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Harrison's Principle of Internal Medicine 20th Edition > Nephrology > Flashcards

Nephrology Flashcards

1
Q

Which of the following is true regarding the mean glomerular filtration rate (GFR)? (HPIM C305 P2111)

a. An increase in GFR is expected with aging

b. Mean GFR is lower in women than in men

c. A mild elevation in serum creatinine often signifies a substantial reduction in GFR in younger individuals

d. Relying on serum creatinine concentration is sufficient to stage chronic kidney disease (CKD)

A

b. Mean GFR is lower in women than in men

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2
Q

Which of the following disorders in CKD is associated with low bone turnover with low or normal parathyroid hormone (PTH) levels? (HPIM C305 P2114-2115)

a. Osteitis fibrosa cystica

b. Secondary hyperparathyroidism

c. Osteomalacia

d. Adynamic bone disease

A

d. Adynamic bone disease

HIGH BONE TURNOVER
Hyperparathyroidism
• Stimulated by increase in phosphate, uremic toxin
• Bone pain and fragility
• Brown tumors
• Compression syndrome (caused by brown tumors)
• EPO resistance

Osteitis fibrosa cystica
• caused by HYPERPARATHYROIDISM which stimulates increase bone turn over
• Formation of bone cyst
~ if with hemorrhage, hence termed as brown tumor

LOW BONE TURNOVER
Adynamic Bone Disease
• Reduced bone volume and mineralization due to excessive suppression of PTH secondary to the use of vitamin D preparations or excessive calcium exposure (im the form of calcium containing phosphate binders or high calcium dialysis solutions),
• Increased incidence of bone pain
• Increased vascular and cardiac calcification
• Muslce pain

Osteomalacia
• Softening of the bones
• Consequent to reduced production and action of 1,25 (OH)2 D3 leading to non-mineralized osteoid.

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3
Q

45-year-old male comes in for chest pain. He has been on dialysis for 5 years, but missed his past few sessions due to financial constraints. On examination, he had a friction rub with diffuse ST segment elevation and PR depression on ECG. Which of the following is true regarding the management? (HPIM C305 P2117)

a. This is a relative indication for intensification of dialysis prescription

b. This condition is more often observed in those starting dialysis, rather than in those underdialyzed, non-adherent patients

c. This condition is always associated with significant pericardial effusion

d. Hemodialysis should be done without heparin

A

Hemodialysis should be done without heparin

◇ Pericardial Disease
• Pericarditis, Pericardial effusion
• Observed in advanced uremia, underdialyzed and NONADEHERENT patients
• TREATMENT:
–> ABSOLUTE indication for urgent dialysis or ⬆️ intensity of current HD
–> Pericardial Drainage indicated in patients with recurrent pericardial effusion

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4
Q

What is the target BP in CKD patients with diabetes or proteinuria >1 g per 24 h? (HPIM C305 P2117)

a. <120/70 mmHg

b. <125/70 mmHg

c. <120/80 mmHg

d. <130/80 mmHg

A

d. <130/80 mmHg

¤ Target BP
• Proteinuria >1g/ 24 hour: <130/80 mmHg
• Proteinuria <1g/ 24 hour: <140/80 mmHg
• Lower target BP is not applicable because of the lack of autoregulation to maintain GFR in the face of low perfusion pressure.

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5
Q

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

A

¤ Calcium channel blockers
• Diltiazem, Verapamil
• Exhibit superior antiproteinuric and renoprotective effect

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6
Q

Most important complication of arteriovenous grafts is: (HPIM C305, P2123)

a. High output heart failure

b. Infection

c. Bleeding from rupture

d. Thrombosis of the graft

A

d. Thrombosis of the graft

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7
Q

69-year-old male CKD patient on chronic dialysis patient comes in for dyspnea after being unable to undergo his dialysis for 2 weeks. His ECG shows sinus rhythm, peaked T-waves, and widened QRS complexes. His potassium level is probably at what range? (HPIM C49 P309-311, F49-8)

a. 5.5-6.5 mmol/L

b. 6.5-7.5 mmol/L

c. 7.0-8.0 mmol/L

d. >8.0 mmol/L

A

7.0-8.0 mmol/L

5.5 - 6.5 Tall peaked T waves
6.6- 7.5 Loss of P waves
7.0- 8.0 Widened QRS complexes
> 8.0 mM Sine wave pattern

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8
Q

First step in the diagnostic evaluation of hyper- or hypocalcemia is to: (HPIM C50 P313)

a. Ensure that the alteration is not due to abnormal albumin concentrations

b. Ensure adequate hydration of the patient

c. Determine the baseline renal function

d. Rule out other electrolyte abnormalities

A

Ensure that the alteration is not due to abnormal albumin concentrations

Approach to Hypo or Hypercalcemia
(1) Calcium
(2) Albumin, phosphorus, and magnesium levels.
(3) PTH
• Central to the evaluation of hypocalcemia.
• ⬇️ Suppressed (or “inappropriately low”) PTH level in the setting of hypocalcemia establishes absent or reduced PTH secretion (hypoparathyroidism) as the cause of the hypocalcemia
• ⬆️ Elevated PTH level (secondary hyperparathyroidism) should direct attention to the vitamin D axis as the cause of the hypocalcemia.

(4) serum 25-hydroxyvitamin D levels
• assesses nutritional vitamin D deficiency
• reflect vitamin D stores

(5) serum 1,25(OH)2D levels
• In the setting of renal insufficiency or suspected vitamin D resistance,

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9
Q

What is the cell of origin of clear cell carcinoma? (HPIM C81 P617 T81-2)

a. Proximal tubule

b. Distal tubules

c. Cortical collecting duct

d. Medullary collecting duct

A

a. Proximal tubule

🌸 Clear cell carcinoma (70%)
• predominant histology in >80% of metastatic disease
• arise from the epithelial cells of the proximal tubule

🌸 Papillary carcinoma (10%)
• bilateral and multifocal

🌸 Oncocytomas (5-10%)
• benign neoplasms

🌸 Medullary carcinoma
• similar features with Bellini duct tumors
• associated with sickle cell trait

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10
Q

24-year-old female presents with a 3-day history of dysuria associated with frequency in urination. She has no fever nor vaginal discharge. Her LNMP was 1 week ago. According to the 2013 Philippine CPG in the Diagnosis and Management of UTI, what is the appropriate initial management in this patient? (Philippine CPG on the Diagnosis and Treatment of UTI in Adults. 2013 Update. P13, 21)

a. Request for a urinalysis

b. Perform dipstick test to confirm UTI

c. Treat with Fosfomycin 3 g, single dose

d. Start amoxicillin 500 mg/tab TID x 5 days

A

c. Treat with Fosfomycin 3 g, single dose

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11
Q

According to the 2015 Philippine CPG on the Diagnosis and Management of UTI, which of the following conditions define complicated UTI? (Philippine CPG on the Diagnosis and Treatment of UTI in Adults. 2015 Update. Part 2. P50)

a. Didelphys uterus

b. Urine culture finding of Candida species

c. History of UTI 3 months prior

d. Post-void urine of 50 mL on KUB ultrasound

A

Urine culture finding of Candida species

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12
Q

All of the following patients with recurrent UTI need further screening for urologic abnormalities EXCEPT: (Philippine CPG on the Diagnosis and Treatment of UTI in Adults. 2015 Update. Part 2. P23)

a. Persistent microscopic hematuria

b. Elevated serum creatinine

c. History of pyelonephritis

d. Multiple sexual partners

A

d. Multiple sexual partners

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13
Q

Which segment of the renal tubule is most sensitive to ischemia-related injury? (HPIM C304 P2102)

a. S3 segment of proximal tubule

b. Thin ascending loop of Henle

c. Thick descending loop of Henle

d. Collecting duct

A

a. S3 segment of proximal tubule

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14
Q

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

A

Percutaneous renal artery angioplasty

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15
Q

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+

A

b. Proteinuria < 3.5 g/24 hours

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16
Q

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

A

Sodium, Water Homeostasis
🔅 Dietary intake exceeds urinary excretion leading to sodium retention and extracellular fluid volume expansion = peripheral edema, hypertension = ⬆️ NEPHRON INJURY

Potassium Homeostasis
🔅 Decline in the urinary potassium excretion brought about by injury in the distal nephron (aldosterone dependent secretion)= • Increased arrhythmia – Lowers cell-resting action potential and preventing repolarization, leading to muscle paralysis.

Metabolic Acidosis
🔅 Decrease in excretion of acids due to decrease in renal function
🔅 INTACT urine acidifying property BUT LESS AMMONIA produced thus unable to excrete normal quantity of Hydrogen

17
Q

main feature differentiating pyelonephritis from cystitis is:

a. Fever

b. Flank pain

c. Dysuria

d. Vomiting

A

Fever

18
Q

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

A

volume depletion

19
Q

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

A

Granular Cast

👾 Acute Tubular Necrosis:
• prolonged periods of pre renal azotemia that lead to ischemic injury.
• inflammation, apoptosis, altered regional perfusion
• caused by sepsis, drug induced, immune complexes

Urinalysis
• Hyaline cast: Pre-renal azotemia
• Muddy brown granular cast and tubular epithelial cells: ATN
• Oxalate crystals: ethylene glycol toxicity (dumbbells, biconcave disk, ovoids)
• Uric acid crystals: tumor lysis syndrome (needle shape)
• Crystalluria: Acyclovir (needle shape, bright bifringence)
• Triple phosphate crystals: Urea splitting Proteus (coffin lid shape)

FeNa
- ATN: can have FeNa >1 if osmolality <50 or <1
◇ Low Fena <1% : Pre-renal- Avid tubular sodium reabsorption
– EXCEPTION: >1% in pre-renal azotemia: concurrent CKD, diuretics
– DIFFERENTIALS: early onset of glomerulonephritis, hemolysis
– SUGGESTIVE, but not synonymous to effective intravascular volume depletion

◇ High FeNa >1% : Ischemic- damage in tubules and inability to reabsob sodium
– EXCEPTION: <1% in ischemic azotemia: early sepsis, rhabdomyolysis, contrast nephropathy
– DIFFERENTIALS: CKD

20
Q

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

A

Granular Cast

👾 Acute Tubular Necrosis:
• prolonged periods of pre renal azotemia that lead to ischemic injury.
• inflammation, apoptosis, altered regional perfusion
• caused by sepsis, drug induced, immune complexes

Urinalysis
• Hyaline cast: Pre-renal azotemia
• Muddy brown granular cast and tubular epithelial cells: ATN
• Oxalate crystals: ethylene glycol toxicity (dumbbells, biconcave disk, ovoids)
• Uric acid crystals: tumor lysis syndrome (needle shape)
• Crystalluria: Acyclovir (needle shape, bright bifringence)
• Triple phosphate crystals: Urea splitting Proteus (coffin lid shape)

FeNa
- ATN:
◇ Low Fena <1% : Pre-renal- Avid tubular sodium reabsorption
– EXCEPTION: >1% in pre-renal azotemia: concurrent CKD, diuretics
– DIFFERENTIALS: early onset of glomerulonephritis, hemolysis
– SUGGESTIVE, but not synonymous to effective intravascular volume depletion

◇ High FeNa >1% : Ischemic- damage in tubules and inability to reabsob sodium
– EXCEPTION: <1% in ischemic azotemia: early sepsis, rhabdomyolysis, contrast nephropathy
– DIFFERENTIALS: CKD

21
Q

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 > 20I

b. FeNa > 1 %

c. Sterile pyuria

d. Urine osmolality < 200 mosm/L

A

a. BUN/Creatinine ratio > 20

Pre-renal Azotemia
- BUN/Crea >20
- FeNa <1%
- Urine osmolality >500
- Hyaline casts

22
Q

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

A

Malnutrition

Clear indications for initiation of renal replacement therapy for patients with CKD include
[ ] uremic pericarditis
[ ] encephalopathy
[ ] intractable muscle cramping
[ ] anorexia, and nausea not attributable to reversible causes such as peptic ulcer disease, and evidence of malnutrition,
[ ] fluid and electrolyte abnormalities, principally hyperkalemia
[ ] ECFV overload, that are refractory to other measures.

23
Q

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

A

WBC casts

24
Q

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

A

Subepithelial “hump”-like deposits

Post streptococcal GN
• 1- 3 weeks after streptococcal pharyngitis
☆ ASO titer, Antihyaluronidase antibodies, Anti-Dnase
• Confirms the diagnosis

☆ CH50, C3 (Low)
• in the 1st week of symptoms
• 60-70%
C4 normal

☆ Renal biopsy
• Rarely indicated for diagnosis
• LM: hypercellularity in mesangiun
• EM: granular subepithelial (“humps”: SPEB, nephritogenic strains) and subendothelial immune deposits

TREATMENT
Supportive

25
Q

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 diseas

A

Absence of macroscopic hematuria

26
Q

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

A

Diarhhea **

27
Q

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

A

b. Uric acid 3.5 mg/dl

Euvolemic Hyponatremia
◇ Uric Acid
• Low uric ( <4mg/dL) : SIADH,
• Elevated: hypovolemic

28
Q

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

A

a. Alcoholism

29
Q

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

A

a. Sodium bicarbonate

♡ Stages 1 and 2 CKD
• Usually asymptomatic except for the underying disease (edema in nephropathy or HTN in PKD)
• hyperkalemia
• Hyperchloremic metabolic acidosis

♡ CKD Stage 3, 4
• Anemia and associated easy fatigability, decreasing appetite with progressive malnutrition
• Abnormalities in calcium, phosphorus, and mineral-regulating hormones: 1,25(0H)2D; (calcitnol), parathyroid hormone (PTH), fibroblast growth factor 23 (FGF-23)
• Abdnormalities in Na, K, water and acid-base homeostasis

** Stage 2, 3 = seen in elderly, no further ⬇️ in renal function

♡ CKD Stage 3
• Anemia (early)
• Uremic neuromuscular Disease

♡ CKD Stage 4
• Anemia (universal)
• Peripheral neuropathy

♡ CKD Stage 5
• marked disturbance, eventually with uremic syndrome

¤ Bicarbonate
• Given to improve cardiac inotropy and lactate utilization
• Reacts with H ions to form water and CO2, and acts as a buffer by raising pH
Alkali supplementation should be considered when bicarbonate concentration falls below 20-23 mmol/L to avoid protein catabolic state (especially in RTA, HAG in CKD

30
Q

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

A

b. Patient with esophageal carcinoma on total parenteral nutrition

31
Q

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

a. 12%

b. 22%

c. 32%

d. 42%

A

22%

Harrison's Principle of Internal Medicine 20th Edition (7 decks)

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