NEPHROLOGY

Question 1

A 35/M post ESWL returns to your clinic with a kidney stone analysis showing calcium oxalate stones. How will you advise diet modification as a tool to prevent stone recurrence?

a. Ensure adequate intake of calcium to prevent oxalate absorption
b. Completely avoid oxalate-rich food
c. Take mega-doses of Vitamin C
d. Reduce sodium intake to <3g/day

Answer 1

The correct answer is: Ensure adequate intake of calcium to prevent oxalate absorption

Question 2

Which of the following is true of the indices used to measure glomerular filtration rate (GFR)?

a. Creatinine varies markedly day to day due to muscle metabolism.
b. Inulin is reabsorbed but not secreted throughout the tubule making it the most reliable index.
c. Iothalamate is an indirect index used to measure GFR.
d. Urea clearance may underestimate GFR because of urea reabsorption in the tubule.

Answer 2

The correct answer is: Urea clearance may underestimate GFR because of urea reabsorption in the tubule.

Question 3

Which of the following laboratory indices is suggestive of prerenal azotemia?

a. BUN/ Plasma creatinine ratio 15:1
b. FENa <1%
c. Urine osmolality 200 mOsm/L H2O
d. Urine/ plasma creatinine ratio 10

Answer 3

The correct answer is: FENa <1%

Question 4

Which of the following entities is associated with severely increased albuminuria range (300-3500 mg/d or 300-3500 mg/g) on quantification?

a. Amyloidosis
b. Essential hypertension
c. Exercise
d. Membranous glomerulopathy

Answer 4

The correct answer is: Exercise

Question 5

A patient consults for “increased urinary frequency.” Further work-up, including a 24-hour urine collection, confirms true polyuria with urine volume of 3.2 liters. Which of the following is the most appropriate next step?

a. Cranial MRI
b. Serum AVP levels
c. Urine osmolality
d. Water deprivation test

Answer 5

The correct answer is: Urine osmolality

Question 6

Which of the following is TRUE regarding the clinical features of patients with hypokalemia?

a. Hypokalemia causes skeletal myopathy and predisposes to rhabdomyolysis.
b. Hypokalemia delays the progression of hypertension.
c. Hypokalemia is a potential risk factor for ventricular but not atrial arrhythmias.
d. Hypokalemia manifests itself electrocardiographically with ST elevation and QT prolongation.

Answer 6

The correct answer is: Hypokalemia causes skeletal myopathy and predisposes to rhabdomyolysis.

Question 7

A patient presenting with recurrent bouts of hypokalemia went to the OPD for evaluation. Spurious hypokalemia, poor oral intake and drugs/ toxins are ruled out. Based on the diagnostic approach to hypokalemia, what would be the next step?

a. Assess patient’s acid base status
b. Determine urine potassium
c. Check for aldosterone levels
d. Measure trans-tubular potassium gradient (TTKG)

Answer 7

The correct answer is: Determine urine potassium

Question 8

Diabetic patients are prone to develop osmotic hyperkalemia in response to which of the following medications?

a. ACE inhibitors
b. COX-2 inhibitors
c. Digoxin
d. Hypertonic glucose

Answer 8

The correct answer is: Hypertonic glucose

Question 9

Which of the following acid-base disturbances is likely to be seen in patients with stage 3 chronic kidney disease (CKD)?

a. Chronic metabolic alkalosis
b. Chronic respiratory alkalosis
c. High-anion gap metabolic acidosis
d. Non-anion gap metabolic acidosis

Answer 9

The correct answer is: Non-anion gap metabolic acidosis

Question 10

A 50/M is in the ER for restlessness after a weekend of drinking binge followed by vomiting. He is a hypertensive and diabetic who enjoys his alcohol and cigarettes. He has been drinking heavily since he was 30 years old. ABG reveals metabolic acidosis of 7.2. Which of the following contributes most to his acidosis?

a. Lactic acidosis
b. Elevated serum B-hydroxybutyrate
c. Hypokalemia
d. Prolonged vomiting

Answer 10

The correct answer is: Elevated serum B-hydroxybutyrate

Question 11

Treatment of asymptomatic bacteriuria is warranted in which of the following patients?

a. 34-year-old woman with psoriatic arthritis prior to methotrexate therapy
b. 50-year-old woman with neutropenia after chemotherapy for leukemia
c. 55-year-old man who is leaving to work as a seafarer
d. 76-year-old man who will undergo sclerotherapy of his anorectal hemorrhoids

Answer 11

The correct answer is: 50-year-old woman with neutropenia after chemotherapy for leukemia

Question 12

A 35/F G2P1 16 weeks AOG presents at your clinic with dysuria and frequency. She denies fever, flank pain, and vomiting. On PE, she has stable VS, afebrile, with no CVA tenderness. Her lab results show significant pyuria on urinalysis and positive leukocyte esterase and nitrite on urine dipstick. Urine GS/CS is sent. Other labs showed OGTT: FBS 97 mg/dL, 2hr OGTT 153mg/dL. Treatment with cefuroxime 500mg twice daily for 7 days was started. After 72 hours, she is reassessed and has no fever with improvement in dysuria. Urine CS also came out that day and shows E. coli susceptible to TMP-SMX, cephalexin, and co-amoxiclav. According to the Philippine CPG on the Diagnosis and Management of UTI in Adults which of the following is TRUE regarding the management?

a. Antibiotics should be adjusted based on urine cultures; shift antibiotics to co-amoxiclav.
b. Complete cefuroxime treatment but she should be monitored at monthly intervals until delivery to ensure sterile urine.
c. Post-treatment urine culture is not necessary in her case.
d. She should be started on metformin as it decreases the risk of UTI in her case.

Answer 12

The correct answer is: Complete cefuroxime treatment but she should be monitored at monthly intervals until delivery to ensure sterile urine.

Question 13

Which of the following best explains the mechanism behind the acute kidney injury due to NSAID use?

a. Afferent arteriole vasoconstriction
b. Decrease in angiotensin II
c. Efferent arteriole vasodilation
d. Increase in vasodilatory prostaglandins

Answer 13

The correct answer is: Afferent arteriole vasoconstriction

Question 14

A 42/M is undergoing chemotherapy for Burkitt lymphoma. On the 3rd day of receiving cyclophosphamide, vincristine, doxorubicin and dexamethasone, he develops decreasing urine output of 0.6 mL/kg/h. His only other medication is as-needed ondansetron. On PE, BP is 130/70. There are multiple lymphadenopathy on the cervical and supraclavicular areas. Cardiac and chest PE are unremarkable. There is hepatosplenomegaly. There are no edema, cyanosis or clubbing. Laboratory studies showed increasing creatinine and multiple urate crystals on urinalysis. Which of the following is NOT expected in the serum electrolytes of this patient?

a. Hypercalcemia
b. Hyperkalemia
c. Hyperphosphatemia
d. Hyperuricemia

Answer 14

The correct answer is: Hypercalcemia

Question 15

Which of the following measures has the most proven benefit in the supportive management of acute kidney injury?

a. Aggressive correction of metabolic acidosis
b. Erythropoiesis-stimulating agents
c. Low-dose dopamine
d. Phosphate binders

Answer 15

The correct answer is: Phosphate binders

Question 16

At which stage of is peripheral neuropathy usually clinically evident?

a. Stage 2
b. Stage 3
c. Stage 4
d. Stage 5

Answer 16

The correct answer is: Stage 4

Question 17

A 57/F patient of yours with last working impression of CKD Stage 4 is lost to follow up. Her only co-morbidity is hypertension. She comes back to you with cramps, twitching, pain at bilateral lower extremities, with progression of her azotemia. Which of the following is the definitive management for her cramps?

a. IV Pyridoxine
b. Oral vitamin B6
c. Oral vitamin B complex
d. Renal replacement therapy

Answer 17

The correct answer is: Renal replacement therapy

Question 18

Which of the following conditions present with normal kidney size even in the face of chronic kidney disease?

a. HIV nephropathy
b. Lupus nephritis
c. Renal artery stenosis
d. Poststreptococcal glomerulonephritis

Answer 18

The correct answer is: HIV nephropathy

Question 19

A 29/F, previously diagnosed with T1DM since age 15, presents to your clinic with a creatinine of 421 umol/L. On PE, she is awake, alert with a BMI of 29 kg/m2. She has stable vital signs. Fundoscopy reveals unremarkable results. Laboratory results include HbA1c 7.8%, Na 140, K 3.7, Mg 0.95. Which of the following warrant kidney biopsy for her case?

a. BMI
b. Fundoscopy findings
c. Type 1 diabetes as a comorbid
d. Biopsy is not indicated

Answer 19

The correct answer is: Fundoscopy findings

Question 20

A patient with end stage kidney disease reports cramps during his dialysis sessions. Which of the following is an acceptable intervention to prevent this from occurring?

a. Administer salt-poor albumin
b. Administer steroids prior to hemodialysis
c. Increase potassium concentration in dialysate
d. Reduce volume removal during dialysis

Answer 20

The correct answer is: Reduce volume removal during dialysis

Question 21

What is the definition of peritonitis as a complication of peritoneal dialysis?

a. Peritoneal fluid leukocyte count 100/mL, 50% PMN
b. Peritoneal fluid leukocyte count 250/mL, 50% PMN
c. Positive culture
d. Cloudy dialysate

Answer 21

The correct answer is: Peritoneal fluid leukocyte count 100/mL, 50% PMN

Question 22

A 32/M utility worker comes to your clinic with a 3-day history of leg edema, decreased urine output, and gross hematuria. He has no known co-morbid illnesses. On PE, BP is elevated at 150/90 mmHg. On further probing, the patient admitted to have an antecedent localized skin infection 4 weeks prior. Which of the following is the most likely diagnosis?

a. Hypertensive nephropathy
b. IgA nephropathy
c. Membranous glomerulonephritis
d. Post-streptococcal glomerulonephritis

Answer 22

The correct answer is: Post-streptococcal glomerulonephritis

Question 23

Which of the following causes of nephrotic syndrome has the highest reported incidence of renal vein thrombosis, pulmonary embolism and deep vein thrombosis?

a. Focal segmental glomerulosclerosis
b. Membranous glomerulonephritis
c. Minimal change disease
d. Renal amyloidosis

Answer 23

The correct answer is: Membranous glomerulonephritis

Question 24

What is the earliest manifestation of diabetic nephropathy?

a. Albuminuria
b. Glucosuria
c. Hypertension
d. Hematuria

Answer 24

The correct answer is: Albuminuria

Question 25

Which of the following fulfills the diagnosis of autosomal dominant polycystic kidney disease (ADPKD) in patients at least 60 years old who have a family history of the disease?

a. At least 2 renal cysts, bilateral or unilateral
b. At least 4 renal cysts, bilateral or unilateral
c. At least 2 renal cysts in each kidney
d. At least 4 renal cysts in each kidney

Answer 25

The correct answer is: At least 4 renal cysts in each kidney

Question 26

A 35/F presented with fever, rash and eosinophilia after taking NSAIDs. Urinalysis showed pyuria and hematuria. What is the most likely diagnosis?

a. Allergic interstitial nephritis
b. Post-streptococcal glomerulonephritis
c. Rapidly progressive glomerulonephritis
d. Tubulointerstitial nephritis with uveitis

Answer 26

The correct answer is: Allergic interstitial nephritis

Question 27

Which of the following diseases affecting the kidney is associated with both glomerular and interstitial involvement?

a. Leptospirosis
b. Systemic lupus erythematosus
c. Sjogren’s syndrome
d. Subacute bacterial endocarditis

Answer 27

The correct answer is: Systemic lupus erythematosus

Question 28

A 35/F is referred to the IM OPD for co-management. She has bipolar I disorder for more than 10 years and is maintained on olanzapine and lithium. She has hypertension, controlled with losartan and amlodipine. Creatinine is noted to be rising with minimal proteinuria. Which is the best action to take?

a. Discontinue lithium
b. Discontinue losartan
c. Continue medications and monitor lithium levels frequently
d. Start amiloride

Answer 28

The correct answer is: Continue medications and monitor lithium levels frequently

Question 29

Which of the following antibodies is considered a negative predictor for scleroderma renal crisis?

a. Anticentromere antibody
b. Antineutrophil cytoplasmic antibodies
c. Antinuclear antibody
d. Anti-U3-RNP

Answer 29

The correct answer is: Anticentromere antibody

Question 30

Which type of kidney stones is most common?

a. Calcium oxalate stones
b. Calcium phosphate stones
c. Cystine stones
d. Uric acid stones

Answer 30

The correct answer is: Calcium oxalate stones

Question 31

Which organism commonly cause struvite stones?

a. Citrobacter spp.
b. E. coli
c. Pseudomonas spp.
d. Klebsiella pneumoniae

Answer 31

The correct answer is: Klebsiella pneumoniae

Question 32

A 36/M is evaluated in the ER for right flank pain of 2 days’ duration and an episode of gross hematuria. He reports no fever, nausea, or gastrointestinal symptoms. He has no other pertinent medical history, and he takes no medications. Family history is notable for a father with kidney stones. On PE, the patient is seen with moderate discomfort. Vital signs are normal. There is no costovertebral angle tenderness. The abdomen is normal without rebound or guarding. The remainder of the examination is unremarkable. Laboratory studies show a normal CBC, electrolyte panel, and kidney function. Urinalysis is significant for blood on dipstick and >50,000 RBCs/hpf. A non-contrast abdominal CT scan reveals a 12-mm stone in the right renal pelvis. Which of the following is the most appropriate management?

a. Dietary modification
b. IV hydration and antibiotics
c. Mechanical stone removal
d. Tamsulosin

Answer 32

The correct answer is: Mechanical stone removal

Question 33

What is a mainstay in the prevention of uric acid stone formation?

a. Limitation of sodium intake
b. Acidification of urine
c. Alkalinization of urine
d. Calcium supplementation

Answer 33

The correct answer is: Alkalinization of urine

Question 34

In prolonged obstruction, which symptoms typically accompany partial urinary tract obstruction?

a. Hypertension and flushing
b. Polyuria and nocturia
c. Urgency and frequency
d. Straining and retention

Answer 34

The correct answer is: Polyuria and nocturia

Question 35

A 25/F G1P0 consulted for a 2-day history of dysuria, not accompanied by fever, chills, back/flank pains, nausea or vomiting. Pregnancy test taken 1 week ago was positive. According to the Philippine CPG on the Diagnosis and Management of UTI in Pregnancy which of the following is the most appropriate next step in management?

a. Send for urinalysis, then start antimicrobial treatment
b. Send for urinalysis and urine culture, then start antimicrobial treatment
c. Start empiric antimicrobial treatment; no need to send for urine studies
d. Refer to an obstetrician-gynecologist

Answer 35

The correct answer is: Send for urinalysis and urine culture, then start antimicrobial treatment

Question 36

What is the mainstay management in alcoholic acidosis?

a. IV administration of saline and glucose
b. IV administration of sodium bicarbonate
c. IV administration of potassium
d. IV administration of vitamin B

Answer 36

The correct answer is: IV administration of saline and glucose

Question 37

Glomerulonephritis is defined as

a. Effacement of glomerular basement membranes
b. Glomerular mesangial cell hyperplasia
c. Thickening of glomerular basement membranes
d. Inflammation of the glomerular capillaries

Answer 37

The correct answer is: Inflammation of the glomerular capillaries

Question 38

TRUE of the progression of glomerular disease

a. Severity of renal failure is disproportionate to the extent of tubulointerstitial nephritis seen histologically
b. Interstitial inflammation results in “leaky glomeruli” and unregulated urine flow
c. Changes in tubular architecture minimally affect solute transport in the tubule
d. Chronic interstitial fibrosis prognosticates permanent loss of glomerular function

Answer 38

Severity of renal failure best correlates with the extent of tubulointerstitial nephritis seen histologically
Interstitial inflammation results in tubular obstruction and impeded renal flow
Changes in tubular architecture compromises solute transport in the tubule
Chronic interstitial fibrosis prognosticates permanent loss of glomerular function

The correct answer is: Chronic interstitial fibrosis prognosticates permanent loss of glomerular function

Question 39

Microalbuminuria is defined as:

a. Urine Albumin: 27mg/24h by radioimmunoassay
b. Albumin/Creatinine: 250mg/g
c. Dipstick proteinuria: (-)
d. 24-h Urine Protein: 135mg/24h

Answer 39

The correct answer is: Albumin/Creatinine: 250mg/g

Question 40

TRUE of the approach to hematuria in glomerular disease

a. Benign prostatic hypertrophy needs to be considered in microscopic hematuria with minimal proteinuria
b. Frank hematuria occurs early in glomerular disease except in IgA nephropathy and sickle cell disease
c. Symptomatic hematuria predominates early in the clinical course of glomerular disease
d. Red blood cell casts when present exclude the diagnosis of glomerulonephritis

Answer 40

Benign prostatic hypertrophy needs to be considered in microscopic hematuria with minimal proteinuria
Frank hematuria occurs early in glomerular disease particularly in IgA nephropathy and sickle cell disease
Asymptomatic hematuria predominates early in the clinical course of glomerular disease
Red blood cell casts when present make the diagnosis of glomerulonephritis likely
The correct answer is: Benign prostatic hypertrophy needs to be considered in microscopic hematuria with minimal proteinuria

Question 41

TRUE of proteinuria in glomerular disease

a. Proteinuria <1g/24 h is associated with glomerular disease
b. Congestive heart failure is a potential cause of transient proteinuria
c. Development of orthostatic proteinuria portends poor outcomes
d. Adult-onset proteinuria is selective and primarily involves Albumin loss

Answer 41

Proteinuria >1-2 g/24h is associated with glomerular disease
Congestive heart failure is a potential cause of transient proteinuria
Development of orthostatic proteinuria has a benign prognosis
Adult-onset proteinuria is nonselective

The correct answer is: Congestive heart failure is a potential cause of transient proteinuria

Question 42

The histopathologic term crescenteric glomerulonephritis refers to this clinical entity

a. Mesangioproliferative Glomerulonephritis
b. Membranoproliferative Glomerulonephritis
c. Minimal Change Disease
d. Rapidly Proliferative Glomerulonephritis

Answer 42

The correct answer is: Rapidly Proliferative Glomerulonephritis

Question 43

A patient presents with BP of 150/100 with 2 g/24 h urine protein, 3-5 rbc/hpf with red blood cell casts. Serum creatinine is 3.2 mg/dL from 0.8 mg/dL three days prior. Which of the options can cause this condition?

a. Multiple myeloma
b. Systemic Lupus Erythematosus
c. Hepatitis C
d. Alport’s Syndrome

Answer 43

Among the possible causes of a rapidly-deteriorating acute nephritic syndrome is SLE. Class IV Lupus nephritis can present with this clinical course.

The correct answer is: Systemic Lupus Erythematosus

Question 44

Which stain is correctly matched with its appropriate cellular component?

a. Periodic-acid Schiff: basement membrane
b. Masson’s trichome: carbohydrate moieties on glomerular tubules
c. Jones-methenamine silver: collagen deposits
d. Congo red: amyloid deposits

Answer 44

Periodic-acid Schiff: carbohydrate moieties on glomerular tubules
Masson’s trichome: collagen deposits
Jones-methenamine silver: basement membrane structure
Congo red: amyloid deposits

The correct answer is: Congo red: amyloid deposits

Question 45

What is the ideal number of glomeruli to be evaluated under light microscopy to identify the presence of discreet lesions?

a. 8
b. 12
c. 16
d. 20

Answer 45

The correct answer is: 20

Question 46

Diffuse glomerular disease connotes this extent of disease involvement?

a. >35%
b. >50%
c. >65%
d. >80%

Answer 46

Diffuse >50%; Focal <50%

The correct answer is: >50%

Question 47

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

a. 16%
b. 22%
c. 32%
d. 54%

Answer 47

Estimated age-related nephrosclerosis = (Age/2) – 10
(64/2) – 10 = 22

The correct answer is: 22%

Question 48

Lupus nephritis typifies this type of immune hypersensitivity reaction?

a. Immediate-type
b. Cytotoxic reaction of antibody
c. Immune-complex formation
d. Delayed-type

Answer 48

Lupus nephritis results from the deposition of circulating immune complexes, which activate the complement cascade leading to complement-mediated damage, leukocyte infiltration, activation of procoagulant factors, and release of various cytokines.” (Type III hypersensitivity)

The correct answer is: Immune-complex formation

Question 49

This is the most common sign of renal disease in SLE

a. Proteinuria
b. Hematuria
c. Azotemia
d. RBC casts in urine

Answer 49

The correct answer is: Proteinuria

Question 50

TRUE of the evaluation of suspected SLE nephritis

a. Serologic abnormalities are uncommon and highly specific for SLE when present
b. Anti-La correlates best with poor outcomes in lupus nephritis
c. Complement abnormalities occur commonly in lupus nephritis with rising levels indicating flare
d. Clinical presentation of nephritis cannot distinguish between the variants of lupus nephritis

Answer 50

“[R]enal biopsy is the only reliable method of identifying the morphologic variants of lupus nephritis.”

Serologic abnormalities are common and not diagnostic for SLE when present
Anti-dsDNA correlates best with the presence of lupus nephritis
(Anti-La = associated with decreased risk for nephritis)
Complement abnormalities occur commonly in lupus nephritis with decreasing levels (i.e. hypocomplementemia) indicating flare
Clinical presentation of nephritis cannot distinguish between the variants of lupus nephritis

The correct answer is: Clinical presentation of nephritis cannot distinguish between the variants of lupus nephritis

Question 51

Patients with Class III lupus nephritis that exhibit mild proliferation in a small percentage of glomeruli respond well to therapy with this agent

a. Hydroxychloroquine
b. Mycophenolate Mofetil
c. Steroids
d. Tacrolimus

Answer 51

Class III SLE Nephritis
“Class III describes focal lesions with proliferation or scarring, often involving only a segment of the glomerulus. Class III lesions have the most varied course. Hypertension, an active urinary sediment, and proteinuria are common with nephrotic-range proteinuria in 25–33% of patients. Elevated serum creatinine is present in 25% of patients. Patients with mild proliferation involving a small percentage of glomeruli respond well to therapy with steroids alone, and fewer than 5% progress to renal failure over 5 years.”

The correct answer is: Steroids

Question 52

TRUE of the classes of lupus nephritis

a. Class II lupus nephritis is characterized by normal histology with mesangial deposits
b. Class I and III are characterized by normal renal function
c. Class IV is predisposed to developing renal vein thrombosis
d. Class V presents with proteinuria in more than half of cases

Answer 52

Class I lupus nephritis is characterized by normal histology with mesangial deposits
Class I and II are characterized by normal renal function
Class V is predisposed to developing renal vein thrombosis (worst prognosis)
Class V presents with proteinuria in more than half of cases (60%)

The correct answer is: Class V presents with proteinuria in more than half of cases
Question 17

Question 53

What is the outcome of renal transplantation in lupus if done 6 months after achieving disease control?

a. Better compared to patients transplanted for other reasons
b. Similar compared to patients transplanted for other reasons
c. Worse compared to patients transplanted for other reasons
d. Unknown

Answer 53

ESRD in SLE Nephritis
“As a group, ~20% of patients with lupus nephritis will reach end-stage disease, requiring dialysis or transplantation. Patients with lupus nephritis have a markedly increased mortality compared with the general population. Renal transplantation in renal failure from lupus, usually performed after ~6 months of inactive disease, results in allograft survival rates comparable to patients transplanted for other reasons.”

The correct answer is: Similar compared to patients transplanted for other reasons

Question 54

TRUE of the epidemiology of diabetic nephropathy

a. Approximately 60% of diabetics will develop nephropathy
b. Majority of patients with nephropathy have type 1 disease
c. Renal lesions are more common in Asians and African Americans
d. Risk factors include smoking

Answer 54

Approximately 40% of diabetics will develop nephropathy
Majority of patients with nephropathy have type 2 disease
Renal lesions are more common in African Americans (More common in African-American, Native American, Polynesian, and Maori populations).
Risk factors include smoking
• Hyperglycemia
• Hypertension
• Dyslipidemia
• Family history of diabetic nephropathy
• Gene polymorphisms affecting the activity of the renin-angiotensin-aldosterone axis

The correct answer is: Risk factors include smoking

Question 55

TRUE of the pathophysiology of diabetic nephropathy

a. Begin 10-20 years after the onset of diabetes
b. Thickening of the glomerular basement membrane correlates with the presence or absence of clinically significant nephropathy
c. Loss of heparan sulfate moieties that form the negatively charged filtration barrier lead to microscopic hematuria
d. Expansion of the mesangium correlates with the clinical manifestations of diabetic nephropathy

Answer 55

Begin 1-2 years after the onset of diabetes

Thickening of the GBM correlates poorly with the presence or absence of clinically significant nephropathy

Loss of heparan sulfate moieties that form the negatively charged filtration barrier lead to proteinuria

Expansion of the mesangium correlates with the clinical manifestations of diabetic nephropathy

The correct answer is: Expansion of the mesangium correlates with the clinical manifestations of diabetic nephropathy

Question 56

Which intervention will produce the LEAST BENEFIT in the management of diabetic nephropathy?

a. Insulin Glargine + Insulin Glulisine
b. Aliskerin + Carvedilol
c. Lisinopril + Candesartan
d. Empaglifozin + Metformin

Answer 56

Evidence suggests increased risk for cardiovascular adverse events with little evidence of efficacy in some patients with a combination of two drugs (ACE inhibitors, ARBs, or renin inhibitors) that suppress several components of the renin-angiotensin system.”

The correct answer is: Lisinopril + Candesartan

Question 57

TRUE of the pathophysiology of diabetic nephropathy

a. Patients with type 1 diabetes present with advanced nephropathy upon diagnosis
b. The degree of glomerular hyperfiltration inversely correlates with the subsequent risk of clinically significant nephropathy
c. Microalbuminuria appears 5–10 years after the onset of diabetes
d. Albuminuria in the range of 20–200 mg/24 h is called microalbuminuria

Answer 57

Patients with type 2 diabetes present with advanced nephropathy upon diagnosis
The degree of glomerular hyperfiltration correlates with the subsequent risk of clinically significant nephropathy
Microalbuminuria appears 5–10 years after the onset of diabetes
Albuminuria in the range of 30-300 mg/24 h is called microalbuminuria

The correct answer is: Microalbuminuria appears 5–10 years after the onset of diabetes

Question 58

In the absence of diabetes, adults with hypertension and cardiovascular risk factors benefit from achieving a systolic BP of ____ in the prevention of hypertensive nephrosclerosis.

a. <140 mmHg
b. <130 mmHg
c. <120 mmHg
d. <110 mmHg

Answer 58

In the absence of diabetes, adults with hypertension and cardiovascular risk factors
BP Control in Hypertensive Nephrosclerosis

“Recent studies suggest, in the absence of diabetes, adults with hypertension and cardiovascular risk factors benefit from achieving a systolic BP <120 mmHg compared to <140 mmHg.”

The correct answer is: <120 mmHg

Question 59

This type of lesion characterizes HIV-associated nephropathy (HIVAN)?

a. Diffuse Proliferative Glomerulonephritis
b. Focal Segmental Glomerulosclerosis
c. Minimal Change Disease
d. Rapidly Progressive Glomerulonephritis

Answer 59

The correct answer is: Focal Segmental Glomerulosclerosis

Question 60

A 43/M presents with nephrotic range proteinuria accompanied by a fever and malaise which developed three weeks after noticing a painless ulcer on his penis. Renal biopsy revealed MGN. Which test will confirm the diagnosis of this patient?

a. Western Blot
b. Nucleic Acid Amplification Tests (NAATs)
c. Gram’s stain of urethral discharge
d. RPR

Answer 60

RPR (syphilis)

The correct answer is: RPR

Question 61

Which agent will be effective in the treatment of the condition in #24?

a. HAART
b. Tetracycline
c. Clindamycin
d. Penicillin

Answer 61

The correct answer is: Penicillin

Question 62

This is the most common manifestation of UTI

a. Acute cystitis
b. Asymptomatic bacteriuria (ASB)
c. Complicated UTI
d. Pyelonephritis

Answer 62

The correct answer is: Acute cystitis

Question 63

TRUE of the epidemiology of UTI

a. UTI is more common among men after the age of 50
b. Prevalence of ASB is higher in women aged 20-40 than in elderly women
c. Cystitis is temporally related to recent sexual intercourse in a dose–response manner
d. Sexual intercourse is not a risk factor for UTI in postmenopausal women

Answer 63

UTI is as common among men as in women after the age of 50
Prevalence of ASB is lower in women aged 20-40 than in elderly women (5% vs. 40-50%)
Cystitis is temporally related to recent sexual intercourse in a dose–response manner
Sexual intercourse is still a risk factor for UTI in postmenopausal women (as are diabetes mellitus and incontinence)

The correct answer is: Cystitis is temporally related to recent sexual intercourse in a dose–response manner

Question 64

TRUE of the epidemiology of UTI

a. Early recurrence of UTI is relapse rather than re-infection
b. Intracellular pods of infecting organisms in the bladder cause recurrent bouts of UTI in women
c. It is uncommon for multiple recurrences to follow an initial infection in healthy women
d. Studies have not shown a decreased likelihood of UTI with increasing time from the last infection

Answer 64

Early recurrence of UTI is relapse rather than re-infection
Intracellular pods of infecting organisms in the bladder cause recurrent bouts of UTI in animal models but its role in humans is unclear
It is common for multiple recurrences to follow an initial infection in healthy women
Studies have shown a decreased likelihood of UTI with increasing time from the last infection

The correct answer is: Early recurrence of UTI is relapse rather than re-infection

Question 65

Treatment of culture-confirmed bacteriuria will be considered in which asymptomatic patients?

a. 57/F Diabetic
b. 44/M Liver Transplant Recipient
c. 27/F PU 24w AOG
d. All of the above

Answer 65

The correct answer is: 27/F PU 24w AOG

Question 66

Treatment of culture-confirmed bacteriuria will be considered in which asymptomatic patients?

a. 50/M who will undergo ureteroscopy for nephrolithiasis
b. 69/M who will undergo colonoscopy and biopsy of a mass
c. 46/F on chronic foley catheterization due spinal cord injury
d. All of the Above

Answer 66

The correct answer is: 50/M who will undergo ureteroscopy for nephrolithiasis

Question 67

TRUE of the relationship between UTI and diabetes

a. Diabetes raises the risk of ASB and UTI in both men and women
b. Age of onset of diabetes <45 increases the risk of UTI
c. Use of insulin increases the risk of UTI
d. Increased cytokine contributes to ASB in women

Answer 67

Diabetes raises the risk of ASB and UTI in women only

Duration of diabetes directly increases the risk of UTI

Use of insulin increases the risk of UTI

Impaired cytokine contributes to ASB in women

The correct answer is: Use of insulin increases the risk of UTI

Question 68

Use of this oral agent increases the risk of UTI.

a. Dapagliflozin
b. Gliclazide
c. Metformin
d. Sitagliptin

Answer 68

Dapagliflozin (Empagliflozin, Canagliflozin)
“The sodium–glucose co-transporter 2 (SGLT2) inhibitors used for treatment of diabetes result in glycosuria and may be associated with small increases in the risk of UTI.”

The correct answer is: Dapagliflozin

Question 69

65/M with bilateral percutaneous nephrostomy came in for fever and pyuria. What is the most likely organism to grow on urine CS?

a. Acinetobacter baumanii
b. Escherichia coli
c. Klebsiella pneumoniae
d. Proteus mirabilis

Answer 69

“In complicated UTI (e.g., CAUTI), E. coli remains the predominant organism”

The correct answer is: Escherichia coli

Question 70

TRUE of host factors in UTI

a. Women with recurrent UTI are likely to have had their first episode of UTI before the age of 15
b. Women with recurrent UTI have persistent vaginal colonization by E. coli
c. Periurethral mucosal cells from women with recurrent UTI have three-fold more uropathogenic bacteria compared to those without recurrent UTI
d. Propensity for recurrent UTI appears to have a genetic component (e.g. mutation in Toll-like receptors and IL-8 receptor)

Answer 70

Women with recurrent UTI are likely to have had their first episode of UTI before the age of 15
Women with recurrent UTI have persistent vaginal colonization by E. coli
Periurethral mucosal cells from women with recurrent UTI have three-fold more uropathogenic bacteria compared to those without recurrent UTI
Propensity for recurrent UTI appears to have a genetic component (e.g. mutation in Toll-like receptors and IL-8 receptor)

The correct answer is: Women with recurrent UTI are likely to have had their first episode of UTI before the age of 15

Question 71

Use of the Nonoxynol-9 promotes infection by affecting this factor behind UTI

a. Environment
b. Host
c. Milieu
d. Organism

Answer 71

“Nonoxynol-9 in spermicide is toxic to the normal vaginal lactobacilli and thus is likewise associated with an increased risk of E. coli vaginal colonization and bacteriuria.”

The correct answer is: Environment

Question 72

This pathogenic factor in E. coli is responsible for binding to mannose on the surface of epithelial cells.

a. D fimbriae
b. P fimbriae
c. Type I Pilus
d. Type II Pilus

Answer 72

P fimbriae: binds to blood group antigen P (D-galactose-D-galactose)

The correct answer is: Type I Pilus

Question 73

A 26/F with no co-morbidities, urinary tract abnormalities, or history of urologic manipulation came in with a 4-day history of dysuria. On examination she had BP 120/80 HR 102 RR 20 and a temperature of 38.4◦C. Which of the following is her likely diagnosis?

a. Asymptomatic bacteriuria
b. Acute cystitis
c. Complicated UTI
d. Acute Pyelonephritis

Answer 73

“Fever is the main feature distinguishing pyelonephritis from cystitis.”

The correct answer is: Acute Pyelonephritis

Question 74

Which best describes the fever pattern in acute pyelonephritis?

a. Febrile episodes for 3-10 days followed by an afebrile period of 3-10 days
b. Febrile episodes every 3rd day
c. Multiple febrile spikes throughout a day
d. Biphasic fever with two spikes occurring days apart following an afebrile period

Answer 74

Febrile episodes for 3-10 days followed by an afebrile period of 3-10 days (Pel-Ebstein: Lymphoma)

Febrile episodes every 3rd day (Tertian Malaria)

Multiple febrile spikes throughout a day (Picket-Fence)

Biphasic fever with two spikes occurring days apart following an afebrile period (Saddleback: Chikungunya)

The correct answer is: Multiple febrile spikes throughout a day

Question 75

Resolution of fever in #38 following appropriate antibiotic therapy is expected by this time period.

a. 24 hours
b. 48 hours
c. 72 hours
d. 96 hours

Answer 75

The correct answer is: 72 hours

Question 76

A 54/M expired due to urosepsis arising from pyelonephritis. Post-mortem evaluation of the decedent’s kidneys revealed yellow coloration of renal tissue with infiltration by lipid-laden macrophages what additional findings can be expected in his kidneys?

a. Flea-bitten appearance of papillae
b. Cortical tumors
c. Staghorn calculi
d. Renal vein thrombus

Answer 76

yellow coloration of renal tissue with infiltration by lipid-laden macrophages
Staghorn calculi (consistent with xanthogranulomatous pyelonephritis)

The correct answer is: Staghorn calculi

Question 77

Which patient is a candidate for patient-initiated management of UTI?

a. 64/F with new-onset frequency and dysuria
b. 33/F pregnant and asymptomatic with pyuria on urinalysis
c. 69/M with recurrent dysuria and urgency
d. 44/F non-pregnant, with recurrent dysuria and frequency

Answer 77

The correct answer is: 44/F non-pregnant, with recurrent dysuria and frequency

Question 78

Which patient presenting with acute onset back pain, nausea, fever, and dysuria may be managed as outpatient?

a. 37/M without co-morbidities
b. 42/F non-pregnant, without co-morbidities
c. 48/M with hypertension
d. 28/F PU 30w AOG

Answer 78

The correct answer is: 42/F non-pregnant, without co-morbidities

Question 79

A 37/F consults due to dysuria. She relates that her husband was recently treated for UTI and “tulo”. In addition to urinalysis, culture, and STI testing what other test should be included in her evaluation?

a. Blood CS
b. Pelvic Exam
c. Ultrasound of the Kidneys and Bladder
d. Transvaginal Ultrasound

Answer 79

The correct answer is: Pelvic Exam

Question 80

TRUE of the urine dipstick test

a. Only member of Enterobacteriaceae convert nitrate to nitrite
b. Forcing fluids and frequent voiding decrease the likelihood of detecting E. coli with a dipstick test
c. Either a positive nitrite and leukocyte esterase is required to confirm a diagnosis of UTI
d. A negative dipstick test is not sufficiently sensitive to rule out bacteriuria in pregnant women

Answer 80

Only member of Enterobacteriaceae convert nitrate to nitrite
Forcing fluids and frequent voiding decrease the likelihood of detecting E. coli with a dipstick test
Either a positive nitrite and leukocyte esterase is required to confirm a diagnosis of UTI
A negative dipstick test is not sufficiently sensitive to rule out bacteriuria in pregnant women

The correct answer is: A negative dipstick test is not sufficiently sensitive to rule out bacteriuria in pregnant women

Question 81

In men, the minimal level indicating infection appears to be a colony count of ____

a. ≥ 102 bacteria/mL
b. ≥ 103 bacteria/mL
c. ≥ 104 bacteria/mL
d. ≥ 105 bacteria/mL

Answer 81

The correct answer is: ≥ 103 bacteria/mL

Question 82

In women with symptoms of cystitis with a colony count threshold of _____ has a sensitivity of 95% and a specificity of 85%.

a. ≥ 102 bacteria/mL
b. ≥ 103 bacteria/mL
c. ≥ 104 bacteria/mL
d. ≥ 105 bacteria/mL

Answer 82

The correct answer is: ≥ 10^2 bacteria/mL

Question 83

A urine culture is recommended in the evaluation men with symptoms of UTI because it allows the elimination of this differential that does not respond to antibacterial therapy.

a. Acute bacterial prostatitis
b. Chronic bacterial prostatitis
c. Chronic pelvic pain syndrome
d. Prostate cancer

Answer 83

The correct answer is: Chronic pelvic pain syndrome

Question 84

In addition to urinalysis and culture, men with a first episode of febrile UTI should undergo this examination.

a. Blood cultures
b. Kidney and Urinary Bladder Ultrasound
c. Meares-Stamey test
d. Prostate biopsy

Answer 84

Blood cultures

Kidney and Urinary Bladder Ultrasound or CT imaging of the GUT

Meares-Stamey test –> in addition to a urology consult if diagnosis is unclear or UTI is recurrent

Prostate biopsy

The correct answer is: Kidney and Urinary Bladder Ultrasound

Question 85

True of the diagnosis of asymptomatic bacteriuria

a. Based on either clinical or microbiologic criteria
b. For non-catheterized patients: ≥10^5 bacterial CFU/mL of urine
c. For catheterized patients: ≥10^3 bacterial CFU/mL of urine
d. Clinical criteria absence of fever with or without dysuria

Answer 85

Based on fulfillment of both clinical or microbiologic criteria

For non-catheterized patients: ≥10^5 bacterial CFU/mL of urine

For catheterized patients: ≥10^5 bacterial CFU/mL of urine

Clinical criteria absence any symptoms

The correct answer is: For non-catheterized patients: ≥105 bacterial CFU/mL of urine

Question 86

This is the single best agent for the treatment of acute uncomplicated cystitis

a. Fosfomycin
b. Nitrofurantoin
c. TMP-SMX
d. None of these

Answer 86

Unfortunately, there is no longer a single best agent for acute uncomplicated cystitis.”

The correct answer is: None of these

Question 87

TRUE of the use of Nitrofurantoin

a. It has intrinsic activity against Proteus and Enterobacter
b. A 5-day course of Nitrofurantoin is equivalent to a 3-day course of TMP-SMX for acute cystitis
c. Due to accumulation of multiple mutations, resistance to Nitrofurantoin is growing
d. At least a 7-day course of Nitrofurantoin is necessary for pyelonephritis

Answer 87

Serratia, Pseudomonas, yeasts, Proteus and Enterobacter are intrinsically resistant to Nitrofurantoin

A 5-day course of Nitrofurantoin is equivalent to a 3-day course of TMP-SMX for acute cystitis

Resistance remains low despite > 60 years of use

Nitrofurantoin is not ideal for pyelonephritis due to the low levels it reaches in tissue

The correct answer is: A 5-day course of Nitrofurantoin is equivalent to a 3-day course of TMP-SMX for acute cystitis

Question 88

CORRECT regimen for the outpatient management of acute pyelonephritis

a. Ciprofloxacin 500 mg/tab, 1 tab PO BID x 7 days
b. Ceftriaxone 1g IV as loading dose followed by Levofloxacin 750 mg OD x 5 days
c. TMP-SMX 1 double strength tablet, PO BID x 10 days
d. Ceftriaxone 1g IV as loading dose followed by Co-Amoxiclav 500+125 mg/tab, 1 tab PO BID x 7 days

Answer 88

Ciprofloxacin 500 mg/tab, 1 tab PO BID x 7 days

Ceftriaxone 1g IV as loading dose followed by TMP-SMX DS tab, 1 tab PO BID x 14 days if pathogen’s sensitivity is unknown

TMP-SMX 1 double strength tablet, PO BID x 14 days if sensitivity is known

Ceftriaxone 1g IV as loading dose followed by Amoxicillin 500 mg/tab, 1 tab PO TID x 7 days (Oral β-lactams are less effective than Quinolones and should be used with caution)

The correct answer is: Ciprofloxacin 500 mg/tab, 1 tab PO BID x 7 days

Question 89

TRUE of the management of UTI in men

a. For acute prostatitis, treatment should be culture guided for 4-6 weeks
b. For chronic prostatitis, treatment should be culture guided for 8-10 weeks
c. For recurrent prostatitis, treatment should be culture guided for 12 weeks
d. None of these

Answer 89

For acute prostatitis, treatment should be culture guided for 2-4 weeks

For chronic prostatitis, treatment should be culture guided for 4-6 weeks

For recurrent prostatitis, treatment should be culture guided for 12 weeks

The correct answer is: For recurrent prostatitis, treatment should be culture guided for 12 weeks

Question 90

TRUE of the management of candiduria

a. Removal of foley catheter is sufficient for resolution of candiduria in >1/3 of asymptomatic cases
b. Treatment of asymptomatic patients decreases the frequency of recurrence of candiduria
c. Increased resistance to Fluconazole has discouraged its use as a first-line agent in the management of candiduria
d. Bladder irrigation with amphotericin B is recommended in the management of Candida isolates with high levels of resistance to Fluconazole

Answer 90

Removal of foley catheter is sufficient for resolution of candiduria in >1/3 of asymptomatic cases
Treatment of asymptomatic patients does not decrease the frequency of recurrence of candiduria
Fluconazole remains to be the first-line agent of choice in the management of candiduria
Bladder irrigation with amphotericin B is generally not recommended in the management of Candida isolates with high levels of resistance to Fluconazole

The correct answer is: Removal of foley catheter is sufficient for resolution of candiduria in >1/3 of asymptomatic cases

Question 91

A rise in Serum Crea or BUN concentration due to inadequate renal plasma flow and intraglomerular hydrostatic pressure results in this type of AKI

a. Prerenal AKI
b. Intrinsic AKI
c. Postrenal AKI
d. Compound AKI

Answer 91

Prerenal azotemia (from “azo,” meaning nitrogen, and “-emia,” meaning in the blood) is the most common form of AKI. It is the designation for a rise in SCr or BUN concentration due to inadequate renal plasma flow and intraglomerular hydrostatic pressure to support normal glomerular filtration.

The correct answer is: Prerenal AKI

Question 92

This agent can cause both prerenal and intrinsic AKI

a. Lisinopril
b. Amikacin
c. Iohexol
d. Celecoxib

Answer 92

Lisinopril (ACEi)

Amikacin (Aminoglycoside)

Iohexol (Iodinated Contrast)

Celecoxib (NSAID)

The correct answer is: Celecoxib

Question 93

Sepsis induces AKI through its action on

a. Glomeruli
b. Tubules
c. Blood vessels
d. Cortex

Answer 93

The correct answer is: Tubules

Question 94

TRUE of renal physiology in AKI

a. Renal blood flow accounts for nearly half of cardiac output
b. Glomerular filtration can be maintained by angiotensin II–mediated renal afferent vasoconstriction
c. Myogenic reflex within the efferent arteriole leads to dilation in the setting of low perfusion pressure
d. Decreased solute delivery to the macula densa elicits dilation of the juxtaposed afferent arteriole

Answer 94

Renal blood flow accounts for 20% of cardiac output

Glomerular filtration can be maintained by angiotensin II–mediated renal efferent vasoconstriction

Myogenic reflex within the afferent arteriole leads to dilation in the setting of low perfusion pressure

Decreased solute delivery to the macula densa elicits dilation of the juxtaposed afferent arteriole

The correct answer is: Decreased solute delivery to the macula densa elicits dilation of the juxtaposed afferent arteriole

Question 95

CORRECTLY describes the compensatory mechanisms that maintain perfusion pressure within the autoregulatory range

a. Afferent arteriolar vasodilation -> Glomerulus -> Efferent arteriolar vasodilation
b. Afferent arteriolar vasoconstriction -> Glomerulus -> Efferent arteriolar vasodilation
c. Efferent arteriolar vasodilation -> Glomerulus -> Afferent arteriolar vasoconstriction
d. Efferent arteriolar vasoconstriction -> Glomerulus -> Afferent arteriolar vasodilation

Answer 95

The correct answer is: Afferent arteriolar vasodilation -> Glomerulus -> Efferent arteriolar vasodilation

Question 96

Autoregulation fails if systolic BP falls below

a. 90 mmHg
b. 85 mmHg
c. 80 mmHg
d. 75 mmHg

Answer 96

The correct answer is: 80 mmHg

Question 97

Which drug is CORRECTLY matched with its pharmacodynamic effect?

a. Amlodipine: limits afferent arteriolar vasodilation
b. Captopril: limits afferent arteriolar vasodilation
c. Irbesartan: limits efferent arteriolar vasoconstriction
d. Naproxen: limits efferent arteriolar vasoconstriction

Answer 97

Amlodipine: limits afferent arteriolar vasodilation

Captopril: limits efferent arteriolar vasoconstriction

Irbesartan: limits efferent arteriolar vasoconstriction
Naproxen: limits afferent arteriolar vasodilation

The correct answer is: Irbesartan: limits efferent arteriolar vasoconstriction
Question 62

Question 98

TRUE of sepsis-associated AKI

a. Hypotension is necessary for sepsis-induced decrease GFR
b. An operative mechanisms is excessive afferent arteriolar vasodilation early in the course of sepsis
c. Renal vasoconstriction from activation of the parasympathetic nervous system contributes to decreased GFR
d. Sepsis induces direct endothelial damage that leads to tubular injury

Answer 98

Sepsis-induced decrease in GFR can occur in the absence of hypotension
An operative mechanisms is excessive efferent arteriolar vasodilation early in the course of sepsis
Renal vasoconstriction from activation of the parasympathetic nervous system contributes to decreased GFR
Sepsis induces direct endothelial damage that leads to tubular injury

The correct answer is: Sepsis induces direct endothelial damage that leads to tubular injury

Question 99

TRUE of postoperative AKI

a. Urologic procedures carry the highest risk of postoperative AKI
b. Males carry a significant risk for postoperative AKI compared to females
c. Cardiac bypass is a unique hemodynamic state characterized by laminar blood flow
d. AKI from percutaneous catheterization of the aorta may arise weeks after the procedure

Answer 99

Cardiac surgery, vascular procedures with aortic cross-clamping, and intra-peritoneal procedures carry the highest risk of postoperative AKI

Risk factors: underlying CKD, older age, DM, CHF, emergency procedures, and use of nephrotoxic agents (including iodinated contrast)

Cardiac bypass is a unique hemodynamic state characterized by non-pulsatile blood flow

AKI from percutaneous catheterization of the aorta may arise weeks after the procedure (i.e. subacute AKI)

The correct answer is: AKI from percutaneous catheterization of the aorta may arise weeks after the procedure

Question 100

Abdominal compartment syndrome arises from abdominal pressures ____ leading to renal vein compression and reduced GFR

a. >10 mmHg
b. >15 mmHg
c. >20 mmHg
d. >30 mmHg

Answer 100

Burns and AKI
“AKI is an ominous complication of burns, affecting 25% of individuals with >10% total body surface area involvement. In addition to severe hypovolemia resulting in decreased cardiac output and increased neurohormonal activation, burns and acute pancreatitis both lead to dysregulated inflammation and an increased risk of sepsis and acute lung injury, all of which may facilitate the development and progression of AKI.
Individuals undergoing massive fluid resuscitation for trauma, burns, and acute pancreatitis can also develop the abdominal compartment syndrome, where markedly elevated intraabdominal pressures, usually >20 mmHg, lead to renal vein compression and reduced GFR.”

The correct answer is: >20 mmHg

Question 101

TRUE of contrast nephropathy

a. The risk of AKI is negligible in those with normal renal function
b. Rise in serum creatinine begins 12-24 hours post-exposure
c. Serum creatinine peaks within 1-2 days
d. AKI resolves within 3 days

Answer 101

Contrast Nephropathy
The risk of AKI is negligible in those with normal renal function but is a concern in those with CKD particularly those with DM nephropathy

“Contrast nephropathy is thought to occur from a combination of factors, including (1) hypoxia in the renal outer medulla due to perturbations in renal microcirculation and occlusion of small vessels; (2) cytotoxic damage to the tubules directly or via the generation of oxygen-free radicals, especially because the concentration of the agent within the tubule is markedly increased; and (3) transient tubule bstruction with precipitated contrast material. Other diagnostic agents implicated as a cause of AKI are high-dose gadolinium used for magnetic resonance imaging and oral sodium phosphate solutions used as bowel purgatives.”

The correct answer is: The risk of AKI is negligible in those with normal renal function

Question 102

TRUE of AKI due to Aminoglycosides

a. Oliguric in nature (<100 cc/day of urine)
b. Occur despite concentrations in the plasma being 3x that in the renal cortex
c. Manifests within 5-7 days of therapy
d. Hypermagnesemia is a common finding

Answer 102

Nonoliguric in nature (>400 cc/day of urine)
Aminoglycosides are freely filtered across the glomerulus and then accumulate within the renal cortex, where concentrations can greatly exceed those of the plasma
Manifests within 5-7 days of therapy
Hypomagnesemia is a common finding

The correct answer is: Manifests within 5-7 days of therapy

Question 103

TRUE of AKI due to Amphotericin B

a. Reactive oxygen species induce renal vasodilation decreasing GFR
b. Nephrotoxicity is time- but not dose-dependent
c. Amphotericin B binds to cholesterol found on tubular membranes
d. HAGMA is a clinical feature of Amphotericin B-induced AKI

Answer 103

Reactive oxygen species induce direct injury as does renal vasoconstriction
Nephrotoxicity is time- and dose-dependent
Amphotericin B binds to cholesterol found on tubular membranes
NAGMA is a clinical feature of Amphotericin B-induced AKI
AKI from Amphotericin B
“Amphotericin B causes renal vasoconstriction from an increase in tubuloglomerular feedback as well as direct tubular toxicity mediated by reactive oxygen species. Nephrotoxicity from amphotericin B is dose and duration dependent. This drug binds to tubular membrane cholesterol and introduces pores. Clinical features of amphotericin B nephrotoxicity include polyuria, hypomagnesemia, hypocalcemia, and nongap metabolic acidosis.”

The correct answer is: Amphotericin B binds to cholesterol found on tubular membranes

Question 104

This intervention may mitigate the nephrotoxic effect of Cisplatin and is done prior to chemotherapy

a. Administration of N-acetylcysteine
b. Administration of MESNA
c. Aggressive Hydration
d. Bolus administration of the drug

Answer 104

The correct answer is: Aggressive Hydration

Question 105

This intervention may mitigate the nephrotoxic effect of Ifosfamide

a. Administration of N-acetylcysteine
b. Administration of MESNA
c. Aggressive Hydration
d. Bolus administration of the drug

Answer 105

The correct answer is: Administration of MESNA

Question 106

This monocolonal antibody against VEGF can cause hypertension, proteinuria, and thrombotic microangiopathy

a. Atezolizumab
b. Bevacizumab
c. Ramucirumab
d. Tocilizumab

Answer 106

monocolonal antibody against VEGF
Atezolizumab (Anti-PDL1)
Bevacizumab
Ramucirumab (Anti-VEGF receptor type 2)
Tocilizumab (Anti-IL 6)

Select Anti-Cancer Agents in AKI

The correct answer is: Bevacizumab

Question 107

Mechanism of AKI arising from multiple myeloma

a. Tumor Lysis Syndrome
b. Formation of intratubular casts
c. Vasoconstriction and volume depletion
d. All of these

Answer 107

AKI in Multiple Myeloma
“The tumor lysis syndrome can also occasionally occur spontaneously or with treatment for solid tumors or multiple myeloma. Myeloma light chains can also cause AKI by direct tubular toxicity and by binding to Tamm-Horsfall protein to form obstructing intratubular casts. Hypercalcemia, which can also be seen in multiple myeloma, may cause AKI by intense renal vasoconstriction and volume depletion.”

The correct answer is: All of these

Question 108

TRUE of postrenal AKI

a. Normal urinary flow rate automatically rules out the presence of partial obstruction
b. Unilateral obstruction may still cause AKI in individuals who develop vasospasm of the ipsilateral kidney
c. Obstructed foley catheters can be and iatrogenic cause of postrenal AKI
d. Postrenal AKI involves hemodynamic alterations triggered by a gradual increase in intratubular pressures

Answer 108

Normal urinary flow rate does not rule out the presence of partial obstruction
Unilateral obstruction may still cause AKI in individuals who develop vasospasm of the contralateral kidney
Obstructed foley catheters can be and iatrogenic cause of postrenal AKI
Postrenal AKI involves hemodynamic alterations triggered by a sudden increase in intratubular pressures

The correct answer is: Obstructed foley catheters can be and iatrogenic cause of postrenal AKI

Question 109

Use of this agent can cause postrenal AKI through its action on the bladder musculature

a. Bethanecol
b. Donepezil
c. Tiotropium
d. Varenicline

Answer 109

Bethanecol (cholinergic)
Donepezil (cholinergic)
Tiotropium (anti-cholinergic)
Varenicline (cholinergic)

Anti-cholinergics (e.g. ipratropium, atropine) can induce relaxation of the smooth muscles of the ureters and bladder wall and slow voiding. These agents can also precipitate urinary retention and potentially cause AKI.

The correct answer is: Tiotropium

Question 110

CORRECTLY defines AKI

a. Rise in serum creatinine by >0.5 mg/dL within 48 hours
b. Rise of at least 30% more than baseline within 1 week
c. Urine output of <0.5 mL/kg per h for >6 hours
d. All of these

Answer 110

By current definitions the presence of AKI is defined by an elevation in the SCr concentration or reduction in urine output. AKI is currently defined by a rise from baseline of at least 0.3 mg/dL within 48 h or at least 50% higher than baseline within 1 week, or a reduction in urine output to <0.5 mL/kg per h for longer than 6 h.”

The correct answer is: Urine output of <0.5 mL/kg per h for >6 hours

Question 111

Following a recent bout of diarrhea, a previously-well 37/F developed behavioral changes and yellowish skin color. On admission CBC showed Hb 68 Hct 25% Plt 96 WBC 11 (N80% L20%), serum creatinine was noted to 3.0 mg/dL. What type of sediments will be expected in the urinalysis of this patient?

a. Eosinophiluria
b. Hyaline casts
c. RBC casts
d. Renal tubular epithelium (RTE) casts

Answer 111

Case describes MAHA arising from HUS

The correct answer is: Hyaline casts

Question 112

An unconscious patient is brought to the ER with serum creatinine of 3.7 mg/dL. Serum laboratories and ABG revealed a serum anion gap of 16 mEq/L and a serum osmolar gap of 14 mosol/kg. What type of sediments will be expected in the urinalysis of this patient?

a. Crystalluria
b. Granular Casts
c. Normal/No sediments
d. WBC casts

Answer 112

Case describes ethylene glycol poisoning

The correct answer is: Crystalluria

Question 113

Enlarged kidneys in a patient with AKI suggests the possibility of this condition

a. Alport syndrome
b. Amyloidosis
c. Diabetes Mellitus
d. HIV

Answer 113

Imaging in AKI
“Imaging may also provide additional helpful information about kidney size and echogenicity to assist in the distinction between acute versus CKD. In CKD, kidneys are usually smaller unless the patient has diabetic nephropathy, HIV-associated nephropathy, or infiltrative diseases. Normal sized kidneys are expected in AKI. Enlarged kidneys in a patient with AKI suggests the possibility of acute interstitial nephritis or infiltrative diseases.”

The correct answer is: Amyloidosis

Question 114

This kidney biomarker is highly associated with AKI due to cardiopulmonary bypass

a. KIM-1
b. IGFBP7
c. NGAL
d. TIMP-2

Answer 114

NGAL is highly upregulated after inflammation and kidney injury and can be detected in the plasma and urine within 2 h of cardiopulmonary bypass–associated AKI.”

The correct answer is: NGAL

Question 115

This kidney biomarker is associated with AKI due to Cisplatin administration

a. KIM-1
b. IGFBP7
c. NGAL
d. TIMP-2

Answer 115

Kidney injury molecule-1 (KIM-1) is a type 1 transmembrane protein that is abundantly expressed in proximal tubular cells injured by ischemia or nephrotoxins such as cisplatin. KIM-1 is not expressed in appreciable quantities in the absence of tubular injury or in extrarenal tissues.”

The correct answer is: KIM-1

Question 116

TRUE of fluid resuscitation in AKI

a. Severe acute blood loss should be treated with crystalloids
b. Excessive chloride administration from 0.9% saline may lead to hyperchloremic metabolic alkalosis and may impair GFR.
c. Hydroxyethyl starch is preferred for patients at risk for severe AKI
d. Crystalloid is preferred to albumin in traumatic brain injury

Answer 116

Severe acute blood loss should be treated with pRBC transfusions
Excessive chloride administration from 0.9% saline may lead to hyperchloremic metabolic acidosis and may impair GFR.
Hydroxyethyl starch should be avoided for patients at risk for severe AKI
Crystalloid is preferred to albumin in traumatic brain injury

The correct answer is: Crystalloid is preferred to albumin in traumatic brain injury

Question 117

Which of the following statements are TRUE about the pathophysiology of chronic kidney disease? (HPIM 20th Chapter 305 page 2111)

a. Maladaptive responses to maintain GFR leads to distortion of glomerular architecture, abnormal podocyte function and disruption.
b. Initiating mechanisms are non-specific to the underlying etiology of CKD.
c. Decreased activity of the renin-angiotensin system (RAS) contributes to both the initial compensatory hyperfiltration and to the subsequent maladaptive hypertrophy and sclerosis.
d. All of the statements are true.

Answer 117

Pathophysiology of CKD (HPIM 20th Chapter 305 page 2111)
• Involves 2 broad sets of mechanisms of damage:
o Initiating mechanisms specific to the underlying etiology (e.g. abnormalities in kidney development, toxin exposure, immune complex deposition in glomerulonephritis.
o Hyperfiltration and hypertrophy of remaining viable nephrons as a common consequence following long-term reduction of renal mass, irrespective of underlying etiology and lead to further decline in kidney function
• Responses to maintain GFR become maladaptive as increased pressure and flow within the nephron predisposes to distortion of the glomerular architecture abnormal podocyte function, and disruption of the filtration barrier leading to sclerosis and dropout of the remaining nephrons.
• Increased intrarenal activity of the renin-angiotensin system (RAS) appears to contribute both to the initial compensatory hyperfiltration and to the subsequent maladaptive hypertrophy and sclerosis.

The correct answer is: Maladaptive responses to maintain GFR leads to distortion of glomerular architecture, abnormal podocyte function and disruption.

Question 118

Which of the following statements is TRUE about the glomerular filtration rate? (HPIM 20th Chapter 305 page 2111)

a. The normal annual mean decline in GFR with age from the peak GFR attained during the second decade of life is ~10 mL/min per year per 1.73 m2.
b. The mean GFR is lower in men than in women.
c. A woman in her eighties with a laboratory report of serum creatinine in the normal range may have a GFR of <50 mL/min per 1.73 m2.
d. Lowered GFR in ageing does not signify true loss of kidney function.

Answer 118

Pathophysiology of CKD (HPIM 20th Chapter 305 page 2111)
• The normal annual mean decline in GFR with age from the peak GFR (~120 mL/min per 1.73 m2) attained during the third decade of life is ~1 mL/min per year per 1.73 m2, reaching a mean value of 70 mL/min per 1.73 m2 at age 70, with considerable inter-individual variability.
• Although reduced GFR is expected with aging, the lower GFR signifies a true loss of kidney function with attendant consequences in terms of risk of CKD complications, and requirement for dose adjustment of medications.
• The mean GFR is lower in women than in men.
• A woman in her eighties with a laboratory report of serum creatinine in the normal range may have a GFR of <50 mL/min per 1.73 m2.

The correct answer is: A woman in her eighties with a laboratory report of serum creatinine in the normal range may have a GFR of <50 mL/min per 1.73 m2.

Question 119

Which of the following patients has the greatest risk of progression to chronic kidney disease? (HPIM 20th Chapter 305 page 2112)

a. 25/M with an estimated glomerular filtration rate (GFR) of 50 mL/min/1.73 m2 and 350 mg/g of persistent albuminuria
b. 55/M with an estimated GFR of 90 mL/min/1.73 m2 and <30 mg/g of persistent albuminuria
c. 75/F with an estimated GFR of 35 mL/min/1.73 m2 and <30 mg/g of persistent
d. 65/F with an estimated GFR of 65 mL/min/1.73 m2 and 45 mg/g of persistent albuminuria

Answer 119

KDIGO Prognosis of CKD by GFR and albuminuria (HPIM 20th Chapter 305 page 2112)
Choices:
A: Stage G3aA3: RED
B: Stage G1A1: Green
C: Stage G3bA1: Orange
D: Stage G2A2: Yellow
Worst prognosis is patient A with severe albuminuria

The correct answer is: 25/M with an estimated glomerular filtration rate (GFR) of 50 mL/min/1.73 m2 and 350 mg/g of persistent albuminuria

Question 120

Which of the following statements is TRUE about the natural history of chronic kidney disease? (HPIM 20th Chapter 305 page 2112)

a. Population-wide screening is recommended to detect asymptomatic stage 1 and stage 2 CKD even in the absence of risk factors.
b. Complications of CKD become prominent with progression to CKD stages 3 and 4, affecting virtually all organ systems.
c. Many elderly patients will have eGFR values compatible with stage 2 or 3 CKD and warrant immediate nephrologist referral.
d. The accumulation of toxins in stage 4 CKD heralds the beginning of uremic syndrome.

Answer 120

Pathophysiology of CKD (HPIM 20th Chapter 305 page 2112)
• Stages 1 and 2 CKD are usually asymptomatic, recognition of CKD occurs as a result of laboratory testing other than suspicion of kidney disease . In the absence of the risk factors, population-wide screening is NOT recommended.
• With progression to CKD stages 3 and 4, clinical and laboratory complications become more prominent. Virtually all organs are affected, but the most evident complications include anemia and associated easy fatigability; decreased appetite with progressive malnutrition; abnormalities in calcium, phosphorus, and mineral-regulating hormones, such as 1,25(OH)2D3 (calcitriol), parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF-23); and abnormalities in sodium, potassium, water, and acid-base homeostasis.
• Many patients, especially the elderly, will have eGFR values compatible with stage 2 or 3 CKD. However, the majority of these patients will show no further deterioration of renal function. The primary care physician is advised to recheck kidney function, and if it is stable and not associated with proteinuria, the patient can usually be followed with interval repeat testing without referral to nephrologist.
• In stage 5 CKD, toxins accumulate such that patients usually experience a marked disturbance in their activities of daily living, well-being, nutritional status, and water and electrolyte homeostasis, eventuating in the uremic syndrome.

The correct answer is: Complications of CKD become prominent with progression to CKD stages 3 and 4, affecting virtually all organ systems.

Question 121

An 85/F consulted your clinic for a creatinine value of 118umol/L (eGFR 36ml/min/1.73m2). She has no previously known illnesses and is not on any maintenance medications nor NSAIDs. Her urinalysis did not show proteinuria. What will be your best advice for this patient? (HPIM 20th Chapter 305 page 2112)

a. Referral to a nephrologist
b. Plan for kidney biopsy
c. Do 24H urine collection to better characterize proteinuria
d. Recheck kidney function after 3 months

Answer 121

Pathophysiology of CKD (HPIM 20th Chapter 305 page 2112)
Many patients, especially the elderly, will have eGFR values compatible with stage 2 or 3 CKD. However, the majority of these patients will show no further deterioration of renal function. The primary care physician is advised to recheck kidney function, and if it is stable and not associated with proteinuria, the patient can usually be followed with interval repeat testing without referral to nephrologist.

The correct answer is: Recheck kidney function after 3 months

Question 122

Which of the following statements is TRUE about the pathophysiology ang biochemistry of uremic syndrome? (HPIM 20th Chapter 305 page 2113)

a. The accumulation of urea and creatinine concentrations alone may account for the many signs and symptoms that characterize the uremic syndrome
b. The metabolic and endocrine functions of the kidneys are generally unimpaired in patients with CKD and do not contribute to uremia.
c. Progressive systemic inflammation associated with CKD contributes to the acceleration of vascular disease and comorbidity associated with advanced kidney disease.
d. The uremic state can be adequately described and measured by monitoring urea and creatinine concentrations.

Answer 122

Pathophysiology and Biochemistry of Uremia (HPIM 20th Chapter 305 page 2113)
• Urea and creatinine are used to measure the excretory capacity of the kidneys but the accumulation of these two molecules themselves does not account for the many symptoms and signs that characterize the uremic syndrome
• Serum concentrations of urea and creatinine are incomplete surrogate markers for retained toxins, and monitoring the levels of urea and creatinine in the patient with impaired kidney function represents a vast oversimplification of the uremic state. The uremic syndrome involves more than renal excretory failure
• A host of metabolic and endocrine functions normally performed by the kidneys is also impaired, and this results in anemia, malnutrition, and abnormal metabolism of carbohydrates, fats, and proteins.
• Plasma levels of many hormones, including PTH, FGF-23, insulin, glucagon, steroid hormones including vitamin D and sex hormones, and prolactin change with CKD as a result of reduced excretion, decreased degradation, or abnormal regulation.
• CKD is associated with increased systemic inflammation. The inflammation associated with CKD is important in the malnutrition-inflammation-atherosclerosis/ calcification syndrome, which contributes in turn to the acceleration of vascular disease and comorbidity associated with advanced kidney disease
In summary, the pathophysiology of the uremic syndrome can be divided into manifestations in three spheres of dysfunction:
1. those consequent to the accumulation of toxins that normally undergo renal excretion;
2. those consequent to the loss of other kidney functions, such as fluid and electrolyte homeostasis and hormone regulation; and
3. progressive systemic inflammation and its vascular and nutritional consequences.

The correct answer is: Progressive systemic inflammation associated with CKD contributes to the acceleration of vascular disease and comorbidity associated with advanced kidney disease.

Question 123

A 26/M recently began nephrology consultations for his CKD stage 3 due to chronic glomerulonephritis. He recently inquired about what will his most likely eventual cause of death be. Which of the following diseases will you answer? (HPIM 20th Chapter 305 page 2113)

a. Myocardial infarction
b. Sepsis
c. Uremia
d. Malignancy

Answer 123

• Majority of patients with early stages of CKD succumb to cardiovascular and cerebrovascular complications before they progress to the more advanced stages of CKD.
• Even minor decrement in GFR or the presence of albuminuria is now recognized as a major risk factor for cardiovascular disease.

The correct answer is: Myocardial infarction

Question 124

A 62/M diabetic consulted for his bipedal edema. He is otherwise asymptomatic and describes good urine output. He is on Losartan 50mg 1 tablet once a day. His present BP is 140/90. His latest laboratories show serum creatinine of 145umol/L (eGFR 44 ml/min/1.73 m2 by CKD-EPI), Na 138 mEq/L, K 3.7 mEg/L, HCO3 20 mmol/L with arterial pH 7.38. What will be the best treatment option for this patient? (HPIM 20th Chapter 305 page 2114)

a. Water restriction
b. Sodium restriction
c. Sodium bicarbonate
d. Initiate dialysis

Answer 124

Treatment of Fluid, Electrolyte and Acid Base Disorders in CKD (HPIM 20th Chapter 305 page 2114)
• This patient has CKD Stage IIIb with extracellular fluid volume expansion as signified by peripheral edema and hypertension and should be initially advised salt restriction.
• Thiazide diuretics have limited utility in stage 3-5 CKD such that loop diuretics such as furosemide may be needed to maintain euvolemia.
• Water restriction is indicated only if there is hyponatremia (normal Na in this patient).
• Use of sodium bicarbonate is indicated when bicarbonate concentration falls below 20-23 mmol/L to avoid the protein catabolic state seen with even mild degrees of metabolic acidosis and to slow the progression of CKD.
• Dialysis is not yet indicated at this stage when there are no signs of uremia, intractable hyperkalemia or severe acidosis.

The correct answer is: Sodium restriction

Question 125

Which of the following best describes the pathophysiologic mechanisms of calcium and phosphate dysfunction among patients with CKD? (HPIM 20th Chapter 305 page 2114)

a. Reduction of phosphate excretion from declining GFR levels leads phosphate retention osteocyte activation, hyperparathyroidism and hypocalcemia.
b. Changes in calcium and phosphate metabolism ensue when the GFR falls below 30 ml/min.
c. The clinical correlate of adynamic bone disease is osteitis fibrosa cystica.
d. Adynamic bone disease may result from excessive suppression of PTH from excessive use of sodium bicarbonate.

Answer 125

Disorders of Calcium and Phosphate Metabolism (HPIM 20th Chapter 305 page 2114)
• The major disorders of bone disease can be classified into:
o High bone turn-over with increased PTH levels (including osteitis fibrosa cystica, the classic lesion of secondary hyperparathyroidism), osteomalacia due to reduced action of the active forms of vitamin D, and
o Low bone turnover with low or normal PTH levels (adynamic bone disease) or most often combinations of the foregoing.
• Secondary hyperparathyroidism and the high-turnover bone disease occurs when declining GFR leads to reduced excretion of phosphate and hyperphosphatemia. Hyperphosphatemia stimulates osteocytes to synthesize FGF-23 and PTH to stimulate the growth of the parathyroid. This process leads to decreased levels of ionized calcium, suppression of calcitriol leading to hypocalcemia. These changes occur when the GFR falls below 60ml/min
o Hyperparathyroidism leads to bone turnover leading to osteitis fibrosa cystica or the brown tumor. Clinical manifestations of hyperparathyroidism include bone pain, fragility, brown tumors, compression syndromes and EPO resistance.
• Adynamic bone disease is characterized by reduced bone volume mineralization and may result from excessive suppression of PTH production from the use of vitamin D preparations or from excessive calcium exposure in calcium-containing phosphate binders or high-calcium dialysis solutions. Complications of adynamic bone disease include and increased incidence of fracture and bone pain and an association with increased vascular and cardiac calcification.

The correct answer is: Reduction of phosphate excretion from declining GFR levels leads phosphate retention osteocyte activation, hyperparathyroidism and hypocalcemia.

Question 126

Which of the following effects of warfarin increases the risk for calciphylaxis among patients with advanced CKD? (HPIM 20th Chapter 305 page 2115)

a. Stimulation of fibroblast growth factor
b. Suppression of PTH
c. Inhibition of calcium absorption
d. Decreased regeneration of matrix GLA protein

Answer 126

Calciphylaxis is a devastating condition seen in advanced CKD heralded by livedo reticularis and patches of ischemic necrosis

It is caused by vascular occlusion associated with extensive vascular and soft tissue calcification

Risk factors include severe hyperparathyroidism, increased used of calcium-containing phosphate binders, and warfarin

Warfarin decreased the vitamin K-dependent regeneration of matrix GLA protein that prevents vascular calcification

The correct answer is: Decreased regeneration of matrix GLA protein

Question 127

Which of the following statements correctly describes cardiovascular abnormalities in CKD? (HPIM 20th Chapter 305 page 2116)

a. Traditional risk factors of ischemic vascular disease in CKD include sleep apnea, anemia and hyperphosphatemia.
b. The absence of hypertension among patients with advanced CKD portends a worse prognosis than does high blood pressure.
c. Single cardiac troponin measurements are more informative than serial monitoring in documenting acute myocardial ischemia.
d. CKD is a low cardiac output state.

Answer 127

Cardiovascular Abnormalities in CKD (HPIM 20th Chapter 305 page 2116) # 1
• Cardiovascular disease is the leading cause of morbidity and mortality in patients at every stage of CKD
• Ischemic Vascular Disease
o Traditional risk factors: hypertension, hypervolemia, dyslipidemia, sympathetic overactivity and hyperhomocysteinemia
o Non-traditional (CKD-related) risk factors: anemia, hyperphosphatemia, hyperparathyroidism, increased FGF-23, sleep apnea, and generalized inflammation
o LV hypertrophy and microvascular disease.
o Cardiac troponin levels are elevated in CKD even without evidence of acute ischemia, hence serial measurements are more informative than a single, elevated level.
Cardiovascular Abnormalities in CKD (HPIM 20th Chapter 305 page 2116) # 2
• Heart Failure
o Secondary to myocardial ischemia, left ventricular hypertrophy, diastolic dysfunction, and frank cardiomyopathy, in combination with the salt and water retention often results in heart failure or even pulmonary edema.
o Heart failure can be a consequence of diastolic or systolic dysfunction, or both. A form of “low-pressure” pulmonary edema can also occur in advanced CKD, manifesting as shortness of breath and a “bat wing” distribution of alveolar edema fluid on the chest x-ray. This finding can occur even in the absence of ECFV overload and is associated with normal or mildly elevated pulmonary capillary wedge pressure. This process has been ascribed to increased permeability of alveolar capillary membranes as a manifestation of the uremic state, and it responds to dialysis.
o Other CKD-related risk factors, including anemia and sleep apnea, may contribute to the risk of heart failure. Anemia and the placement of an arteriovenous fistula for hemodialysis can generate a high cardiac output state and consequent heart failure.
Cardiovascular Abnormalities in CKD (HPIM 20th Chapter 305 page 2116) # 3

• Hypertension and LV hypertrophy
o Hypertension is one of the most common complications of CKD, develops early during the course and is associated with adverse outcomes, including LV hypertrophy and a more rapid loss of renal function.
o LV hypertrophy and dilated cardiomyopathy are among the strongest risk factors of morbidity and mortality in CKD.
o The absence of hypertension may signify poor LV function and it is possible that in late-stage CKD, its presence may carry a worse prognosis than does high blood pressure.

The correct answer is: The absence of hypertension among patients with advanced CKD portends a worse prognosis than does high blood pressure.

Question 128

Which of the following statements describes a correct strategy in the management of hypertension in CKD? (HPIM 20th Chapter 305 page 2117)

a. Among CKD patients with diabetes, blood pressure should be reduced to <140/90
b. Among CKD patients with proteinuria >1g/24H, blood pressure should be reduced to <130/80
c. Volume management with diuretics is considered the first line
d. ACE inhibitors and ARBs are absolutely contraindicated among patients with CKD.

Answer 128

Treatment of Hypertension in CKD (HPIM 20th Chapter 305 page 2117)
Goal of hypertension therapy in CKD is to prevent the extrarenal complications of high BP such as cardiovascular disease and stroke.

In CKD with DM OR proteinuria >1g.24H, BP should be reduced to <130/80

Salt restriction is first line

When volume management alone is not sufficient, choice of antihypertensive agent is similar to the general population.

ACEIs and ARBs, appear to slow the rate of decline of kidney function. Progressive decline in GFR when using ACEIs and ARBs should prompt their discontinuation.

Lack of autoregulation to maintain GFR in the face of low perfusion pressure makes lower BP targets in CKD patients less applicable.

The correct answer is: Among CKD patients with proteinuria >1g/24H, blood pressure should be reduced to <130/80

Question 129

What is the primary cause of anemia among patients with CKD? (HPIM 20th Chapter 305 page 2117)

a. Diminished red blood cell survival
b. Bleeding diathesis
c. Folate deficiency
d. Relative deficiency of erythropoietin

Answer 129

Anemia in CKD (HPIM 20th Chapter 305 page 2117)

Normocytic-normochromic anemia is observed as early as stage 3 and almost universal by stage 4
Primary cause is insufficient production of EPO by diseased kidneys. Additional risk factors are in Table 305-3
Clinical manifestations: fatigue, diminished exercise tolerance, angina, heart failure, decreased cognitive and mental acuity, impaired host defense against infection

The correct answer is: Relative deficiency of erythropoietin

Question 130

Which of the following statements is TRUE about the treatment of anemia among patients with CKD? (HPIM 20th Chapter 305 page 2118)

a. Erythropoietic-stimulating agents have obviated the need of regular blood transfusions in severely anemic patients
b. Intravenous iron is preferred among patients who have not yet started dialysis
c. Complete normalization of hemoglobin concentration has been demonstrated to be of benefit among CKD patients
d. Current practice is to target hemoglobin concentration of 90g/L.

Answer 130

Treatment of Anemia in CKD (HPIM 20th Chapter 305 page 2118)
Erythropoiesis-stimulating agents (ESA) have obviated the need for BT, reducing the incidence of transfusion-associated infections and iron overload.

Iron supplementation is essential to ensure optimal response to ESA

For the CKD patient not yet on dialysis, oral iron supplementation should be attempted

For patients on hemodialysis, IV iron can be administered during dialysis, weighing the risk for infection

Adequate supply of other major substrates and cofactors for RBC production must be ensured including Vitamin B12 and folate

RCTs of ESA in CKD have failed to show an improvement in CV outcomes with therapy.

Complete normalization of hemoglobin has not been demonstrated to be of benefit to CKD patients

Current practice is to target Hb concentration of 100-115g/L

The correct answer is: Erythropoietic-stimulating agents have obviated the need of regular blood transfusions in severely anemic patients

Question 131

Which of the following classes of antidiabetic medications has been shown to stabilize GFR by reactivating the tubulo-glomerular feedback loop? (HPIM 20th Chapter 305 page 2119)

a. Insulin
b. Sulfonylureas
c. Dipeptidyl peptidase inhibitors
d. Sodium-glucose transport inhibitors

Answer 131

Glucose Metabolism in CKD (HPIM 20th Chapter 305 page 2119)
Glucose metabolism is impaired in CKD, FBS is usually normal or only slightly elevated, mild glucose intolerance does not require specific therapy

Diminished renal degradation of insulin leads to reduction of doses of required by patients as their renal function worsens

Many antidiabetic drugs, including gliptins, require dose reduction in renal failure, and some, such as metformin and sulfonylureas are contraindicated when the GFR is less than half of normal

Sodium-glucose transport inhibition at the proximal tubule results in striking reduction in kidney function decline and in CV events. Their stabilizing effect on GFR and urine albumin exceretion appears to result from correction of hyperfiltration early in T2DM via reactivation of the tubuloglomerular feedback loop.

The correct answer is: Sodium-glucose transport inhibitors

Question 132

A 27/F CKD patient consulted your clinic with her husband asking for advice regarding planning for pregnancy. Her latest GFR is 38ml/min. Which of the following statements is applicable for this patient in relation to pregnancy in CKD? (HPIM 20th Chapter 305 page 2119)

a. Only 20% of pregnancies are carried to term once GFR is less than 40 ml/min
b. Pregnancy does not affect the progression of kidney disease
c. Inability to carry pregnancies to term is a more common problem than infertility
d. Elevations in estrogen predispose female patients with CKD to infertility.

Answer 132

Women with CKD (HPIM 20th Chapter 305 page 2119)
Estrogen levels are low, menstrual abnormalities, infertility, and inability to carry pregnancies to term are common.

When the GFR has declined to ~40 mL/min, pregnancy is associated with a high rate of spontaneous abortion, with only ~20% of pregnancies leading to live births

Pregnancy may hasten the progression of the kidney disease itself.

Women with CKD who are contemplating pregnancy should consult first with a nephrologist in conjunction with an obstetrician specializing in high-risk pregnancy

The correct answer is: Only 20% of pregnancies are carried to term once GFR is less than 40 ml/min

Question 133

A 68-year-old female is in your OPD for follow-up. She has a 20-year history of HTN and dyslipidemia. Medications are atorvastatin, and enalapril, 20 mg/d. BP is 130/70, HR 72, RR 12, BMI 29. There is no lower extremity edema. There is decreased sensation to monofilament testing in the feet. Labs are as follows: HBA1C 6.8%, Creatinine 2 mg/dL. Electrolytes normal, Urine albumin-creatinine ratio 460mg/g (5 years ago: <30 mg/g). Which of the following is the next step in management? (HPIM 20th ed.C305,p 2118)

a. Add Amlodipine
b. Initiate dialysis
c. Add Insulin
d. Add Losartan

Answer 133

Neuromuscular Abnormalities in CKD
CNS, peripheral and autonomic neuropathy as well as abnormalities in muscle structure and function
Subtle manifestations of uremic neuromuscular disease become evident at stage 3 CKD
Early: mild disturbance in memory, concentration and sleep
Later stages: neuromuscular irritability, hiccups, cramps and twitching
Advanced: asterixis, myoclonus, seizures and coma
Peripheral neuropathy: evident at stage 4
Evidence of peripheral neuropathy: indication for RRT

The correct answer is: Initiate dialysis

Question 134

Which of the following GI manifestations of CKD is an indication for dialysis? (HPIM 20th Chapter 305 page 2118)

a. Uremic fetor
b. Gastritis
c. Anorexia
d. Protein-energy malnutrition

Answer 134

Gastrointestinal Manifestations (HPIM 20th Chapter 305 page 2118)
Uremic fetor, a urine-like odor on the breath, derives from the break-down of urea to ammonia in saliva and is often associated with an unpleasant metallic taste (dysgeusia).

Gastritis, peptic disease, and mucosal ulcerations at any level of the GI tract occur in uremic patients and can lead to abdominal pain, nausea, vomiting, and GI bleeding.

CKD patients are prone to constipation and can be worsened by the administration of calcium and iron supplements.

The retention of uremic toxins also leads to anorexia, nausea, and vomiting.

Protein restriction may be useful to decrease nausea and vomiting; however, it may put the patient at risk for malnutrition and should be carried out, if possible, in consultation with a registered dietitian specializing in the management of CKD patients.

Weight loss and protein-energy malnutrition, a consequence of low protein and caloric intake, is common in advanced CKD and is often an indication for initiation of renal replacement therapy.

Metabolic acidosis and the activation of inflammatory cytokines can promote protein catabolism.

The correct answer is: Protein-energy malnutrition

Question 135

A 40/M consulted your clinic for exertional dyspnea. He has no known illnesses and with no significant past medical history. His hemoglobin was found to be low at 105 mg/dL with normal MCV and MCHC. His serum ferritin and TIBC were normal. His creatinine was elevated at 180 mg/dL with calcium of 9.2 mg/dL and albumin of 38 mg/dL. His urinalysis showed proteinuria, but no RBCs and WBCs. Which of the following tests will confirm your diagnosis for this patient?

a. Urine RBC morphology
b. ANA
c. HIV screen
d. Serum and urine protein electrophoresis

Answer 135

Approach to a Patient with CKD (HPIM 20th Chapter 305 page 2119)
HISTORY AND PHYSICAL EXAMINATION
Symptoms and overt signs of kidney disease are often subtle or absent until renal failure supervenes.

History of hypertension (which can cause CKD or more commonly be a consequence of CKD), diabetes mellitus, abnormal urinalyses, and problems with pregnancy such as preeclampsia or early pregnancy loss.

A careful drug history should be elicited. Other drugs to consider include:
o Nonsteroidal anti-inflammatory agents
o Gold, penicillamine
o Antimicrobials, chemotherapeutic agents, antiretroviral agents
o Proton pump inhibitors
o Phosphate-containing bowel cathartics
o Lithium
o Prior exposure to medical imaging radiocontrast agents.
A careful family history of kidney disease, together with assessment of manifestations in other organ systems such as auditory, visual, integumentary and others, may lead to the diagnosis of a heritable form of CKD

The physical examination should FOCUS on blood pressure and target organ damage from hypertension

Fundoscopy and precordial examination (left ventricular heave, a fourth heart sound) should be carried out

Fundoscopy is important in diabetics – may show evidence of diabetic retinopathy, which is associated with nephropathy.

Other physical examination manifestations of CKD include edema and sensory polyneuropathy.

Asterixis or a pericardial friction rub NOT attributable to other causes usually signifies presence of the uremic syndrome.

LABORATORY INVESTIGATION
FOCUS on a search for clues to an underlying causative or aggravating disease process and on the degree of renal damage

Serum and urine protein electrophoresis, looking for multiple myeloma, should be obtained in ALL patients >35 years with unexplained CKD, especially if there is associated anemia and elevated, or even inappropriately normal, serum calcium concentration in the face of renal insufficiency.

In the presence of glomerulonephritis, autoimmune diseases such as lupus and underlying infectious etiologies such as hepatitis B and C and HIV should be assessed.

Serial measurements of renal function should be obtained to determine the pace of renal deterioration and ensure that the disease is truly chronic rather than acute or subacute and hence potentially reversible.

Serum concentrations of calcium, phosphorus, vitamin D, and PTH should be measured to evaluate metabolic bone disease.

Hemoglobin concentration, iron, B12, and folate should also be evaluated.

24-h urine collection may be helpful: protein excretion >300 mg = indication for therapy with ACE inhibitors or ARBs.

The correct answer is: Serum and urine protein electrophoresis

Question 136

Which of the following ultrasound findings in CKD is appropriately matched to the possible etiology of CKD? (HPIM 20th Chapter 305 page 2119)

a. u8iBilaterally small kidneys: diabetic nephropathy
b. Hydronephrosis: recurrent urinary tract infections
c. >1 cm size discrepancy: renovascular disease
d. Unilateral kidney: polycystic kidney disease

Answer 136

Imaging studies in CKD (HPIM 20th Chapter 305 page 2119)
MOST useful imaging study is a renal ultrasound:
• Can verify the presence of two kidneys
• Determine if they are symmetric
• Provide an estimate of kidney size
• Rule out renal masses and evidence of obstruction.
Since it takes time for kidneys to shrink as a result of chronic disease, the finding of bilaterally small kidneys supports the diagnosis of CKD of long-standing duration, with an IRREVERSIBLE component of scarring.

If the kidney size is NORMAL, it is possible that the renal disease is acute or subacute. The EXCEPTIONS are:
• Diabetic nephropathy (size is increased at onset of diabetic nephropathy before CKD with loss of GFR supervenes)
• Amyloidosis
• HIV nephropathy (where kidney size may be normal in the face of CKD)
• Polycystic kidney disease that has reached some degree of renal failure will almost always present with enlarged kidneys with multiple cysts

A discrepancy >1 cm in kidney length suggests either:
• Unilateral developmental abnormality
• Disease process or renovascular disease with arterial insufficiency affecting one kidney more than the other.
The diagnosis of renovascular disease can be undertaken with different techniques, including Doppler sonography, nuclear medicine studies, or CT or MRI studies.

If there is a suspicion of reflux nephropathy (recurrent childhood urinary tract infection, asymmetric renal size with scars on the renal poles), a voiding cystogram may be indicated.

Radiographic contrast imaging studies are NOT particularly helpful in the investigation of CKD.

Intravenous or intraarterial dye should be AVOIDED where possible in the CKD patient, especially with diabetic nephropathy, because of the risk of radiographic contrast dye–induced renal failure.

The correct answer is: >1 cm size discrepancy: renovascular disease

Question 137

Which of the following patients can safely undergo a kidney biopsy? (HPIM 20th Chapter 305 page 2120)

a. 57/F with recurrent UTI and bilaterally small kidneys
b. 25/M with suspected glomerulonephritis and BP of 190/100
c. 29/F with acute pyelonephritis
d. 25/F lupus patient with BMI 20

Answer 137

Kidney biopsy in CKD (HPIM 20th Chapter 305 page 2120)
In the patient with bilaterally small kidneys, renal biopsy is not advised because
1. it is technically difficult and has a greater likelihood of causing bleeding and other adverse con-sequences
2. there is usually so much scarring that the underlying disease may not be apparent,
3. the window of opportunity to render disease-specific therapy has passed.
Other contraindications to renal biopsy include uncontrolled hypertension, active urinary tract infection, bleeding diathesis (including ongoing anticoagulation), and severe obesity.

Ultrasound-guided percutaneous biopsy is the favored approach

Surgical or laparoscopic approach can be considered, especially in the patient with a single kidney where direct visualization and control of bleeding are crucial.

In the CKD patient in whom a kidney biopsy is indicated (e.g., suspicion of a concomitant or super-imposed active process such as interstitial nephritis or in the face of accelerated loss of GFR), the bleeding time should be measured, and if increased, desmopressin should be administered immediately prior to the procedure.

A brief run of hemodialysis (without heparin) may also be considered prior to renal biopsy to normalize the bleeding time.

The correct answer is: 25/F lupus patient with BMI 20

Question 138

What is blood pressure target has been shown to be renoprotective? (HPIM 20th Chapter 305 page 2120)

a. 115/75
b. 120/75
c. 125/80
d. 130/80

Answer 138

The correct answer is: 130/80

Question 139

Which of the following statements is TRUE about the use of ACEIs and ARBs in CKD? (HPIM 20th Chapter 305 page 2120)

a. ACEIs and ARBs have been shown to be effective in slowing progression of CKD only in diabetic patients.
b. Combined use of ACEIs and ARBs is associated with a greater reduction in proteinuria and should be first line.
c. Combined used of ACEIs and ARBs should be avoided due to increased incidence of adverse cardiac events.
d. ACEIs and ARBs are the only antihypertensive medications shown to have reno-protective effects.

Answer 139

Slowing the progression of CKD (HPIM 20th Chapter 305 page 2120)
Increased intraglomerular filtration pressures and glomerular hypertrophy develop as a RESPONSE to loss of nephron number from different kidney diseases: this response is MALADAPTIVE, as it promotes the ongoing decline of kidney function even if the inciting process has been treated or spontaneously resolved.
Control of systemic and glomerular hypertension is important in slowing the progression of CKD
Antihypertensive therapy in patients with CKD also AIMS to slow the progression of nephron injury by reducing intraglomerular hypertension.
Elevated blood pressure INCREASES proteinuria by increasing its flux across the glomerular capillaries.
Renoprotective effect of antihypertensive medications is gauged through the consequent REDUCTION of proteinuria.
The more effective a given treatment is in lowering protein excretion, the greater subsequent impact on protection from decline in GFR.
This observation is the basis for the treatment guideline establishing 130/80 mmHg as the TARGET blood pressure in proteinuric CKD patients.

ACE inhibitors and ARBs are effective in slowing the progression of renal failure in patients with advanced stages of both diabetic and nondiabetic CKD

In the absence of an anti-proteinuric response with either agent alone, combined treatment with both ACE inhibitors and ARBs has been considered.

The combination is associated with a greater reduction in proteinuria compared to either agent alone. Insofar as reduction in proteinuria is a surrogate for improved renal outcome, the combination would appear to be advantageous. However, there is a greater incidence of acute kidney injury and adverse cardiac events from such combination therapy.

On balance, therefore, ACE inhibitor plus ARB therapy should be avoided.

A progressive increase in serum creatinine concentration with these agents may suggest the presence of renovascular disease within the large or small arteries.

Development of side effects may mandate the use of second-line antihypertensive agents instead of ACE inhibitors or ARBs

Among the calcium channel blockers, diltiazem and verapamil may exhibit superior antiproteinuric and renoprotective effects compared to the dihydropyridines.

At least two different categories of response can be considered:

• One in which progression is strongly associated with systemic and intraglomerular hypertension and proteinuria (e.g., diabetic nephropathy, glomerular diseases) and in which ACE inhibitors and ARBs are likely to be the first choice; and
• Another in which proteinuria is mild or absent initially (e.g., adult polycystic kidney disease and other tubulointerstitial diseases), where the contribution of intraglomerular hypertension is less prominent and other antihypertensive agents can be useful for control of systemic hypertension.

The correct answer is: Combined used of ACEIs and ARBs should be avoided due to increased incidence of adverse cardiac events.

Question 140

A 55/M patient is on a follow-up visit for stage G3b/A3 chronic kidney disease due to T2DM. He is asymptomatic and denies dyspnea, insomnia, and anorexia. He has good functional capacity. He is on a basal-bolus insulin regimen and enalapril, 2.5 mg/day. His current BP is 150/80, HR 82, RR 16, no neck vein distention, lungs are clear with no peripheral edema. Labs are as follows: Crea 150 mmol/L, Estimated GFR 41, Urine protein-creatinine ratio 589 mg/g, Kidney ultrasound: no obstruction. Which of the following is the next step in management? (HPIM 20th c305, p2120)

a. Increase enalapril dose
b. Add an ARB
c. Switch enalapril to amlodipine
d. Continue present management

Answer 140

Slowing the Progression of CKD (HPIM 20th c305, p2120)
Target BP 130/80
Use ACE inhibitors or ARBs to decrease proteinuria
ACE inhibitor plus ARB therapy should be avoided.
Development of side effects may mandate the use of second-line antihypertensive agents instead of ACE inhibitors or ARBs.
Among the calcium channel blockers, diltiazem and verapamil may exhibit superior antiproteinuric and reno-protective effects compared to the dihydropyridines.

The correct answer is: Increase enalapril dose

Question 141

Renal replacement therapy is indicated in which of the following patients? (HPIM 20th Chapter 305 page 2121)

a. 64/M, asymptomatic diabetic with eGFR 15 ml/min with K 4.8 and no ECG changes
b. 25/F SLE patient with eGF15 ml/min, hypotension, distant heart sounds and pericardial friction rub on PE
c. 45/M complaining of abdominal pain with bilaterally palpable kidneys on PE
d. 68/M hypertensive noted with rise of creatinine from previous after 3 episodes of diarrhea

Answer 141

Clear indications for initiation of RRT
• Uremic pericarditis
• Uremic encephalopathy
• Intractable muscle cramping, anorexia and nausea
• Evidence of malnutrition
• Fluid and electrolyte abnormalities refractory to other measures
Dialysis in Renal Failure (HPIM 20th Chapter 306 page 2122
Commonly accepted criteria for initiating patients on maintenance dialysis:
• Presence of uremic symptoms
• Hyperkalemia unresponsive to conservative measures
• Persistent extra-cellular volume expansion despite diuretic therapy
• Acidosis refractory to medical therapy
• Bleeding diathesis
• Creatinine clearance or estimated glomerular filtration rate (GFR) <10 mL/min per 1.73 m2

The correct answer is: 25/F SLE patient with eGF15 ml/min, hypotension, distant heart sounds and pericardial friction rub on PE

Question 142

What is the target urea reduction ratio or the fractional reduction in blood urea nitrogen per session evaluated to determine if hemodialysis is effective? (HPIM 20th ed. C 306 p. 2124)

a. >65%
b. >80%
c. >35%
d. >45%

Answer 142

Goals of Dialysis (HPIM 20th ed. C 306 p. 2124)
Current targets include a urea reduction ratio (the fractional reduction in blood urea nitrogen per hemodialysis session) of >65–70% and a body water–indexed clearance × time product (Kt/V) >1.2 or 1.05, depending on whether urea concentrations are “equilibrated.”

The correct answer is: >65%

Question 143

For the majority of patients with ESRD, how many hours of dialysis is required each week? (HPIM 20th ed, c306, p2124)

a. 4-8 hours
b. 9-12 hours
c. 12-14 hours
d. >14 hours

Answer 143

Goals of Dialysis (HPIM 20th ed. C 306 p. 2124)
For the majority of patients with ESRD, between 9 and 12 h of dialysis are required each week, usually divided into three equal sessions. Several studies have suggested that longer hemodialysis session lengths may be beneficial (independent of urea clearance), although these studies are confounded by a variety of patient characteristics, including body size and nutritional status.

The correct answer is: 9-12 hours

Question 144

Which of the following is the most common acute complication of hemodialysis? HPIM 20th Ch 306 p 2124

a. Anaphylactoid reactions
b. Hypoglycemia
c. Syncope
d. Hypotension

Answer 144

Complications during hemodialysis (HPIM 20th Ch 306 p 2124)
• Hypotension is the most common acute complication of hemodialysis, particularly among patients with diabetes mellitus
• Muscle cramps during dialysis are also a common complication
• Anaphylactoid reactions to the dialyzer, particularly on its first use, have been reported most frequently with the bioincompatible cellulosic-containing membranes

The correct answer is: Hypotension

Question 145

A patient undergoing hemodialysis was referred to you for hypotension of BP 70/40. The patient was asymptomatic and denied dyspnea nor chest pain. After discontinuing ultrafiltration, what is you next step in managing this patient’s hypotension?

a. Position patient in the Trendelenberg
b. Request for a STAT 12L ECG
c. Adminiter D50-50 bolus
d. Give a bolus of 100ml normal saline

Answer 145

Hemodialysis complications (HPIM 20th Ch 306 p 2124)
Hypotension: most common, especially in DM patients

o Management: Discontinue ultrafiltration or administer 100-250 mL IV pNSS or salt-poor albumin
o Prevention: Ultrafiltration modelling, sequential ultrafiltration, cooling of the dialysate during dialysis treatment, and avoiding heavy meals during dialysis
Muscle cramps

o Management: reduce volume removal, ultrafiltration profiling, use of sodium modeling
o Prevention: reducing volume removal during dialysis, ultrafiltration profiling, and the use of sodium modeling
Anaphylactoid reactions

o Type A: IgE-mediated intermediate hypersensitivity to ethylene oxide, usually within minutes of treatment
o Type B: nonspecific chest and back pain, results from complement activation and cytokine release
o Treatment with steroids or epinephrine may be needed if symptoms are severe.

The correct answer is: Give a bolus of 100ml normal saline

Question 146

A patient on continuous ambulatory peritoneal dialysis (CAPD) developed sudden onset fever, malaise, and abdominal pain. The peritoneal dialysate was remarkably cloudy. Which of the following peritoneal fluid (dialysis effluent) test results would confirm your diagnosis of peritonitis? (HPIM 20th Ch 306 p 2126)

a. WBC >100/mm3, at least 25% PMNs
b. WBC >100/mm3, at least 50% PMNs
c. WBC >250/mm3, at least 25% PMNs
d. WBC >250/mm3, at least 50% PMNs

Answer 146

COMPLICATIONS DURING PERITONEAL DIALYSIS (HPIM 20th Ch 306 p 2126)
• Peritonitis
• Catheter-associated non-peritonitis infections
• Weight gain and other metabolic disturbances
• Residual uremia (especially among patients with no residual kidney function).
Peritoneal Dialysis - Peritonitis
Develops when there has been a break in sterile technique during one or more of the exchange procedures

Defined by an elevated peritoneal fluid leukocyte count (100/mm3, at least 50% are polymorphonuclear neutrophils)

Cutoffs are LOWER than in spontaneous bacterial peritonitis because of the presence of dextrose in peritoneal dialysis

Solutions and rapid bacterial proliferation in this environment without antibiotic therapy

Clinical presentation: pain and cloudy dialysate, often with fever and other constitutional symptoms

Common culprit organisms:
• MOST common: gram-positive cocci, including Staphylococcus, reflecting the origin from the SKIN
• Gram-negative rod infections are less common
• Fungal and mycobacterial infections: seen in selected patients, particularly after antibacterial therapy
MOST cases of peritonitis can be managed either with intraperitoneal or oral antibiotics, depending on the organism;

Many patients with peritonitis do not require hospitalization.

In cases where peritonitis is due to hydrophilic gram negative rods (e.g., Pseudomonas sp.) or yeast, antimicrobial therapy is usually NOT sufficient, and catheter REMOVAL is required to ensure complete eradication of infection.
The correct answer is: WBC >100/mm3, at least 50% PMNs

Question 147

Which of the following is an absolute contraindication to kidney transplantation? (HPIM 20th C 307 p 2126)

a. HIV
b. Active hepatitis
c. Presence of ABO antibodies
d. Active tuberculosis

Answer 147

Kidney Transplantation HPIM 20th C 307 p 2126
There are FEW absolute contraindications to renal transplantation.

The transplant procedure is relatively noninvasive, as the organ is placed in the inguinal fossa without entering the peritoneal cavity.

Recipients without perioperative complications often can be discharged in excellent condition within 5 days of the operation.

The current standard of care is that the candidate should have a life expectancy of >5 years to be put on a deceased organ wait list.

For living donation, the candidate should also have >5 years of life expectancy

An aggressive approach to diagnosis of the following should be a routine part of the candidate workup:
o Correctable coronary artery disease
o Presence of latent or indolent infection (HIV, hepatitis B or C, tuberculosis)
o Neoplasm
Most centers consider overt AIDS and active hepatitis ABSOLUTE contraindications because of high risk of opportunistic infection but some centers are now transplanting individuals with hepatitis and even HIV infection under strict protocols to determine whether the risks and benefits favor transplantation over dialysis.

Among the few absolute "immunologic" contraindications to transplantation is the presence of a potentially harmful antibody against the donor kidney at the time of the anticipated transplant. Harmful antibodies that can cause very early graft loss include:
o	Natural antibodies against the ABO blood group antigens
o	Antibodies against human leukocyte antigen (HLA) class I (A, B, C) or class II (DR) antigens.

The correct answer is: Presence of ABO antibodies

Question 148

Which of the following pathogenic organisms commonly infects a patient > 6months post transplant? (HPIM 20th c307, p2130)

a. CMV
b. Legionella
c. Aspergillus
d. Listeria

Answer 148

Common Opportunistic Infections in KT Patients (HPIM 20th ed, c307, p2130)

The correct answer is: Aspergillus
Question 113

Question 149

A 34-year old female patient with CKD sec to CGN recently underwent kidney transplant for which she took immunosuppresive drugs thereafter. Two months into the medication, she developed hirsutism as well as gum hyperplasia. Which among the drugs should you suspect to have caused these side effects? (HPIM 20th ed, c307, p2128)

a. Cyclosporine
b. Tacrolimus
c. Azathioprine
d. Mycophenolate Mofetil

Answer 149

Maintenance Immunosuppressive Drugs and their Side Effects (HPIM 20th ed, c307, p2128)

The correct answer is: Cyclosporine

Question 150

Which class of immunosuppresive drug have an afferent arteriolar constrictor effect on the kidney, and may produce permanent vascular and interstitial injury after sustained high-dose therapy? (HPIM 20th ed, c307, p2129)

a. TOR inhibitors
b. Calcineurin inhibitors
c. Antimetabolites
d. Steroids

Answer 150

Calcineurin inhibitors (cyclosporine and tacrolimus) have an afferent arteriolar constrictor effect on the kidney, and may produce permanent vascular and interstitial injury after sustained high-dose therapy. This action will lead to a deterioration in renal function difficult to distinguish from rejection without a renal biopsy. Interstitial fibrosis, isometric tubular vacuolization, and thickening of arteriolar walls are suggestive of this side effect, but not diagnostic.

The correct answer is: Calcineurin inhibitors

Question 151

Which among the anti-hypertensive medications is used initially among patients suffering from elevated blood pressure post transplant? (HPIM 20th ed, c307, p2131)

a. Amlodipine
b. Enalapril
c. Losartan
d. Thiazides

Answer 151

Management Problems in the Recipient (HPIM 20th ed, c307, p2131)
Hypertension may be caused by
(1) native kidney disease,
(2) rejection activity in the transplant,
(3) renal artery stenosis if an end-to-end anastomosis was constructed with an iliac artery branch, and
(4) renal calcineurin inhibitor toxicity, which may improve with reduction in dose.
(5) Whereas ACE inhibitors may be useful, calcium channel blockers are more frequently used initially.
(6) Amelioration of hypertension to the range of 120–130/70–80 mmHg should be the goal in all patients.

Management Problems in the Recipient (HPIM 20th ed, c307, p2131)

Hypercalcemia after transplantation may indicate failure of hyper-plastic parathyroid glands to regress.

Aseptic necrosis of the head of the femur is probably due to preexisting hyperparathyroidism, with aggravation by glucocorticoid treatment.

With improved management of calcium and phosphorus metabolism during chronic dialysis, the incidence of parathyroid-related complications has fallen dramatically.

Persistent hyperparathyroid activity may require subtotal parathyroidectomy.

Although most transplant patients have robust production of ery-thropoietin and normalization of hemoglobin, anemia is commonly seen in the posttransplant period.

Often the anemia is attributable to bone marrow–suppressant immunosuppressive medications such as azathioprine, mycophenolic acid, and sirolimus.

Gastrointestinal bleeding is a common side effect of high-dose and long-term steroid administration.

Many transplant patients have creatinine clearances of 30–50 mL/min and can be considered in the same way as other patients with chronic renal insufficiency for anemia management, including supplemental erythropoietin.

Chronic hepatitis, particularly when due to hepatitis B virus, can be a progressive, fatal disease over a decade or so.

Patients who are persistently hepatitis B surface antigen–positive are at higher risk, according to some studies, but the presence of hepatitis C virus is also a concern when one embarks on a course of immunosuppression in a transplant recipient.

However, the introduction of the new highly effective direct acting hepatitis C antiviral medications promises to reduce this risk significantly.

The correct answer is: Amlodipine

Question 152

A 62/M came in the ER due to anuria. Creatinine was noted to be doubled from his baseline. A foley catheter was inserted but no urine output was noted. What is the next step? (HPIM 20th C313 P2175 F313-1)

a. Forced diuresis
b. CT stonogram
c. KUB ultrasound
d. Intravenous pyelography

Answer 152

Diagnostic Approach for Urinary Tract Obstruction in Unexplained Renal Failure (HPIM 20th C313 P2175 F313-1)

The correct answer is: KUB ultrasound

Question 153

A 45-year-old male is evaluated during an annual routine health maintenance visit. History is notable for type 2 DM (diet controlled) diagnosed 3 months ago. Family history is significant for his father who developed end-stage kidney disease due to diabetes at age 68 years. He reports no symptoms and takes no medications. VS are normal, BMI is 31. Chest and cardiac PE are normal. There is 1+ peripheral edema and serum creatinine is 1.0 mg/dL (88.4 mmol/L). Estimated GFR is at 88. Spot first-morning urine protein-to-creatinine ratio is 30 mg/g. What is the KDIGO classification? (HPIM 20th C305 p2112)

a. G1A2
b. G2A2
c. G1A1
d. G2A1

Answer 153

The correct answer is: G2A2

Question 154

A 29/M is consulting for hypertension. He is concerned that he might develop the “kidney problems” that his siblings had as well as his mother who developed CKD in her 40s. PE revealed bilateral palpable nodular masses on deep palpation at the area of the 11-12th ribs. What is your diagnosis? (HPIM 20th C309 p2153)

a. Autosomal recessive polycystic kidney disease
b. Autosomal dominant polycystic kidney disease
c. Diabetic nephropathy
d. Amyloidosis

Answer 154

Autosomal Dominant Polycystic Kidney Diseae (HPIM 20th C309 p2153)
ADPKD is inherited as an autosomal dominant trait with complete penetrance, but variable expressivity

Characterized by the progressive bilateral formation of renal cysts. Focal renal cysts are typically detected in affected subjects aged <30 years. Hundreds to thousands of cysts are usually present in the kidneys of most patients in the fifth decade.

Enlarged kidneys can each reach a fourfold increase in length, and weigh up to 20 times the normal weight.

Patients are asymptomatic until the fourth to fifth decade of life and are diagnosed by incidental discoveries of hypertension or abdominal masses, back or flank pain is a frequent symptom in ~60% of patients with ADPKD.

The correct answer is: Autosomal dominant polycystic kidney disease

Question 155

Which of the following statements is TRUE about the diagnosis of autosominal dominant polycystic kidney disease? (HPIM 20th C309 p2153)

a. Diagnosis is based on an autosomal dominant pattern of inheritance and bilateral multiple kidney cysts
b. CT scan of the abdomen is often used for pre-symptomatic screening of at-risk subjects and for evaluation of potential living-related kidney donors from ADPKD families
c. The presence of at least 1 renal cyst is sufficient for diagnosis
d. Genetic testing is a requirement of the diagnosis of ADPKD

Answer 155

Autosomal Dominant Polycystic Kidney Disease (HPIM 20th C309 p2153)
Diagnosis is typically made from a positive family history consistent with autosomal dominant inheritance and multiple kidney cysts bilaterally.

Renal ultrasonography is often used for pre-symptomatic screening of at-risk subjects and for evaluation of potential living-related kidney donors from ADPKD families

The presence of at least two renal cysts (unilateral or bilateral) is sufficient for diagnosis among at-risk subjects between 15 and 29 years of age

Genetic testing by linkage analyses and mutational analyses are available for ambiguous cases

The correct answer is: Diagnosis is based on an autosomal dominant pattern of inheritance and bilateral multiple kidney cysts

Question 156

Which of the following statements is TRUE about the pathogenesis of diabetic nephropathy? (HPIM 20th C398 p2878)

a. Diabetic nephropathy is a macrovascular complication of hyperglycemia
b. Diabetic nephropathy is characterized by hyperfiltration and decreased GFR during its first few years
c. Screening for albuminuria should commence 5 years after the onset of type 1 DM and at the time of diagnosis of type 2 DM
d. Albuminuria is not a risk factor for kidney disease progression in T1 DM

Answer 156

Diabetic Nephropathy (HPIM 20th C398 p2878)
Diabetic nephropathy is the leading cause of chronic kidney disease (CKD), ESRD, and CKD requiring renal replacement therapy 

Like other microvascular complications, the pathogenesis of diabetic nephropathy is related to chronic hyperglycemia

Glomerular hyperperfusion and renal hypertrophy occur in the first years after the onset of DM and are associated with an increase of the estimated glomerular filtration rate (GFR).

After 5–10 years of type 1 DM, many individuals begin to excrete small amounts of albumin in the urine.

Once there is marked albuminuria and a reduction in GFR, the pathologic changes are likely irreversible

Screening for albu-minuria should commence 5 years after the onset of type 1 DM and at the time of diagnosis of type 2 DM.

The correct answer is: Screening for albuminuria should commence 5 years after the onset of type 1 DM and at the time of diagnosis of type 2 DM

Question 157

A 55/F diabetic is consulting about an elevated creatinine of 1.4mg/dL (eGFR 42ml/min/1.73m2) and spot albuminuria to crea ratio of 100mg/g Cr. Her BP is normal and is asymptomatic. After controlling her sugars, what will be your next best step in slowing the progression of her kidney disease? (HPIM 20th C398 p2878)

a. No intervention but strict monitoring
b. Start Amlodipine
c. Start ARB
d. Start insulin

Answer 157

Diabetic Nephropathy (HPIM 20th C398 p2878)
The optimal therapy for diabetic nephropathy is prevention by control of glycemia

Interventions effective in slowing progression of albuminuria include

1. improved glycemic control
2. strict blood pressure control, and
3. administration of an ACE inhibitor or ARB.

Dyslipidemia should also be treated.

The correct answer is: Start ARB

Question 158

Which of the following symptoms are correctly matched to its clinical syndrome? (HPIM 20th C 130 p 970)

a. Dysuria, urinary frequency and urgency: asymptomatic bacteriuria
b. Fever, rigors and flank pain: pyelonephritis
c. Low back pain, pelvic pain, dyspareunia: cystitis
d. Fever, urinary frequency, flank pain: cystitis

Answer 158

Clinical Manifestations of UTI (HPIM 20th C 130 p 970)

1. Asymptomatic Bacteriuria
   a. No local or systemic symptoms referable to the urinary tract
   b. Incidental finding when a patient undergoes screening urine culture for a reason unrelated to the GU tract
2. Cystitis: dysuria, urinary frequency, urgency
   o Nocturia, hesitancy, suprapubic discomfort, and gross hematuria may be noted
   o Unilateral back or flank pain is generally an indication that the upper urinary tract is involved.
   o Fever also is an indication of invasive infection of either the kidney or the prostate.
3. Pyelonephritis: symptoms of cystitis may or may not be present
   a. Fever with or without CVA pain
   b. Severe: high fever, rigors, nausea and vomiting
4. Prostatitis:
   a. Chronic pelvic pain syndrome (chronic prostatitis)
   b. Acute bacterial prostatitis: dysuria, frequency and pain in the prostatic or perineal area
5. Complicated UTI

Symptomatic episode of cystitis or pyelonephritis in a man or woman with an anatomic predisposition to infection, with a foreign body in the urinary tract, or with factors predisposing to a delayed response to therapy

The correct answer is: Fever, rigors and flank pain: pyelonephritis

Question 159

A 65/F with uncontrolled diabetes is admitted for cystitis, flank pain and non-remitting fevers despite antibiotics for 48H. A CT of the abdomen revealed fat stranding and air-fluid levels in the L perinephric area. What is your diagnosis? (HPIM 20th C 130 p 971)

a. Acute uncomplicated pyelonephritis
b. Xanthogranulomatous pyelonephritis
c. Emphysematous pyelonephritis
d. Suppurative pyelonephritis

Answer 159

The correct answer is: Emphysematous pyelonephritis

Question 160

Which of the following symptoms is not typical of cystitis? (HPIM 20th C 130 p 971)

a. Fever
b. Dysuria
c. Frequency
d. Back pain

Answer 160

Fever is the main feature distinguishing cystitis from pyelonephritis.

The fever of pyelonephritis typically exhibits a high spiking “picket-fence” pattern and resolves over 72 h of therapy

Bacteremia develops in 20–30% of cases of pyelonephritis.

Patients with diabetes may present with obstructive uropathy associated with acute papillary necrosis when the sloughed papillae obstruct the ureter.

Papillary necrosis may also be evident in some cases of pyelonephritis complicated by obstruction, sickle cell disease, analgesic nephropathy, or combinations of these conditions.

In the rare cases of bilateral papillary necrosis, a rapid rise in the serum creatinine level may be the first indication of the condition.

Emphysematous pyelonephritis is a particularly severe form of the disease that is associated with the production of gas in renal and perinephric tissues and occurs almost exclusively in diabetic patients

Xanthogranulomatous pyelonephritis occurs when chronic urinary obstruction (often by staghorn calculi), together with chronic infection, leads to suppurative destruction of renal tissue On pathologic examination, the residual renal tissue frequently has a yellow coloration, with infiltration by lipid-laden macrophages.

Pyelonephritis can also be complicated by intraparenchymal abscess formation; this development should be suspected when a patient has continued fever and/or bacteremia despite antibacterial therapy.

The correct answer is: Fever

Question 161

A 76-year-old man consults in the clinic for a 3-day history of suprapubic pain associated with terminal dysuria. He has hypertension, diabetes, dyslipidemia and gout, and is on losartan, canagliflozin, fenofibrate and allopurinol. Which among his medications may be associated with increased risk in developing UTI? (HPIM 20th C130 P969)

a. Allopurinol
b. Canagliflozin
c. Fenofibrate
d. Losartan

Answer 161

Epidemiology and Risk Factors for UTI (HPIM 20th C130 P969)
Cystitis: Recent use of a diaphragm with spermicide, frequent sexual intercourse, and a history of UTI are independent risk factors for acute cystitis. Postmenopausal women: diabetes, incontinence

Pyelonephritis: frequent sexual intercourse, a new sexual partner, a UTI in the previous 12 months, a maternal history of UTI, diabetes, and incontinence.

Men with UTI: functional or anatomic abnormality of the urinary tract, most commonly urinary obstruction secondary to prostatic hypertrophy. Lack of circumcision

Diabetics: Increased duration of diabetes and the use of insulin rather than oral medication are associated with an elevated risk of UTI among women with diabetes. Poor bladder function, obstruction in urinary flow, and incomplete voiding are additional factors commonly found in patients with diabetes that increase the risk of UTI. Impaired cytokine secretion may con-tribute to ASB in diabetic women. The sodium–glucose co-transporter 2 (SGLT2) inhibitors used for treatment of diabetes result in glycosuria and may be associated with small increases in the risk of UTI.

The correct answer is: Canagliflozin

Question 162

Which of the following is TRUE regarding the role of urine dipstick in the diagnosis of urinary tract infections (UTIs)? (HPIM 20th C130 P973)

a. The leukocyte esterase test detects this enzyme from lysed polymorphonuclear leukocytes in the patient’s urine, but is much less sensitive in detecting the enzyme from intact cells.
b. Among women with acute cystitis, increasing fluid intake and voiding frequently will increase sensitivity of the urine dipstick test.
c. Both nitrite and leukocyte esterase tests should be positive for one to confirm the diagnosis of UTIs.
d. Urine dipstick test for nitrite will only be positive when the organisms are members of the family Enterobacteriaceae.

Answer 162

Detailed history

Urine Dipstick Test
• Only members of the family Enterobacteriaceae convert nitrate to nitrite, and enough nitrite must accumulate in the urine to reach the threshold of detection. Increased fluid intake and voiding frequently may render the test to be less positive, even when E. coli is present
• Leukocyte esterase test: detects this enzyme in polymorphonuclear leukocytes in the host’s urine, whether the cells are intact or lysed
• Urine dipstick test can confirm the diagnosis of uncomplicated cystitis in a patient with a reasonably high pretest prob-ability of this disease; either nitrite or leukocyte esterase positivity can be interpreted as a positive result.

The correct answer is: Urine dipstick test for nitrite will only be positive when the organisms are members of the family Enterobacteriaceae.

Question 163

Treatment of asymptomatic bacteriuria is warranted in which of the following patients? (HPIM 20th C130 P975)

a. 34-year-old woman with psoriatic arthritis prior to methotrexate therapy
b. 50-year-old woman with neutropenia after chemotherapy for leukemia
c. 55-year-old man who is leaving to work as a seafarer
d. 76-year-old man who will undergo sclerotherapy of his anorectal hemorrhoids

Answer 163

Treatment of Asymptomatic Bacteriuria (HPIM 20th C130 P975)
Treatment of ASB does not decrease the frequency of symptomatic infections or complications except in:
-> pregnant women
-> persons undergoing urologic surgery
-> perhaps neutropenic patients and renal transplant patients

The correct answer is: 50-year-old woman with neutropenia after chemotherapy for leukemia

Question 164

What is the of antibiotic-of-choice for the treatment of asymptomatic bacteriuria in pregnant patients or those undergoing urologic surgery? (HPIM 20th, C130 P975)

a. Ciprofloxacin
b. Co-trimoxazole
c. Nitrofurantoin
d. Guided by culture results

Answer 164

Treatment of Asymptomatic Bacteriuria (HPIM 20th C130 P975)
There is no empiric antibiotic recommended for the treatment of asymptomatic bacteriuria. For pregnant patients or those undergoing urologic surgery, treatment must be guided by culture results. In all other populations, screening for and treatment of ASB is discouraged.

The correct answer is: Guided by culture results

Question 165

In the Medical ICU, you have a 41 year-old hypertensive, nondiabetic patient admitted and intubated for Acute Respiratory Distress Syndrome from COVID-19. At his 7th hospital day, decreasing urine output prompted a repeat urinalysis. Results incidentally revealed candiduria, though he denies dysuria, hypogastric or flank pain. Which of the following is TRUE regarding candiduria? (HPIM 20th, C130 P976)

a. >50% of urinary Candida isolates have been found to be of the albicans species.
b. Removal of the urethral catheter results in resolution of candiduria in more than one-third of asymptomatic cases.
c. Fluconazole, though widely-used in clinical practice for the treatment of candiduria, does not reach high levels in urine, and is thus not recommended as first line therapy.
d. Bladder irrigation with amphotericin B is an effective treatment for candiduria while avoiding the systemic toxicity associated with parenteral amphotericin B.

Answer 165

Candiduria (HPIM 20th, C130 P976)
• >50% of urinary Candida isolates have been found to be non-albicans species.
• Fluconazole (200-400mg/day for 7-14 days) reaches high levels in urine and is the first-line regimen for Candida infections of the urinary tract.
• Bladder irrigation with amphotericin B generally is not recommended for treatment of candiduria.

The correct answer is: Removal of the urethral catheter results in resolution of candiduria in more than one-third of asymptomatic cases.

Question 166

Which of the following patients need to be screened for asymptomatic bacteriuria? UTI CPG 2015

a. 60/M with benign prostatic hyperplasia about to undergo CTURP
b. 24/M undergoing routine pre-employment examination
c. 70/F osteoporotic with complaint of low back pain
d. All of the above

Answer 166

Indications for screening and treatment for asymptomatic bacteriuria (UTI CPG 2015)
Screening is recommended among the following to prevent bacteremia and sepsis
• Patients who will undergo genitourinary manipulation or instrumentation
• All pregnant women
Treatment:
• Antibiotics depending on culture for 7 days

The correct answer is: 60/M with benign prostatic hyperplasia about to undergo CTURP

Question 167

A 35/F diabetic who is 8 weeks pregnant consults for 10-15 WBCs in her urinalysis. She is asymptomatic. Which of the following antibiotics is a good choice for her treatment? (UTI CPG 2015)

a. Ciprofloxacin
b. Erythromycin
c. Meropenem
d. Fosfomycin

Answer 167

Antibiotics for ASB in pregnancy

The correct answer is: Fosfomycin
Question 132

Question 168

Which of the following statements is TRUE about asymptomatic bacteriuria? (UTI CPG 2015)

a. Urine collection in screening for asymptomatic bacteriuria should be collected using catheterization to assure proper collection
b. For asymptomatic women, bacteriuria is defined as two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥ 100,000 cfu/mL
c. In men, bacteriuria is defined as two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥ 50,000 cfu/mL
d. All diagnosis of asymptomatic bacteriuria (ASB) should be based on results of urinalysis that are collected aseptically and with no evidence of contamination

Answer 168

Asymptomatic Bacteriuria (UTI CPG 2015)
All diagnosis of asymptomatic bacteriuria (ASB) should be based on results of urine culture specimens that are collected aseptically and with no evidence of contamination.

For asymptomatic women, bacteriuria is defined as two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥ 100,000 cfu/mL.

In men, a single, clean-catch voided urine specimen with one bacterial species isolated in a quantitative count ≥ 100,000 cfu/mL identifies bacteriuria.

The correct answer is: For asymptomatic women, bacteriuria is defined as two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts ≥ 100,000 cfu/mL

Question 169

Which of the following patients need to undergo periodic screening for asymptomatic bacteriuria? (UTI CPG 2015)

a. 72/F with well-controlled T2DM
b. 35/M obese with indwelling catheter for neurogenic bladder after a vehicular crash
c. 23/F on her 12th week of pregnancy
d. 28/M post kidney transplantation patient

Answer 169

Routine screening and treatment for asymptomatic bacteriuria is NOT recommended for healthy adults.

Periodic screening and treatment for asymptomatic bacteriuria is NOT recommended in the following:
•	Patients with diabetes mellitus
•	Elderly patients
•	Patients with indwelling catheters
•	Solid organ transplant patients
•	People living with human immunodeficiency virus (HIV)
•	Spinal cord injury patients
•	Patients with urologic abnormalities

The correct answer is: 23/F on her 12th week of pregnancy

Question 170

Which of the following will prompt a clinician to workup for urologic abnormalities in a patient with recurrent UTI? (UTI CPG 2015)

a. 25/F single, non-pregnant with 3 episodes of UTI in the past 12 months
b. 78/M with intermittency, nocturia and weak stream
c. 65/F with uncontrolled T2DM on empagliflozin
d. 24/M promiscuous male

Answer 170

Screening for urologic abnormalities in recurrent UTI (UTI CPG 2015)
Recurrent UTI is diagnosed when a healthy non-pregnant woman with no known urinary tract abnormalities has 3 or more episodes of acute uncomplicated cystitis documented by urine culture during a 12-month period OR 2 or more episodes in a 6- month period.

Routine screening for urologic abnormalities is not recommended for the general patient population.

Screening for urologic abnormalities is recommended in the following situations
• No response to appropriate antimicrobial therapy or rapid relapse after such therapy
• Gross hematuria during a UTI episode or persistent microscopic hematuria
• Obstructive symptoms
• Clinical impression of persistent infection
• Infection with urea-splitting bacteria (Proteus, Morganella, Providencia)
• History of pyelonephritis
• History of or symptoms suggestive of urolithiasis
• History of childhood UTI
• Elevated serum creatinine

The correct answer is: 78/M with intermittency, nocturia and weak stream

Question 171

Which of the following conditions predispose to complicated UTI? (UTI CPG 2015)

a. Adult polycystic kidney disease
b. HIV infection
c. Pregnancy
d. Menopause

Answer 171

The correct answer is: Adult polycystic kidney disease

Question 172

When is catheter-associated urinary tract infection (CA-UTI) suspected? (UTI CPG 2015)

a. Urinary symptoms in a patient with an indwelling urethral catheter which has been removed within the previous 72 hours
b. Febrile patient with 103 colony forming units (cfu)/mL of E coli from a catheter-extracted urine
c. New-onset fever in a catheterized patient and an new infiltrate on chest x-ray
d. Hematuria in a patient with a recently removed indwelling catheter

Answer 172

CATHETER-ASSOCIATED URINARY TRACT INFECTION (UTI) (UTI CPG 2015)
UTI in patients with an indwelling urethral or suprapubic catheter or in those undergoing intermittent catheterization is termed as CAUTI.
• Fever and/or other signs or symptoms compatible with UTI are present with no other identified source of infection
• At least 103 colony forming units (cfu)/mL of at least 1 bacterial species are present in a single catheter urine specimen or in a midstream voided urine specimen;
• In a patient with an indwelling urethral, suprapubic or condom catheter, or which has been removed within the previous 48 hours.

The correct answer is: Febrile patient with 103 colony forming units (cfu)/mL of E coli from a catheter-extracted urine

Question 173

Which of the following statements is TRUE about the treatment catheter-associated urinary tract infection (CA-UTI)? (UTI CPG 2015)

a. The choice of empiric antibiotics to be used is institution-specific depending on the local susceptibility pattern.
b. A course of seven days is sufficient for all patients with CA-UTI
c. Removal and/or replacement of indwelling catheter is not necessary.
d. Irrigation of antibiotics to the indwelling catheter may be done in lieu of replacement of catheter

Answer 173

Treatment catheter-associated urinary tract infection (CA-UTI) (UTI CPG 2015)
The choice of empiric antibiotics to be used will be institution-specific depending on the local susceptibility patterns and the severity of patient’s illness

Whenever possible, the indwelling catheter should be removed to help eradicate the bacteriuria.

For patients in whom indwelling bladder catheterization is necessary, long-term indwelling catheters should be replaced with new catheters before initiating antimicrobial therapy for symptomatic UTI.

The following SHOULD NOT be done due to lack of evidence:
• Use of antibiotic–coated catheters
• Routine use of systemic prophylactic antibiotics at the time of insertion, during and upon removal of indwelling urinary catheters
• Catheter or bladder irrigation with antimicrobial agents
• Routine addition of antibiotics or antiseptics to drainage bags and antireflux vents and valves
• Daily meatal care
• Changing of catheters and drainage bags at arbitrarily fixed intervals

The correct answer is: The choice of empiric antibiotics to be used is institution-specific depending on the local susceptibility pattern.

Question 174

Which of the following is the most common etiologic agent in UTI that account for 75-90% of isolates? HPIM 20th C130 p969

a. Staphylococcus saprophyticus
b. Escherichia coli
c. Enterococcus spp
d. Proteus spp.

Answer 174

The correct answer is: Escherichia coli

Question 175

This treatment strategy for acute uncomplicated cystitis has a known side effect of Achilles tendon rupture, especially for adults > 60 y/o. (HPIM 20th C130 p 974)

a. TMP-SMX
b. Quinolones
c. Nitrofurantoin
d. Fosfomycin

Answer 175

The correct answer is: Quinolones

Question 176

What is the best strategy for the prevention of catheter-associated UTI? (HPIM 20th C130 p968)

a. Antibiotic cycling
b. Frequent catheter change
c. Avoidance of catheter insertion
d. Suprapubic cystostomy

Answer 176

Prevention of CA-UTI (HPIM 20th C130 p968)
The best strategy for prevention of CAUTI is to avoid inser-tion of unnecessary catheters and to remove catheters once they are no longer necessary

Antimicrobial catheters impregnated with silver or nitrofurazone have not been shown to provide significant clinical benefit in terms of reducing rates of symptomatic UTI.

Evidence is insufficient to recommend suprapubic catheters and condom catheters as alterna-tives to indwelling urinary catheters as a means to prevent bacte-riuria.

However, intermittent catheterization may be preferable to long-term indwelling urethral catheterization in certain populations (e.g., spinal cord–injured persons) to prevent both infectious and anatomic complications.

The correct answer is: Avoidance of catheter insertion

Question 177

What is the most common type of kidney stones? (HPIM 20th C 312 p 2168)

a. Calcium oxalate stones
b. Calcium phosphate stones
c. Uric acid stones
d. Struvite stones

Answer 177

Nephrolithiasis HPIM 20th C 312 p 2168
It is clinically important to identify the stone type, which informs prognosis and selection of the optimal preventive regimen.
• Calcium oxalate stones are most common (~75%)
• Calcium phosphate (~15%)
• Uric acid (~8%)
• Struvite (~1%)
• Cystine (<1%) stones.

The correct answer is: Calcium oxalate stones

Question 178

What is the most clinically important inhibitor of calcium-containing stones? (HPIM 20th C 312 p 2168)

a. Urine citrate
b. Urine bicarbonate
c. Urine oxalate
d. Urine permanganate

Answer 178

Pathogenesis of Nephrolithiases
Supersaturation (the point at which the concentration product exceeds the solubility product)

Presence of inhibitors of crystallization prevents the majority of the population from continuously forming stones

The most clinically important inhibitor of calcium-containing stones is urine citrate

Renal biopsies of stone formers have revealed calcium phosphate in the renal interstitium

Calcium phosphate deposits at the thin limb of the loop of Henle, and then extends down to the papilla and erodes through the papillary epithelium, where it provides a site for deposition of calcium oxalate and calcium phosphate crystals.

The majority of calcium oxalate stones grow on calcium phosphate at the tip of the renal papilla (Randall’s plaque).

Tubular plugs of calcium phosphate may be the initiating event in calcium phosphate stone development.

Thus, the process of stone formation may begin years before a clinically detectable stone is identified. The processes involved in interstitial deposition are under active investigation.

The correct answer is: Urine citrate

Question 179

Which of the following is TRUE about dietary risk factors for nephrolithiasis? (HPIM 20th C 312 p 2168)

a. Higher dietary calcium reduced intestinal absorption of dietary oxalate and lowers urine oxalate, reducing risk for stone formation.
b. Supplemental calcium decreases risk for stone formation similar to the mechanism of dietary calcium.
c. Decreasing dietary oxalate among stone formers is not beneficial.
d. Vitamin C supplementation increases calcium concentrations in urine

Answer 179

Dietary risk factors of nephrolithiasis (HPIM 20th C 312 p 2168)
Calcium
• Dietary calcium: protective: reduction of intestinal absorption of dietary oxalate, lowering urine oxalate
• Supplemental calcium: increases risk: timing of supplemental calcium intake leading to higher urinary calcium excretion

Oxalate
• Urinary oxalate is derived from both endogenous produc-tion and absorption of dietary oxalate
• Oxalate in food is not readily absorbed, but may be higher in stone formers.
• Dietary oxalate is only a weak risk factor for stone formation, urinary oxalate is a strong risk factor for calcium oxalate stone formation
Other Nutrients
• Animal protein may lead to increased excretion of calcium and uric acid as well as decreased excretion of citrate –> stone formation
• Higher sodium and sucrose –> increases calcium excretion
• Higher potassium –> decreases calcium excretion
• Magnesium and phyate inconsistently lower stone risk

Vitamin C
• Increased risk of calcium oxalate stones in men, increases oxalate levels in urine
Fluid and Beverages
• The risk of stone formation increases as urine volume decreases.
• When the urine output is <1 L/d, the risk of stone formation more than doubles.
• Fluid intake is the main determinant of urine volume, and the importance of fluid intake in preventing stone formation
• Observational studies have found that coffee, tea, beer, wine, and orange juice are associated with a reduced risk of stone formation.
• Sugar-sweetened beverage consumption may increase risk.

The correct answer is: Higher dietary calcium reduced intestinal absorption of dietary oxalate and lowers urine oxalate, reducing risk for stone formation.

Question 180

What is an autosomal recessive disorder that causes excessive oxalate generation by the liver with consequent calcium oxalate stone formation? (HPIM 20th C312 p2169)

a. Primary cystinuria
b. Primary calciuria
c. Primary hyperoxaluria
d. Primary uricosuria

Answer 180

Genetic risk factors (HPIM 20th C312 p2169)
The risk of nephrolithiasis is more than twofold greater in individuals with a family history of stone disease.

The two most common and well-characterized rare monogenic disorders that lead to stone formation are primary hyperoxaluria and cystinuria.
• Primary hyperoxaluria is an autosomal recessive disorder that causes excessive endogenous oxalate generation by the liver, with consequent calcium oxalate stone formation and crystal deposition in organs. Intraparenchymal calcium oxalate deposition in the kidney can eventually lead to renal failure.
• Cystinuria is an autosomal recessive disorder that causes abnormal reabsorption of filtered basic amino acids. The excessive urinary excretion of cystine, which is poorly soluble, leads to cystine stone formation. Cystine stones are visible on plain radiographs and often manifest as staghorn calculi or multiple bilateral stones. Repeat episodes of obstruction and instrumentation can cause a reduction in the glomerular filtration rate (GFR).

The correct answer is: Primary hyperoxaluria

Question 181

A 36/M presents to the ER with renal colic. He had several episodes of passing out sandy urine followed by hematuria. Which of the following diagnostic modalities is best utilized to confirm the diagnosis? (HPIM 20th C312 p2170)

a. History and PE
b. KUB ultrasound
c. MRI
d. Helical CT

Answer 181

The correct answer is: Helical CT

Question 182

Which of the following is true in the management and diagnosis of nephrolithiasis? (HPIM 20th C312 p2170)

a. Renal ultrasound or a KUB examination is the typical gold standard diagnostic test for nephrolithiasis
b. The results from 24h urine collections serve as the cornerstone on which therapeutic recommendations are based, and lifestyle modification should be deferred until urine collection is complete
c. The baseline assessment should collect at least three 24-h urine samples while consuming low protein diet with increased fluid intake
d. None of the choices are true

Answer 182

The correct answer is: The results from 24h urine collections serve as the cornerstone on which therapeutic recommendations are based, and lifestyle modification should be deferred until urine collection is complete

Question 183

Which of the following is true regarding renal colic? (HPIM 20th C312 p2169)

a. Pain is never associated with nausea and vomiting
b. Usually sudden in onset, bilateral flank pain
c. If it lodges in the lower part of the ureter it may radiate anteriorly
d. Occasionally a patient may present with gross hematuria without pain

Answer 183

Approach to the patient with nephrolithiasis (HPIM 20th C312 p2169)
There are two common presentations for individuals with an acute stone event: renal colic and painless gross hematuria.

Renal colic is a misnomer because pain typically does not subside completely; rather, it varies in intensity
• Often accompanied by nausea and vomiting, may radiate depending on the location of stone
• Sudden unilateral flank pain
• If the stone lodges in the upper part of the ureter, pain may radiate anteriorly; if the stone is in the lower part of the ureter, pain can radiate to the ipsilateral testicle in men or the ipsilateral labium in women.
Occasionally, a patient has gross hematuria without pain.

The correct answer is: Occasionally a patient may present with gross hematuria without pain

Question 184

Which of the following is true with regards to the diagnosis of nephrolithiasis? (HPIM 20th C312 p2170

a. The diagnosis is often made on the basis of the history, physical examination, and urinalysis
b. It is necessary to wait for a radiographic confirmation of nephrolithiasis before treating the symptoms for a directed approach.
c. Helical CT in the diagnosis of nephrolithiasis is avoided among patients who presents with AKI due to the use of contrast agents
d. Helical CT detects stones as small as 2 mm that may be missed by other modalities.

Answer 184

Diagnosis of nephrolithiasis (HPIM 20th C312 p2170)
Clues: renal colic on history

Serum chemistry: normal but WBC may be elevated

Urine sediment: RBCs and WBCs with occasional crystals
• Absence of hematuria does not exclude a stone
Diagnosis is often made on the basis of history, PE and urinalysis

Diagnosis is confirmed by helical CT without contrast, detecting stones as small as 1mm: gold standard

The results from 24-h urine collections serve as the cornerstone on which therapeutic recommendations are based. Recommendations on lifestyle modification should be deferred until urine collection is complete.

As a baseline assessment, patients should collect at least two 24-h urine samples while consuming their usual diet and usual volume of fluid.

The correct answer is: The diagnosis is often made on the basis of the history, physical examination, and urinalysis

Question 185

For all stone types, consistently diluted urine reduces the likelihood of crystal formation. What should the urine volume should at least be to prevent crystallization? (HPIM 20th C312 p2171)

a. 1L/day
b. 2L/day
c. 3L/day
d. 4L/day

Answer 185

Prevention of new stone formation (HPIM 20th C312 p2171)
For all stone types, consistently diluted urine reduces the likelihood of crystal formation.

Urine volume should be at least 2 L/d. Because of differences in insensible fluid losses and fluid intake from food sources, the required total fluid intake will vary from person to person.

Rather than specify how much to drink, it is more helpful to educate patients about how much more they need to drink in light of their 24-h urine volume.

For example, if the daily urine volume is 1.5 L, then the patient should be advised to drink at least 0.5 L more per day in order to increase the urine volume to the goal of 2 L/day.

The correct answer is: 2L/day

Question 186

A 34/M presented at the ER with severe left flank pain. A CT stonogram was done revealing a 0.5 cm stone at the left ureter with no evidence of hydronephrosis. His creatinine is normal, and urinalysis did not show pyuria. What is the most appropriate next step for this patient? (HPIM 20th C312 p2170)

a. Give a total of 3L pLR bolus
b. Give high-dose opioids
c. Start on alpha blockers
d. Refer to nephrology service

Answer 186

Parenterally administered NSAIDs (such as ketorolac) are as effective as opioids in relieving symptoms with less side effects.

Excessive fluid administration has not been shown to be beneficial;

If the pain can be adequately controlled and the patient is able to take fluids orally, hospitalization can be avoided.

Use of an alpha blocker may increase the rate of spontaneous stone passage.

Urologic intervention should be postponed unless there is evidence of UTI, a low probability of spontaneous stone passage (e.g., a stone measuring >/=6 mm or an anatomic abnormality), or intractable pain

Most appropriate intervention is determined by the size, location and composition of the stone, urinary tract anatomy and the experience of the urologist

The correct answer is: Start on alpha blockers

Question 187

Which of the following characteristics is a risk for chronic kidney disease despite normal glomerular filtration rate?

a. Malnutrition
b. Dyslipidemia
c. Family history of hypertension
d. Abnormal urinary sediment

Answer 187

The correct answer is: Abnormal urinary sediment

Question 188

What is the CKD Stage of a patient with an eGFR of 32?

a. 2
b. 3
c. 4
d. 5

Answer 188

The correct answer is: 3

Question 189

What is the mechanism that predominantly mediates potassium balance in CKD?

a. Exogenous intake of potassium
b. Excretion of excess in the GI tract
c. Transcellular shift from the acid-base disturbance
d. Aldosterone dependent secretion in the distal nephron

Answer 189

The correct answer is: Aldosterone dependent secretion in the distal nephron

Question 190

What complication is prevented by supplemental bicarbonate in CKD?

a. Anemia
b. Hyperkalemia
c. Hypocalcemia
d. Protein catabolism

Answer 190

The correct answer is: Protein catabolism

Question 191

Which of the following cases poses a contraindication to kidney biopsy?

a. A 57 year old female with recurrent UTI and contracted kidneys by renal UTZ
b. A 34 yo female SLE patient with BMI of 25
c. An APAS patient with BP of 130/88 mmHg
d. A CKD stage 2 patient of unknown primary recently treated UTI

Answer 191

The correct answer is: A 57 year old female with recurrent UTI and contracted kidneys by renal UTZ

Question 192

Relative erythropeitin deficiency is an important cause of anemia in CKD. What vitamin deficiency compounds this problem?

a. Ascorbic acid
b. Thiamine
c. Folic acid
d. Riboflavin

Answer 192

The correct answer is: Folic acid

Question 193

Which of the following characteristics is a risk for chronic kidney disease despite normal glomerular filtration rate?

a. Malnutrition
b. Dyslipidemia
c. Family history of hypertension
d. Abnormal urinary sediment

Answer 193

The correct answer is: Abnormal urinary sediment

Question 194

What is the CKD Stage of a patient with an eGFR of 32?

a. 2
b. 3
c. 4
d. 5

Answer 194

The correct answer is: 3

Question 195

The potassium balance in CKD is predominantly mediated by what mechanism?

a. Exogenous intake of potassium
b. Excretion of excess in the GI tract
c. Transcellular shift from the acid-base disturbance
d. Aldosterone dependent secretion in the distal nephron

Answer 195

The correct answer is: Aldosterone dependent secretion in the distal nephron

Question 196

Bicarbonate supplementation in CKD prevents what complication? (

a. Anemia
b. Hyperkalemia
c. Hypocalcemia
d. Protein catabolism

Answer 196

The correct answer is: Protein catabolism

Question 197

What is the leading cause of mortality in patients with CKD?

a. Uremia
b. Infections
c. Pulmonary embolism
d. Cardiovascular disease

Answer 197

The correct answer is: Cardiovascular disease

Question 198

What is the primary cause of anemia in patients with CKD?

a. Bleeding diathesis
b. Chronic inflammation
c. Erythropoietin deficiency
d. Iron deficiency from poor absorption

Answer 198

The correct answer is: Erythropoietin deficiency

Question 199

At what stage of CKD do subtle neuromuscular manifestations of the disease become apparent?

a. 2
b. 3
c. 4
d. 5

Answer 199

The correct answer is: 3

Question 200

A 50/M consulted the OPD due to increased creatinine on routine laboratory exam. His eGFR is 10 ml/min. Previous creatinine determinations revealed similar trends. Renal ultrasound showed normal-sized kidneys. Which of the following is the most likely cause?

a. Amyloidosis
b. Hypertension
c. Glomerulonephritis
d. Chronic tubulointerstitial nephritis

Answer 200

The correct answer is: Amyloidosis

Question 201

Which of the following is a contraindication to kidney biopsy?

a. Uncontrolled hyperglycemia
b. Treated urinary tract infection
c. History of thrombosis
d. Severe obesity

Answer 201

The correct answer is: Severe obesity

Question 202

What is the target blood pressure for patients with CKD and concomitant proteinuria?

a. 120/70
b. 125/75
c. 130/80
d. 135/85

Answer 202

The correct answer is: 130/80

Question 203

What is the most common acute complication of hemodialysis?

a. Hypotension
b. Hypoglycemia
c. Chills
d. Muscle cramps

Answer 203

The correct answer is: Hypotension

Question 204

A 25/F came in due to abdominal pain. She is a known CKD patient who is on peritoneal dialysis. She has been having vague abdominal pain over the past 3 days with associated undocumented fever. During the last drainage of her dialysate, she noted that the fluid appeared cloudy. What type of organisms are the most likely cause of her infection? (HPIM

a. Gram positive cocci
b. Gram negative bacilli
c. Anaerobes
d. Fungal

Answer 204

The correct answer is: Gram positive cocci

Question 205

The mechanism of urinary tract infection in pregnant women is:

a. Increase in vaginal pH
b. Change in vaginal flora
c. Decreased ureteral tone leading to vesicoureteral reflux
d. Washout of normal vaginal flora due to increased urinary frequency

Answer 205

The correct answer is: Decreased ureteral tone leading to vesicoureteral reflux

Question 206

What is the main feature distinguishing pyelonephritis from cystitis?

a. Flank pain
b. Nausea
c. Fever
d. Dysuria

Answer 206

The correct answer is: Fever

Question 207

What is the gold standard for the diagnosis of urinary tract infections?

a. Urine dipstick test
b. Urine gram stain
c. Urine culture
d. KUB ultrasound

Answer 207

The correct answer is: Urine culture

Question 208

What is the threshold for diagnosing asymptomatic bacteriuria in urine culture (expressed in bacterial CFU/mL)?

a. ≥ 102
b. ≥ 103
c. ≥ 104
d. ≥ 105

Answer 208

The correct answer is: ≥ 105

Question 209

A 30/F consulted due to fever with associated flank pain, occasional nausea and vomiting. Her past medical history is unremarkable with no recent antibiotic exposure. Your physical examination revealed vital signs of BP 100/60 HR 110 RR 18 T 38.3. CVA tenderness was elicited. What is the most appropriate management for this patient?

a. Send for urine culture and wait for the results to institute culture-guided therapy
b. Give the patient oral ciprofloxacin to complete 7 days and send the patient home.
c. Admit the patient, start IV ceftriaxone
d. Admit the patient, start IV Piperacillin-Tazobactam

Answer 209

The correct answer is: Give the patient oral ciprofloxacin to complete 7 days and send the patient home.

Question 210

A 24/F pregnant patient on her 1st trimester was referred for asymptomatic bacteriuria. Her medical history is pertinent for a penicillin allergy. Which of the following treatment options is the best option for the patient?

a. Fosfomycin 3g single dose
b. Co-trimoxazole 160/800mg/tab BID for 7 days
c. Co-amoxiclav 625mg/tab 1 tab BID for 7 days
d. Cefuroxime 500mg/tab 1 tab BID for 7 days

Answer 210

The correct answer is: Fosfomycin 3g single dose

Question 211

Which of the following is a pre-renal cause of acute kidney injury?

a. Aminoglycosides
b. Cyclosporine
c. Amphotericin B
d. Cisplatin

Answer 211

The correct answer is: Cyclosporine

Question 212

Which portion of the kidney is particularly susceptible to ischemic damage?

a. Inner medulla
b. Outer medulla
c. Inner cortex
d. Outer cortex

Answer 212

The correct answer is: Outer medulla

Question 213

Which of the following conditions with the corresponding urinary sediment is correctly matched?

a. RBC cast: Pyelonephritis
b. Granular cast: Allergic interstitial nephritis
c. Crystalluria: Ethylene glycol
d. Eosinophiluria: Malignany hypertension

Answer 213

The correct answer is: Crystalluria: Ethylene glycol

Question 214

Which of the following specific management strategies in patients with AKI is INAPPROPRIATE?

a. Rasburicase for rhabdomyolysis
b. Aluminum hydroxide for hyperphosphatemia
c. Calcium gluconate for hyperkalemia
d. Sodium bicarbonate for serum pH <7.2

Answer 214

The correct answer is: Rasburicase for rhabdomyolysis

Question 215

A 50/M 70-kg diabetic patient was admitted for community-acquired pneumonia. On arrival, his BP was palpatory and was unresponsive to adequate fluid administration. He was then started on vasopressors. His vitals remained labile and urine output was continuously declining with concomitant increase in creatinine. He was eventually started on continuous renal replacement therapy. Given the patient’s clinical picture, what is the maximum protein intake that this patient should receive?

a. 56 g
b. 105 g
c. 119 g
d. 140 g

Answer 215

The correct answer is: 119 g

Question 216

Which of the following is an indication for dialysis in AKI?

a. Acidosis responsive to bicarbonate supplementation
b. Encephalopathy
c. Hypertension
d. Abdominal pain

Answer 216

The correct answer is: Encephalopathy

Question 217

A 23/M with a history of impetigo 3 weeks ago came in due to hematuria. On work up, he was also noted to have hypertension and proteinuria, The most likely assessment was:

a. IgA nephropathy
b. Rapidly progressive glomerulonephritis
c. Post-streptococcal glomerulonephritis
d. Minimal change disease

Answer 217

The correct answer is: Post-streptococcal glomerulonephritis

Question 218

What class of lupus nephritis will present with thickened basement membranes with diffuse subepithelial immune deposits?

a. Class II
b. Class III
c. Class IV
d. Class V

Answer 218

The correct answer is: Class IV

Question 219

. A 56/M diagnosed with stage III colon cancer presented with nephrotic syndrome. What is the most likely histopathologic picture of this patient’s kidneys?

a. Minimal change disease
b. Focal segmental glomerulosclerosis
c. Rapidly progressive glomerulonephritis
d. Membranous glomerulonephritis

Answer 219

The correct answer is: Membranous glomerulonephritis

Question 220

Which of the following fulfills the diagnosis of autosomal dominant polycystic kidney disease in patients aged 30-59 years old who have a family history of the disease?

a. At least two renal cysts, bilateral or unilateral
b. At least four renal cysts, bilateral or unilateral
c. At least two renal cysts in each kidney
d. At least four renal cysts in each kidney

Answer 220

The correct answer is: At least two renal cysts in each kidney

Question 221

What is the recommended urine volume for patients to avoid stone formation?

a. 1 L/day
b. 2 L/day
c. 3 L/day
d. 4 L/day

Answer 221

The correct answer is: 2 L/day

Question 222

A 66/M came in the ER due to anuria. Creatinine was noted to be doubled from his baseline. A foley catheter was inserted but no urine output was noted. What is the next step? Forced diuresis

a. CT stonogram
b. KUB ultrasound
c. Intravenous pyelography

Answer 222

The correct answer is: Intravenous pyelography