NEPHROLOGY Flashcards

Question

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 1

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

Answer 2

The correct answer is: Allergic interstitial nephritis

Answer 3

The correct answer is: Systemic lupus erythematosus

Answer 4

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

Answer 5

The correct answer is: Anticentromere antibody

Answer 6

The correct answer is: Calcium oxalate stones

Answer 7

The correct answer is: Klebsiella pneumoniae

Answer 8

The correct answer is: Mechanical stone removal

Answer 9

The correct answer is: Alkalinization of urine

Answer 10

The correct answer is: Polyuria and nocturia

Answer 11

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

Answer 12

The correct answer is: IV administration of saline and glucose

Answer 13

The correct answer is: Inflammation of the glomerular capillaries

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

The correct answer is: Rapidly Proliferative Glomerulonephritis

Answer 19

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

Answer 20

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

Answer 21

The correct answer is: 20

Answer 22

Diffuse >50%; Focal <50% The correct answer is: >50%

Answer 23

Estimated age-related nephrosclerosis = (Age/2) – 10 (64/2) – 10 = 22 The correct answer is: 22%

Answer 24

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

Answer 25

The correct answer is: Proteinuria

Answer 26

“[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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

The correct answer is: Focal Segmental Glomerulosclerosis

Answer 36

RPR (syphilis) The correct answer is: RPR

Answer 37

The correct answer is: Penicillin

Answer 38

The correct answer is: Acute cystitis

Answer 39

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

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

“In complicated UTI (e.g., CAUTI), E. coli remains the predominant organism” The correct answer is: Escherichia coli

Answer 46

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

Answer 47

“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

Answer 48

P fimbriae: binds to blood group antigen P (D-galactose-D-galactose) The correct answer is: Type I Pilus

Answer 49

“Fever is the main feature distinguishing pyelonephritis from cystitis.” The correct answer is: Acute Pyelonephritis

Answer 50

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

Answer 51

The correct answer is: 72 hours

Answer 52

``` yellow coloration of renal tissue with infiltration by lipid-laden macrophages Staghorn calculi (consistent with xanthogranulomatous pyelonephritis) ``` The correct answer is: Staghorn calculi

Answer 53

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

Answer 54

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

Answer 55

The correct answer is: Pelvic Exam

Answer 56

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

Answer 57

The correct answer is: ≥ 103 bacteria/mL

Answer 58

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

Answer 59

The correct answer is: Chronic pelvic pain syndrome

Answer 60

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

Answer 61

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

Answer 62

Unfortunately, there is no longer a single best agent for acute uncomplicated cystitis.” The correct answer is: None of these

Answer 63

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

Answer 64

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

Answer 65

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

Answer 66

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

Answer 67

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

Answer 68

Lisinopril (ACEi) Amikacin (Aminoglycoside) Iohexol (Iodinated Contrast) Celecoxib (NSAID) The correct answer is: Celecoxib

Answer 69

The correct answer is: Tubules

Answer 70

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

Answer 71

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

Answer 72

The correct answer is: 80 mmHg

Answer 73

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

Answer 74

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

Answer 75

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

Answer 76

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

Answer 77

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

Answer 78

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

Answer 79

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

Answer 80

The correct answer is: Aggressive Hydration

Answer 81

The correct answer is: Administration of MESNA

Answer 82

``` 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

Answer 83

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

Answer 84

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

Answer 85

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

Answer 86

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

Answer 87

Case describes MAHA arising from HUS The correct answer is: Hyaline casts

Answer 88

Case describes ethylene glycol poisoning The correct answer is: Crystalluria

Answer 89

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

Answer 90

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

Answer 91

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

Answer 92

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

Answer 93

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.

Answer 94

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.

Answer 95

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

Answer 96

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.

Answer 97

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

Answer 98

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.

Answer 99

* 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

Answer 100

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

Answer 101

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.

Answer 102

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

Answer 103

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.

Answer 104

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

Answer 105

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

Answer 106

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

Answer 107

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

Answer 108

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

Answer 109

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

Answer 110

``` 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

Answer 111

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

Answer 112

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

Answer 113

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

Answer 114

The correct answer is: 130/80

Answer 115

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.

Answer 116

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

Answer 117

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

Answer 118

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%

Answer 119

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

Answer 120

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

Answer 121

``` 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

Answer 122

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

Answer 123

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

Answer 124

Common Opportunistic Infections in KT Patients (HPIM 20th ed, c307, p2130) The correct answer is: Aspergillus Question 113

Answer 125

Maintenance Immunosuppressive Drugs and their Side Effects (HPIM 20th ed, c307, p2128) The correct answer is: Cyclosporine

Answer 126

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

Answer 127

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

Answer 128

Diagnostic Approach for Urinary Tract Obstruction in Unexplained Renal Failure (HPIM 20th C313 P2175 F313-1) The correct answer is: KUB ultrasound

Answer 129

The correct answer is: G2A2

Answer 130

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

Answer 131

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

Answer 132

``` 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

Answer 133

``` 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

Answer 134

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

Answer 135

The correct answer is: Emphysematous pyelonephritis

Answer 136

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

Answer 137

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

Answer 138

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.

Answer 139

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

Answer 140

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

Answer 141

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.

Answer 142

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

Answer 143

Antibiotics for ASB in pregnancy The correct answer is: Fosfomycin Question 132

Answer 144

``` 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

Answer 145

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

Answer 146

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

Answer 147

The correct answer is: Adult polycystic kidney disease

Answer 148

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

Answer 149

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.

Answer 150

The correct answer is: Escherichia coli

Answer 151

The correct answer is: Quinolones

Answer 152

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

Answer 153

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

Answer 154

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

Answer 155

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.

Answer 156

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

Answer 157

The correct answer is: Helical CT

Answer 158

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

Answer 159

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

Answer 160

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

Answer 161

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

Answer 162

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

Answer 163

The correct answer is: Abnormal urinary sediment

Answer 164

The correct answer is: 3

Answer 165

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

Answer 166

The correct answer is: Protein catabolism

Answer 167

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

Answer 168

The correct answer is: Folic acid

Answer 169

The correct answer is: Abnormal urinary sediment

Answer 170

The correct answer is: 3

Answer 171

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

Answer 172

The correct answer is: Protein catabolism

Answer 173

The correct answer is: Cardiovascular disease

Answer 174

The correct answer is: Erythropoietin deficiency

Answer 175

The correct answer is: 3

Answer 176

The correct answer is: Amyloidosis

Answer 177

The correct answer is: Severe obesity

Answer 178

The correct answer is: 130/80

Answer 179

The correct answer is: Hypotension

Answer 180

The correct answer is: Gram positive cocci

Answer 181

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

Answer 182

The correct answer is: Fever

Answer 183

The correct answer is: Urine culture

Answer 184

The correct answer is: ≥ 105

Answer 185

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

Answer 186

The correct answer is: Fosfomycin 3g single dose

Answer 187

The correct answer is: Cyclosporine

Answer 188

The correct answer is: Outer medulla

Answer 189

The correct answer is: Crystalluria: Ethylene glycol

Answer 190

The correct answer is: Rasburicase for rhabdomyolysis

Answer 191

The correct answer is: 119 g

Answer 192

The correct answer is: Encephalopathy

Answer 193

The correct answer is: Post-streptococcal glomerulonephritis

Answer 194

The correct answer is: Class IV

Answer 195

The correct answer is: Membranous glomerulonephritis

Answer 196

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

Answer 197

The correct answer is: 2 L/day

Answer 198

The correct answer is: Intravenous pyelography

NEPHROLOGY Flashcards

(222 cards)