CIS Renal Cases

Question 1

Describe nitroglycerin

Answer 1

Advantage over nitroprusside since it preferentially dilates veins more than arterioles, thus enhancing oxygenation of myocardial cells

• CABG
• MI
• Unstable angina
• left ventricular failure

Question 2

30 y/o M presents with dysuria and perineal pain. No fever. PMH negative. Intermittent past 6 weeks. Urine negative. Descries pain as where he sits down.
What is the most likely diagnosis?

Answer 2

Chronic prostatitis

Question 3

Describe third spacing of fluid in cells

Answer 3

Intracellular: fluid within cell
Intercellular/interstitial: fluid between cells
Intravascular: fluid within blood vessels

Question 4

What are cancers that cause ascites?

Answer 4

Ovarian 25%
Breast 16%
Gastric 13%
Colon 13%
CUP 8%
Other 25%

Question 5

What is often seen in advance liver disease?

Answer 5

Ascites

Question 6

56 y/o M admitted to hospital for work-up of b/l flank pain, mild swelling, 10 lb weight loss over last month and nocturia approx 10x/night. Urine dipstick showed 4+ protein in primary care office, and BP 170/100. A year ago, he was told he had high BP and high cholesterol.
FH: positive for HTN, and father died at 45 for kidney problem.
Variety of jobs with potential toxins: heavy metal miner (bronze, copper, platinum), rancher (cows, pigs, alfalfa, insecticides), construction/roofing
No current meds. NKDA
Urine dipstick 4+protein.
BUN 10
Cr 0.9
EGFR 75.8
Albumin 1.8

1. Which would be your admitting diagnosis?
A. IgA nephropathy
B. Interstitial nephritis
C. Tubular necrosis
D. Polycystic kidney disease
E. Idiopathic nephrotic syndrome

2. What additional test would confirm your initial assessment?
A. Complete blood count
B. Chest xray
C. Electrocardiogram
D. Catecholamines
E. 24 hr urine protein.

Answer 6

1.A. IgA nephropathy: tubular process. Protein is glomerular
B. Interstitial nephritis: tubular process. Protein is glomerular
C. Tubular necrosis: tubular process. Protein is glomerular
D. Polycystic kidney disease: more commonly associated with hematuria instead of proteinuria
E. Idiopathic nephrotic syndrome

2. A. Complete blood count: not specific
   B. Chest xray: not specific
   C. Electrocardiogram: not specific
   D. Catecholamines: not episodic. Usually younger
   E. 24 hr urine protein. quantify how much protein to establish baseline

Question 7

Describe systemic causes of nephrotic syndrome

Answer 7

DM, SLE, amyloidosis
Drugs: gold, penicillamine, probenecid, captopril,NSAIDs, heroin
Infections: bacterial endocarditis, Hep B, shunts, syphilis, malaria
Malignancy: Hodgkin’s, non-hodgkin’s lymphoma, leukemia, breast & GI cancer

Question 8

Describe primary glomerular disease

Answer 8

Nephrotic syndrome
Biopsy needed to diagnose
Rule out systemic causes first, then determine type of GN by biopsy

Question 9

28 y/o F is a IV heroin user. She arrives to ER confused, complaining of back pain and generally not feeling well. She got scared when her urine looked pink, starting yesterday.
She has a murmur consistent with tricuspid regurgitation
Pregnancy test is negative, and she denies any dysuria, nausea, vomiting, or diarrhea

Which of the following is most likely cause of her hematuria?
A. E coli 0157 aka enterohemorrhagic E coli infection (EHEC)
B. Granulomatosis with polyangiitis
C. Systemic lupus erythematosis
D. Pyelonephritis
E. Endocarditis

Answer 9

E. Endocarditis

All above can cause hematuria, but her history of IV drug use and her cardiac exam makes this most likely

Question 10

25 y/o F in 2nd trimester of pregnancy has BP 160/100, increasing peripheral edema, and newly diagnosed proteinuria.

Which would be best treatment choice?
A. Hydrochlorothiazide
B. Enalapril
C. Furosemide
D. Acetazolamide
E. Hydralazine

Answer 10

A. Hydrochlorothiazide: diuretic, decreases volume
B. Enalapril: teratogenic
C. Furosemide: loop diuretic
D. Acetazolamide:
E. Hydralazine (and methyldopa good, too)

Question 11

40 y/o M with white cell casts. Has active sediment and rash with fever that developed 24 hrs after starting an antibiotic for sinus infection. Creatinine increased by 50%.

Which would help confirm your diagnosis?
A. Muddy brown casts
B. Urate crystals
C. Dysmorphic red cells
D. Leukocyte esterase
E. Eosinophils

Answer 11

A. Muddy brown casts: Acute tubular necrosis
B. Urate crystals: gout
C. Dysmorphic red cells: glomerular, as are RBC casts
D. Leukocyte esterase: positive in urinary tract infections
E. Eosinophils: need to specifically request on urine. Doesn’t come on routine UA. Supports allergic interstitial nephritis (AIN)

Question 12

What is active sediment?

Answer 12

Any positive findings on microscopic, particularly those suggesting kidney (vs bland that is normal)

Question 13

72 y/o F with chest pain. She presents with increasing mid-sternal chest pain that radiates to her left arm. Previously in good health, on no meds. NKDA
BP 240/120.
Heart: muffled. Tachypneic
Skin clammy

Which IV medication would be best choice to lower BP?
A. Nitroprusside
B. Enalaprilat
C. Clonidine
D. Hydralazine
E. Nitroglycerine

Answer 13

A. Nitroprusside: good rapid on/off so titratable, but there is a better choice
B. Enalaprilat: intravenous ACEI, not as rapid on/off
C. Clonidine: not titratable
D. Hydralazine: not as rapid on/off
E. Nitroglycerine preferentially dilates venous side greater than arterial side. Used with cardiac

Question 14

52 y/o F being treated with high dose prednisone for an exacerbation of her sarcoidosis. She usually has a normal BP and takes no meds. Electrolytes were normal.

Which of the following is most likely cause of her HTN?
A. Coarctation of aorta
B. Pheochromocytoma
C. Primary aldosteronism
D. Fibromuscular dysplasia
E. Cushings syndrome

Answer 14

Cushings syndrome induced by corticosteroids