Nephro

Question 1

A 27/F presented with hypertension uncontrolled on hydrochlorothiazide, amlodipine, and losartan. Her eGFR doubled after one month of taking losartan and she was hospitalized twice for flash pulmonary edema. Which additional treatment would be most appropriate for her condition?

a. Clonidine

b. Spironolactone

c. Percutaneous renal artery angioplasty

d. Unilateral adrenalectomy

Answer 1

Percutaneous renal artery angioplasty

Question 2

Which of the following conditions may yield mixed bacterial species in an uncontaminated specimen for urine culture?

a. Asymptomatic bacteriuria

b. Pregnancy

c. Urinary urge incontinence

d. Vesicovaginal fistula

Answer 2

Vesicovaginal fistula

Question 3

Which of the following is considered a risk factor for the development of chronic kidney disease?

a. Previous history of acute kidney injury

b. Large for gestation birth weight

c. Young age

d. Malnutrition

Answer 3

Previous history of acute kidney injury

Question 4

Which of these findings is most suggestive of chronic renal failure?

a. Osmolality > 500 mosm/L

b. Proteinuria < 3.5 g/24 hours

c. Urinary eosinophils > 10%

d. Urine sugar 2+

Answer 4

Proteinuria < 3.5 g/24 hours

Question 5

In chronic kidney disease, which of the following acid-base/electrolyte disorders and their consequences are correctly paired?

a. Hypocalcemia: vascular calcification

b. Hyponatremia: edema

c. Hyperkalemia: hemolysis

d. Metabolic acidosis: protein loss

Answer 5

Metabolic acidosis: protein loss

Question 6

The main feature differentiating pyelonephritis from cystitis is:

a. Fever

b. Flank pain

c. Dysuria

d. Vomiting

Answer 6

Fever

Question 7

A 22/F presented at the clinic with a 3-day history of fever, left-sided flank pain, and vomiting. Which feature would prompt you to admit this patient for treatment?

a. Fever for > 48 hours

b. Positive urine culture

c. Persistent vomiting

d. Young age

Answer 7

Persistent vomiting

Question 8

Which is the most common cause of acute kidney injury in community-dwelling patients?

a. Diabetes mellitus

b. Heart or liver failure

c. Urinary tract infection

d. Volume depletion

Answer 8

Volume depletion

Question 9

A patient was admitted for moderate risk community-acquired pneumonia. Metabolic workup shows creatinine at 3.5 mg/dL from a previous baseline of 0.9 mg/dL with no other electrolyte abnormalities. Urinalysis sediment showed tubular casts. Which of the following is true about the patient’s acute kidney injury (AKI)?

a. Occurs due to hypotension

b. Arises due to generalized arterial vasoconstriction

c. Mediated by cytokines that downregulate NO synthase

d. Increases microvascular leukocyte adhesion and migration

Answer 9

Increases microvascular leukocyte adhesion and migration

Question 10

A 21/M arrives at the ER in frank seizures after ingesting toilet cleaner solution one day prior. Workup shows creatinine 5.2 mg/dL, Na 124 mmol/L, K 7.0 mmol/L, corrected Ca 1.94 mg/dL, TCO2 10.2 mmol/L. Which of the following laboratory findings would be consistent with the etiology of the acute kidney injury?

a. BUN/Creatinine ratio > 20

b. FeNa < 1%

c. Granular casts

d. Hyaline casts

Answer 10

Granular casts

Question 11

A factory worker was involved in a workplace incident and was rushed to the ER. They sustained flame burns involving 40% of their total body surface area. After three days of admission, laboratory work-up showed the following: Crea 3.2 mg/dL, Na 150 mmol/L, K 5.5 mmol/Ll, TCO2 18 mmol/L. Which of the following laboratory findings would be consistent with the etiology of the acute kidney injury?

a. BUN/Creatinine ratio > 20

b. FeNa > 1 %

c. Sterile pyuria

d. Urine osmolality < 200 mosm/L

Answer 11

BUN/Creatinine ratio > 20

Question 12

ACE inhibitors and ARBs are effective in slowing the progression of CKD through:

a. Afferent vasoconstriction

b. Afferent vasodilatation

c. Efferent vasoconstriction

d. Efferent vasodilatation

Answer 12

Efferent vasodilatation

Question 13

Which of the following is an indication to initiate renal replacement therapy in a patient with chronic kidney disease?

a. Creatinine 5 mg/dL

b. Potassium 6 mmol/L

c. Malnourished state

d. Pulmonary congestion

Answer 13

Malnourished state

Question 14

A 32/M with uncontrolled type 2 diabetes mellitus presents with rising creatinine trends over a 6-month period. Which feature would be an indication for biopsy in this patient?

a. Anemia

b. Diabetic retinopathy

c. Nephrotic proteinuria

d. WBC casts

Answer 14

WBC casts

Question 15

Renal ultrasonography of a patient with chronic kidney disease may show normal-sized kidneys in the following condition:

a. Diabetic nephropathy

b. Hypertensive nephropathy

c. Membranous nephropathy

d. Reflux nephropathy

Answer 15

Diabetic nephropathy

Question 16

A 19 year old asymptomatic patient who consulted for an annual physical examination had the following urinalysis results: pH 5.0, specific gravity 1.010, glucose negative, protein 3+, nitrite negative, leukocyte esterase negative, RBC 0/hpf, WBC 0/hpf, and no epithelial cells. They were advised to do an spot albumin/creatinine ratio, which was 2000 mg/g. Which condition is likely to explain this finding?

a. Alcoholism

b. Diabetes

c. Exercise

d. Glomerulopathy

Answer 16

Exercise

Question 17

For questions 17 and 18: A 45 year old patient with type 2 diabetes mellitus presented with a 1-week history of tea-colored urine, bipedal edema and new-onset hypertension with BP 150/90. She has been on metformin for the past 2 years. She recalled an episode of sore throat with low-grade fever 2 weeks ago. Workup showed creatinine 4.8 mg/dL, K 5.0 mmol/L and low CH50 and C3 levels. Urinalysis was significant for RBC casts and proteinuria 3+. 24-hour urine collection showed 3.7 g protein/day. Which of the following will be most likely found on this patient’s kidney biopsy?

a. Subepithelial “hump”-like deposits

b. Diffuse subepithelial immune deposits

c. Mesangial interposition with “tram-tracking”

d. Subcapsular hemorrhages

Answer 17

Subepithelial “hump”-like deposits

Question 18

Most appropriate treatment for this case:

a. Antibiotics

b. Cyclophosphamide

c. High-dose steroids

d. Supportive treatment

Answer 18

Supportive treatment

Question 19

A patient with lupus nephritis had persistent RBC casts and proteinuria on urinalysis. Kidney biopsy showed focal endocapillary and extracapillary proliferation with subendothelial deposits. The most appropriate course of action would be:

a. Reassure the patient that this does not need treatment

b. Repeat the urinalysis and biopsy after 3 months

c. Refer the patient for immunosuppressive therapy

d. Start the patient on ACE inhibitor to slow renal injury

Answer 19

Refer the patient for immunosuppressive therapy

Question 20

An asymptomatic 20/F consulted for persistent hematuria (RBC 5/hpf) on urinalysis every annual physical examination. Her father also had a similar condition. Which feature would predispose this patient to loss of renal function?

a. Absence of proteinuria

b. Absence of macroscopic hematuria

c. Female sex

d. Young onset of disease

Answer 20

Absence of macroscopic hematuria

Question 21

A 27/M construction worker presents with acute sharp colicky right-sided flank pain with episodes of hematuria. He consumes pork or beef almost every day and have limited access to drinking water at his workplace. He takes vitamin C 500 mg twice daily. On urinalysis, bipyramidal crystals were seen. Which of the following interventions are most appropriate for this patient?

a. Dietary sodium restriction, urinary alkalinization

b. Dietary sodium restriction, thiazide diuretic

c. Dietary sodium restriction, thiazide diuretic, urinary alkalinization

d. Dietary sodium restriction, thiazide diuretic, urinary alkalinization, surgery

Answer 21

Dietary sodium restriction, thiazide diuretic, urinary alkalinization

Question 22

A 19 year old student presents with recurrent episodes of bilateral flank pain and passage of sand-like material in the urine. On work-up, bilateral staghorn calculi with pelvocaliectasia were noted. Urinalysis showed hexagonal crystals. Which of the following is consistent with the patient’s condition?

a. Forms at urine pH<5.5

b. Forms at urine pH>6.5

c. Forms at urine pH>7.5

d. Not influenced by urine pH

Answer 22

Not influenced by urine pH

Question 23

A patient with diabetes mellitus presents with a 3-day history of fever with dysuria and bilateral flank pain. On work-up, bilateral staghorn calculi with pelvocaliectasia were noted. Urinalysis showed crystal with coffin-lid appearance. Which of the following interventions are most appropriate for this patient?

a. Surgical intervention, antibiotic therapy

b. Dietary sodium restriction, surgical intervention

c. Thiazide diuretic, urinary alkalinization, antibiotic therapy

d. Dietary sodium restriction, thiazide diuretic, surgical intervention

Answer 23

Surgical intervention, antibiotic therapy

Question 24

A patient with coronary artery disease admitted for percutaneous intervention developed increasing creatinine trends 2 days after the procedure. On a repeat physical exam, a new-onset mottled purple net-like pattern appeared on the patient’s thigh. Urinalysis was normal. Which is the most appropriate course of action?

a. Initiate anticoagulation

b. Confirm the diagnosis with biopsy

c. Request renal angiography

d. Supportive treatment

Answer 24

Supportive treatment

Question 25

Which of the following causes of volume depletion can present with elevated urine pH and urine Na >20 mmol/L?

a. Blood loss

b. Burns

c. Diarrhea

d. Heart failure

Answer 25

Diarrhea

Question 26

A patient presented with sudden dense hemiplegia was diagnosed to have a stroke. On PE, he had moist oral mucosal membranes and normal skin turgor. Metabolic workup showed Na 118 mmol/L. Which of the following laboratory features would be consistent with the patient’s presentation?

a. Urine Na 10 mmol/L

b. Uric acid 3.5 mg/dl

c. Urine osmolality 150 mOsm/L

d. BUN 15.0 mmol/L

Answer 26

Uric acid 3.5 mg/dl

Question 27

A patient who lived alone presented with dense hemiplegia for several days and was later diagnosed to have had a stroke. On PE, he had moist oral mucosal membranes and good skin turgor. Metabolic workup showed Na 118 mmol/L, urine Na 10 mM, urine osmolality 90 mOsm/L. Which of the following features on history would present similar to this patient’s condition?

a. Alcoholism

b. History of selective serotonin reuptake inhibitor (SSRI) use

c. Presence of a lung mass

d. Ongoing treatment for tuberculosis

Answer 27

Alcoholism

Question 28

Compensatory responses during acid-base disturbances return the pH towards, but not to, the normal value, except during _________ which may return the pH to normal.

a. Acute respiratory alkalosis

b. Chronic respiratory alkalosis

c. Acute respiratory acidosis

d. Chronic respiratory acidosis

Answer 28

Chronic respiratory alkalosis

Question 29

A patient with known COPD presents with a 3-day history of worsening cough, dyspnea, and sputum production. He is poorly compliant with his LABA-LAMA inhaler, instead taking furosemide tablets as suggested by their neighbor. ABG results at the ER showed: pH 7.50, pCO2 45 mmHg, pO2 75 mgHg, HCO3 35 mmol/L at FiO2 40%. What is the most appropriate course of action for the primary acid-base disturbance?

a. Start the patient on spironolactone

b. Appraise the patient for intubation

c. Hook the patient to non-invasive ventilation

d. Discontinue furosemide and hydrate with saline

Answer 29

Discontinue furosemide and hydrate with saline

Question 30

A patient with diabetes mellitus presented with an eGFR of 44 mL/min/1.73 m2. Tests showed: Na 136 mmol/L, K 4.9 mmol/L, Cl 100 mmol/L, corrected Ca 2.15 mmol/L, TCO2 19 mmol/L. Which of the following medications would be appropriate to initiate for this patient?

a. Sodium bicarbonate

b. Furosemide

c. Ferrous sulfate

d. Calcium carbonate

Answer 30

Sodium bicarbonate

Question 31

Which of the following patients would most likely present with hypokalemia?

a. Patient admitted for intentional ingestion of methanol

b. Patient with esophageal carcinoma on total parenteral nutrition

c. Patient with acute myeloid leukemia with oliguria post-chemotherapy

d. Patient with community-acquired pneumonia receiving piperacillin-tazobactam

Answer 31

Patient with esophageal carcinoma on total parenteral nutrition

Question 32

A patient who underwent renal transplant 5 months prior developed high-grade fever with cough. Which of the following is the most likely pneumonia pathogen in this case?

a. Aspergillus

b. Candida

c. Cytomegalovirus

d. Herpes

Answer 32

Cytomegalovirus

Question 33

What is the extent of age-related nephrosclerosis expected in a 64/F patient?

a. 12%

b. 22%

c. 32%

d. 42%

Answer 33

22%

Question 34

Among the calcium channel blockers, which of the following may exhibit superior antiproteinuric and renoprotective effects?

a. Amlodipine

b. Felodipine

c. Nifedipine

d. Verapamil

Answer 34

Verapamil

Question 35

The progression of autosomal dominant polycystic kidney disease (ADPKD) has striking variability. Which of the following is a risk factor for its progression to end-stage renal disease?

a. Hypertension

b. Late diagnosis of ADPKD

c. Microscopic hematuria

d. Small kidneys

Answer 35

Hypertension

Question 36

What is the definitive treatment for hepatorenal syndrome?

a. Midodrine, norepinephrine

b. Orthotopic liver transplantation

c. Recurrent paracentesis

d. Transjugular intrahepatic portosystemic shunt

Answer 36

Orthotopic liver transplantation

Question 37

SM a 56/y.o. male diabetic underwent coronary angiography. Laboratory tests after the procedure revealed creatinine elevation from baseline (1.0 to 2.5 mg/dL). PE showed lace-like purplish discoloration of the lower extremities. What is the most likely diagnosis?

a. Contrast Induced Nephropathy
b. Prerenal azotemia
c. Acute Tubular Necrosis
d. Atheroembolic AKI

Answer 37

d. Atheroembolic AKI

Question 38

JL, 67 year old female is currently admitted in the ICU due to Urosepsis. She is hypotensive and is on inotropic support. Urine output is only 50 mL for the past 24 hours. Laboratory results revealed WBC 25,000 with neutrophilic predominance, Na 134 mmoL/L, Potassium 5.1mmol/L, creatinine 4.0 mg/dL, BUN 40 mg/dL. What is an expected microscopic finding?
a. Calcium oxalate crystals
b. Dysmorphic RBCs
c. Muddy brown granular cast
d. hyaline cast

Answer 38

c. Muddy brown granular cast

Question 39

A 30/F was brought to the emergency room due to unresponsiveness. Patient has seizure disorder and recently stopped taking her medications. Upon history, she had an episode of prolonged seizure 30 minutes before she was brought to the ER. Labs showed an elevated creatinine, increased creatinine kinase, hyperkalemia and a dark colored urine. What is the pathophysiology of AKI in this disease?

a. Intravascular volume depletion
b. Tubular obstruction of distal nephron
c. Generalized vasodilation
d. Embolization

Answer 39

b. Tubular obstruction of distal nephron

Question 40

What is the recommended protein intake in a 34-year-old male patient weighing 50 kg with AKI in a hypercatabolic state?

a. 40 – 50 g/day
b. 50 – 60 g/day
c. 60 – 75 g/day
d. Up to 85 g/day

Answer 40

d. Up to 85 g/day

Question 41

What is the therapy for established AKI in rhabdomyolysis?

a. Renal replacement therapy
b. Alkaline fluid hydration
c. Diuretics
d. Mannitol

Answer 41

a. Renal replacement therapy

Question 42

A 27 year female sought consult with you via telemedicine with a chief complaint of dysuria. She claims this is accompanied by urgency and urinary frequency and these symptoms started after sexual intercourse. She denies fever and vaginal discharge. She has no known comorbidities and this is her first time experiencing said symptoms. She has no history of intake of any medications.
What is the next step in the management of this patient?

a. Do a Urine dipstick test
b. Order for a urine culture and sensitivity.
c. Request for an ultrasound of the kidneys, ureter, bladder.
d. Give empiric antibiotics

Answer 42

d. Give empiric antibiotics

Question 43

A 29-year-old pregnant lady on her 16th week age of gestation was found to have asymptomatic bacteriuria. You prescribe her cefuroxime 500 mg/tab 1 tab 2x a day for 7 days based on the urine culture and sensitivity results. What do you do next?
a. No further test are needed since she is asymptomatic.
b. Do urine culture one week after she completes her cefuroxime regimen.
c. Do urinalysis one week after she completes her cefuroxime regimen.
d. Do urine dipstick every month until she delivers.

Answer 43

b. Do urine culture one week after she completes her cefuroxime regimen.

Question 44

The only consistently documented behavioral risk factors for recurrent UTI include:
a. Spermicide use
b. Vaginal douching
c. Wiping from anus toward urethra
d. Use of an intrauterine device

Answer 44

a. Spermicide use

Question 45

A 24-year-old nonpregnant woman was on cefalexin 125 mg once daily at bedtime when she developed dysuria, urinary frequency and urgency. She calls you up to inform you of this. How would you advise her?
a. Continue cefalexin at the same dose and do a urine culture.
b. Continue cefalexin but increase dose to 250 mg once a day at bedtime, and do a urine culture.
c. Do a urine culture, and shift antibiotic to ciprofloxacin 250 mg 2x a day.
d. Continue cefalexin but increase dose and frequency to 500 mg 3x a day for 7 days, and do a urine culture.

Answer 45

c. Do a urine culture, and shift antibiotic to ciprofloxacin 250 mg 2x a day.

Question 46

What is the definitive management in staghorn calculi found in the left renal pelvis?
a. Extracorporeal shockwave lithotripsy
b. Percutaneous nephrostomy
c. Percutaneous nephrostolithotomy
d. Tiopronin

Answer 46

c. Percutaneous nephrostolithotomy

Question 47

We can opt NOT to perform kidney biopsy on which of these patients?

a. A 30-year-old male presenting with normal serum creatinine, nephrotic-range proteinuria, anasarca, hypoalbuminemia, negative hepatitis serologies, with normal C3 and C4

b. A 60-year-old female with chronic cough, presenting with nephrotic-range proteinuria, bipedal edema, a serum creatinine level of 1.5 mg/dL, negative hepatitis serologies, with normal C3 and C4

c. An 18-year-old with a documented streptococcal pharyngitis three weeks prior, presenting with tea-colored urine, slightly elevated blood pressure, normal serum creatinine, low C3, normal C4

d. An 18-year-old female with malar rash, alopecia, arthralgias, anemia, proteinuria, hematuria, low C3, elevated anti-dsDNA

Answer 47

c. An 18-year-old with a documented streptococcal pharyngitis three weeks prior, presenting with tea-colored urine, slightly elevated blood pressure, normal serum creatinine, low C3, normal C4

Question 48

A 25-year-old female was diagnosed to have systemic lupus erythematosus (SLE) and underwent renal biopsy for heavy proteinuria (spot urine protein to creatinine ratio 5 g/g). Histopathologic findings include thickened basement membranes with diffuse subepithelial immune deposits. What class Lupus Nephritis does she have?

a. Class III – focal nephritis
b. Class IV – diffuse nephritis
c. Class V – membranous nephritis
d. Class VI – sclerosing nephritis

Answer 48

c. Class V – membranous nephritis

Question 49

The detection of anti-PLA2R antibodies is associated with the idiopathic form of which glomerular disease?
a. Minimal change disease
b. Focal segmental glomerulosclerosis
c. Membranoproliferative glomerulonephritis
d. Membranous glomerulonephritis

Answer 49

d. Membranous glomerulonephritis

Question 50

If on histopathology, sclerosis affects 12 out of 20 glomeruli you were able to obtain during kidney biopsy, there is said to be:
a. Global glomerulosclerosis
b. Focal glomerulosclerosis
c. Diffuse glomerulosclerosis
d. Segmental glomerulosclerosis

Answer 50

c. Diffuse glomerulosclerosis

Question 51

A 60-year old African-American man was admitted for generalized edema and pallor. Physical examination revealed BP of 130/80. Chest examination revealed decreased breath sounds at the lung bases. There was also noted ascites and grade 3 bipedal edema. Labs: WBC 11,000/mm, Hb 8.7 g/dL, plt 164,000/mm, crea 2.8 mg/dL, Alb 1.8 g/dL. Urinalysis: RBC 12-15/hpf. Urine protein 5 g/24 h. Anti-HIV was positive while tests for Hep B Virus and Hep C Virus were negative. What is the expected clinic-pathologic syndrome based on the demographic and clinical profile?
a. Poststreptococcal Glomerulonephritis
b. Minimal Change Disease
c. Membranous Nephropathy
d. Focal Segmental Glomerulosclerosis

Answer 51

d. Focal Segmental Glomerulosclerosis

Question 52

A 62 year-old female presents at the emergency room with nausea, vomiting, pruritus, lethargy and lower extremity edema. Past medical revealed longstanding history of hypertension and diabetes. Aside from an elevated blood glucose, she remembers her creatinine to be “abnormal” during her last check-up three years ago but was lost to follow-up.

On physical exam BP was 180/110, HR 80, RR 24, afebrile. Body weight was 56.5 kg. Fundoscopy: A-V nicking and copper wire changes consistent with hypertensive injury. Cardiac exam had an S1, S2 and S4, 2+ lower extremity edema and superficial excoriations of the skin from scratching.

Pertinent Labs: Na 133, K 6.2, Cl 100, BUN 170, Crea 16 , Glucose 138, Ca 7.2, Phos 10.5, Hemoglobin 8.6, 24h-urine protein 45 mg/g. ABG: pH 7.1, HCO3 18, pCO2 22. Renal ultrasound: right 7 x 6.0 cm, left 7.5 x 5.8 cm, with increased cortical echogenicity indicative of chronic parenchymal disease

Which is NOT a diagnostic clue that could point towards a diagnosis of chronic kidney disease?

a. 24 hour urinary protein
b. Kidney Ultrasound
c. Hyperkalemia
d. Blood pressure

Answer 52

d. Blood pressure

Question 53

In a CKD patient with metabolic acidosis, what is the bicarbonate level to maintain in this patient?
a. 16-19 mmol/L
b. 20-23 mmol/L
c. 24-28 mmol/L
d. 29-32 mol/L

Answer 53

b. 20-23 mmol/L

Question 54

A CKD patient presented with hypocalcemia and hyperphosphatemia. She then manifested with large purple net-like patterns on her legs which became ulcers with black-brown crusts. What condition does this patient have?
a. Tumoral calcinosis
b. Calciphylaxis
c. Nephrogenic fibrosing dermopathy
d. Livedo reticularis

Answer 54

b. Calciphylaxis

Question 55

A CKD presented with chest pain. Serum troponin level was requested and was seen to be elevated. Which statement is TRUE in this case?

a. Patient has myocardial infarction
b. If a stress echocardiography will be done at this time, it will surely show signs of ischemia
c. A second troponin level should be requested
d. Consistently elevated levels of troponin is not prognostic of adverse CV events

Answer 55

c. A second troponin level should be requested

Question 56

A 43 year-old diabetic male patient was brought to the emergency room due to chest pain accompanied by difficulty of breathing, vomiting, muscle cramps and weight loss. He was a known End Stage Renal disease patient on maintenance hemodialysis 3x/week. Due to financial constraints, his wife tearfully informed you that he had missed his last 3 dialysis sessions. On physical exam BP 160/100, HR 90, RR 26 24 T 37.7. Cardiac exam + friction rub at the apical area during end expiration upon leaning forward
What is an expected finding in his ECG?
a. ST depression
b. PR depression
c. Diffuse T wave elevation
d. Early repolarization

Answer 56

b. PR depression