9/25- Renal III: AKI, CKD, and Everything Else Flashcards Preview

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Flashcards in 9/25- Renal III: AKI, CKD, and Everything Else Deck (36)
1

An infant is found to have glucosuria, bicarbonaturia, and aminoaciduria. Serum bicarbonate is stable at 14.

What is the renal defect?

A. Abnormality of sodium coupled transport in the proximal nephron

B. Abnormality of sodium coupled transport in the cortical collecting duct

C. Abnormality of sodium coupled “tri-transport” in the loop of Henle.

D. Abnormality of electrogenic sodium channel in medullary collecting duct

What is the renal defect?

A. Abnormality of sodium coupled transport in the proximal nephron

B. Abnormality of sodium coupled transport in the cortical collecting duct

C. Abnormality of sodium coupled “tri-transport” in the loop of Henle.

D. Abnormality of electrogenic sodium channel in medullary collecting duct

- Proximal tubular RTA

2

A patient with altered mental status is being seen in ER, and has the following electrolytes:

Na=140, K=2.4, Cl=125, HCO3=4 .

Which disease is compatible with these electrolytes?

A. Diabetic keto-acidosis

B. Methanol poisoning

C. Septic shock

D. Distal renal tubular acidosis

Which disease is compatible with these electrolytes?

A. Diabetic keto-acidosis

B. Methanol poisoning

C. Septic shock

D. Distal renal tubular acidosis

- AG = 140 - 125 - 4 = 11

- NAGMA

3

A hypertensive patient on no medications has edema, hypokalemia, and a high serum bicarbonate.

You find that the aldosterone is elevated and renin is low.

Which single medication will most likely cure his hypertension

A. The angiotensin converting enzyme inhibitor lisinopril.

B. The aldosterone receptor blocker spironolactone.

C. The beta blocker atenolol.

D. The calcium antagonist amlodipine.

Which single medication will most likely cure his hypertension

A. The angiotensin converting enzyme inhibitor lisinopril.

B. The aldosterone receptor blocker spironolactone?

C. The beta blocker atenolol.

D. The calcium antagonist amlodipine.

- If you have low K (hypokalemia) and HTN, need to look at renin/aldosterone levels

High renin:

- Renal artery stenosis

- Renin-secreting tumor

High aldosterone (hyperaldosteronism)

- Renal hyperplasia

Nl aldosterone and low renin

- Liddle's syndrome

- Licorice

4

A patient presents to the emergency room with a serum potassium of 8 mEq/L and EKG changes.

Why did the senior resident in the ER give calcium gluconate first?

A. Calcium reestablishes cardiac repolarization, even though serum potassium remains high.

B. Calcium decreases proximal tubule potassium absorption.

C. Calcium depolarizes thick ascending limb of Henle, inhibiting the Na-K-2Cl transporter.

D. Calcium competes with sodium for the principal cell sodium channel, stimulating K secretion by the collecting duct.

Why did the senior resident in the ER give calcium gluconate first?

A. Calcium reestablishes cardiac repolarization, even though serum potassium remains high.

B. Calcium decreases proximal tubule potassium absorption.

C. Calcium depolarizes thick ascending limb of Henle, inhibiting the Na-K-2Cl transporter.

D. Calcium competes with sodium for the principal cell sodium channel, stimulating K secretion by the collecting duct.

Other treatments:

- Lasix/loop diuretics

- Insulin (+ glucose)

- Bicarb (if acidotic)

- Diuretics

5

What can be seen on EKG in hyperkalemia?

- Sine wave

- PT wave

6

Which of the following statements about the hormone PTH is correct?

A. PTH decreases urinary phosphorus excretion

B. PTH increases calcium release from osteoclasts

C. PTH decreases 1-alpha hydroxylase at the kidney, reducing levels of 1,25OH vitamin D

D. PTH and calcitonin work together to raise calcium levels

Which of the following statements about the hormone PTH is correct?

A. PTH decreases urinary phosphorus excretion

B. PTH increases calcium release from osteoclasts

C. PTH decreases 1-alpha hydroxylase at the kidney, reducing levels of 1,25OH vitamin D

D. PTH and calcitonin work together to raise calcium levels

7

A patient has the following lab tests:

[Na+] = 140 mEq/L, [K+] = 3.2 mEq/L, [Cl-] = 96 mEq/L, [HCO3] = 32 mEq/L, arterial pH = 7.48, pCO2=46.

What is the correct diagnosis?

A. Type IV Renal Tubular Acidosis

B. Primary hyperaldosteronism

C. Proximal (Type 2) renal tubular acidosis

D. Ethylene glycol intoxication

E. Distal (Type 1) renal tubular acidosis

What is the correct diagnosis?

A. Type IV Renal Tubular Acidosis

B. Primary hyperaldosteronism

C. Proximal (Type 2) renal tubular acidosis

D. Ethylene glycol intoxication

E. Distal (Type 1) renal tubular acidosis

 - Metabolic alkalosis?

- Know principal cell working

8

Which of the following mechanisms is responsible for hypokalemia seen after vomiting?

A. GI loss of potassium

B. High aldosterone state due to volume depletion

C. Increased delivery of H+ to the kidney

Which of the following mechanisms is responsible for hypokalemia seen after vomiting?

A. GI loss of potassium

B. High aldosterone state due to volume depletion

C. Increased delivery of H+ to the kidney

- Principal cell reabsorbs Na with sacrifice of K

9

Syphilis can cause what renal dz?

Membranous nephropathy

10

Your patient needs a loading dose of 1000 mg of Penicillin to treat his tertiary syphilis. You realize he has CKD and a GFR of 20 ml/min.

Syphilis also causes membranous nephropathy and his albumin is 2.0 g/L. The drug is 50% protein bound.

How many mg of Penicillin should you load with?

A. 1000 mg

B. 500 mg

C. 250 mg

D. 50 mg

?

11

A patient presents with severe left flank pain and hematuria. Her urine pH is 8.5. She has a history of several urinary tract infections in the past. You look at the urine and the picture below is seen.

What is the most likely composition of the kidney stone?

A. Calcium Oxalate

B. Struvite

C. Drug induced (crystalline)

D. Cysteine 

What is the most likely composition of the kidney stone?

A. Calcium Oxalate

B. Struvite

C. Drug induced (crystalline)

D. Cysteine 

- Associated with certain bacteria (commonly urease-producing)

- Result from chronic urinary infection

  • Urea splitting organisms (e.g., Proteus)
  • Alkaline pH
  • Urinary debris and crystal niduses

- Stones composed of magnesium, calcium, ammonium, phosphate, carbonate (Struvite)

- Radiopaque

- Difficult or impossible to eliminate stones

  • Staghorn calculi (cast of pelvicocalyceal system)

12

If you give a normal patient without CKD one liter of Normal Saline (0.9%), what will happen to his serum sodium level?

A. Increase

B. Decrease

C. Stay the same

If you give a normal patient without CKD one liter of Normal Saline (0.9%), what will happen to his serum sodium level?

A. Increase

B. Decrease

C. Stay the same

13

You are sitting in the renal review session and develop an acute RIGHT sided flank pain. By the end of class, the pain seems to be migrating towards the front. You have a history of kidney stones and this feels like another stone.Your serum creatinine is normal.

What test will the ER likely order to confirm this diagnosis?

A. Non contrast CT scan

B. IV Pyelogram (IVP)

C. Ultrasound

D. Typically, ER will wait until stone passes to do stone analysis

What test will the ER likely order to confirm this diagnosis?

A. Non contrast CT scan

B. IV Pyelogram (IVP)

C. Ultrasound

D. Typically, ER will wait until stone passes to do stone analysis

- US is good if stone in kidney, but non-contrast CT scan is good if you need to find exactly where the stone is (if it's moving/where exactly)

14

You are consulted for a currently 50 kg female patient with a serum sodium of 150. You wish to normalize his serum sodium to 140. His blood pressure is 140/80 and he is euvolemic. Which fluid do you give; what is his water deficit?

A. Normal Saline; 1.8 Liters

B. Normal Saline; 4 Liters

C. Dextrose-Water; 1.8 Liters

D. Dextrose-Water; 4 Liters

Water deficit = TBW x (NApt/NAnl - 1)

(pt's sodium level - normal sodium level)

- Dehydrated people need water!

- Hypovolemic people need salt! (low BP)

15

Tachycardia could indicate what in regard to volume status?

Hypovolemia (decreased BP -> reflex tachycardia)

16

You admit a patient from the ER with hypovolemic hyponatremia, Na is 106 meq/L. The overzealous intern agressively treats the patient with normal saline and 12 hours later, his serum sodium is 130 meq/L.

What is this patient at risk for?

A. Central Pontine Myelinolysis

B. Myocardial Infarction

C. Diabetes Insipidus

D. Hypertension

Treatment?

What is this patient at risk for?

A. Central Pontine Myelinolysis

B. Myocardial Infarction

C. Diabetes Insipidus

D. Hypertension

(aka Osmotic Demyelination; doesn't just happen in pons)

- Don't correct more than 10 in 24 hours

Treatment:

- Hypertonic saline (3 x 154 = 462); pulls out water and prevents some symptoms

17

The urine anion gap tests answers which of the following questions?

A. Is there an ingestion of an alcohol?

B. Is the kidney able to acidify urine?

C. Is the body producing too much acid?

The urine anion gap tests answers which of the following questions?

A. Is there an ingestion of an alcohol?

B. Is the kidney able to acidify urine?

C. Is the body producing too much acid?

- Osmolar gap tests for alcohol ingestion

18

A patient presents with potassium of 1.7 meq/L (LOW) and sodium of 115 meq/L (LOW).

What is the effect of giving this patient potassium

A. Raise the serum sodium

B. Lower the serum sodium

C. No change to serum sodium

What is the effect of giving this patient potassium

A. Raise the serum sodium

B. Lower the serum sodium

C. No change to serum sodium

- Because of Na/K/ATPase, if you give K, Na will move out

- Raise serum sodium 

19

Which statement regarding change in renal function with increasing age is true.

A. The estimated GFR progressively falls

B. The renal vascular resistance progressively decreases

C. The normal range for serum creatinine increases

D. The kidney size slowly increases.

Which statement regarding change in renal function with increasing age is true.

A. The estimated GFR progressively falls

B. The renal vascular resistance progressively decreases

C. The normal range for serum creatinine increases

D. The kidney size slowly increases.

20

Which statement about diabetic nephropathy is true?

A. The majority of diabetics will develop nephropathy at some time in their lives.

B. Any finding of microalbuminuria indicates structural renal damage (such as cysts)

C. Patients with large kidneys do not have diabetic nephropathy

D. Persistent micro albuminuria indicates nephropathy

Which statement about diabetic nephropathy is true?

A. The majority of diabetics will develop nephropathy at some time in their lives.

B. Any finding of microalbuminuria indicates structural renal damage (such as cysts)

C. Patients with large kidneys do not have diabetic nephropathy

D. Persistent micro albuminuria indicates nephropathy

- This is the test for diabetic kidney disease

21

A patient with diabetes for 15 years has hypertension and nephrotic range proteinuria.

Which combination of medications below has the greatest probability of slowing diabetic nephropathy.

A. ACE-inhibitors [angiotensin converting enzyme, such as captopril] and statins [lipid lowering agents]

B. Thiazide diuretics and statins [lipid lowering agents]

C. Beta Blockers (Metoprolol) and aspirin

D. Direct vasodilators (Minoxidil) and statins [lipid lowering agents]

Which combination of medications below has the greatest probability of slowing diabetic nephropathy.

A. ACE-inhibitors [angiotensin converting enzyme, such as captopril] and statins [lipid lowering agents]

B. Thiazide diuretics and statins [lipid lowering agents]

C. Beta Blockers (Metoprolol) and aspirin

D. Direct vasodilators (Minoxidil) and statins [lipid lowering agents]

- ACEIs are mainstay of treatment (lower BP in glomerulus, lowering hydrostatic pressure, and decreasing protein filtration)

22

Effects of ACEI/ARB?

- Lower systemic BP

- Lower PGC

- Lower proteinuria

- Inhibit non-hemodynamic effects of A-II

  • Less proliferation, hypertrophy, matrix expansion, growth factor synthesis.
  • Inhibits macrophage activation, proliferation and migration

- Natriuretic

23

A ten-year old child with palpable purpura, proteinuria, hematuria, and abdominal pain most likely has…

A. Minimal Change Disease

B. Henoch-Schonlein Purpura (HSP)

C. Lupus Nephritis

D. IgA Nephropathy

A ten-year old child with palpable purpura, proteinuria, hematuria, and abdominal pain most likely has…

A. Minimal Change Disease

B. Henoch-Schonlein Purpura (HSP)

C. Lupus Nephritis

D. IgA Nephropathy

24

What would you expect the fractional excretion of sodium (FeNa) to be in a patient who is profoundly volume depleted?

A. < 1%

B. 1-3%

C. > 3%

What would you expect the fractional excretion of sodium (FeNa) to be in a patient who is profoundly volume depleted?

A. < 1%??

B. 1-3%

C. > 3%

FeNA > 1% (esp > 2%) is indicative of tubular injury (not absorbing Na)

25

A 55 year old patient presents to you with advanced kidney disease. He has never seen a doctor in his life. You decide to do a kidney biopsy and the image is shown below.You inform him that he has the most common cause of ESRD in the United States.

What is the diagnosis?

A. FSGS

B. Diabetic Nephropathy

C. IgA Nephropathy

D. Hypertensive Nephroscloerosis

What is the diagnosis?

A. FSGS

B. Diabetic Nephropathy

C. IgA Nephropathy

D. Hypertensive Nephroscloerosis

26

What cell is indicated by the arrow?

A. Podocyte (Visceral epithelial cell)

B. Glomerular Basement Membrane Cell

C. Endothelial Cell

D. Parietal epithelial cell

What cell is indicated by the arrow?

A. Podocyte (Visceral epithelial cell)

B. Glomerular Basement Membrane Cell

C. Endothelial Cell

D. Parietal epithelial cell

27

A. Acute Tubular Necrosis

B. Pre-renal state secondary to volume depletion

C. Calcium Oxalate Crystaluria

D. Acute Tubulointerstitial Nephritis

A. Acute Tubular Necrosis

B. Pre-renal state secondary to volume depletion

C. Calcium Oxalate Crystaluria

D. Acute Tubulointerstitial Nephritis

- Muddy brown cast

28

The most common form of Polycystic Kidney Disease that is diagnosed in adulthood is typically inherited…

A. X-linked

B. Autosomal Dominant

C. Autosomal Recessive

D. Mitochondrial

The most common form of Polycystic Kidney Disease that is diagnosed in adulthood is typically inherited…

A. X-linked

B. Autosomal Dominant

C. Autosomal Recessive

D. Mitochondrial

29

A 35 year old man suffers a ruptured right kidney in a motor vehicle accident, and undergoes a right nephrectomy, effectively decreasing the number of nephrons by half. One year later, his serum creatinine is still in the normal range.

Changes in the left kidney would include:

A. Vasodilatation of post (efferent) glomerular arterioles

B. Increase intra-glomerular pressure

C. Hypertrophy of proximal nephron cells

D. Increase in total number of nephrons in left kidney

Changes in the left kidney would include:

A. Vasodilatation of post (efferent) glomerular arterioles

B. Increase intra-glomerular pressure

C. Hypertrophy of proximal nephron cells

D. Increase in total number of nephrons in left kidney

30

The “Brenner Hypothesis” (surviving nephron hypothesis) for the progressive nature of renal disease involves

A. Hyperfiltration with increased glomerular hydrostatic pressure

B. Hypofiltration with decreased glomerular hydrostatic pressure

C. Chronic afferent arterial constriction

D. Deposition of immune deposits along glomerular basement membrane

?

31

You admit a patient from the Emergency Room with hyponatremia (Na 125 meq/L). He is euvolemic and has severe nausea. The urine sodium is 60 meq/L, urine osmolarity is 616 meq/L. You diagnose him with SIADH.Overnight, he is given 2 liters of normal saline (Na 154, Cl 154) by the intern on call.

What should happen to her serum sodium level…

A. Increase

B. Decrease

C. Stay the same

- Urine osmolarity basically measures ADH

- If ADH is high, urine osmolarity will be high (normal is 300)

- In SIADH, there is a fixed urine osmolarity

32

A 23 year old male 2nd year medical student at Baylor presents to a Nephrologist with dark urine and non-nephrotic range proteinuria. He currently has low grade fever and an upper respiratory infection. On history, he reveals a prior episode of dark urine around the time of his last URI. He has no past medical history.

The immunofluorescence pattern most likely seen is:

A. IgG-C3 Pattern (lumpy-bumpy)

B. Mesangial IgA deposits

C. IgA, IgG, C3, C4, C1Q: all show positivity

D. Linear IgG along the GBM

The immunofluorescence pattern most likely seen is:

A. IgG-C3 Pattern (lumpy-bumpy)

B. Mesangial IgA deposits

C. IgA, IgG, C3, C4, C1Q: all show positivity

D. Linear IgG along the GBM

- Big question is if he has infection and glomerular disease (IgA nephropathy) or disease after infection (Post-infectious GN)

33

Which nephrotic syndrome is associated with subepithelial immune complex deposits?

A. Membranous Nephropathy

B. Minimal Change Disease

C. Focal Segmental Glomerulosclerosis

D. Membranoproliferative Glomerulonephritis 

Which nephrotic syndrome is associated with subepithelial immune complex deposits?

A. Membranous Nephropathy

B. Minimal Change Disease

C. Focal Segmental Glomerulosclerosis

D. Membranoproliferative Glomerulonephritis 

34

Your 10 year old female patient with heavy proteinuria (>12 grams per day), hypoalbuminemia, hyperlipidemia is at the highest risk for which of the following conditions?

A. Renal Vein Thrombosis

B. Potter’s Facies

C. Urinary Tract Infection

D. Cyst formation in the kidney

?

- This is probably minimal change disease (young child presenting with nephrotic syndrome)

35

A diabetic presents to the ER with a blood sugar of 420 mg/dL. Serum K is 6.4 and EKG shows peaked T waves.

Which drug will you give first to lower the serum potassium as fast as possible?

A. Furosemide

B. Insulin

C. Beta blocker infusion

D. Lisinopril (Ace-inhibitor)

E. Calcium infusion

Which drug will you give first to lower the serum potassium as fast as possible?

A. Furosemide

B. Insulin (fastest)

C. Beta blocker infusion

D. Lisinopril (Ace-inhibitor)

- Ca infusion would treat peaked T waves but not change K

36

You admit a patient with metabolic alkalosis and a high urinary chloride. He does not have hypertension.

What is the most likely diagnosis?

A. Bartter’s Syndrome

B. Conn’s Syndrome

C. Raghavan’s Syndrome

D. Cushing’s Syndrome

What is the most likely diagnosis?

A. Bartter’s Syndrome

B. Conn’s Syndrome

C. Raghavan’s Syndrome

D. Cushing’s Syndrome