Nephrology Flashcards
Questions 1–3 pertain to the following case.
R.B. is a 50-year-old woman who has been on hemodialysis
(HD) for 9 years. Her medical history includes end-stage
renal disease (ESRD) secondary to type 2 diabetes (DM),
diabetic neuropathy, hypertension, and gastroesophageal
reflux disease. She generally adheres to her HD prescription. Current medications include: calcium acetate 667 mg
1 capsule with meals three times a day, insulin glargine
10 units every morning and insulin aspart 3–5 units with
meals, ranitidine 150 mg once daily, aspirin 81 mg once
daily, renal multivitamin 1 tablet daily, gabapentin 600
mg once daily at bedtime, and atorvastatin 20 mg once
daily. She receives epoetin alfa 8000 units intravenously
and paricalcitol 2 mcg intravenously at each HD session.
The patient received dietary counseling and states that she
adheres to her diet as closely as possible. Her serum albumin concentration is 4.0 g/dL. Her most recent laboratory
values show intact parathyroid hormone (PTH) 700 pg/
mL, calcium 10.4 mg/dL, and phosphorus 6.8 mg/dL.
- Which is the best recommendation for controlling
R.B.’s phosphorus concentration?
A. Increase calcium acetate to 2 capsules three times
a day.
B. Discontinue calcium acetate and initiate calcium
carbonate 1000 mg with meals and 500 mg with
snacks.
C. Discontinue calcium acetate and initiate aluminum hydroxide 1 g with meals and snacks.
D. Discontinue calcium acetate and initiate sevelamer
carbonate 1600 mg with meals three times a day. - For R.B., the nephrology team considers the addition
of cinacalcet to directly reduce the PTH concentration.
Which laboratory value is most important to monitor
for safety?
A. Liver function.
B. Calcium.
C. PTH.
D. Creatinine. - R.B.’s epoetin dose has been unchanged for 6 months.
Most recently, her laboratory values were as follows:
hemoglobin 8.8 g/dL, transferrin saturation (TSAT)
14%, and serum ferritin 90 ng/mL. In the past month,
her hemoglobin concentration was 9.4 g/dL. There are
no obvious signs of infection or bleeding.Which therapeutic changes would be most appropriate to manage
this patient’s anemia?
A. Administer intravenous iron sucrose 100 mg with
each dialysis session for 10 dialysis sessions.
B. Counsel the patient to take ferrous sulfate 325 mg
twice daily with meals.
C. Initiate folic acid 1 mg orally once daily.
D. Increase the epoetin dose to 10,000 units intravenously with each HD session.
- Answer: D
This patient’s PTH, calcium, and phosphorus values are not
at goal. Answer A is incorrect because it would add more
calcium load. Answer B similarly gives a calcium product to someone whose calcium concentration is too high
already. Aluminum should be avoided in patients with CKD
because of the risk of aluminum intoxication (Answer C is
incorrect). Sevelamer is the best choice because it lowers
phosphorus while avoiding additional calcium administration. Sevelamer dosage may have to be adjusted to reduce
phosphate concentrations to goal (Answer D is correct). - Answer: B
Cinacalcet is a good choice for this patient because both
the high calcium and the high phosphorus values limit the
use of vitamin D analogs. However, serum calcium values
should be monitored closely because hypocalcemia can
occur. Hypocalcemia may lead to seizures (most likely in
patients with a history of them), and/or QT prolongation
(Answer B is correct). Parathyroid hormone should also
be monitored because its concentration should decrease,
but this is a sign of efficacy (Answer C is incorrect). Liver
function tests may be performed, but serious liver problems are rare (Answer A is incorrect). Creatinine does not
have to be monitored in a patient already receiving dialysis
(Answer D is incorrect). - Answer: A
This patient’s anemia has worsened while receiving epoetin
therapy, most likely because of iron deficiency. Answer A
is a recommended iron-loading regimen. Patients undergoing dialysis universally require parenteral iron to maintain
iron stores (Answer A is correct). Oral iron is not recommended in patients receiving HD. It is unlikely to provide
sufficient iron to overcome the anemia and replenish body
stores (Answer B is incorrect). Folic acid is already being
administered to this patient with her renal multivitamin,
and it does not address the primary problem of iron deficiency (Answer C is incorrect). Although increasing the
epoetin dose might increase the patient’s hemoglobin
concentration minimally, it is not appropriate without
first addressing the patient’s iron deficiency. In addition, it
will increase dialysis-related costs with little benefit to the
patient (Answer D is incorrect).
- Which drug is most likely to be removed by high-flux
HD?
Water Solubility
Molecular Weight (Da)
Volume of Distribution (L/kg)
Drug A Moderate 180 1
Drug B High 1400 7
Drug C High 250 0.3
Drug D Low 300 2
A. Drug A.
B. Drug B.
C. Drug C.
D. Drug D
- Answer: C
For a drug to be dialyzed, it should be water soluble
(Answers A and D are incorrect). In addition, drugs with
relatively large volumes of distribution are not effectively
removed by dialysis because the drug is in the tissues
(Answer B is incorrect). With high-flux membranes, molecules of up to 20,000 Da molecular weight are removed,
so molecular weight is not an issue with any of these drugs.
Consequently, drug C is most likely to be removed by dialysis (Answer C is correct).
- An adult patient with stage 5 chronic kidney disease
(CKD) who is receiving maintenance automated peritoneal dialysis (PD) is experiencing abdominal pain,
fever, and cloudy dialysate bags. The nephrology team
suspects peritonitis and wants to initiate empiric antibiotic therapy. Which is the best empiric antibiotic
therapy for this patient?
A. Oral ciprofloxacin and metronidazole.
B. Intraperitoneal vancomycin alone.
C. Intravenous gentamicin alone.
D. Intraperitoneal cefazolin and ceftazidime
- Answer: D
This patient has the classic signs and symptoms of
PD-associated peritonitis. Immediate treatment is indicated. Empiric therapy must cover both gram-positive
species (Staphylococcus spp. and Streptococcus spp.)
and gram-negative species (including Pseudomonas
spp.). Answer D is best at covering both, and the drugs
are administered by the preferred, intraperitoneal route.
Answer A uses oral medications and provides insufficient
gram-positive coverage. In addition, the anaerobic coverage provided by metronidazole is not recommended for
empiric treatment of PD-related peritonitis. Answer B provides only gram-positive coverage. Answer C is incorrect
because it has inadequate gram-positive coverage and uses
the intravenous route
Questions 6 and 7 pertain to the following case.
A.M. is a 54-year-old man who presents with diagnosed
type 2 DM. His serum creatinine (SCr) concentration is 1.6
mg/dL, and a spot albumin/creatinine ratio (ACR) is 410
mg/g. His blood pressure is 145/89 mm Hg and hemoglobin
A1C (A1C) is 7.1%.
Nephrology
ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
1130
6. Which would provide the best therapeutic intervention at this time to slow A.M.’s diabetic kidney disease
progression?
A. Clonidine.
B. Lisinopril.
C. Metoprolol.
D. Amlodipine.
7. Which dietary intervention is best to reduce A.M.’s
albuminuria?
A. Protein-restricted diet.
B. Omega-3 fatty acid administration.
C. Low-carbohydrate (Atkins) diet.
D. Low-potassium diet
- Answer: B
The presence of albuminuria category A2 or greater
indicates that an ACEI or ARB is beneficial to reduce
intraglomerular pressure and slow kidney disease progression (Answer B is correct). Because this patient’s blood
pressure is above goal, lowering it would be beneficial.
However, neither clonidine, metoprolol, nor amlodipine
decrease proteinuria significantly (Answers A, C, and D
are incorrect). - Answer: A
Protein restriction to 0.8 g/kg/day or less will likely reduce
albuminuria and is the best choice (Answer A is correct).
Omega-3 fatty acids have not been studied in diabetic
kidney disease (Answer B is incorrect). Atkins diet is not
recommended because it tends to be a high-protein diet
(Answer C is incorrect). A low-potassium diet would be
appropriate for a patient with advanced kidney disease (not
this patient) to prevent hyperkalemia but would not affect
disease progression (Answer D is incorrect)
- A 76-year-old woman presents with an acute febrile
illness that includes diarrhea and generalized aches.
She has been taking ibuprofen for pain for the past
48 hours and presents to the emergency department
feeling “awful.” Her laboratory tests and physical
examination suggest she is not volume depleted. Her
SCr has doubled since her last visit 1 year ago. Her
physician believes she has acute kidney injury (AKI).
A urinalysis does not reveal red blood cells (RBCs),
white blood cells, or cellular casts. Which is the most
likely diagnosis in this case?
A. Prerenal AKI.
B. Hemodynamically mediated AKI.
C. Intrinsic AKI.
D. Postrenal AKI
- Answer: B
This is a typical presentation of hemodynamically
mediated AKI. In this case, the NSAID is inhibiting vasodilating prostaglandins in the afferent arteriole (Answer B
is correct). Prerenal kidney injury refers to abrupt changes
in kidney function caused by low-flow states to the kidney (e.g., hypotension; Answer A is incorrect). Intrinsic
AKI includes acute tubular necrosis and acute interstitial
nephritis. The presentation and a urinalysis confirming
absence of cellular casts rule out this option (Answer C is
incorrect). Postrenal failure is usually caused by obstruction, and there is no reason to suspect obstruction in this
patient (Answer D is incorrect)
