Drug-induced renal disease: prevention and management MCQs With Answer
Introduction: Drug-induced renal disease is a critical topic for M.Pharm students preparing to counsel clinicians on safe pharmacotherapy. This set of MCQs focuses on pathophysiology, commonly implicated drugs, early detection, preventive strategies and evidence-based management of nephrotoxic drug reactions. Questions emphasize mechanism-based understanding — for example hemodynamic, tubular, interstitial and obstructive injuries — and practical prevention: hydration protocols, dose adjustment by renal function, drug-drug interactions, and antidotes or protective agents. Answers highlight best practices for monitoring and interventions including when to stop a drug, when to use corticosteroids, and when renal replacement therapy is indicated.
Q1. What is the principal renal lesion caused by aminoglycoside antibiotics leading to nephrotoxicity?
- Immune complex deposition in glomeruli
- Proximal tubular epithelial cell necrosis resulting in acute tubular necrosis
- Interstitial fibrosis with chronic nephritis
- Obstructive crystalline nephropathy
Correct Answer: Proximal tubular epithelial cell necrosis resulting in acute tubular necrosis
Q2. Which mechanism best explains NSAID-induced acute kidney injury?
- Direct tubular cytotoxicity causing proximal tubular necrosis
- Inhibition of renal prostaglandin synthesis causing afferent arteriole vasoconstriction and reduced GFR
- Immune-mediated glomerulonephritis
- Formation of uric acid crystals in renal tubules
Correct Answer: Inhibition of renal prostaglandin synthesis causing afferent arteriole vasoconstriction and reduced GFR
Q3. Which is the most evidence-based primary preventive measure for contrast-induced acute kidney injury (CI-AKI)?
- High-dose N-acetylcysteine routinely for all patients
- Peri-procedural isotonic saline hydration
- Oral sodium bicarbonate for 7 days before procedure
- Routine use of mannitol to force diuresis
Correct Answer: Peri-procedural isotonic saline hydration
Q4. Why can ACE inhibitors cause an acute rise in serum creatinine in some patients?
- They constrict the afferent arteriole increasing glomerular capillary pressure
- They dilate the efferent arteriole by blocking angiotensin II effects, reducing glomerular filtration pressure
- They cause tubular obstruction by crystals
- They directly destroy glomerular endothelial cells
Correct Answer: They dilate the efferent arteriole by blocking angiotensin II effects, reducing glomerular filtration pressure
Q5. Which antimicrobial is classically associated with crystal-induced obstructive nephropathy when given intravenously at high doses or without adequate hydration?
- Vancomycin
- Acyclovir
- Linezolid
- Ceftriaxone
Correct Answer: Acyclovir
Q6. The recommended initial management for drug-induced acute interstitial nephritis (AIN) includes:
- Immediate renal biopsy in all suspected patients only
- Continue the suspected drug and observe for improvement
- Discontinue the offending agent and consider corticosteroid therapy if renal function does not promptly improve
- Start high-dose aminoglycoside antibiotics
Correct Answer: Discontinue the offending agent and consider corticosteroid therapy if renal function does not promptly improve
Q7. For aminoglycoside therapy, which monitoring strategy most helps reduce nephrotoxicity risk?
- Daily measurement of C-reactive protein
- Monitoring trough (pre-dose) aminoglycoside concentrations and renal function
- Only monitoring peak levels without renal function tests
- Routine urine cultures every 12 hours
Correct Answer: Monitoring trough (pre-dose) aminoglycoside concentrations and renal function
Q8. Which agent is used to reduce cisplatin-induced nephrotoxicity in high-risk patients?
- Amifostine
- Nitrofurantoin
- Probenecid
- Allopurinol
Correct Answer: Amifostine
Q9. Vancomycin nephrotoxicity risk is increased most by which of the following co-prescriptions?
- Beta-lactam antibiotics such as amoxicillin
- Aminoglycosides such as gentamicin
- Oral macrolides such as azithromycin
- Topical mupirocin
Correct Answer: Aminoglycosides such as gentamicin
Q10. Which anticoagulant commonly requires dose adjustment or monitoring in patients with reduced renal function to prevent bleeding complications?
- Warfarin
- Enoxaparin
- Heparin (unfractionated) with standard dosing)
- Aspirin
Correct Answer: Enoxaparin
Q11. Which biomarker is emerging as an earlier indicator of acute kidney injury than serum creatinine?
- Serum alanine aminotransferase (ALT)
- Neutrophil gelatinase-associated lipocalin (NGAL)
- C-reactive protein (CRP)
- Fasting blood glucose
Correct Answer: Neutrophil gelatinase-associated lipocalin (NGAL)
Q12. Which dosing strategy for aminoglycosides has been shown to reduce nephrotoxicity while maintaining efficacy in many infections?
- Multiple daily low doses with no level monitoring
- Once-daily high-dose administration with monitoring of trough levels
- Continuous intravenous infusion for 7 days
- Alternating daily dosing with beta-lactams
Correct Answer: Once-daily high-dose administration with monitoring of trough levels
Q13. Which formulation of amphotericin B is associated with lower risk of nephrotoxicity compared with conventional amphotericin B deoxycholate?
- Liposomal amphotericin B
- Oral amphotericin suspension
- Amphotericin B combined with gentamicin
- Amphotericin B prodrug
Correct Answer: Liposomal amphotericin B
Q14. Combining which two lipid-lowering agents notably increases risk of severe rhabdomyolysis and consequent renal injury?
- Statin with fibrate (e.g., simvastatin + gemfibrozil)
- Bile acid sequestrant with ezetimibe
- Niacin with omega-3 fatty acids
- PCSK9 inhibitor with low-dose statin
Correct Answer: Statin with fibrate (e.g., simvastatin + gemfibrozil)
Q15. Best practice regarding metformin when a patient with reduced renal function is scheduled for radiocontrast administration?
- Continue metformin without changes in all patients
- Stop metformin at time of contrast and withhold for 48 hours, reassess renal function before restarting in at-risk patients
- Double the metformin dose the day before procedure
- Replace metformin with glyburide immediately
Correct Answer: Stop metformin at time of contrast and withhold for 48 hours, reassess renal function before restarting in at-risk patients
Q16. Which urinalysis finding is most characteristic of acute tubular necrosis from nephrotoxic drugs?
- Red blood cell casts predominating
- Muddy brown granular casts
- Heavy albuminuria (>3.5 g/day) with oval fat bodies
- Purely white cell casts without other sediment
Correct Answer: Muddy brown granular casts
Q17. Administration of ACE inhibitors is relatively contraindicated in which renal vascular condition due to risk of precipitous renal failure?
- Bilateral renal artery stenosis
- Renal papillary necrosis
- Simple renal cysts
- Chronic pyelonephritis with scarring
Correct Answer: Bilateral renal artery stenosis
Q18. Which commonly prescribed class of drugs is increasingly recognized as a cause of acute interstitial nephritis (AIN)?
- Proton pump inhibitors (PPIs)
- Beta blockers
- Topical corticosteroids
- Oral iron supplements
Correct Answer: Proton pump inhibitors (PPIs)
Q19. Which of the following clinical scenarios is an accepted indication for initiating urgent dialysis in severe drug-induced renal failure?
- Asymptomatic mild rise in serum creatinine only
- Refractory hyperkalemia with ECG changes despite medical therapy
- Isolated mild metabolic alkalosis
- Stable oliguric renal failure with no uremic symptoms
Correct Answer: Refractory hyperkalemia with ECG changes despite medical therapy
Q20. Which preventive approach is most important to reduce risk of acyclovir-associated crystal nephropathy during intravenous therapy?
- Rapid bolus administration to minimize exposure time
- Adequate intravenous hydration and slow infusion of acyclovir
- Co-administration with high-dose NSAIDs
- Give acyclovir only with loop diuretics
Correct Answer: Adequate intravenous hydration and slow infusion of acyclovir
