Paper II — Kidney, endocrine and metabolic disease

Night-Before Master Sheet — All 36 Questions

One row per question. Left column = the line that must appear in your answer. Right column = the current-evidence line that lifts it above a pass.

PART I — RENAL PHYSIOLOGY AND ASSESSMENT

Question Must-write core Update to quote

1 GFR Peak 140 in the third decade, −8 mL/min/1.73 m² per KDIGO 2024: race-free eGFRcr-cys preferred, decade; creatinine 1 mg/dL = GFR 120 at age 20 but 60 at especially where creatinine is unreliable; age 80; Cockcroft–Gault for drug dosing; one-third of point-of-care testing where labs are scarce older adults show no decline 2 Renal biopsy Same indications as the young, but complications more Biopsy-free membranous diagnosis if anti-serious; nephrotic syndrome = 50% of biopsies; PLA2R positive with normal function — but crescentic GN peaks at 60–79 biopsy the atypical elderly, since amyloid coexists PART II — FLUID, ELECTROLYTE AND ACID–BASE DISORDERS Question Must-write core Update to quote 3 Fluid & Lead with ageing physiology: blunted thirst, concentrating Correction cap 8–10 mEq/24 h with DDAVP electrolytes −30 mOsm/kg per decade, free water clearance 5.9 vs re-lowering; empagliflozin for SIAD; 16.2 mL/min, salt and urea wasting, hypoaldosteronism. potassium binders before stopping RASi Hypovolaemia is always pathological in the old 4 Hyponatraemia Serum osm → urine osm (100) → urine Na (20 / 30–40) Cap 8–10 mEq/24 h (6–8 if high risk); active → volume status. Cognitive impairment even with mild re-lowering; beware autocorrection once the hyponatraemia thiazide stops 5 SIADH Four features: high urine osm, continued natriuresis, Empagliflozin 25 mg raised Na by 4.1 euvolaemia, normal renal/adrenal/thyroid. Low uric mEq/L in chronic SIAD; urea preferred over acid. Exclude cerebral salt wasting vaptans; deprescribing the SSRI is definitive 6 K⁺ and Mg²⁺ Correct magnesium before potassium (ROMK Deprescribe the PPI rather than escalate unblocking); never IV potassium in dextrose; U waves vs magnesium; SGLT2i incidentally raise serum torsades magnesium 7 Potassium 5.7 Not an emergency without ECG change. Repeat the KDIGO 2024: binder before reducing RASi; sample, ECG, drug review, salt substitute, bicarbonate for SZC/patiromer; resonium removed from type 4 RTA acute algorithms 8 Hypercalcaemia Correct for albumin (+0.8 per 1 g/dL) → measure PTH Endocrine Society: denosumab preferred → branch. Saline + zoledronate 4 mg / pamidronate 90 to IV bisphosphonate first-line in mg; calcitonin for speed (2–4 h vs 72 h) malignancy; combine with calcitonin if severe 9 Metabolic acidosis Albumin-corrected anion gap → GOLD MARK vs urine Keep serum bicarbonate ≥22 mEq/L in CKD; anion gap; type 4 RTA in the older diabetic; Winter's veverimer failed VALOR-CKD, so bicarbonate formula remains standard PART III — KIDNEY DISEASE Question Must-write core Update to quote 10 AKI Prerenal and postrenal are reversible — dehydration and Balanced crystalloid; STARRT-AKI — no the prostate. FENa unreliable in the old. No recovery by benefit from early dialysis; AKI alerts, 3 months = CKD nephrotoxin stewardship, post-AKI follow-up 11 CKD Six mechanisms of progression (HUP–PEP); distinguish KDIGO 2024: eGFRcr-cys, KFRE risk equation, senile hypofiltration; conservative kidney management SGLT2i regardless of diabetes, statin for all is an active six-component pathway over 50 12 Starting RRT AEIOU for urgent dialysis; symptom-driven at eGFR 5–10; PMNDP + AB-PMJAY + Ayushman Vay access at 15–20; frailty and dependency, not age, Vandana Card; conservative kidney predict outcome management as an explicit third option 13 PD vs HD Survival similar; PD for cardiovascular instability and Shared decision-making across three residual diuresis; median HD survival 15.6 and 11.6 pathways; assisted/home PD expanding in months; withdrawal 38% of deaths India under the national dialysis programme 14 Acute GN Crescentic GN peaks at 60–79; renal vasculitis is the KDIGO AAV: rituximab preferred in older commonest primary cause of renal failure in the old; adults; reduced-dose steroid taper; avacopan red cell casts for steroid sparing 15 Nephrotic / Membranous is commonest; 20% secondary to KDIGO: anti-PLA2R positive + normal membranous malignancy (lung, colon); highest thrombosis risk of the function = no biopsy; rituximab first-line in primary glomerular diseases moderate/high risk 16 Interstitial Delayed hypersensitivity to NSAIDs, diuretics, PPIs; Checkpoint-inhibitor AIN — longer latency, nephritis triad in <10%; stopping the drug is the treatment; no eosinophilia; steroid delay beyond 2 weeks steroids early predicts incomplete recovery 17 Diabetic Mogensen I–V; suspect non-diabetic disease if no FLOW 2024: semaglutide ↓ kidney events nephropathy retinopathy; RASi with creatinine rise ≤30% acceptable 24%; four-pillar therapy — RASi + SGLT2i + finerenone + GLP-1 RA PART IV — DIABETES MELLITUS Question Must-write core Update to quote 18 New diabetic, Dual therapy from the outset: metformin + GLP-1 RA ADA 2026: organ protection independent of HbA1c 10% (weight, ASCVD, knee OA) or SGLT2i; avoid HbA1c; obesity as a treatment target; sulphonylurea and pioglitazone; ACEi/ARB + statin tirzepatide; watch lean mass 19 SGLT2i / GLP-1 RA No intrinsic hypoglycaemia; watch volume depletion, FLOW: 24 / 18 / 20 (kidney / MACE / genital infection, sarcopenia; SGLT2i down to eGFR 20 death); ADA 2026 — treat the organ, not the HbA1c 20 Alpha- Block brush-border α-glucosidase → ↓ postprandial Displaced internationally (no CV benefit, ACE glucosidase glucose; treat hypoglycaemia with GLUCOSE, never trial) but retain an Indian niche for inhibitors sucrose postprandial control and cost 21 Newer insulins Degludec and glargine U300 = flattest, least nocturnal Insulin icodec once weekly — approved for hypoglycaemia; match the regimen to coping ability, not type 2, not type 1 (ONWARDS 6 physiology hypoglycaemia)

Question Must-write core Update to quote

22 Hypoglycaemia Levels 70 / 54 / assistance; blunted autonomic ADA 2026: CGM for older adults on insulin; warning; presents as falls and delirium; sulphonylurea annual screening for geriatric syndromes, overdose needs 24–48 h observation hypoglycaemia and polypharmacy 23 DKA / HHS Fluids → Insulin → Potassium; HHS = older type 2, ADA/EASD 2024: glucose ≥200, β-OHB ≥3.0, higher mortality, slower correction; insulin 0.1 vs 0.05 pH <7.3; anion gap removed; euglycaemic units/kg/h DKA on SGLT2i 24 Diabetic foot Neuropathy + PAD + pressure + limited joint mobility; IWGDF 2023: SINBAD for communication 70% of amputations follow an ulcer; 50% three-year and audit; non-removable knee-high survival after amputation offloading (total contact cast) first choice PART V — THYROID DISEASE Question Must-write core Update to quote 25 Subclinical Treat if TSH >10; individualise 4.5–10; in the oldest old TRUST: 737 patients over 65 — TSH fell, but hypothyroidism it is harmless or possibly protective; higher TSH target no symptomatic, cognitive or functional 6–7 benefit 26 TSH 50 + heart Start 12.5–25 µg, titrate every 6–8 weeks; empty Age-adjusted TSH target (upper half of failure stomach, 4 h from calcium/iron/PPI; lifelong; report chest range); no T3 or combination therapy; pain. The "heart failure" may be the myxoedema amiodarone need not be stopped 27 Hashimoto's Commonest cause of hypothyroidism in old age; Checkpoint-inhibitor thyroiditis; selenium ageing → fewer T-suppressor cells, more autoantibodies; not recommended; antibodies justify rapidly enlarging gland = lymphoma surveillance, not treatment 28 Hyperthyroidism Apathetic, paucisymptomatic, atrial fibrillation, no ATA: long-term low-dose antithyroid goitre in one-third; 131I is the treatment of choice; drugs now accepted; 2025 network meta-accept hypothyroidism as the planned outcome analysis of the three modalities 29 Thyroid nodule 95% benign; risk equal for solitary and multinodular; Benign nodules rarely grow — ultrasound at first test = TSH; hot = no FNAB; never suppress with 12 months then 2–5 yearly; active surveillance levothyroxine of low-risk microcarcinoma PART VI — ENDOCRINE AND METABOLIC BONE DISEASE Question Must-write core Update to quote 30 Testosterone Andropause does not exist; treat only symptomatic, TRAVERSE 2023: MACE non-inferior, but biochemically confirmed low T; target 300–400 ng/dL; more atrial fibrillation, VTE, AKI and monitor haematocrit and PSA fractures 31 Osteomalacia Low Ca + low PO₄ + high ALP + high PTH; bone pain with Endocrine Society 2024: empiric vitamin D proximal myopathy; Looser's zones; replete before any for all aged ≥75; against routine 25(OH)D bisphosphonate testing in the healthy; VITAL caveat PART VII — CRYSTAL ARTHROPATHY Question Must-write core Update to quote 32 Acute podagra Aspirate — needle-shaped, negatively birefringent; ACR: ULT may be started during a flare exclude sepsis. Urate is often normal in the attack. under anti-inflammatory cover; HLA-Choose the drug by comorbidity. Don't start ULT — but B*5801 testing in those of Southeast Asian don't stop it either descent 33 Management of Allopurinol first-line, preferred over probenecid in Treat-to-target is the central shift; STOP-gout the elderly; start low, titrate every 2–5 weeks; target Gout — allopurinol non-inferior to urate <6 mg/dL; prophylaxis 3–6 months febuxostat when properly titrated 34 Pseudogout Rhomboid, weakly positively birefringent; knee and ACR/EULAR 2023 classification criteria; wrist; the 5 Hs; no crystal-lowering therapy exists; ultrasound validated; anakinra when NSAIDs, aspiration alone is often therapeutic colchicine and steroids are all contraindicated PART VIII — ENVIRONMENTAL AND SYSTEMIC DISORDERS Question Must-write core Update to quote 35 Heat stroke Core >40°C + CNS dysfunction; mortality up to 80%; SCCM 2025: target <39°C in 30 minutes, rate cool first, transport second; immersion beats fanning; ≥0.155°C/min; NCDC India March 2024 no antipyretics, no dantrolene cooling protocol; NDMA Heat Action Plans 36 Chronic fatigue Post-exertional malaise is the cardinal feature; a NICE NG206: PEM mandatory, 3-month syndrome diagnosis of exclusion; pacing within the energy diagnosis, graded exercise therapy NOT envelope; full recovery only 5–10% recommended, CBT adjunct only Cross-Cutting Principles and Indian Context SIX THREADS THAT RUN THROUGH EVERY ANSWER IN THIS BANK