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This MCQ relates to the learning outcomes in the drugs and the kidney lecture. Good luck!

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Drugs and the kidney

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Question 1

Which of the following is not a consideration when prescribing for a patient with renal disease?

A
How their renal impairment affects their ability to process/ excrete the drug
B
Whether the drug will worsen their renal impairment
C
If they will be able to handle the dose normally given to people without kidney disease
D
Whether the drug should be delivered orally or intravenously
Question 1 Explanation: 
All other options are key considerations when prescribing in the context of renal impairment. The method of administration will not have an effect on the ability of the kidney to excrete the drug
Question 2

A patient with acute kidney injury (AKI) is prescribed spironolactone to help reduce their blood pressure. What are the issues with prescribing this drug?

A
Spironolactone is filtered and not secreted so the kidney needs to be functioning properly in order for the drug to enter the kidney and have its effect
B
Side effects of the drug can end up worsening the AKI in the long term
C
It can cause hyperkalaemia
D
It can suppress normal functioning of other organs
Question 2 Explanation: 
Spironolactone is a mineralocorticoid antagonist and as such will have effects on organs outside of the kidney by blocking mineralocorticoid activity. The organs that tend to be effected are the sexual organs such as the breasts and gonads in high doses.
Question 3

Which of the following is not a consideration when adjusting the dose of anti-hypertensives?

A
Degree of renal impairment
B
Proportion of drug eliminated by renal excretion
C
Drug toxicity
D
Their diet
Question 3 Explanation: 
It's important to note that diet can effect some drugs e.g. iron supplements shouldn't be taken with milk, and a diet high in leafy, green vegetables may effect the efficacy of warfarin.
Question 4

A patient with chronic kidney disease and heart disease is placed on dialysis and atenolol. What is the issue with their treatment?

A
This drug is only effective in patients with AKI
B
The atenolol prescribed for their heart disease will be removed by dialysis
C
The drug is nephrotoxic
D
Being put on dialysis can worsen their heart disease
Question 4 Explanation: 
Atenolol is a beta 1 receptor selective antagonist and can be used in hypertension and angina. Dialysis will mimic the effect of the kidneys and so will remove any drug in the blood. This will decrease the efficacy of the medication.
Question 5

What is a diuretic?

A
A substance that promotes the formation of urine by promoting renal excretion of sodium
B
A substance that makes you retain water
C
A substance that makes you excrete potassium
D
A substance that makes you excrete calcium
Question 6

A patient with heart failure has peripheral oedema. How would prescribing furosemide help to reduce their oedema?

A
The drug prevents water from exiting the bloodstream by osmosis
B
The drug causes diuresis, thus excess interstitial fluid would be removed from the interstitial space and back into blood vessels by osmosis
C
The drug can cause hypokalemia and thus water moves into cells more easily, causing oedema
D
It blocks the expression of ENAC channels in the distal convoluted tubule, increasing diuresis
Question 6 Explanation: 
Furosemide is a powerful loop diuretic which inhibits the Na+/K+/2CL- transporter in the loop of Henle. This will increase the amount of fluid excreted and so will allow excess fluid to be removed and interstitial fluid to be drawn back into vessels.
Question 7

Which of the following is not an accurate mechanism of action for the given drug class?

A
Thiazides act by blocking the sodium and chloride symporter in the eDCT
B
Loop diuretics block the sodium, potassium, 2 chloride symporter, increasing the concentration of the filtrate and promoting diuresis
C
Carbonic anhydrase inhibitors block the conversion of water and carbon dioxide to protons and bicarbonate
D
Osmotic diuretics cross the cell and nuclear membrane blocking transcription of ENAC channels that are subsequently expressed on the cell membrane
Question 7 Explanation: 
Osmotic diuretics increase the osmolality of the filtrate and therefore prevent water reabsorption. They act best where most osmotic reabsorption occurs (i.e. proximal tubule, descending loop of Henle). They elevate plasma osmolarity. All other answers are correct.
Question 8

A patient with high blood pressure is prescribed furosemide and subsequently develops hypokalaemia. Explain why this has happened.

A
Furosemide causes secretion of potassium into the filtrate and down regulates other potassium channels so it cannot be reabsorbed.
B
Furosemide increases the concentration of sodium in the filtrate so there is a higher rate of Na/K exchange in the distal convoluted tubules.
C
Furosemide is excreted in the urine and binds to potassium so more is excreted.
D
Furosemide decreases the concentration of potassium in the filtrate. Potassium is then drawn into the filtrate down its concentration gradient through diffusion.
Question 8 Explanation: 
Hypokalaemia means low serum potassium. Furosemide blocks the Na+/K+/2Cl- transporter in the loop of Henle. This means more sodium is retained in the filtrate. In the distal convoluted tubules, sodium is reabsorbed via secondary active transport in exchange for serum potassium, which is then excreted in the filtrate.
Question 9

Which of the following is not an indication for acetazolamide?

A
Raised intraoccular pressure
B
Prophylaxis for mountain sickness
C
Diarrhoea
D
Epilepsy
Question 9 Explanation: 
Acetazolamide is a carbonic anhydrase inhibitor and reduce aqueous humour volume. Although carbonic anhydrase is also found the gastric mucosa (in the production of stomach acid) acetazolamide has no impact on diarrhoea.
Question 10

You are using an ophthalmoscope on a patient and you notice that they have papilledema. Which of the following drugs are indicated for the condition this is associated with?

A
Macrogol
B
Mannitol
C
Bisacodyl
D
Spironolactone
Question 10 Explanation: 
An ophthalmoscope is used to visualise the back of a patient’s eye. Papilledema is swelling of the optic disc inside the eye, that can be visualised using this instrument. Papilledema is a sign of raised intracranial pressure, which can be treated using mannitol.
Question 11

Describe the mechanism of action of amiloride.

A
It increases the oncotic pressure of the filtrate, preventing water to flow into the tubular epithelial cells by osmosis
B
It prevents the movement of sodium and chloride into the tubular epithelial cells
C
It blocks ENaC channels in the DCT, preventing sodium uptake into tubular epithelial cells
D
It blocks the enzyme carbonic anhydrase in the proximal convoluted tubule
Question 11 Explanation: 
Amiloride is a potassium-sparing diuretic that will cause the blockade of sodium reabsorption by blocking the epithelial sodium channel
Question 12

A patient has an adrenal gland tumor causing an increase in serum aldosterone concentration. What can be a consequence of this?

A
Polyuria
B
Polydipsia
C
Hypokalaemia
D
Hyponatremia
Question 12 Explanation: 
Aldosterone acts in the nucleus to increase transcription and translation of ENAC channels on tubular epithelial cells. As a consequence sodium uptake into the cell is increased and the sodium , potassium ATPase activity increases to return the cell to its resting membrane potential. Since the sodium, potassium ATPase activity is increased, more potassium is drawn out from the interstitial fluid, thus causing hypokalaemia.
Question 13

A patient is prescribed Losartan for their hypertension. Relating to its mechanism of action, which of the following are correct?

A
Renin is released by juxtaglomerular cells —> Losartan blocks angiotensinogen to angiotensin 1 —> No angiotensin 2 is produced
B
Renin is released by juxtaglomerular cells —> Renin converts angiotensinogen to angiotensin 1 —> angiotensin 1 is converted to angiotensin 2 by Angiotensin converting enzyme —> Losartan binds to Angiotensin 2 receptors, preventing its actions
C
Losartan inhibits the synthesis of renin in the kidney
D
Losartan blocks the synthesis of Angiotensin converting enzyme (ACE), preventing the conversion of angiotensin 1 to angiotensin 2 by ACE
Question 13 Explanation: 
Angiotensin 2 causes potent vasoconstriction, aldosterone and ADH release. Losartan blocks the last step in this pathway by competitively binding to Angiotensin 2 receptors, preventing an increase in blood pressure.
Question 14

Where is Angiotensin converting enzyme (ACE) produced?

A
Lungs
B
Liver
C
Kidney
D
Brain
Question 15

A patient on your ward is admitted with acute kidney injury (AKI). What part of the RAAS system would most likely be affected by this?

A
Production of angiotensin converting enzyme (ACE)
B
Production of spironolactone
C
Production of renin
D
Production of alpha-1 hydroxylase
Question 15 Explanation: 
Production of angiotensin converting enzyme occurs in the lungs. Spironolactone is a drug so is not produced in the body, alpha-1 hydroxylase is produced in the kidneys and in other sites like the skin. Renin is only released by juxtaglomerular cells in the kidney and so is most likely to be effected.
Question 16

What is the intermediate step of the reaction catalysed by carbonic anhydrase?

A
Sulfuric acid
B
Carbonic acid
C
Bicarbonate and proton
D
Calcium carbonate
Question 16 Explanation: 
  H2O + CO2 <- ->H2CO3<- -> H+ + HCO3-
Question 17

There is a high concentration  of H+ + HCO3- inside a tubular epithelial cell. What is the most likely product of this reaction?

A
H2O + CO2 
B
H2O only
C
H2CO3
D
H+ + HCO3-
Question 17 Explanation: 
According to Le Chatelier’s principle, in a readily reversible reaction, the side of the reaction with a higher concentration of molecules will move to the opposite side of the equation in an attempt to restore equilibrium. In this case as there is a higher concentration of products (H+ + HCO3- ) the reaction will be forced to the side of the reactants (H2O + CO2 ) to restore equilibrium, thus increasing the concentration of reactants.
Question 18

Which of the following is not considered a thiazide

A
Bendroflumethiazide
B
Hydrochlorothiazide
C
Chloroflumethiazide
D
Indapamide
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