questions about kidneys

7/26/2019 questions about kidneys

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Nephrology Board Review MCQsDisorders of Acid-Base and Potassium Balance

! A ""-year-old woman presents to the emergency department with nausea# vomiting# and a$dominalpain of days% duration! &er fluid $alance profile is as follows' Na(# )*+ ,(# *!+ Cl-# )*+ &C./

-# )*+B0N# /1+ Cr# )!2+ glucose# 13+ 0A# ( 4etones!5hat is the $est initial treatment of this patient%s acid-$ase disorder6! A! 7ree water! B! Normal saline! C! Normal saline# sodium $icar$onate# and insulin! D! &alf-normal saline and insulin! 8! Normal saline and insulin,ey Concept9.$:ective' ;o understand the diagnosis and treatment of dia$etic 4etoacidosisMeta$olic acidosis can $e classified into two types' that associated with an elevation inthe anion gap# and that in which the anion gap is normal! A calculation of the aniongap in this patient reveals a gap of "*! Among the causes of acidosis associated with anelevated anion gap are alcoholic 4etoacidosis# lactic acidosis# starvation# ingestion ofalcohols# ingestion of salicylates# and dia$etic 4etoacidosis! # optimal initial treatment includes fluid replacementwith normal saline to promote 4etonuria and insulin to facilitate glucose transport!Bicar$onate therapy is not usually indicated unless the acidosis is severe or severehyper4alemia is present! =Answer' 8?@Normal saline and insulin>----------------------------------------------------------------------------------------------

*! A "-year-old woman presents with nausea# vomiting# and left flan4 pain with radiation to the groin+these symptoms have persisted for / days! A helical C; scan reveals a stone in the left ureter! .n the $asisof urinalysis and serum chemistries# a diagnosis of type ) renal tu$ular acidosis =R;A> is made!5hich of the following is N.; consistent with type ) R;A6! A! Normal-anion-gap meta$olic acidosis! B! 0rine p& *!/! C! &ypo4alemia! D! 0rinary calcium phosphate crystals

! 8! :!gren syndrome,ey Concept9.$:ective' ;o understand the diagnosis of type ) R;ARenal tu$ular acidosis is one of the causes of normal-anion-gap meta$olic acidosis!.ther causes are administration of &Cl and losses of $icar$onate from the gastrointestinaltract! ;ype ) R;A may $e congenital# or it may occur in association with variousimmune disorders# such as :!gren syndrome! ;he underlying defect involves theina$ility of the intercalated cells of the collecting tu$ule to pump out hydrogen ions!As a result# the urine p& is always greater that *!/! &ypo4alemia occurs secondary toenhanced Na(-,( echange in the distal tu$ule# $ecause hydrogen ions are not secretedin response to sodium rea$sorption! A ma:or complication of type ) R;A is nephrocalcinosis!Nephrocalcinosis is caused $y calcium phosphate crystals# which occur secondaryto an increase in the resorption of proimal tu$ular citrate through meta$olic acidosis!;he decrease in urinary citrate facilitates the precipitation of calcium phosphatecrystals in the collecting tu$ule! =Answer' B?@0rine p& *!/>

-------------------------------------------------------------------------------------------------2! A 23-year-old man with chronic renal insufficiency presents with wea4ness# paresthesias# and progressivelyworsening shortness of $reath! &e has $een eperiencing these symptoms for days! a$oratoryfindings show a potassium level of 1!"+ an electrocardiogram reveals pea4ed ; waves and widening of theQR comple!5hich of the following is N.; indicated in the initial treatment of this patient6! A!


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! 8! Beta $loc4ers,ey Concept9.$:ective' ;o understand the diagnosis and treatment of hyper4alemia;he initial manifestations of hyper4alemia are usually neuromuscular in origin and arenonspecific! Diagnosis is $ased on serum potassium level+ emergent treatment is $asedon whether cardiac arrhythmias are present or electrocardiographic changes are occurring!;reatment involves the use of intravenous calcium to reduce the ecita$ility ofcardiac cell mem$rane and use of intravenous glucose and insulin to facilitate transport

of potassium into the intracellular space! odium polystyrene sulfonate is used toincrease the ecretion of potassium in the colon! 7or more information# see Blac4 RM' ) Nephrology' ! Dale DC# 7edermanDD# 8ds! 5e$MD


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! D! .$struction impairs the a$ility of the 4idneys to concentrate theurine and thus contri$utes to a polyuric state! 8! Common causes of o$struction include nephrolithiasis and neurogenic$ladder =and# in women# an enlarging cervical cancer>,ey Concept9.$:ective' ;o $e a$le to recogniGe urinary o$struction as a cause of acute renalfailure.$struction of urine flow can occur anywhere along the urinary tract# from the renal

pelvis to the urethra! Anuria suggests complete urinary o$struction# although anuriacan also $e a feature of $ilateral renal artery throm$osis# acute cortical necrosis# orsevere acute tu$ular necrosis! can$e measured $y "-hour collection of urine# or it can $e estimated through use of a formulathat involves the patient%s age# ideal $ody weight =# and plasma creatinine=Cr>' CCr L =) C age> ? =9=1" ? Cr>! reflects a reduction in creatinine clearance $y a$out half!


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)! A 2-year-old man who presented with fatigue and $one pain is found to $e anemic and throm$ocytopenic!8amination reveals pale con:unctivae and thigh tenderness $ut no peripheral edema! Radiographsdemonstrate osteolytic lesions in several thoracic verte$rae and the left femur! erum chemistries reveal acreatinine level of )!" mg9dl# a calcium level of E!* mg9dl# a total protein level of )) mg9dl# and an al$uminlevel of /!" mg9dl! .n $one marrow $iopsy# there is replacement of normal marrow with sheets ofplasma cells! 0rinalysis is unremar4a$le# $ut a "-hour urine study reveals proteinuria of "! g9day!

5hich of the following statements regarding this patient%s proteinuria is true6! A! ;he li4ely underlying pathology involves a structural a$normalityof the filtration $arrier that results in loss of negatively charged proteins! B! titer and serum complement level!5hich of the following statements regarding this patient%s condition is false6! A! 7indings on urinalysis identify the source of $leeding as glomerularin origin! B! Renal $iopsy is li4ely to reveal mesangial deposition ofimmunoglo$ulin A = on immunofluorescence microscopy! C! Results of analysis of the urine sediment are consistent with a findingof hypercalciuria as a cause of the hematuria

! D! ;he time course of the illness and the serum complement level helpto differentiate this patient%s condition from acute postinfectiousglomerulonephritis,ey Concept9.$:ective' ;o recogniGe Berger disease and the urinary findings associated withglomerulonephritisMicroscopic evaluation of urinary sediment is an important component of the wor4upof hematuria $ecause it may help localiGe the $leeding to either the upper urinary tract=i!e!# glomeruli> or the lower urinary tract =i!e!# renal pelvis# ureters# $ladder# urethra>!;he presence of red cell casts =formed from erythrocytes passing through the renaltu$ules> is virtually pathognomonic for acute glomerulonephritis! Dysmorphic red cellsand red cell casts would not typically $e seen in patients with hematuria caused $y


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a$normalities of the lower urinary tract# such as nephrolithiasis# malignancy# or prostatitis!;his patient presented with recurrent episodes of macroscopic hematuria followingan upper respiratory infection# which is a common finding in patients with ! ;his condition constitutes )K to K of all cases of primaryglomerulonephritis and is associated with increased serum

Management of Chronic ,idney Disease

)/! A *1-year-old woman with hypertension# mitral valve prolapse with regurgitation# asthma# and a historyof alcoholism presents to your office to esta$lish primary care! Because the patient has hypertension#you order a $asic meta$olic profile and urinalysis as a part of your initial evaluation! ;he la$oratory callsto notify you that the patient?s serum creatinine level is "!/ mg9dl!5hich of the following statements regarding chronic 4idney disease =C,D> is true6! A! C,D is defined as a glomerular filtration rate =H7R> of less than /ml9min9)!1/ m" for longer than / months! B! Persistently increased proteinuria in the setting of a normal orincreased H7R signifies the presence of stage ) C,D! C! Measurement of "-hour creatinine clearance to assess H7R is more


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accurate than estimating H7R from the Modification of Diet inRenal Disease =MDRD> eFuation! D! ;reatment of comor$id conditions# interventions to slow progressionof 4idney disease# and measures to reduce cardiovascular diseaseshould $egin during C,D stage /,ey Concept9.$:ective' ;o understand the $asic principles of the diagnosis and treatment ofC,D

C,D is defined as either 4idney damage or a H7R of less than 2 ml9min9)!1/ m" forlonger than / months! ;he MDRD and Coc4croft-Hault eFuations provide useful estimatesof H7R in adults! Clinical practice guidelines point out that clinicians should notuse serum creatinine concentration as the sole means of assessing the level of 4idneyfunction!


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that the patient%s H7R has declined $y less than "*K! B!


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the ris4 of aluminum toicity! Constipation can cause hyper4alemia to worsen $ecausepotassium secretion $y the colon is su$stantial in patients with advanced renal failure!evere anemia contri$utes to the development of left ventricular hypertrophy#which in turn is an important predictor of su$seFuent cardiac mor$idity and mortalityin patients receiving dialysis! ;hus# early institution of erythropoietin therapy canimprove dialysis outcomes! ;his is an important reason for timely referral of the patientwith renal insufficiency to a nephrologist! A target hematocrit value of /K in young

patients who have no evidence of cardiovascular disease should provide relief of symptomsattri$uta$le to anemia! By contrast# older patients with comor$idities may $enefit$y targeting the hematocrit value closer to normal! 7ailure to respond to erythro-poietin therapy is most commonly the result of iron deficiency! =Answer' B?@Constipationshould $e avoided $ecause it can cause the hyper4alemia to worsen>-----------------------------------------------------------------------------------------------

)1! A /-year-old man with dia$etes and hypertension comes for a chec4-up! &is creatinine level is normalat )! mg9dl# and he has microal$uminuria of )" mg9" hr!5hich of the following statements is true regarding the appropriate measures to slow progression ofrenal disease6! A! Aggressive control of hyperglycemia may $e more li4ely to slow progressionof renal disease in patients with type ) dia$etes mellitusthan in patients with type " dia$etes mellitus

! B! ;he targeted $lood pressure should $e $elow )9E mm &g! C! Because this patient has dia$etes# microal$uminuria is predictive ofprogression of renal disease! D! mo4ing is a ris4 factor for microal$uminuria $ecause of its associationwith hypertension! 8! Although not clearly of $enefit# a low-protein diet can $e prescri$edwith little concern a$out deleterious effects,ey Concept9.$:ective' ;o understand the ris4 factors for renal disease progression8vidence clearly shows that aggressive control of hyperglycemia in patients with type) dia$etes mellitus will reduce the occurrence of microal$uminuria and macroal$uminuriaand will slow the progression of nephropathy! Control of hyperglycemia inpatients with type " dia$etes mellitus is more controversial# as there are conflictingresults of this approach in the literature! ;his may $e related to the fact that renallesions resulting from type " dia$etes are more heterogeneous than the typical lesion

from type ) dia$etes! Because uncontrolled hypertension can contri$ute to the progressionof renal disease# target $lood pressure values have $een esta$lished! ;hese valuesvary slightly# depending on the source of the recommendation# $ut in general# a$lood pressure of )/93 mm &g or less should $e sought! Microal$uminuria is a ris4factor for progression to end-stage renal disease in dia$etic and nondia$etic patientswith renal disease! mo4ing is an independent ris4 factor for microal$uminuria in $othhypertensive and normotensive patients! 7inally# a low-protein diet can easily lead tomalnutrition and calorie deficiency and therefore must $e closely monitored! =Answer'A?@Aggressive control of hyperglycemia may $e more li4ely to slow progression of renal disease inpatients with type ) dia$etes mellitus than in patients with type " dia$etes mellitus>

Hlomerular Diseases

)3! A previously healthy *-year-old woman presents with a /-wee4 history of arthralgias and edema! &ereamination is remar4a$le for a $lood pressure of )19)2 mm &g# $i$asilar pulmonary crac4les# andlower etremity edema! A freshly voided urine reveals red $lood cells and red cell casts! A diagnosis ofglomerulonephritis is made! &er serology is positive for antineutrophil cytoplasmic anti$ody =ANCA>!7or this patient# a renal $iopsy with immunofluorescent staining would $e epected to show whichof the following6! A! Positive staining for immune complees! B! Positive staining for immune deposits


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! 8! Negative staining for anti$ody or C/

,ey Concept9.$:ective' ;o understand that ANCACassociated glomerulonephritis is not associatedwith staining for immunoglo$ulin# complement# or immune depositsANCA-associated glomerulonephritis involves a vasculitic process of the small- andmedium-siGed $lood vessels that usually presents as a focal segmental necrotiGingglomerulonephritis! Renal involvement is usually acute# severe# and progressive# and

glomeruli contain crescents! ANCA-associated glomerulonephritis is one of the causesof rapidly progressive glomerulonephritis# which many authors consider a medicalemergency! ANCA-associated glomerulonephritis can $e limited to the 4idney or coeistwith systemic illness such as 5egener granulomatosis! antigens and cryoglo$ulins! Approimatelyone third of patients present with microscopic hematuria and nonnephrotic proteinuria#and another third presents with nephrotic-range proteinuria with a mild decreasein renal function! &ypertension is a very common finding on initial presentation! &CIassociatedmem$ranoproliferative glomerulonephritis is usually treated with antiviraltherapy when remission is common and relapse is freFuent! =Answer' 8?@erum anti$odytesting for hepatitis C>--------------------------------------------------------------------------------------------

"! A ")-year-old woman of Peruvian descent presents with hypertension# fatigue# and microscopic hematuria!A renal $iopsy demonstrates glomerulonephritis secondary to focal segmental glomerulosclerosis=7H>!5hich of the following would $e the most appropriate step to ta4e net in the treatment of this

patient%s disease6! A! Renal dialysis! B! Cyclosporine! C! Prednisone! D! Cyclophosphamide! 8! Captopril

,ey Concept9.$:ective' ;o understand that glucocorticoids represent the 4ey initial medicaltherapy for patients diagnosed with 7H7H is one of the most common causes of nephrotic syndrome in adults!


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in *K of adults with 7H! As in all glomerular diseases# if a secondary cause can $efound =e!g!# correcting the underlying cause is the first priority!&owever# many causes are idiopathic! ;he first line of therapy in adults with 7H isprednisone! should $e tried!


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$lood in her urine on two occasions after ecessive eercise! Physical eamination is unremar4a$leecept for some mild muscle tenderness! 0rinalysis is positive for /( $lood! ;he $lood urea nitrogen=B0N> level is )3 mg9dl# and the creatinine level is )!) mg9dl!5hat is the most li4ely cause of this patient%s symptoms6! A! Postinfectious glomerulonephritis! B! Myoglo$inuria caused $y rha$domyolysis! C! --------------------------------------------------------------------------------------------

"! A */-year-old woman presented to the emergency department with a cough# fever# and yellow sputumproduction+ she had $een eperiencing these symptoms for ) wee4! .n physical eamination# crac4leswere heard in the left lower and middle lung Gones# and the patient eperienced pain on inspiration!a$oratory results were as follows' Na# )"3 m8F9+ ,# "!3 m8F9+ B0N# "* mg9dl+ creatinine# )!) mg9dl!A chest radiograph showed a consolidation in the left lower lo$e! ;he patient was admitted and treatedwith


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pain# and progressive lower etremity edema! he first noticed these symptoms " months ago+ $eforethen# she had $een in good health! .n physical eamination# her $lood pressure is elevated to )3*9)*mm &g# she has no fever# and her heart rate and respiratory rate are normal! Results of cardiovascular#lung# and a$dominal eaminations are normal! All her :oints are normal# and no redness# warmth# oreffusions are noted! Jou corro$orate pitting edema up to her midshin $ilaterally! a$oratory results areas follows' creatinine# /!* mg9dl+ B0N# *2 mg9dl! ;he levels of all the electrolytes are normal!5hich of the following results of urinalysis would $e most consistent with this patient%s clinical picture6

! A! Moderate num$er of hyaline and finely granular casts! B! Presence of moderate to severe proteinuria =/( to (># red $lood cells=RBCs># and RBC casts! C! Dipstic4 is positive for $lood with few or no RBCs! D! Dirty-$rown granular casts and granular epithelial cells# $oth freeand in casts! 8! Relatively normal results with no cells or few cells and no casts,ey Concept9.$:ective' ;o understand the value of microscopic eamination of the urine indetermining the etiology of AR70rinalysis can provide invalua$le information for patients with AR7! Prompt processingof the specimen is of paramount importance! Patients with myoglo$inuria or hemoglo$inuriacharacteristically have positive findings on dipstic4 testing for $lood and ana$sence of RBCs on microscopic eamination of the urine! 7or patients with postrenalaGotemia and those with hepatorenal syndrome# findings on urinalysis are relatively

$enign# and there is an a$sence of casts and cells! Patients with prerenal aGotemiademonstrate hyaline and finely granular casts unless their condition has progressed toA;N! # the urine sedimenthas characteristic dirty-$rown granular casts and $oth free renal epithelial cellsand epithelial cell casts! ;his patient is li4ely to have proliferative glomerulonephritis+the urine sediment of such patients ehi$its significant proteinuria# RBCs# and RBCcasts! ;he differential diagnosis for proliferative glomerulonephritis includes connectivetissue diseases# systemic vasculitis# postinfectious glomerulonephritis# and otherdiseases! =Answer' B?@Presence of moderate to severe proteinuria S/( to (T# red $lood cells SRBCsT#and RBC casts>

Iascular Diseases of the ,idney

"2! A /"-year-old woman presents to you after a recent hospital admission for flash pulmonary edema! hewas diagnosed with hypertension several months ago! &er $lood pressure remains poorly controlleddespite compliance with a regimen of hydrochlorothiaGide# amlodipine# and metoprolol! he denies havingheadache and palpitation! &er physical eamination is remar4a$le for a $lood pressure of "9)2mm &g in the left arm and $ilateral a$dominal $ruits! Jou consider the diagnosis of renal artery stenosis=RA> secondary to fi$romuscular dysplasia =7MD>!5hich of the following statements regarding RA and 7MD is true6! A! Renal ultrasonography should $e the first step in the evaluation ofRA $ecause a finding of symmetrical 4idneys precludes the needfor further testing! B! Angioplasty with stenting has $ecome the most common method ofmanaging 7MD associated with hypertension and renal insufficiency+this procedure completely cures more then *K of patients withhypertension and improves renal function in over one third

! C! ;he segmental nature of medial fi$roplasia# the most common su$typeof 7MD# results in the classic so-called $eads-on-a-string appearancein the proimal third of the main renal artery! D! urgical repair of aneurysms is reFuired if their diameter is greaterthan )!* cm or if the patient has uncontrolled hypertension or ispregnant,ey Concept9.$:ective' ;o understand the diagnosis and treatment of 7MDMedial fi$roplasia# the most common su$type of 7MD# is characteriGed $y a predominanceof fi$rotic material in the media# with sparing of the intima and adventitia!


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measure 4idney siGe!


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,ey Concept9.$:ective' ;o understand the pathogenesis# diagnostic criteria# and treatment ofPAN;he pathogenesis of PAN is unclear! ;here appears to $e an association with hepatitis Bviral infection! ;he diagnosis of PAN is made $y demonstration of the characteristiclesion in an artery! erologic tests are not diagnostic in PAN# $ut low-titer anti$odies torheumatoid factor and nuclear antigen may $e present! may $e positive# $ut the more specific test?@serum 8 and myeloperoidase?@is negative! #for up to ) year is used in patients whose disease does not respond to steroids or inpatients who are at ris4 for serious complications! AC8 inhi$itors and ARBs should $eused cautiously in patients with PAN# $ecause renal involvement may produce a functionaleFuivalent of classic renal artery stenosis! =Answer' C?@AC8 inhi$itors and angiotensinreceptor $loc4ers SARBsT should $e used cautiously in patients with PAN $ecause renal involvement

may produce a functional eFuivalent of RA>---------------------------------------------------------------------------------------------

"E! A *-year-old man presents with a -day history of low-grade fever and confusion! &e was previouslyhealthy! &is physical eamination is significant for pallor and ecchymoses! a$oratory studies reveal ahemoglo$in of 1!2 g9dl# a 5BC of 3#"9WXl# and a platelet count of )"#9WXl! ;he peripheral $lood smearshows schistocytes and a decreased num$er of platelets!7or this patient# which of the following statements regarding throm$otic microangiopathies =;MAs>is true6! A! 5hen plasma activity of metalloprotease =ADAM;-)/> is elevated#von 5ille$rand antigens predominate+ those antigens $ind toplatelets and cause aggregation and throm$i in the small vessels! B! A presumptive diagnosis of throm$otic throm$ocytopenic purpura=;;P> is often $ased on the presence of throm$ocytopenia# schistocytes#

and prolonged prothrom$in time =P;> and partial throm$oplastintime =P;;>! C! &emolytic-uremic syndrome =&0> is characteriGed $y plateletaggregation and the presence of large von 5ille$rand multimers! D! ;he clinical presentation of antiphospholipid syndrome =AP> generallycomprises a single throm$otic event in the arterial system,ey Concept9.$:ective' ;o understand the pathogenesis and clinical presentations of the variousthrom$otic microangiopathies;he classic ;MAs include ;;P and &0! ;he critical role of ADAM;-)/ =a disintegrinand metalloprotease with throm$ospondin type ) motif> in the pathogenesis of ;;P hasemerged in the past ) years! ADAM;-)/# which is found on the surface of endothelialcells# normally cleaves large multimers of the von 5ille$rand antigen as they are secreted$y the cell! ;hese large multimers $ind more efficiently than the cleaved von5ille$rand antigen to platelets =at the


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and# occasionally# some other enteropathogenic organism! ystemically# higa toinsproduced $y the $acteria play two 4ey roles in the development of throm$i composedof platelets and von 5ille$rand antigen! 7irst# they impair the secretion ofADAM;-)/ through an unspecified mechanism# resulting in large von 5ille$randmultimers! econd# they activate platelet adherence via the glycoprotein # cough# dyspnea# and a )-l$ weight loss over the past / to months! &e wor4s as a manager for a grocery store chain# has never used

with 5egener granulomatosis and are a relatively specific indication of 5egener granulomatosiswhen present in a cytoplasmic staining distri$ution! ung $iopsy thatshows necrotiGing granulomas is diagnostic! arcoidosis and ;B cause noncaseatinggranulomas# not necrotiGing granulomas in lung tissue! arcoidosis usually causes pulmonaryfi$rosis# $ronchiectasis# and cavitation# along with mediastinal adenopathy!Renal sarcoidosis usually causes renal insufficiency through hypercalcemia or tu$ulardysfunction from granulomatous interstitial nephritis! Although pulmonary ;B maycause hemoptysis# it more characteristically causes a focal infiltrate in the upper lo$e ofthe lung or appears in a miliary pattern on chest -ray! 7urthermore# ;B involving the4idneys more li4ely causes significant pyuria! Classic polyarteritis does not involve thelungs and is characteriGed $y a perinuclear# not cytoplasmic# ANCA staining pattern!Hoodpasture syndrome is a pulmonary renal syndrome with a presentation similar tothat of 5egener granulomatosis# $ut in Hoodpasture syndrome# ANCA test results arenegative! =Answer' 8?@5egener granulomatosis>

------------------------------------------------------------------------------/)! 5hat treatment would $e most appropriate for the patient descri$ed in Question /6! A! Prednisone! B! AGathioprine! C! 7our-drug therapy for ;B! D! ;rimethoprim-sulfamethoaGole! 8! Cyclophosphamide plus prednisone,ey Concept9.$:ective' ;o 4now that the appropriate treatment of 5egener granulomatosis iscyclophosphamide in com$ination with prednisone8arly treatment with the com$ination of cyclophosphamide and prednisone is the


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most effective way to prevent rapid progression to renal failure in patients with5egener granulomatosis! ;his com$ination can also induce remission in up to 1*K ofpatients! Prednisone may cause temporary clinical improvement $ut rarely results inremission! Neither aGathiaprine nor four-drug ;B therapy would $e useful against5egener granulomatosis!


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with the vasculitides often overlap# renal $iopsy findings are not usually diagnostic!A$dominal C; scanning is not sensitive enough to pic4 up the microaneurysms of polyarteritisnodosa! ANCA with a perinuclear staining pattern is more li4ely to $e presentin microscopic polyarteritis than in the classic form of polyarteritis nodosa! 8lectro-myopathy can assist in determining whether nerve damage is aonal or demyelinating#although it is rarely diagnostic! =Answer' A?@Angiography>------------------------------------------------------------------------------------------------------

/! A ")-year-old college student reports a$dominal pain# $ilateral an4le and 4nee pain# $loody urine# anda worsening rash that $egan on his lower legs and has spread to his trun4! &e denies having had anyrecent infectious eposures or infections+ he also denies using !


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! 8! Most patients with this disorder $ecome oligoanuric,ey Concept9.$:ective' ;o understand the clinical manifestations and management of acuteinterstitial nephritis =AIirtually all WZ-lactam anti$iotics =i!e!# penicillins and cephalosporins> can produce A

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/2! A 2*-year-old man with hypertension and reflu disease presents to your office for routine follow-up! &ehas no complaints! a$oratory data reveal an increased serum potassium level of *!3 m8F9! .n Fuestioning#you learn that the patient has a history of hesitancy# dri$$ling# and a decrease in the urinarystream!5hich of the following statements pertaining to renal interstitial damage from physical factors isfalse6! A! 7or patients with vesicoureteral reflu# medical therapy is unhelpful#and surgical intervention should $e recommended immediately! B!


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;reatment consists of relieving the o$struction! =Answer' A?@7or patients with vesicoureteralreflu# medical therapy is unhelpful# and surgical intervention should $e recommended immediately>----------------------------------------------------------------------------------------------

/1! A /3-year-old man comes to your office for evaluation of a urinalysis that revealed proteinuria! 7urtherevaluation demonstrated proteinuria in the nonnephrotic range and a creatinine level of )!3 mg9dl! ;hepatient has celiac disease with steatorrhea# which was diagnosed many years ago! Jou suspect he has

chronic interstitial nephritis that is associated with celiac disease!5hich of the following scenarios is N.; associated with tu$ulointerstitial nephritis6! A! A patient who several years ago underwent stomach $ypass surgeryfor mor$id o$esity! B! A /*-year-old woman who has non-&odg4in lymphoma with $ul4ydisease and is " days post chemotherapy! C! A patient with vitamin D deficiency who presents with tetany andparesthesias! D! A 23-year-old man with hypertension who ingested moonshine for years,ey Concept9.$:ective' ;o understand the meta$olic distur$ances that can produce renal tu$ulointerstitiala$normalities# as well as environmental factors that can cause renal damage.alic acid is a dicar$oylic end product of meta$olism that is removed from the $odyonly $y renal ecretion! Precipitation of calcium oalate can produce nephrolithiasis#

acute renal failure# or chronic tu$ulointerstitial damage! Patients with steatorrhea fromvarious intestinal diseases?@including celiac disease# Crohn disease# 5ilson disease# andchronic pancreatitis?@or from small $owel resection or $ypass operations for o$esitymay hypera$sor$ oalate from the large $owel! ;he pathogenesis of oalate hypera$sorptioninvolves the a$normal $inding of intraluminal gut calcium to fats# which freesmore oalate for a$sorption! low-level


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proteinuria# as seen on urinary dipstic4 measurement# in con:unction with high-levelproteinuria# as seen on "-hour Fuantitative measurement =the dipstic4 primarilydetects al$umin# not Bence-Oones protein># ="> a low anion gap =caused $y the cationiccharge on some monoclonal immunoglo$ulins># =/> hypercalcemia in the presence ofrenal failure and a high serum phosphate level# and => anemia that is out of proportionto the degree of renal insufficiency! A common manifestation of myeloma is renalinsufficiency# present in more than *K of patients! 8cessive production and filtration

of monoclonal light chains =Bence-Oones protein> can cause direct tu$ular cell damage#as well as tu$ular o$struction $y casts! Dysproteinemias can also $e associated withtu$ulointerstitial precipitation of urate crystals# caused $y urate overproduction or lysisof plasma cells!


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sta$le at )* ml9min! &is $lood urea nitrogen =B0N> level is E mg9dl# and his creatinine level is 3!*mg9dl! A nephrologist recently referred the patient to a vascular surgeon for hemodialysis vascular access!&e states that his nephrologist has advised that he initiate hemodialysis therapy as soon as his vascularaccess is placed and matured!5hich of the following statements regarding end-stage renal disease =8RD> and hemodialysis isfalse6! A! ----------------------------------------------------------------------------------------

)! A 23-year-old man with chronic renal failure secondary to type " dia$etes mellitus presents withhematemesis! ------------------------------------------------------------------------------------------

"! A *-year-old woman with 8RD on hemodialysis presents with a traumatic fracture of the humerus! Anorthopedic consultation recommends an open reduction and internal fiation to $e performed the followingday!5hich of the following medications should most $e avoided for this patient6! A! Acetaminophen! B! Morphine sulfate


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! C! Meperidine! D! &ydromorphone! 8! .ycodone,ey Concept9.$:ective' ;o appreciate the need to choose medications carefully for the patientwith 8RD;his patient reFuires postoperative pain management! Most narcotics are meta$oliGedprimarily $y the liver# $ut the meta$olites of meperidine can accumulate# especially in

the setting of compromised renal function! ;his leads to an increased ris4 of seiGure!;herefore# alternative narcotic =and nonnarcotic> analgesics should $e used and thedoses monitored closely! =Answer' C?@Meperidine>/! A *3-year-old woman presents to discuss potential hemodialysis! he has had progressive renal failuresecondary to polycystic 4idney disease and awaits renal transplantation!5hich of the following meta$olic a$normalities would most li4ely $e present in this patient6! A! Meta$olic acidosis! B! &ypo4alemia! C! &ypophosphatemia! D! &ypercalcemia! 8! Meta$olic al4alosis

,ey Concept9.$:ective' ;o $e a$le to recogniGe common meta$olic a$normalities in chronicrenal failure

A num$er of meta$olic a$normalities can occur in the setting of chronic renal failure!Potassium levels tend to clim$ $ecause of decreased ecretion! Phosphate levels also rise$ecause of the reduction in urine output! ;he fall in calcium levels is caused $y manyfactors# including decreased intestinal a$sorption# decreased hydroylation of vitaminD# increased levels of P;& =with decreased sensitivity># and# at times# decreased inta4e!;ypically# the acid-$ase disorder is that of meta$olic acidosis! ;his is related to decreasedammonia secretion and ina$ility to ecrete titrata$le acid! ;here may also $e type ! =Answer' A?@Meta$olic acidosis>----------------------------------------------------------------------------------------------------

! A 2)-year-old man on chronic hemodialysis undergoes elective hip replacement! --------------------------------------------------------------------------------------------

*! A 23-year-old woman presents with progressive renal failure secondary to hypertension! .n routinela$oratoryscreening# she is found to have a calcium level of 1!3 and an al$umin level of !"!5hich of the following is contri$uting to this patient%s calcium level6! A! 8nhanced intestinal calcium a$sorption! B! ow levels of circulating parathyroid hormone =P;&>! C! &ypophosphatemia! D! Decreased vitamin D hydroylation! 8! Decreased fecal calcium,ey Concept9.$:ective' ;o $e a$le to recogniGe the a$normalities in calcium management in


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the patient with 8RDCalcium homeostasis is dramatically altered in the patient with 8RD! ;here is decreasedintestinal a$sorption in the small intestine! ;he com$ination of low calciumlevels and elevated phosphate levels leads to an increase in P;&! ;he 4idney itself is nolonger a$le to adeFuately hydroylate vitamin D! ;his com$ination of factors leads toa worsening in $one health! Critical interventions include 4eeping phosphate levelsdown# assuring adeFuate calcium ingestion# and# if necessary# replacing hydroylated

vitamin D! =Answer' D?@Decreased vitamin D hydroylation>

Renal ;ransplantation

2! A 22-year-old man with dia$etes mellitus# hypertension# and chronic 4idney disease presents for a routinefollow-up visit! Despite good control of his hypertension =$lood pressure# )"91" mm &g> and dia$etes=hemoglo$in A)c level# 1!K># the patient?s creatinine level continues to slowly increase =Cr# /!1mg9dl>! ;he patient is concerned a$out the long-term implications of his 4idney disease and would li4emore information regarding his ultimate treatment options!7or this patient# which of the following statements is true6! A! ,idney transplantation results in an improvement in Fuality of life$ut a decrease in long-term survival! B! Being older than 2* years precludes this patient from $eing considered

as a 4idney transplant recipient! C! ,idney transplant recipients initially have an increase in mortality#$ut they have an overall improvement in long-term survival! D! Quality of life is similar for dialysis patients and transplantationpatients,ey Concept9.$:ective' ;o $e a$le to counsel patients who are considering 4idney transplantationContinued improvement in outcomes has made transplantation the treatment ofchoice for patients with end-stage renal disease! 0nli4e dialysis patients# transplantationpatients have a documented improvement in Fuality of life and a comparativelyhigh rate of return to employment! A study of more than ""# patients showed thatlong-term survival of patients who received a renal transplant was superior to that ofpatients who either remained on the transplantation waiting list or continued withlong-term dialysis! Patients who underwent transplantation had an initial increase inmortality related to the surgical procedure+ however# this initial ris4 was rapidly

eclipsed $y the improved long-term survival of transplant recipients! Most transplantationprograms offer transplants to medically appropriate recipients regardless of age!Data show that older transplant recipients have ecellent survival rates after renaltransplantation and may in fact have a lower incidence of episodes of acute re:ectionthan younger recipients! =Answer' C?@,idney transplant recipients initially have an increase inmortality# $ut they have an overall improvement in long-term survival>-----------------------------------------------------------------------------------------

1! ;he condition of the patient in Question 2 worsens over the net few years# and he undergoes renaltransplantation from a living# nonrelated donor! &e is started on an immunosuppressant regimen consistingof prednisone# cyclosporine# and mycophenolate mofetil! As his primary care provider# you continueto follow the patient for his hypertension and dia$etes# which remain well controlled!7or this patient# which of the following statement is true6! A! ;he leading cause of death in 4idney transplant recipients is opportunistic

infection secondary to immunosuppressive therapy! B! Recurrent glomerular 4idney disease is the most common cause ofgraft loss! C! Nephrotoicity is the most common side effect of mycophenolatemofetil! D! ;here is a direct correlation $etween systolic $lood pressure andgraft half-life+ goal systolic $lood pressure should $e )/ mm &gor less,ey Concept9.$:ective' ;o understand the complications following renal transplantation;he leading cause of death in transplant recipients# as in the general population# is cardiovasculardisease! ;he three most important causes of allograft dysfunction are recurrent


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glomerular 4idney disease# acute re:ection# and chronic allograft nephropathy!Although recurrent 4idney disease can occur and# in selected cases# may result in pro-gressive loss of renal function# it is much less li4ely to occur than acute re:ection orchronic allograft nephropathy! ong-term studies show that chronic re:ection remainsthe single most important cause of graft loss! Antimeta$olites such as mycophenolatemofetil are an important part of immunosuppressive strategies# largely $ecause theyhave no demonstra$le nephrotoicity and little effect on $lood pressure# cholesterol

levels# or glycemic control! =Answer' D?@;here is a direct correlation $etween systolic $lood pressureand graft half-life+ goal systolic $lood pressure should $e )/ mm &g or less>--------------------------------------------------------------------------------------------

3! A *2-year-old woman presents to your clinic for follow-up visit after undergoing renal transplantation /months ago! he has $een eperiencing increasing symptoms of shortness of $reath and has had feversof up to ))? 7 =/3!/? C>! Jou admit her to the hospital and initiate a wor4-up of her symptoms!Cytomegalovirus =CMI> serologies are positive# and you initiate treatment!5hich of the following interventions could have decreased the li4elihood of this patient developingher illness and could have decreased the severity of her illness6! A!


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native 4idneys# use of immunosuppressive medications# graft dysfunction# and# rarely#transplant renal artery stenosis! Although calcineurin inhi$itors are the cornerstones ofimmunosuppression# as a class# these agents commonly cause hypertension! pecifically#cyclosporine causes direct vasoconstriction and induces preglomerular vasoconstriction#resulting in a volume-dependent form of high $lood pressure! .ther classes ofimmunosuppressants that cause hypertension are corticosteroids and ;.R =target ofrapamycin> inhi$itors! Antimeta$olites# however# such as aGathioprine and mycophenolate

mofetil# are important in immunosuppressive agents $ecause of their lac4 ofnephrotoicity and $ecause they have little effect on $lood pressure! =Answer' D?@Cyclosporine commonly induces a volume-dependent form of hypertension>-----------------------------------------------------------------------------------

*! A /-year-old woman with end-stage renal disease =8RD> presents to your clinic for renal transplantevaluation! he has focal segmental glomerular sclerosis and has $een doing well for some time onhemodialysis# $ut she is concerned a$out [losing the transplanted 4idney[ $ecause of her original disease!5hich of the following statements regarding recurrence and graft loss associated with her primaryrenal disease is false6! A! Primary glomerular diseases freFuently recur and are commonlyassociated with graft loss! B! upus nephritis rarely recurs after transplantation! C! ;ype disease in the allograft,ey Concept9.$:ective' ;o understand the ris4 of disease recurrence in patients with primaryglomerular disease;he recurrence rates of different primary renal diseases vary! Primary glomerular diseasesfreFuently recur in the transplanted 4idney+ however# graft loss secondary torecurrence is uncommon! ;he patients who are at greatest ris4 of graft loss are those inwhom renal function deteriorated rapidly and aggressively!


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lipid a$normalities resolve within 2 months posttransplantation secondary to a reductionin the doses of immunosuppressant agents# elevations in lipid levels need to $etreated aggressively! 0sually# dietary measures will not control these lipid a$normalities#and statins are needed for adeFuate control! 7i$rates and nicotinic acid may also$e necessary to control refractory lipid levels!


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incontinence! ;he physician should loo4 for evidence of systemic diseases that can presentwith lower urinary tract symptoms# particularly urinary freFuency and nocturia!8amples of such diseases include dia$etes# heart failure# and hyperparathyroidism!Routine tests performed on men with lower urinary tract symptoms should generallyinclude a urinalysis to screen for hematuria and infection! Pyuria suggests infection#either primary or superimposed on $ladder outlet o$struction! Microscopic hematuriamay indicate simply that the prostate is enlarged and vascular# $ut it should prompt

further evaluation for genitourinary malignancy! 0pper urinary tract imaging =$y ultrasonography#computed tomography# or intravenous pyelography> and urethrocystoscopyare not indicated for routine cases of lower urinary tract symptoms attri$uta$leto BP&! =Answer' C?@A$dominal and pelvic ultrasound are indicated in the initial wor4up of BP&>------------------------------------------------------------------------------------------------

*! A patient of yours whom you follow for BP hypertension# and osteoarthritis presents to your office!&e has had symptoms of BP& for / years now# $ut over the past " to / months# his symptoms of hesitancyand straining have worsened to the point that he wishes to pursue therapy!5hich of the following statements regarding the medical management of BP& is true6! A! Alpha)-adrenergic $loc4ers wor4 primarily through relaation of thedetrusor muscle of the $ladder! B! Alpha)-adrenergic $loc4ers reduce prostate siGe and lower prostatespecificantigen =PA> levels

! C! ;he *W-reductase inhi$itors reduce prostate siGe and lower PA levels! D! Alpha $loc4ers offer the same symptom relief as do *W-reductaseinhi$itors,ey Concept9.$:ective' ;o understand the medical management of BP&Alpha)-adrenergic $loc4ers wor4 primarily through relaation of prostatic smoothmuscle and relief of the dynamic component of $ladder outlet o$struction! &owever#additional mechanisms have $een proposed# including increased apoptosis of prostaticcells! Alpha $loc4ers neither reduce prostate siGe nor lower PA levels! ;heir onset ofaction is relatively rapid# although most alpha $loc4ers reFuire dose titration to achievea maimal therapeutic effect while minimiGing side effects! ;he *W-reductase inhi$itorscurrently availa$le for the treatment of BP& are finasteride and dutasteride! 7inasterideselectively and irreversi$ly $inds with the type " *W-reductase isoenGyme# which predominatesin the prostate and there$y $loc4s conversion of testosterone to dihydrotestosterone=D&;># the dominant intraprostatic androgen! ;his agent lowers serum

D&; $y a$out 1K and intraprostatic D&; to an even greater degree! Dutasteride is adual *W-reductase inhi$itor+ it $loc4s $oth type ) and type " isoenGymes and lowersserum D&; $y a$out EK! Men who ta4e finasteride at the recommended dose of * mgdaily or dutasteride at !* mg daily can epect a "K to "*K reduction in prostate siGeover the first year of therapy# accompanied $y a$out a *K reduction in PA level!=Answer' C?@;he *W-reductase inhi$itors reduce prostate siGe and lower PA levels>---------------------------------------------------------------------------------------------------

**! A 2)-year-old man presents for a follow-up visit for BP&! &e has $een ta4ing an alpha)-adrenergic $loc4erfor years now+ he is currently ta4ing the maimum dose! &is symptoms have continued to progress#and he wishes to $e referred to a urologist for surgical intervention!5hich of the following statements regarding the surgical treatment of BP& is false6! A! Retrograde e:aculation is a common outcome of transurethralprostatectomy =;0RP>

! B! .pen prostatectomy remains the gold standard for relieving symptomsand reducing the ris4 of complications for men with BP&! C! Acute urinary retention does not always reFuire surgery and can $emanaged with $ladder rest via catheter drainage! D! ymptom reduction is higher in patients who undergo ;0RP thanin patients placed on watchful waiting,ey Concept9.$:ective' ;o understand the surgical options for patients with BP&;0RP remains the gold standard for relieving symptoms and reducing the ris4 of complicationsfor men with BP&! ;0RP involves resecting the central adenoma of thehyperplastic prostate transurethrally under direct visualiGation using a resectoscopewith an electrified cutting loop! Retrograde e:aculation is a common outcome of ;0RP#


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occurring in the ma:ority of cases! Acute urinary retention used to $e considered ana$solute indication for surgery! &owever# small case series have documented that up tohalf of men with acute retention have a successful voiding trial after a period of $ladderrest via catheter drainage# and most of the men who eperience success will continueto void# at least over the net 2 months! =Answer' [email protected] prostatectomy remains thegold standard for relieving symptoms and reducing the ris4 of complications for men with BP&>----------------------------------------------------------------------------------------------------

*2! 6! A! A 2-year-old man with long-standing hypertension who has nocturiaof new onset and intermittent shortness of $reath at night! B! A *3-year-old man who complains of wea4 stream# lower a$dominaldiscomfort# and gross hematuria of " months% duration! C! A **-year-old man who descri$es symptoms of wea4 stream andintermittent straining to urinate# which he has $een eperiencingfor / to months! D! An o$ese /*-year-old man with nocturia of recent onset# daytimeurinary freFuency# and increased thirst! 8! A 1"-year-old man with dysuria of " days% duration

,ey Concept9.$:ective' ;o understand the need to assess for other clinical disorders in patientswho present with urinary symptoms similar to BP&;he lower urinary tract symptoms seen in patients with BP& result from $ladder outleto$struction! ;ypical symptoms of BP& with $ladder outlet o$struction are related toimpaired $ladder emptying =e!g!# straining# hesitancy# intermittency# wea4 stream# terminaldri$$ling# and incomplete emptying> and $ladder irritation9detrussor insta$ility=e!g!# daytime freFuency# nocturia# urgency# and urge incontinence>! # dia$etes mellitus#urinary tract infection# and prostatitis! Although patients with BP& may have some

hematuria# other diagnoses =including upper urinary tract disease and $ladder cancer>should always $e ruled out $efore gross hematuria is attri$uted to BP&!


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o$structive symptoms in patients with BP& and should $e avoided! D! ;he only reasona$le approach to managing this patient involves;0RP $efore discharge! 8! ;he patient%s incontinence is li4ely the result of overflow from ano$structed $ladder

,ey Concept9.$:ective' ;o recogniGe o$structive uropathy as a potential conseFuence of BP&

and understand the treatment options;his patient has developed severe urinary outflow tract o$struction# resulting in acuterenal failure!


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mg at $edtime for several days to avoid [first-dose[ hypotension! ;he average effectivedo

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questions about kidneys