Renal Medicine (AKI, CKD, Nephrotic/Nephritic, RTA, Electrolytes) MCQs

Medicine · 161 free questions with answers & explanations.

  1. A 25-year-old man presents with hematuria, red cell casts, and proteinuria of 1.8 g/day, 2 weeks after a sore throat. BP is 155/95 mmHg. Serum C3 is low, C4 is normal. ASO titer is elevated. What is the most likely diagnosis?
  2. A 55-year-old woman on chronic NSAIDs and an ACE inhibitor for hypertension undergoes coronary angiography with iodinated contrast. Twenty-four hours later, her serum creatinine rises from 1.0 to 2.4 mg/dL. Urinalysis shows bland sediment with no casts. Urine sodium is 8 mEq/L, fractional excretion of sodium (FeNa) is 0.3%. Which type of AKI does this represent?
  3. A 48-year-old man with CKD stage 4 (eGFR 22 mL/min) has serum potassium of 6.8 mEq/L. ECG shows absent P waves, widened QRS, and tall peaked T waves. The first intervention should be:
  4. A 35-year-old woman presents with fatigue, bone pain, and recurrent nephrolithiasis. Labs: serum Na 138, K 2.8 mEq/L, Cl 112 mEq/L, HCO₃ 14 mEq/L, anion gap = 12. Urine pH is 6.2. Serum potassium is low. Urine anion gap is positive (+8). Which type of renal tubular acidosis (RTA) is most consistent with this picture?
  5. A 68-year-old man with CKD stage 3b (eGFR 32 mL/min) is on lisinopril 10 mg for diabetic nephropathy. He is admitted with a 3-day history of vomiting and diarrhea. Serum creatinine has risen from 1.9 to 3.6 mg/dL. Urine sodium is 48 mEq/L, FeNa is 2.8%, and urine osmolality is 290 mOsm/kg. What type of AKI is present?
  6. A 30-year-old woman presents with recurrent renal stones (calcium phosphate) and osteoporosis. ABG: pH 7.30, PCO2 32 mmHg, HCO3 16 mEq/L. Urine pH is 6.5 despite systemic acidosis. Serum potassium is 2.9 mEq/L. Serum calcium is 10.6 mg/dL. What is the most likely diagnosis?
  7. A 52-year-old woman with focal segmental glomerulosclerosis and nephrotic syndrome is treated with high-dose prednisone for 6 months but fails to achieve remission. Which second-line agent, specifically approved for steroid-resistant FSGS and acting by inhibiting calcineurin, is recommended?
  8. A 30-year-old woman develops nephrotic syndrome with massive proteinuria, hypoalbuminaemia, and oedema. Kidney biopsy shows effacement of foot processes on electron microscopy without immune deposits or hypercellularity. Initial treatment with prednisolone 1 mg/kg/day is initiated. She is classified as 'steroid-sensitive' after achieving complete remission. She now has her third relapse within 1 year of stopping steroids. What is the most appropriate next step?
  9. A 50-year-old man with CKD stage 4 (GFR 22 mL/min) due to diabetic nephropathy has serum potassium of 5.8 mEq/L on ACE inhibitor. He has hyperphosphataemia (2.1 mmol/L), elevated intact PTH (350 pg/mL), and hypocalcaemia (2.0 mmol/L). Which intervention is most critical to prevent progression to tertiary hyperparathyroidism and metastatic calcification?
  10. A 25-year-old woman presents with recurrent nephrolithiasis (calcium oxalate stones) and is found to have serum potassium 3.1 mEq/L, urine pH 6.5 (inappropriately alkaline), hyperchloraemic metabolic acidosis, and urine anion gap of +10. Serum bicarbonate is 15 mEq/L. What is the diagnosis and underlying defect?
  11. A 60-year-old woman on hydrochlorothiazide develops serum sodium of 118 mEq/L over 3 days with progressive confusion. She is euvolaemic. Serum osmolality is 245 mOsm/kg, urine osmolality 580 mOsm/kg, and urine sodium 55 mEq/L. What is the most appropriate correction rate for sodium in chronic hyponatraemia to avoid osmotic demyelination syndrome (ODS)?
  12. The KDIGO 2022 guidelines for CKD classify all stages of CKD using GFR category (G1–G5) and albuminuria category (A1–A3). The combination of G3bA3 denotes which risk category for adverse CKD outcomes?
  13. A 30-year-old woman presents with profound hypokalaemia (K 2.1 mEq/L), metabolic alkalosis, low-normal blood pressure, elevated plasma renin, and elevated aldosterone. Urinary chloride is low. Which diagnosis fits this picture?
  14. In the CREDENCE trial, canagliflozin in patients with diabetic nephropathy (eGFR 30–90, albuminuria ≥300 mg/g, on max RAAS blockade) reduced the primary composite renal outcome. The renoprotective mechanism of SGLT2 inhibitors independent of glycaemic control involves:
  15. A hyperchloraemic normal anion gap metabolic acidosis with urinary anion gap (UAG) = +10 mEq/L suggests which diagnosis?
  16. A 45-year-old woman presents with AKI (creatinine rising from 0.9 to 4.2 mg/dL over 4 weeks), haemoptysis, haematuria, and red cell casts. cANCA (anti-PR3) is strongly positive. Renal biopsy is most likely to show:
  17. A patient with chronic kidney disease stage G4 (eGFR 22 mL/min) has serum bicarbonate of 16 mEq/L, pH 7.28, and anion gap of 18 mEq/L. The MOST likely acid-base disorder is:
  18. A 35-year-old woman presents with recurrent renal calculi (calcium oxalate stones), hypophosphataemia, phosphaturia, and proximal renal tubular dysfunction (glycosuria with normoglycaemia, aminoaciduria, uricosuria). The MOST likely unifying diagnosis is:
  19. KDIGO 2022 guidelines now recommend which medication as first-line for slowing CKD progression in patients with CKD and albuminuria (ACR ≥ 30 mg/g), regardless of whether they have heart failure or T2DM?
  20. A 68-year-old man develops oliguria and rising creatinine after CABG surgery. Urine output is 180 mL in 8 hours. Urine sodium is 62 mEq/L, urine creatinine 45 mg/dL, serum creatinine 3.2 mg/dL (baseline 1.0 mg/dL). Urine osmolality is 210 mOsm/kg. Based on these parameters, the fractional excretion of sodium (FENa) is approximately 3.2%, indicating:
  21. A 35-year-old woman presents with recurrent renal stones and serum chemistry showing hyperchloremic metabolic acidosis with normal anion gap, serum K+ 2.9 mEq/L, and urine pH 6.8 despite serum bicarbonate of 16 mEq/L. The diagnosis is:
  22. A 45-year-old man with IgA nephropathy (Oxford MEST-C classification: M1, E1, S1, T1, C1) has proteinuria 2.8 g/day and eGFR 52 mL/min. He is on ACE inhibitor. According to the TESTING trial and current KDIGO 2021 guidelines, what is the recommended additional therapy?
  23. A 62-year-old man with CKD stage 4 (eGFR 22 mL/min) presents with serum phosphate 6.8 mg/dL, calcium 8.1 mg/dL, PTH 380 pg/mL, and FGF-23 markedly elevated. This pattern describes CKD-Mineral Bone Disorder (CKD-MBD). The sequence of events in CKD-MBD initiation is best described as:
  24. A 35-year-old man presents with hemoptysis, hematuria, and rapidly progressive glomerulonephritis. Serum creatinine is 5.6 mg/dL. Anti-GBM antibody is positive. Kidney biopsy shows linear IgG deposits along GBM with crescents. What is the most appropriate initial treatment?
  25. A 55-year-old man with type 2 diabetes, CKD Stage 3b (eGFR 38 mL/min), and ACE inhibitor + MRA therapy develops hyperkalemia (K+ 6.2 mEq/L). After dietary restriction and optimizing diuretics, potassium remains elevated. Which novel agent is most appropriate to manage hyperkalemia and allow continued RAASi therapy?
  26. A 28-year-old woman presents with recurrent nephrolithiasis (calcium phosphate stones), hypokalemia, and a non-anion gap metabolic acidosis. Urine pH is 6.5 despite systemic acidosis. Urinary anion gap is positive. What is the most likely diagnosis?
  27. A 45-year-old woman with lupus nephritis (class IV by ISN/RPS classification) is being treated with mycophenolate mofetil (MMF) and prednisolone. After 6 months, repeat biopsy shows persistent class IV activity with chronicity index of 5/12. What is the significance of the chronicity index in decision-making?
  28. A 50-year-old woman develops AKI (creatinine 3.2 mg/dL, baseline 0.9 mg/dL) after starting NSAIDs for arthritis. Urinalysis: no cells/casts, urine sodium 12 mEq/L, FENa 0.4%, urine osmolality 620 mOsm/kg. Which mechanism best explains this pattern?
  29. A 35-year-old woman with type 1 distal RTA (urinary pH persistently >5.5 despite acidaemia) develops bilateral nephrolithiasis and nephrocalcinosis. Which biochemical mechanism directly links distal RTA to stone formation?
  30. A 60-year-old CKD stage 4 (eGFR 22 mL/min) patient has haemoglobin 9.2 g/dL, serum ferritin 95 ng/mL, TSAT 18%. He is not on dialysis. According to KDIGO 2012 CKD anaemia guidelines, what is the preferred next step?
  31. A 55-year-old diabetic man presents with progressive CKD stage G4A3 (eGFR 24 mL/min, UACR 650 mg/g). BP 142/88 mmHg on maximum-dose ACE inhibitor. HbA1c 7.1% on insulin. According to KDIGO 2022 and recent FIDELIO-DKD/FIGARO-DKD trial data, which agent should be added to further reduce CKD progression?
  32. A 22-year-old woman presents with recurrent urolithiasis and low back pain. Arterial blood gas: pH 7.30, HCO3 12 mEq/L, pCO2 28 mmHg, Na+ 138, K+ 2.8 mEq/L, Cl- 112 mEq/L. Urine pH is 6.8 despite systemic acidosis. Urine anion gap is positive (+14). The most likely diagnosis is:
  33. A 65-year-old man post-cardiac surgery develops oliguric AKI. Serum creatinine rises from 1.0 to 3.8 mg/dL over 48 hours. Urine output is 0.3 mL/kg/hr. By KDIGO AKI classification, this is:
  34. A 68-year-old woman on lisinopril and spironolactone for heart failure develops serum K+ of 6.4 mEq/L. ECG shows peaked T waves. After IV calcium gluconate is given, the next immediate priority to shift potassium intracellularly is:
  35. A 35-year-old man presents with hematuria and 4+ proteinuria following an upper respiratory infection 2 days ago (synpharyngitic nephritis). Complement C3 is normal. Renal biopsy shows mesangial IgA deposits. He has hypertension (BP 145/92) and proteinuria of 2.8 g/day. eGFR is 58 mL/min. Which therapy has the strongest evidence to slow CKD progression in this patient?
  36. A 65-year-old woman develops AKI (creatinine rises from 0.8 to 3.2 mg/dL in 3 days) after starting ibuprofen for knee pain. FENa is 0.8%. Urine microscopy shows granular casts and renal tubular epithelial cells. Urinary sodium is 45 mEq/L. The most likely diagnosis is:
  37. A 45-year-old man with chronic diarrhea has: serum Na 138, K 2.8 mEq/L, Cl 112 mEq/L, HCO3 12 mEq/L, pH 7.28. Urine pH is 5.2, urine Na 18, urine K 12, urine Cl 38 mEq/L. Calculated serum anion gap = 138 − (112+12) = 14 mEq/L. Urine anion gap = 18+12−38 = −8 mEq/L (negative). The acid-base diagnosis is:
  38. A 72-year-old woman on hydrochlorothiazide develops confusion. Labs: Na 118 mEq/L, K 3.1 mEq/L, serum osmolality 248 mOsm/kg, urine osmolality 520 mOsm/kg, urine sodium 68 mEq/L. She has no edema, normal BP, and is euvolemic clinically. The most likely cause is:
  39. A 65-year-old man with CKD stage 3b (eGFR 38 mL/min) and T2DM presents with worsening proteinuria (urine ACR 620 mg/g). He is already on maximum dose ACE inhibitor and blood pressure is well controlled at 128/76 mmHg. According to the FIDELIO-DKD and FIGARO-DKD trial evidence, which additional agent significantly reduces CKD progression and cardiovascular events in diabetic kidney disease?
  40. A 25-year-old woman presents with weakness and hypokalaemia (K+ 2.8 mEq/L). Urine pH is consistently 6.2. Arterial blood gas shows pH 7.28, HCO3 13 mEq/L, PaCO2 30 mmHg. Urine potassium-to-creatinine ratio is elevated. Which renal tubular acidosis does this represent and what is its most common cause in young women?
  41. A 70-year-old man is found to have serum sodium of 122 mEq/L. He is on a thiazide diuretic for hypertension. His urine osmolality is 480 mOsm/kg, urine sodium is 55 mEq/L, and he appears euvolaemic. Thyroid and adrenal function are normal. What is the likely mechanism and first-line treatment?
  42. A 55-year-old woman has serum potassium of 6.8 mEq/L. ECG shows peaked T waves, widened QRS, and prolonged PR interval. She is on ACE inhibitor and has CKD stage 4. What is the correct sequence of emergency management?
  43. A 28-year-old man with recurrent nephrolithiasis has serum potassium 3.1 mEq/L, serum bicarbonate 14 mEq/L, serum chloride 115 mEq/L, urinary pH 6.8 (non-acidic despite systemic acidosis), and urine anion gap (UAG) is positive (+12). The MOST likely diagnosis is:
  44. A 65-year-old man with CKD stage G3b (eGFR 32 mL/min) and proteinuria 1.8 g/day is on an ACE inhibitor. Serum potassium is 5.8 mEq/L. He develops worsening oedema and serum albumin falls to 2.2 g/dL. Renal biopsy shows effacement of foot processes with no immune deposits on immunofluorescence. The diagnosis is minimal change disease (MCD) in an adult. The CORRECT initial treatment is:
  45. The CREDENCE trial demonstrated that canagliflozin reduced renal outcomes in type 2 diabetics with CKD. The criteria for inclusion in this trial (defining the target patient population for SGLT2 inhibitor nephroprotection) included:
  46. A 70-year-old woman post-cardiac surgery develops oliguric AKI. Urine output is 180 mL in the past 8 hours. Urine sodium is 8 mEq/L, serum creatinine rose from 0.9 to 2.8 mg/dL in 24 hours. Fractional excretion of sodium (FENa) is 0.4%. The MOST likely category of AKI and appropriate first management step is:
  47. Per KDIGO 2012 criteria, AKI is defined as which of the following?
  48. A 35-year-old woman presents with nephrotic syndrome: 6 g/day proteinuria, albumin 2.0 g/dL, and cholesterol 380 mg/dL. Renal biopsy shows effacement of podocyte foot processes on electron microscopy with no immune deposits on immunofluorescence. Light microscopy is normal. What is the most likely diagnosis and first-line treatment?
  49. A patient with distal renal tubular acidosis (Type 1 RTA) is expected to show which characteristic urine finding during a systemic metabolic acidosis?
  50. A patient with CKD stage 4 (eGFR 22 mL/min/1.73 m²) has serum potassium 5.8 mEq/L. He is on ACE inhibitor (lisinopril 20 mg) and spironolactone. After stopping spironolactone, his potassium remains 5.8 mEq/L despite dietary restriction. Which potassium binder has demonstrated long-term efficacy and safety for hyperkalemia in CKD, allowing ACE inhibitor continuation?
  51. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) must be distinguished from cerebral salt wasting (CSW) in a patient with hyponatraemia following subarachnoid haemorrhage. Which single finding best differentiates SIADH from CSW?
  52. A 35-year-old man presents with macroscopic hematuria coinciding with an upper respiratory tract infection (synpharyngitic hematuria). Urine shows dysmorphic red blood cells and red cell casts. Kidney biopsy shows mesangial IgA deposits on immunofluorescence. Which histological finding on the Oxford MEST-C score predicts the worst long-term renal outcome?
  53. A 50-year-old diabetic patient in ICU develops oliguria after contrast-enhanced CT (CIAKI). Creatinine rises by 1.8 mg/dL (>0.3 mg/dL within 48 hours). On further assessment, urine sodium is 8 mmol/L, FENa is 0.4%, and urine osmolality is 620 mOsm/kg. These findings indicate:
  54. A 40-year-old woman with nephrotic syndrome has serum albumin 1.8 g/dL, 24-hour urine protein 9 g, and normal renal function. Kidney biopsy shows diffuse glomerular basement membrane thickening with a 'spike and dome' pattern on silver stain and granular IgG and C3 deposits on immunofluorescence in a subepithelial distribution. The MOST likely diagnosis is:
  55. A 55-year-old woman on long-term tenofovir disoproxil fumarate for HIV develops proximal tubular dysfunction with glucosuria (euglycemic), phosphaturia, aminoaciduria, and low serum uric acid. Serum bicarbonate is 16 mEq/L, urine pH is 5.5. This is consistent with:
  56. A 65-year-old man with CKD stage G4 (eGFR 22 mL/min) develops serum potassium of 6.8 mEq/L with peaked T waves on ECG. His current medications include lisinopril, spironolactone, and trimethoprim-sulfamethoxazole. The FIRST intervention for cardiac membrane stabilisation in hyperkalaemia with ECG changes is:
  57. A 65-year-old woman develops AKI after contrast-enhanced CT. Creatinine rises from 1.1 to 1.8 mg/dL at 48 hours. Urine sodium is 14 mEq/L, urine osmolality 520 mOsm/kg. FENa is 0.6%. What does this suggest about the etiology?
  58. A 35-year-old woman has recurrent nephrolithiasis (calcium oxalate stones), nephrocalcinosis, and an arterial blood gas showing: pH 7.30, pCO2 40 mmHg, HCO3 18 mEq/L, urine pH 6.8 despite systemic acidosis. Serum potassium is 2.8 mEq/L. What is the diagnosis?
  59. A 60-year-old man with CKD stage 4 (eGFR 24 mL/min) has serum potassium of 6.2 mEq/L and is on ramipril. ECG shows peaked T waves. Which is the most appropriate IMMEDIATE step to stabilize the cardiac membrane?
  60. A 28-year-old man presents with sudden onset gross hematuria 2 days after an upper respiratory tract infection. His blood pressure is 130/85 mmHg, creatinine 1.1 mg/dL. Urinalysis shows RBC casts. Renal biopsy immunofluorescence shows mesangial IgA deposits. What is the most important long-term prognostic predictor in this condition?
  61. A 70-year-old man undergoes elective CABG. On post-operative day 2, urine output drops to 0.3 mL/kg/hr for 8 hours and creatinine rises from a baseline of 1.0 to 1.8 mg/dL. Urine sodium is 12 mEq/L, fractional excretion of sodium (FeNa) is 0.4%, urine osmolality 480 mOsm/kg. Which KDIGO AKI stage is this, and what is the most likely aetiology?
  62. A 35-year-old woman presents with recurrent nephrolithiasis (calcium oxalate stones), osteomalacia and proximal renal tubular acidosis. Serum bicarbonate is 14 mEq/L, potassium 2.8 mEq/L, urine pH 5.0 after acid load test. She has nephrocalcinosis. The diagnosis is:
  63. A 48-year-old patient with CKD stage 4 (eGFR 22) presents with ECG changes: peaked T waves, widened QRS, PR prolongation. Potassium is 7.2 mEq/L. Bicarbonate is 14 mEq/L. Which is the FIRST therapeutic step to administer?
  64. A 28-year-old man develops nephrotic syndrome: proteinuria 8 g/day, serum albumin 1.8 g/dL, oedema. Renal biopsy shows diffuse mesangial IgA deposits with crescents in 40% of glomeruli, fibronectin staining, and segmental endocapillary proliferation. MEST-C Oxford score is M1E1S1T1C2. He has serum creatinine 2.4 mg/dL. Current KDIGO 2021 guidelines suggest which induction therapy?
  65. A 35-year-old woman presents with acute kidney injury (creatinine rising from 0.9 to 3.2 mg/dL over 3 days), haematuria, red cell casts on urine microscopy, proteinuria 3.2 g/24h, and systemic features of sinusitis and hemoptysis. ANCA (PR3-ANCA/c-ANCA) is positive at high titre. Which syndrome is present and what is the acute induction therapy?
  66. A 50-year-old man with CKD stage 4 (eGFR 22 mL/min/1.73m²) due to diabetic nephropathy has potassium 5.8 mEq/L on repeated testing. ABG shows pH 7.28, HCO3 17 mEq/L, pCO2 38 mmHg. Urinary pH is 5.5 with a urine anion gap of +12. Which type of renal tubular acidosis (RTA) is consistent?
  67. A 28-year-old woman presents with her fourth episode of gross hematuria, always occurring during upper respiratory tract infections (synpharyngitic hematuria). Urinalysis shows 3+ blood and 2+ protein. Serum creatinine is 1.1 mg/dL. Complement levels are normal. Renal biopsy shows mesangial IgA deposits on immunofluorescence. What is the key prognostic factor that determines initiation of immunosuppressive therapy in IgA nephropathy?
  68. A 60-year-old man with known CKD (stage 3b, eGFR 38 mL/min) is started on oral sodium bicarbonate for persistent metabolic acidosis. His hemoglobin is 9.1 g/dL, serum iron 60 μg/dL, TSAT 22%, ferritin 280 ng/mL, reticulocyte count low, and EPO level 18 IU/L (inappropriately low for his degree of anemia). What is the treatment of his anemia?
  69. A 45-year-old man develops severe hyponatremia (serum Na 118 mEq/L) over 48 hours with confusion. He is euvolemic on examination. Urine sodium is 55 mEq/L and urine osmolality is 480 mOsm/kg. Serum osmolality is 248 mOsm/kg. He was started on citalopram 6 weeks ago for depression. What is the maximum safe rate of sodium correction over the first 24 hours to prevent osmotic demyelination syndrome (ODS)?
  70. A 70-year-old man undergoes coronary angiography with 180 mL iodinated contrast. Baseline creatinine is 142 µmol/L (eGFR 42). Forty-eight hours later, creatinine rises to 215 µmol/L. Urine output has been adequate. Urinalysis shows granular casts. The most appropriate preventive strategy that should have been used pre-procedure is:
  71. A 35-year-old woman presents with a 2-week history of haematuria, proteinuria (2.8 g/day), periorbital oedema, and oliguria. Blood pressure is 165/100 mmHg. Serum complement C3 is markedly reduced; C4 is normal. ANCA and anti-GBM are negative. Throat swab 3 weeks prior grew Streptococcus pyogenes. The most likely diagnosis is:
  72. A 50-year-old man with CKD stage 4 (eGFR 22 mL/min) presents with serum potassium 6.8 mEq/L and ECG changes including peaked T waves and a widened QRS (0.14 s). Blood pressure is 130/80 mmHg. The immediate priority treatment that shifts potassium intracellularly fastest is:
  73. A 25-year-old man with recurrent nephrolithiasis has serum bicarbonate of 19 mEq/L, serum potassium 3.0 mEq/L, pH 7.32, urine pH consistently 6.5 (inappropriately alkaline), and nephrocalcinosis on ultrasound. The underlying defect is:
  74. A 55-year-old diabetic patient develops AKI post-contrast CT. Serum creatinine rises from 1.2 mg/dL to 1.9 mg/dL within 48 hours. FENa is 0.4%, urine sodium 12 mEq/L, urine osmolality 520 mOsm/kg. Which pattern of injury does this MOST likely represent?
  75. A 28-year-old woman presents with nephrotic syndrome (proteinuria 7 g/day, serum albumin 2.0 g/dL, peripheral oedema). Renal biopsy on electron microscopy shows diffuse effacement of podocyte foot processes with no immune deposits. Light microscopy shows no significant abnormality. What is the MOST appropriate first-line treatment?
  76. A 42-year-old man presents with recurrent nephrolithiasis and is found to have non-anion gap metabolic acidosis. Serum potassium is 2.8 mEq/L. Urine pH is 6.8 despite systemic acidosis. Urine anion gap is positive (+12). What is the MOST likely type of renal tubular acidosis?
  77. A 68-year-old man with CKD stage 4 (eGFR 22 mL/min/1.73m²) and type 2 diabetes is on lisinopril, furosemide, and amlodipine. He develops serum potassium of 6.2 mEq/L on routine bloods with no ECG changes. Which intervention is MOST appropriate FIRST?
  78. A 28-year-old man presents with haematuria, proteinuria (1.8 g/day), and hypertension. Serum creatinine is 1.6 mg/dL. Renal biopsy shows mesangial IgA deposits on immunofluorescence. Electron microscopy shows paramesangial electron-dense deposits. Oxford MEST-C score: M1 E0 S1 T1 C0. What does this Oxford classification indicate about prognosis?
  79. A 65-year-old diabetic woman on ACE inhibitor develops AKI after starting an NSAID for joint pain. Serum creatinine rises from 1.1 to 2.9 mg/dL. FENa is 0.3%. Urine microscopy shows hyaline casts only. What is the mechanism of NSAID-induced AKI in this setting?
  80. A 35-year-old woman with nephrotic syndrome secondary to minimal change disease has been on prednisolone for 10 weeks with no response (steroid-resistant nephrotic syndrome). What is the next treatment step?
  81. A patient with chronic diarrhoea presents with hypokalaemia (K⁺ 2.8 mEq/L), metabolic acidosis (HCO₃⁻ 14 mEq/L), and urine pH consistently 5.2. Urine anion gap is negative. What type of renal tubular acidosis (RTA) does this pattern suggest?
  82. A 65-year-old man with CKD stage 4 (eGFR 22 mL/min/1.73m²), type 2 diabetes, and serum potassium of 5.8 mEq/L develops worsening hyperkalaemia despite dietary restriction and standard measures. He requires RAAS blockade for cardiorenal protection. According to current guidelines, which novel agent is preferred for managing chronic hyperkalaemia to enable continuation of RAAS blockade?
  83. A 28-year-old man presents with peripheral oedema, frothy urine, serum albumin 2.1 g/dL, and 24-hour urine protein 6.8 g. Complement levels are normal. Renal biopsy shows podocyte foot process effacement on electron microscopy with no immune deposits on immunofluorescence. The diagnosis is:
  84. A 42-year-old woman with CKD stage 3b and anaemia (Hb 9.2 g/dL, serum ferritin 280 ng/mL, TSAT 28%) is started on erythropoiesis-stimulating agent (ESA) therapy. The Hb target according to KDIGO 2012 guidelines and updated guidance is:
  85. A 55-year-old woman with type 1 RTA has a non-anion gap metabolic acidosis and hyperchloraemia. Urine anion gap is positive (+12 mEq/L). Urine pH is 6.5 despite systemic acidosis (pH 7.28). The urine anion gap indicates:
  86. A patient with type 1 RTA (distal RTA) has which characteristic set of findings?
  87. A 68-year-old woman with CKD stage 4 (eGFR 22 mL/min/1.73m²) has serum potassium 6.2 mEq/L. She is on lisinopril, amlodipine, and furosemide. ECG shows peaked T waves. Which is the first drug given for cardiac membrane stabilisation?
  88. The DAPA-CKD trial demonstrated the benefit of dapagliflozin in CKD patients regardless of the presence or absence of type 2 diabetes. What was the primary composite outcome significantly reduced in this trial?
  89. A 25-year-old woman develops nephrotic syndrome with 8 g/day proteinuria, hypoalbuminaemia, and oedema. Renal biopsy shows podocyte effacement on electron microscopy with no immune deposits on immunofluorescence. She is initially treated with prednisolone 1 mg/kg/day. After 16 weeks she remains non-responsive. Which is the next step per KDIGO 2021 guidelines?
  90. A 55-year-old man has serum sodium of 118 mEq/L, low plasma osmolality, urine osmolality 520 mOsm/kg, urine sodium 68 mEq/L. He has no oedema, euvolaemic. Serum urate is low. He is a known small cell lung cancer patient. Which is the correct management?
  91. A 45-year-old woman with nephrotic syndrome and renal biopsy showing membranous nephropathy is anti-PLA2R antibody positive with proteinuria of 8 g/day. She has been on supportive therapy (ACE inhibitor, statins) for 6 months with no improvement. Which is now the first-line immunosuppressive therapy per KDIGO 2021?
  92. A 60-year-old diabetic man has eGFR 22 mL/min/1.73 m² and serum potassium 5.8 mEq/L. He is on losartan 50 mg/day. Arterial blood gas shows pH 7.30, HCO3 16 mEq/L, pCO2 32 mmHg. Urine anion gap is +12. What is the acid-base disorder and most likely cause of the hyperchloraemic metabolic acidosis?
  93. A 70-year-old man with CKD (eGFR 18 mL/min) develops acute kidney injury after IV contrast for CT scan. Serum creatinine rises from 3.2 to 4.9 mg/dL over 48 hours. What is the most important preventive strategy to reduce contrast-induced nephropathy in high-risk CKD patients?
  94. A 35-year-old man presents with haemoptysis and rapidly progressive glomerulonephritis. Creatinine is 4.8 mg/dL. Anti-GBM antibody is positive. ANCA is also positive. Renal biopsy shows >90% crescents. Lungs show diffuse alveolar haemorrhage on bronchoscopy. What is the treatment of choice?
  95. A 45-year-old diabetic woman has CKD stage 3b (eGFR 38 mL/min/1.73m²), urine ACR 650 mg/g, BP 148/92 despite amlodipine 10 mg. She is on metformin 500 mg twice daily. Which combination of additional therapies has the strongest evidence to slow CKD progression in diabetic nephropathy?
  96. A 28-year-old man with recurrent nephrolithiasis has serum potassium 3.1 mEq/L, bicarbonate 14 mEq/L, urine pH 6.8 (inappropriately alkaline), urine anion gap +12. Urine calcium is elevated. Which type of renal tubular acidosis does he have, and what is the underlying defect?
  97. A 22-year-old woman presents with nephrotic syndrome: proteinuria 8 g/day, albumin 2.1 g/dL, oedema. Renal biopsy shows effacement of podocyte foot processes on electron microscopy with no immune deposits on immunofluorescence and normal light microscopy. What is the diagnosis and the first-line treatment?
  98. A 25-year-old woman presents with recurrent macroscopic hematuria following upper respiratory tract infections (synpharyngitic hematuria) over 3 years. No proteinuria. Renal biopsy shows mesangial IgA deposits on immunofluorescence. Which Oxford MEST-C criterion is associated with the worst prognosis in IgA nephropathy?
  99. A 38-year-old man develops acute kidney injury (creatinine rising from 0.9 to 3.8 mg/dL over 4 days) after starting vancomycin and piperacillin-tazobactam for a soft tissue infection. Urinalysis shows sterile pyuria and white cell casts. Urine eosinophils are positive (Hansel stain). Kidney biopsy would most likely show:
  100. A 52-year-old man with CKD stage 4 (eGFR 22 mL/min) has serum bicarbonate of 16 mEq/L. According to KDIGO guidelines, what is the target bicarbonate and how should it be treated?
  101. A 35-year-old man with sickle cell disease presents with proteinuria 2.8 g/day and eGFR 55 mL/min. Renal biopsy shows focal segmental glomerulosclerosis (FSGS) on light microscopy and foot process effacement >80% on electron microscopy. The pattern is consistent with:
  102. A 62-year-old woman with CKD-5D on hemodialysis for 5 years develops severe pruritus and patchy indurated skin plaques on the extremities and trunk. Skin biopsy shows dermal fibrosis with spindle cells positive for CD34. Which condition does she have, and what is the main precipitating factor?
  103. A 28-year-old man presents with nephrotic syndrome (proteinuria 8 g/day, albumin 2.1 g/dL). Renal biopsy reveals segmental sclerosis with collapse of glomerular tufts, visceral epithelial cell hypertrophy, and protein resorption droplets. Electron microscopy shows diffuse podocyte foot process effacement. What is the most likely diagnosis?
  104. A 65-year-old diabetic woman with CKD G3b (eGFR 36) has persistent albuminuria 680 mg/g on ACE inhibitor and optimal blood pressure control. Which additional agent has been shown in recent trials to reduce CKD progression independent of glycaemic control?
  105. A 35-year-old woman presents with hypokalaemia (K+ 2.9 mEq/L), metabolic alkalosis (HCO3− 32 mEq/L), normal blood pressure, and low urinary chloride (< 10 mEq/L) after prolonged vomiting. What is the underlying pathophysiology?
  106. A 72-year-old man with known CKD G4 (eGFR 22) is admitted with a serum potassium of 6.8 mEq/L. ECG shows peaked T waves and widened QRS complexes. Which is the FIRST intervention to perform?
  107. A 35-year-old man presents with haematuria, RBC casts in urine, hypertension, and declining GFR. Serum complement C3 is low, C4 is normal. ANCA is negative, ANA negative, anti-dsDNA negative. ASO titre is elevated. Renal biopsy shows diffuse endocapillary hypercellularity with 'humps' on electron microscopy. What is the diagnosis?
  108. A 28-year-old woman has plasma pH 7.31, bicarbonate 14 mEq/L, pCO2 30 mmHg, serum Na 138 mEq/L, Cl 110 mEq/L, K 2.8 mEq/L. Anion gap = 14 mEq/L (normal). Urine pH is 6.2 (alkaline). Urine anion gap is +10 (positive). Which type of RTA is present?
  109. A 60-year-old man develops severe hyponatraemia (serum Na 112 mEq/L) after elective hip replacement. He is symptomatic with confusion and mild seizures. What is the correct initial rate of sodium correction to prevent osmotic demyelination syndrome (ODS) while treating acute symptoms?
  110. A 72-year-old man with CKD stage 4 (eGFR 22) is referred for nephrology care. Fasting blood glucose is 140 mg/dL, haemoglobin 9.8 g/dL with MCV 82, serum ferritin 350 ng/mL, transferrin saturation 18%. Which erythropoiesis-stimulating agent (ESA) consideration is most important here?
  111. A 22-year-old man presents with acute nephritic syndrome 10 days after streptococcal pharyngitis. Serum C3 is markedly reduced, C4 is normal. Renal biopsy shows diffuse endocapillary proliferation with 'humps' on electron microscopy and granular IgG and C3 on immunofluorescence. The MOST likely glomerular disease and the expected course are:
  112. A 35-year-old man with recurrent calcium oxalate renal stones has a 24-hour urine: calcium 420 mg, oxalate 48 mg, citrate 95 mg (low), pH 5.9, and volume 900 mL. Which is the MOST important pharmacological intervention to reduce stone recurrence?
  113. A 45-year-old man has Type 4 renal tubular acidosis (hyperkalaemic distal RTA) secondary to diabetic nephropathy. Which of the following is the MECHANISM and which drug CORRECTS both hyperkalaemia and acidosis?
  114. A 68-year-old woman is on ACEI for CKD stage 3b (eGFR 34). Her serum potassium is 5.8 mEq/L and creatinine is 2.4 mg/dL. She has no oedema and BP is well-controlled at 128/78. What is the MOST appropriate management?
  115. A 65-year-old man on long-term lithium therapy presents with polyuria (6 litres/day) and polydipsia. Serum sodium 148 mmol/L, serum osmolality 310 mosm/kg, urine osmolality 140 mosm/kg, urine sodium 20 mmol/L. Water deprivation test: urine osmolality increases to only 165 mosm/kg. After desmopressin injection: urine osmolality 175 mosm/kg (increase <10%). This pattern is consistent with:
  116. A 35-year-old woman presents with recurrent renal stones (calcium oxalate) and is found to have hyperchloraemic non-anion-gap metabolic acidosis, serum potassium 2.8 mmol/L, and urine pH 6.5 despite serum pH 7.28. 24-hour urine citrate is low. This presentation is MOST consistent with:
  117. A 72-year-old man with diabetes and CKD stage 3a (eGFR 55) is admitted with bilateral leg oedema and frothy urine. 24-hour urine protein is 5.8 g. Renal biopsy shows diffuse glomerulosclerosis on LM; on EM, spike-and-dome pattern with subepithelial electron-dense deposits. The MOST likely diagnosis is:
  118. A 55-year-old woman with CKD stage 5D on haemodialysis (3× weekly) develops hyperkalaemia (K+ 6.8 mmol/L) with peaked T waves on ECG between dialysis sessions. Which oral potassium binder approved in India/globally has a mechanism of non-absorbed sodium-free exchange in the GI tract?
  119. A 42-year-old woman with HIV on tenofovir, emtricitabine, and efavirenz for 4 years develops proximal muscle weakness, polyuria, and bone pain. Labs: serum phosphate 0.45 mmol/L (low), K+ 2.9 mmol/L, bicarb 18 mmol/L, urine glucose ++ (serum glucose normal), mild proteinuria. X-ray shows pseudofractures. This syndrome is BEST explained by:
  120. A 50-year-old man with IgA nephropathy (confirmed by biopsy showing mesangial IgA deposits) has proteinuria 2.8 g/day despite 3 months of maximal RAS blockade (ACE inhibitor + ARB optimization), eGFR 48 mL/min/1.73m², BP 128/78. Per 2023 KDIGO guidelines, what is the next recommended therapy?
  121. A 45-year-old HIV-positive patient on tenofovir disoproxil fumarate (TDF)-based ART develops proximal tubular dysfunction: hypophosphatemia, glycosuria with normal blood glucose, hypokalemia, low urine uric acid reabsorption, and low serum uric acid. Serum creatinine is 1.6 mg/dL (rising from baseline 1.0). What is the likely diagnosis and best management?
  122. A 30-year-old woman with SLE presents with serum bicarbonate 14 mEq/L, urine pH 6.8 (inappropriately high), serum potassium 3.0 mEq/L, urine anion gap positive (+12), and normal anion gap metabolic acidosis. Serum creatinine 1.0. What type of renal tubular acidosis (RTA) does she have and what is its mechanism?
  123. A 60-year-old man with hypertension and CKD Stage 4 (eGFR 24) has serum potassium 5.8 mEq/L on ACE inhibitor + spironolactone. He has no ECG changes. He is on dietary potassium restriction. What is the preferred pharmacological approach to hyperkalemia in this CKD patient?
  124. A patient with AKI due to rhabdomyolysis has a creatinine of 4.8 mg/dL on day 3. Urine dipstick is strongly positive for blood but microscopy shows no red blood cells. The mechanism responsible for this discordant finding is:
  125. A 40-year-old woman with a history of recurrent renal calculi has serum: Na 139, K 2.9, Cl 114, HCO3 14 mmol/L, albumin normal. Urine pH is 6.5. Urine anion gap is +12 mEq/L (positive). Which type of renal tubular acidosis (RTA) does this represent?
  126. Regarding CKD mineral and bone disorder (CKD-MBD), the earliest metabolic derangement that appears even in CKD Stage 2 (eGFR 60–89), before any change in serum calcium or phosphorus, is:
  127. A 35-year-old man presents with severe hyponatraemia (serum Na 116 mmol/L) and is confused. Brain MRI done 3 days after correction shows symmetric T2 hyperintensities in the pons and extrapontine structures. This complication is known as osmotic demyelination syndrome (ODS). The MOST important preventable cause was:
  128. A 60-year-old man with diabetic nephropathy has eGFR 32 mL/min and urine ACR 620 mg/g. He is on maximum-dose ACE inhibitor. Per KDIGO 2022 guidelines, which therapy should be ADDED to provide additional renoprotection?
  129. In renal tubular acidosis (RTA), a patient has hyperchloraemic non-anion gap metabolic acidosis with serum K+ 5.8 mEq/L and urine pH 5.8. Urine anion gap is positive. This pattern is MOST consistent with:
  130. Contrast-induced acute kidney injury (CI-AKI) is defined as a rise in serum creatinine by what threshold within 48 hours of contrast administration, according to the 2023 KDIGO AKI guidelines?
  131. A patient on lithium therapy for bipolar disorder develops polyuria of 6 litres/day with dilute urine (osmolality 120 mOsm/kg). Urine osmolality does not rise after intranasal desmopressin. This presentation is consistent with:
  132. A 55-year-old woman with hypertension and type 2 diabetes has proteinuria of 3.8 g/24 hours and eGFR 42 mL/min. She is already on ramipril 10 mg daily. Her blood pressure is 132/80 mmHg. According to KDIGO 2022 CKD guidelines, what additional agent has the strongest evidence to slow CKD progression in this patient?
  133. A 25-year-old man presents with hypokalaemia (K⁺ 2.6 mmol/L), metabolic alkalosis (HCO3⁻ 32 mmol/L), normal blood pressure, and urinary chloride of 45 mmol/L. Serum magnesium is 0.52 mmol/L (low). Which diagnosis best explains this constellation?
  134. A patient is found to have a urine pH of 6.2, serum bicarbonate of 14 mmol/L, and normal anion gap metabolic acidosis. Urinary ammonium excretion (estimated from urine anion gap) is positive (+12 mmol/L). What type of renal tubular acidosis is present?
  135. A 44-year-old woman with a known history of Sjögren's syndrome develops distal renal tubular acidosis (dRTA). Arterial blood gas: pH 7.29, HCO3 14 mEq/L, pCO2 30 mmHg. Serum K+ 2.9 mEq/L. Urine pH is 6.8 despite systemic acidosis. Which mechanism best explains dRTA pathogenesis in Sjögren's syndrome?
  136. A 62-year-old man with CKD stage 4 (eGFR 22 mL/min/1.73m², serum potassium 5.6 mEq/L, phosphate 5.9 mg/dL, bicarbonate 19 mEq/L) is reviewed. His iPTH is 220 pg/mL and calcium is 9.1 mg/dL. Per KDIGO 2023 guidelines on CKD-MBD, which agent is preferred for managing his hyperphosphataemia at this stage?
  137. A 34-year-old woman with primary nephrotic syndrome (proteinuria 7.2 g/day, albumin 2.1 g/dL) shows minimal change disease on biopsy. She is on prednisolone 1 mg/kg/day for 6 weeks with minimal response. Cyclophosphamide therapy is considered. Which pathophysiological explanation best describes the mechanism of podocyte injury in minimal change disease?
  138. A 58-year-old man with a serum sodium of 116 mEq/L, severe confusion, and grand-mal seizures is brought to the emergency. He has polydipsia and dilute urine (osmolality 95 mOsm/kg). The diagnosis is psychogenic polydipsia. What is the maximum safe rate of sodium correction in the first 24 hours?
  139. A 40-year-old woman has a serum potassium of 2.8 mEq/L, normal blood pressure, and urinary potassium excretion of 60 mEq/day (raised). Serum bicarbonate is 30 mEq/L. Blood gas shows metabolic alkalosis. Serum aldosterone and renin are BOTH suppressed. Which is the MOST likely diagnosis?
  140. A 55-year-old man develops AKI after cardiac surgery (creatinine rises from 0.9 to 3.2 mg/dL). Urine microscopy reveals muddy-brown granular casts and tubular epithelial cell casts. FENa is 3.2%. The MOST appropriate management is:
  141. A 35-year-old woman has recurrent kidney stones. Urine pH is persistently 6.5–7.0 despite hydration. Serum potassium is 3.0 mEq/L, HCO3 is 16 mEq/L. Urine anion gap is positive (+12). Urine pH fails to drop below 5.5 with ammonium chloride loading. She is non-acidotic at presentation. Which RTA type is this?
  142. A 60-year-old woman on long-term lithium for bipolar disorder develops nephrogenic diabetes insipidus (NDI). Serum sodium is 152 mEq/L. Urine osmolality is 180 mOsm/kg after water deprivation. Which is the MOST appropriate treatment to reduce urine output in lithium-induced NDI?
  143. A 70-year-old man with stage 5 CKD on haemodialysis three times weekly is found to have serum calcium 8.0 mg/dL, phosphate 7.2 mg/dL, PTH 820 pg/mL, and 25-OH vitamin D 12 ng/mL. Which treatment should be initiated FIRST according to KDIGO 2017 CKD-MBD guidelines?
  144. A 35-year-old woman presents with hematuria, proteinuria, and hypertension after a sore throat 10 days ago. C3 is low, C4 is normal, and anti-streptolysin O (ASO) titre is elevated. Renal biopsy shows subepithelial humps ('starry sky') on electron microscopy. What is the mechanism of complement activation?
  145. A patient has normal anion gap metabolic acidosis with hypokalemia. Urine pH is 6.5 (alkaline). She has a history of Sjögren's syndrome. What is the MOST likely diagnosis?
  146. A 72-year-old patient with CKD Stage 4 (eGFR 22 mL/min/1.73m²) develops secondary hyperparathyroidism with PTH 450 pg/mL. Serum phosphate is 6.2 mg/dL. Which medication is preferred as a phosphate binder with the LOWEST risk of hypercalcemia?
  147. A 40-year-old man develops profound hyponatremia (Na+ 112 mEq/L) after marathon running; he is symptomatic with nausea and confusion. What is the appropriate correction rate to avoid osmotic demyelination syndrome (ODS)?
  148. A 38-year-old man presents with bilateral flank pain, haematuria, and a serum creatinine of 3.2 mg/dL over 3 weeks. He had an upper respiratory infection 3 weeks ago. Urinalysis shows 3+ blood, 2+ protein, and RBC casts. Complement C3 is 62 mg/dL (low), C4 is 18 mg/dL (normal). ANCA, anti-GBM, ANA, anti-dsDNA are all negative. Anti-streptolysin O (ASO) titre is 180 Todd units (borderline). What is the most likely diagnosis and the expected course?
  149. A 55-year-old man with type 2 diabetes, proteinuria (urine albumin-creatinine ratio 850 mg/g), and eGFR 42 mL/min/1.73m² is on maximum-dose ACE inhibitor and SGLT-2 inhibitor. Which additional therapy has been shown in the FIDELIO-DKD and FIGARO-DKD trials to reduce CKD progression and cardiovascular events in diabetic kidney disease?
  150. A 42-year-old woman presents with muscle weakness, polyuria, and polydipsia. Lab results: serum K+ 2.8 mEq/L, serum bicarbonate 32 mEq/L, arterial pH 7.48, serum sodium 142 mEq/L, urine K+ 48 mEq/L on spot urine (high). Blood pressure is 160/100 mmHg. Serum magnesium is normal. What is the TRANSTUBULAR POTASSIUM GRADIENT (TTKG) in this scenario, and what does it indicate?
  151. A patient presents with renal tubular acidosis. Lab results: serum Na+ 138, K+ 3.1 mEq/L, Cl− 112 mEq/L, HCO3− 14 mEq/L, pH 7.30. Urine pH is 5.5. Urine anion gap (UAG = urine Na+ + urine K+ − urine Cl−) is −15 mEq/L. Which type of RTA does this pattern indicate?
  152. A 60-year-old woman develops AKI after contrast exposure for CT angiography (creatinine rises from 1.0 to 1.9 mg/dL at 48 hours). Urinalysis shows muddy brown granular casts. Fractional excretion of sodium (FENa) is 3.2%. What type of AKI is this?
  153. A 25-year-old woman has recurrent nephrolithiasis. Urine pH is consistently 6.5-7.0. Serum bicarbonate is 16 mEq/L, potassium 2.8 mEq/L, and chloride 112 mEq/L. Urine anion gap is positive. Which type of renal tubular acidosis (RTA) is MOST likely?
  154. A 68-year-old man with CKD stage 4 (eGFR 22) and metabolic acidosis (serum bicarbonate 18 mEq/L) is not on oral bicarbonate. According to KDIGO 2022, when should oral bicarbonate supplementation be initiated in CKD?
  155. A 35-year-old patient with nephrotic syndrome (proteinuria 6.8 g/day, serum albumin 1.8 g/dL) develops a flank pain and haematuria. Doppler ultrasound shows no flow in the left renal vein. Which anticoagulation is recommended?
  156. A 55-year-old man has serum sodium of 122 mEq/L with symptoms of confusion and nausea. He has no oedema, BP is normal, urine osmolality is 480 mOsm/kg, serum osmolality is 254 mOsm/kg, and urine sodium is 62 mEq/L. TSH and morning cortisol are normal. What is the MOST likely diagnosis?
  157. A 55-year-old woman with nephrotic syndrome (proteinuria 8 g/day, albumin 1.9 g/dL) has a renal biopsy showing glomerular capillary wall 'spike and dome' deposits by silver stain, with subepithelial electron-dense deposits on EM, and granular IgG and C3 deposits on immunofluorescence. Anti-PLA2R antibody is positive. The first-line treatment is:
  158. A 48-year-old HIV-positive man on tenofovir alafenamide (TAF)-based ART for 3 years develops weakness, bone pain, and polyuria. Labs: Na 136, K 2.9, Cl 112, HCO3 14 mEq/L, phosphate 1.8 mg/dL, uric acid 2.1 mg/dL, glucose 85 mg/dL (urine glucose positive). Urine shows glycosuria, aminoaciduria, and phosphaturia. The underlying tubular syndrome is:
  159. A 67-year-old man with type 2 diabetes and established atherosclerotic cardiovascular disease (prior MI, PAD) has HbA1c 8.1%, eGFR 62, and is on metformin. Which additional antidiabetic agent is recommended as second-line by current ADA/ESC guidelines for cardiorenal protection?
  160. A 48-year-old woman presents with episodic flushing, diarrhoea, and wheezing. Urine 5-HIAA is markedly elevated at 78 mg/24h (normal <8 mg). CT abdomen shows a 2.3 cm ileal mass with liver metastases. Echocardiography shows tricuspid regurgitation and pulmonary stenosis. What complication of carcinoid syndrome is demonstrated by the echocardiographic findings?
  161. A 35-year-old man presents with progressive exertional dyspnoea, clubbing, and cyanosis since childhood. Echocardiography shows right-to-left shunt through a VSD and Eisenmenger physiology (pulmonary arterial pressure equal to systemic). SpO2 is 82% on room air. Which therapy is now approved and most appropriate for symptom and haemodynamic improvement in Eisenmenger syndrome?
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