO 2017 suggests restricting calcium-based binders because positive calcium balance is linked to vascular calcification. PTH in dialysis is kept around 2-9 times the upper normal limit, not normalised.

3. Question 3Chronic Kidney Disease and Complicationsmedium

   A patient has eGFR 40 mL/min/1.73 m2 and urine albumin-to-creatinine ratio 45 mg/mmol, both persisting over 3 months. What is the KDIGO category?

   1. AG3a A2
   2. BG3b A2
   3. CG4 A3
   4. DG3b A3
   Show answer and explanation▾

   Answer: D. G3b A3

   G3b covers eGFR 30-44 and A3 is ACR above 30 mg/mmol. G3a is 45-59 and A2 is 3-30 mg/mmol.

4. Question 4Chronic Kidney Disease and Complicationsmedium

   A patient with CKD G4 has persistent serum bicarbonate of 16 mmol/L. What is the most appropriate management?

   1. AStart a loop diuretic
   2. BIncrease dietary animal protein
   3. CStart oral alkali therapy
   4. DNo treatment is required
   Show answer and explanation▾

   Answer: C. Start oral alkali therapy

   Bicarbonate below 18 mmol/L should prompt consideration of oral sodium bicarbonate or dietary change to prevent bone and muscle loss and possibly slow progression. More animal protein increases acid load.

5. Question 5Glomerular Diseaseseasy

   A 9-year-old has cola-coloured urine, edema and hypertension 2 weeks after tonsillitis. Serum C3 is low and C4 is normal. What is the most likely diagnosis?

   1. AIgA nephropathy with macroscopic flare
   2. BClass IV lupus nephritis
   3. CPost-streptococcal glomerulonephritis
   4. DMinimal change nephropathy
   Show answer and explanation▾

   Answer: C. Post-streptococcal glomerulonephritis

   A latent period of 1-3 weeks after streptococcal infection with low C3 is typical of post-streptococcal GN. IgA nephropathy presents within days of infection and complement is normal.

6. Question 6Dialysismedium

   A peritoneal dialysis patient has abdominal pain and cloudy effluent with 450 white cells/µL, 80% neutrophils. What is the recommended initial treatment?

   1. AOral antibiotics with Gram-positive cover only
   2. BIntraperitoneal antibiotics with broad Gram cover
   3. CImmediate catheter removal and transfer to hemodialysis
   4. DAwait effluent culture before giving any antibiotics
   Show answer and explanation▾

   Answer: B. Intraperitoneal antibiotics with broad Gram cover

   Effluent WBC above 100/µL with over 50% neutrophils indicates peritonitis; empirical intraperitoneal therapy covers both Gram-positive and Gram-negative organisms. Delaying antibiotics for culture worsens outcomes.

7. Question 7Kidney Transplantationhard

   Six months after transplant, creatinine rises. Biopsy shows glomerulitis and peritubular capillaritis with C4d staining, and a new donor-specific antibody is detected. What is the diagnosis?

   1. AAcute T-cell-mediated rejection
   2. BCalcineurin inhibitor toxicity
   3. CActive antibody-mediated rejection
   4. DBK polyomavirus nephropathy
   Show answer and explanation▾

   Answer: C. Active antibody-mediated rejection

   Microvascular inflammation, C4d deposition and DSA satisfy Banff criteria for active antibody-mediated rejection. T-cell-mediated rejection features tubulitis and interstitial inflammation rather than capillaritis with C4d.

8. Question 8Kidney Transplantationeasy

   Which donor/recipient CMV serostatus carries the highest risk of CMV disease after kidney transplantation?

   1. ADonor positive, recipient negative
   2. BDonor negative, recipient positive
   3. CDonor positive, recipient positive
   4. DDonor negative, recipient negative
   Show answer and explanation▾

   Answer: A. Donor positive, recipient negative

   A seronegative recipient of a seropositive kidney has no pre-existing immunity and the highest risk, and receives valganciclovir prophylaxis. D-/R- has the lowest risk.

9. Question 9Fluid, Electrolytes and Acid-Basemedium

   A woman with Sjogren syndrome has normal anion gap metabolic acidosis, potassium 2.9 mmol/L, urine pH 6.5 and nephrocalcinosis. What is the most likely diagnosis?

   1. AProximal (type 2) renal tubular acidosis
   2. BType 4 renal tubular acidosis
   3. CDistal (type 1) renal tubular acidosis
   4. DDiarrhea-related bicarbonate loss
   Show answer and explanation▾

   Answer: C. Distal (type 1) renal tubular acidosis

   Inability to acidify urine below 5.5 despite systemic acidosis, hypokalemia and nephrocalcinosis characterise distal RTA, often seen in Sjogren syndrome. Type 4 RTA causes hyperkalemia.

10. Question 10Glomerular Diseasesmedium

    A 24-year-old has visible hematuria 2 days after a sore throat, with normal complement and similar previous episodes. What is the most likely diagnosis?

    1. APost-streptococcal GN
    2. BAnti-GBM disease
    3. CThin basement membrane disease
    4. DIgA nephropathy
    Show answer and explanation▾

    Answer: D. IgA nephropathy

    Synpharyngitic hematuria with normal complement and recurrent episodes is the classic presentation of IgA nephropathy. Post-streptococcal GN follows after 1-3 weeks and lowers C3.

11. Question 11Hypertension and Renovascular Diseasemedium

    A 45-year-old has hypertension on three drugs and potassium 3.1 mmol/L. What is the best screening test for the likely cause?

    1. A24-hour urine metanephrines
    2. BOvernight dexamethasone suppression
    3. CAldosterone-to-renin ratio
    4. DRenal artery Doppler
    Show answer and explanation▾

    Answer: C. Aldosterone-to-renin ratio

    Resistant hypertension with hypokalemia suggests primary aldosteronism, screened with the aldosterone-to-renin ratio. Metanephrines screen for pheochromocytoma, which usually presents with paroxysms rather than hypokalemia.

12. Question 12Kidney Transplantationmedium

    A stable kidney transplant recipient on tacrolimus is prescribed clarithromycin for pneumonia. What is the expected effect?

    1. ALower tacrolimus levels with acute rejection risk
    2. BNo significant interaction
    3. CRaised mycophenolate levels only
    4. DRaised tacrolimus levels with nephrotoxicity risk
    Show answer and explanation▾

    Answer: D. Raised tacrolimus levels with nephrotoxicity risk

    Clarithromycin inhibits CYP3A4 and P-glycoprotein, increasing tacrolimus levels and the risk of nephrotoxicity. Enzyme inducers such as rifampicin, not macrolides, lower tacrolimus levels.

13. Question 13Kidney Transplantationmedium

    A transplant recipient has slowly rising creatinine, rising plasma BK viral load and SV40-positive tubular nuclei on biopsy. What is the main management?

    1. AReduce maintenance immunosuppression
    2. BIncrease tacrolimus target levels
    3. CStart high-dose glucocorticoids
    4. DStart valganciclovir treatment
    Show answer and explanation▾

    Answer: A. Reduce maintenance immunosuppression

    There is no proven antiviral for BK nephropathy; reducing immunosuppression lets immunity clear the virus. Increasing immunosuppression would worsen viral replication.

14. Question 14Tubulointerstitial, Stones and Inherited Diseasemedium

    A man with gout passes a radiolucent stone; 24-hour urine pH is persistently 5.0. Which measure best prevents recurrence?

    1. AThiazide diuretic to lower urinary calcium excretion
    2. BStrict dietary calcium restriction
    3. CAcidification with ammonium chloride
    4. DUrinary alkalinisation with potassium citrate
    Show answer and explanation▾

    Answer: D. Urinary alkalinisation with potassium citrate

    Uric acid is poorly soluble in acid urine; raising urine pH to about 6.0-6.5 with potassium citrate prevents and can dissolve stones. Calcium restriction is not relevant to uric acid stones and raises oxalate stone risk.

15. Question 15Tubulointerstitial, Stones and Inherited Diseasemedium

    A 35-year-old with ADPKD has enlarged kidneys and eGFR falling by 4 mL/min/1.73 m2 per year. Which drug is approved to slow progression?

    1. ASirolimus
    2. BTolvaptan
    3. CSpironolactone
    4. DAllopurinol
    Show answer and explanation▾

    Answer: B. Tolvaptan

    Tolvaptan, a vasopressin V2 receptor antagonist, slows kidney growth and eGFR decline in rapidly progressive ADPKD; liver tests must be monitored. mTOR inhibitors such as sirolimus did not show benefit in trials.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.