Renal path 2

Question 1

Presenting signs of ____ most commonly include hypertension, hypokalemia, metabolic alkalosis and decreased plasma renin activity

Answer 1

hyperaldosteronism

*treat with aldosterone antagonist (Eplerenone/Spironolactone)

Question 2

is the cause of type IV renal tubular acidosis

Answer 2

hypoaldosteronism

Question 3

symmetric bilateral lower extremity pitting edema and tortuous, vertical abdominal veins are concerning for an _______ obstruction, which, in the setting of a left-sided flank mass, suggests renal cell carcinoma (RCC)
with extension into the IVC.

Answer 3

Inferior vena cava (IVC)

Question 4

Renal cell carcinoma causes a variety of paraneoplastic syndromes including _____ and hypercalcemia (due to parathyroid hormone–related peptide). *Also, ACTH or Renin tumors

Answer 4

erythrocytosis (due to excessive erythropoietin production causing high Hb levels)

Question 5

intermittent, painless gross hematuria, in an older patient, raises suspicion for _____
A history of smoking or occupational exposure to rubber, plastics, aromatic amine–containing dyes, textiles, or leather increases the risk

Answer 5

urinary tract cancer, especially

urothelial (transitional cell) bladder cancer (UBC)

Question 6

Clear cell carcinoma originates from proximal tubular epithelial cells and contains copious amounts of intracellular ____ & _____.

Answer 6

glycogen

lipids

Question 7

Urothelial (transitional cell) carcinoma is the most common type of bladder cancer.Tumor invasion into the muscularis propria layer of the bladder wall carries an ____ prognosis.

Answer 7

bad/unfavorable

• Tumor stage (depth & LN invasion) is the most important factor for determining prognosis

Question 8

Angiomyolipomas are rare tumors that arise from ___ epithelioid cells.

Answer 8

perivascular

Question 9

Benign renal neoplasms often associated with tuberous sclerosis.

Answer 9

Angiomyolipomas

Question 10

Hyperphosphatemia induces hypocalcemia directly by binding free calcium and depositing in tissues, and indirectly by triggering ___ secretion (decreases calcitriol production and intestinal calcium absorption).

Answer 10

fibroblast growth factor 23

*Hypocalcemia = neuromuscular excitability (carpal spasm).

Question 11

This patient’s symptoms (eg, fatigue, weakness, itching) are most likely due to accumulation of uremia toxins secondary to progressive

Answer 11

chronic kidney disease

Question 12

Widespread renal arteriolar vasoconstriction +
Renal biopsy shows deposition of glassy, eosinophilic PAS+ material in the intima and media of small arteries and arterioles, which is characteristic of

Answer 12

hyaline arteriolosclerosis

Question 13

hyaline arteriolosclerosis is typically seen in patients with (2)

Answer 13

untreated or poorly controlled hypertension (HTN)
diabetes mellitus (DM)

Question 14

Nephropathy in multiple myeloma is most often due to excess excretion of free light chains (Bence Jones proteins) that precipitate with Tamm-Horsfall protein to form obstructing tubular casts (cast nephropathy). These casts are seen as amorphous hyaline material in the

Answer 14

tubular lumen

Question 15

Nephropathy in multiple myeloma is most often due to excess excretion of free ____ that precipitate with Tamm-Horsfall protein to form obstructing tubular casts (cast nephropathy).

Answer 15

Ig light chains (Bence Jones proteins)

Question 16

__ and fibrinoid necrosis of the renal arterioles are typical morphologic findings in hypertensive (malignant) nephrosclerosis.

Answer 16

Hyperplastic arteriosclerosis (“onion-skinning”)

Question 17

Due to Malignant HTN, leakage of fibrinogen and coagulation factors through the damaged endothelium causes fibrin deposition in vessel walls, which appear as circumferential, acellular eosinophilic deposits (fibrinoid necrosis).

Over time, release of growth factors by damaged tissue stimulates the formation of concentric layers of collagen and ____ cells, resulting in an “onion skin” appearance (hyperplastic arteriosclerosis) of the arteriole.

Answer 17

proliferating smooth muscle

Question 18

___ occur more commonly in patients with chronic kidney disease due to electrolyte abnormalities
(hyperphosphatemia, hypercalcemia)
and
chronic inflammation
(secondary to atherosclerosis and/or uremia).

Answer 18

Vascular calcifications

ex: calcified abdominal aorta wall

Question 19

Sevelamer/Lanthanum is a nonabsorbable anion-exchange resin that binds intestinal ___ to reduce systemic absorption.

Answer 19

phosphate

Question 20

Creatinine, a waste product generated by the breakdown of creatine in the muscles, is used to estimate the _____.

Answer 20

glomerular filtration rate (GFR)

*Creatinine formation is dependent on muscle mass and meat intake

Question 21

narrowed arteriolar lumens, due to HTN or DM, causes a progressive decrease in renal blood flow, resulting in glomerular ischemia and

Answer 21

fibrosis (glomerulosclerosis).

Question 22

Prolonged elevation of systemic blood pressure causes the renal arterioles to undergo compensatory medial ____ and fibrointimal proliferation.

Answer 22

hypertrophy

Question 23

Prolonged elevation of systemic blood pressure causes the renal arterioles to undergo compensatory medial hypertrophy and ___ proliferation.

Answer 23

fibro-intimal

*anemia due to low EPO

Question 24

Elevated levels of phosphate and FGF-23 also reduce ___ synthesis by inhibiting the proximal tubular expression of 1-alpha-hydroxylase, resulting in decreased intestinal calcium and phosphate absorption.

Answer 24

calcitriol

Question 25

Analgesic nephropathy is a form of chronic kidney disease caused by prolonged, heavy intake of nonsteroidal anti-inflammatory drugs and/or acetaminophen.  Pathologic characteristics include (2)

Answer 25

chronic interstitial nephritis | renal papillary necrosis

Question 26

Atrophic renal tubules with THICKENED basement membrane. Interstitial mononuclear inflammatory infiltrate Proteinuria, WBCs on UA Bilateral, SHRUNKEN kidneys (+/-) Papillary calcifications

Answer 26

chronic interstitial nephritis

Question 27

usually occurs acutely after a prolonged period of hypotension (eg, sepsis, major surgery); muddy brown casts would be expected on urinalysis.

Answer 27

Ischemic tubular necrosis

Question 28

Symptoms of renal ____ include resistant hypertension recurrent flash pulmonary edema chronic kidney disease.

Answer 28

renal artery stenosis

Question 29

visualized histologically as focal tubular epithelial necrosis, often with extensive granular casts that obstruct the tubular lumen and lead to rupture of the basement membrane

Answer 29

ATN

Question 30

fever and rash, and urinalysis shows pyuria and WBC casts (DONT FORGET) Leukocytic infiltration of the interstitium and tubules

Answer 30

acute (allergic) interstitial nephritis | *occurs after introduction of a new drug. 

Question 31

Hypovolemia (ex: excessive diuresis) can cause acute kidney injury due to reduced ____ Urine Na+ and fractional excretion of Na+ levels are low BUN/creatinine ratio is elevated. 

Answer 31

renal blood flow (prerenal azotemia)

Question 32

``` should be suspected in elderly patients with any combination of hypercalcemia, normocytic anemia, bone pain, elevated gamma gap, or renal failure (waxy casts) ```

Answer 32

Multiple myeloma

Question 33

Cardiorenal syndrome is due to low cardiac output state results in renal hypoperfusion, leading to activation of the RAAS, increased ADH release and increased Beta 1 stimulation.  The resultant increase in sodium and water reabsorption and systemic vasoconstriction have detrimental effects on left ventricular systolic function, further worsening cardiac output and renal perfusion. What happens to levels BUN CRE Aldosterone

Answer 33

all are elevated (Aldosterone increases BUN levels due to increase UREA reabsorption) (Hypoperfusion = increased CRE because not being filtered out fast enough)

Question 34

Livedo reticularis (blue streaks), a blue toe, and acute kidney injury following and Invasive vascular procedure Light microscopy shows a partially or completely obstructed arterial lumen with needle-shaped cholesterol clefts within the atheromatous embolus. this presentation is concerning for ___

Answer 34

atheroembolic disease | Kidney or bowel ischemia or Brain stroke commonly affected

Question 35

causes acute tubular necrosis with vacuolar degeneration and BALLOONING of the proximal tubular cells.  Typical clinical findings include altered mentation, renal failure, high anion gap metabolic acidosis, increased osmolar gap, and ____ crystals in the urine.

Answer 35

Ethylene glycol ingestion | calcium oxalate

Question 36

Advanced liver disease with portal hypertension and splanchnic vasodilation may lead to renal failure (hepatorenal syndrome).  The hallmark of this condition is renal vasoconstriction, resulting in

Answer 36

prerenal azotemia.

Question 37

UA with positive blood but no RBCs on microscopy | ↑↑ Creatinine

Answer 37

Myoglobinuria (Rhabdomyolysis) Prolonged muscle activity (seizure, marathon running) Drug/medication use (statins, amphetamines, heroin) Crush injury

Question 38

Acute kidney injury & electrolyte abnormalities levels of: K P Ca

Answer 38

↑ K ↑ P ↓ Ca

Question 39

Pathology affecting the ___ is common in severe, acute pyelonephritis and in patients with sickle cell disease, diabetes mellitus, or analgesic nephropathy.  Urinalysis shows hematuria or sterile pyuria

Answer 39

renal papillae (papillary necrosis)

Question 40

Recovery phase of ATN (months) Gradual increase in urine output, leading to high-volume diuresis Continued impairment of renal tubular function, resulting in electrolyte wasting ↓↓ ( 4 )

Answer 40

potassium, magnesium, phosphorus, calcium

Question 41

low urine sodium (< ___ mEq/L)

Answer 41

20

Question 42

BUN/creatinine ratio >20

Answer 42

Pre-Renal Azotemia (hemorrhage, diarrhea, vomitting, CHF) | Early intrinsic renal failure

Question 43

In hypovolemic states Urea reabsorption increases to help concentrate the urine, resulting in increased serum levels of urea; creatinine continues to be excreted, resulting in the characteristic BUN/creatinine ratio

Answer 43

>20

Question 44

intrinsic ARF reflects loss of renal reabsorptive capacity.  Water, sodium, and urea are excreted in the urine, leading to lower urine osmolarity, higher urinary sodium, higher urinary FENa (>2) , and a normal serum BUN/creatinine ratio ___

Answer 44

<15

Question 45

ACE inhibitors (eg, lisinopril) cause efferent ___

Answer 45

vasodilation

Question 46

Compensatory mechanisms for hypovolemia include activation of the ___ & increased ___ release

Answer 46

RAAS ADH This results in increased renal sodium, chloride, water, and UREA reabsorption with increased potassium excretion.

Question 47

ATN.  Patients have increased serum creatinine, a blood urea nitrogen/serum creatinine ratio <20 (indicating intrinsic renal pathology), and __

Answer 47

oliguria.

Question 48

Benign prostatic hyperplasia (BPH) is associated with stromal and glandular growth in the periurethral and transitional zone of the prostate.  The hyperplastic cells are supported by the formation of new blood vessels, which may be friable.  Therefore, BPH is often associated with

Answer 48

microscopic or gross hematuria

Question 49

Crampy Flank Pain, Hematuria No fever or dysuria Most likely diagnosis?

Answer 49

Nephrolithiasis | most likely

Question 50

This patient with CVA tenderness, anuria and suprapubic fullness (suggesting a distended bladder) has acute

Answer 50

acute urinary retention (AUR)

Question 51

The most common cause of urinary retention is bladder outlet obstruction (urethral compression) due to

Answer 51

benign prostatic hyperplasia other causes: * anticholinergics, sympathomimetics * DM, Spinal Cord injury, stroke = neurogenic bladder

Question 52

Kidney stones usually cause disruption of the ureteral epithelium/dilation with resulting gross or microscopic hematuria due to the presence of free red blood cells (RBCs) with normal morphology

Answer 52

Urethrolithiasis

Question 53

Radiotherapy for prostate cancer may lead to urethral fibrosis/strictures and result in

Answer 53

obstructive uropathy

Question 54

__ stones are typically seen in patients with recurrent upper urinary infection by urease-producing organisms (eg, Proteus, Klebsiella). 

Answer 54

Struvite

Question 55

In, struvite stones: | Urinalysis shows hematuria and ___ urine pH.

Answer 55

elevated *Hydrolysis of urea yields ammonia, which alkalinizes the urine and facilitates precipitation of magnesium ammonium phosphate.

Question 56

Hyperparathyroidism is a common cause of recurrent ___ and is typically associated with mild hypercalcemia and hypophosphatemia.

Answer 56

kidney stones

Question 57

The kidneys compensate for metabolic acidosis by completely reabsorbing filtered bicarbonate (HCO3-) and excreting excess H+ in the urine.  Most of the excreted H+ is buffered by ___ and ammonium (NH4+)

Answer 57

phosphate (H2PO4-)

Question 58

Refeeding syndrome stimulates insulin secretion and drives ___- intracellularly in an effort to maintain cellular energy metabolism (eg, ATP production);

Answer 58

phosphorus

Question 59

ADH (Vasopressin) effects on ___ Plasma osmolality ___ Urine output ___ Urinary Na+ excretion

Answer 59

Lowers Lowers no change

Question 60

Anti-ADH (Vasopressin) V2 receptor effects on ___ Plasma osmolality ___ Urine output ___ Urinary Na+ excretion

Answer 60

increases increases no change

Question 61

Acute Opioid overdose patients have acute respiratory _____. | Serum bicarbonate is typically near normal in an acute setting

Answer 61

acidosis (low pH, high PaCO2) due to hypoventilation. 

Question 62

causes a primary respiratory alkalosis and a primary metabolic acidosis with an anion gap due to increased lactate production. 

Answer 62

Acute salicylate toxicity (Aspirin)

Question 63

Severe vomiting leads to ______ with a normal anion gap.

Answer 63

metabolic alkalosis

Question 64

Severe vomiting leads to metabolic alkalosis through: loss of H+ from the gastrointestinal tract Cl− depletion that induces renal ____ of HCO3− _____-induced intracellular shifting of H+. 

Answer 64

retention | hypokalemia

Question 65

___ acid-base disturbances can be recognized by inappropriate secondary compensation for one of the primary disturbances, indicating that an additional primary disturbance must be present

Answer 65

Mixed

Question 66

increased serum ___ causes intracellular shifting of HCO3− to maintain electronegative balance. This can be due to excess saline infusion, Diarrhea, or RTA type 2.

Answer 66

Cl−

Question 67

lithium reduces the ability of the kidneys to concentrate urine primarily by antagonizing the action of ___ in the collecting tubules and ducts.

Answer 67

vasopressin (antidiuretic hormone) *Lithium induced Diabetes insipidus

Question 68

Ototoxicity secondary to ____ usually occurs with higher dosages, pre-existing chronic renal disease, rapid intravenous administration, or when used in combination with other ototoxic agents (aminoglycosides, salicylates, and cisplatin).

Answer 68

loop diuretics

Question 69

Side effects of ___ include hypokalemia, hyponatremia and hypomagnesemia, and hyperCALCEMIA.

Answer 69

HCTZ

Question 70

a beta blocker with alpha blocking activity.  Major side effects include bradycardia, hypoglycemia, and fatigue.

Answer 70

Carvedilol

Question 71

used in certain patients with heart failure due to systolic dysfunction to help improve symptoms.  Toxicity can cause cardiac arrhythmias, hyperkalemia, nausea, vomiting and confusion.

Answer 71

Digoxin

Question 72

This patient's markedly elevated blood urea nitrogen (BUN) and serum creatinine in the setting of uncontrolled hypertension & volume overload suggest advanced

Answer 72

chronic kidney disease (CKD) | elevated anion gap metabolic acidosis

Question 73

``` Advanced chronic kidney disease (CKD) elevated anion gap metabolic acidosis effect on levels of: Bicarb PCO2 pH ```

Answer 73

Lowers all 3 values

Question 74

Severe diarrhea cause primary ____

Answer 74

metabolic acidosis | normal anion gap

Question 75

Hypokalemic, hypochloremic metabolic alkalosis | 4

Answer 75

Loop abuse Thiazide abuse Severe vomiting Gastric Suctioning from OD

Question 76

Beta agonist can cause transient

Answer 76

Hypokalemia due to intracellular shift from increases Na+/K+ ATPase activity

Question 77

Mannitol is freely filtered and not reabsorbed by the renal tubules, resulting in a ___ glomerular filtrate.

Answer 77

hyperosmolar | *lowers serum Na+

Question 78

Fibroblast growth factor 23 (FGF23) is secreted by osteocytes in response to _____ it suppresses alpha 1 hydroxylase & Renal Na+/Ph cotransporter in PCT

Answer 78

hyperphosphatemia

Question 79

also referred to as hyperchloremic acidosis because the decrease in serum HCO3− is compensated for by an increase in serum Cl− to maintain electronegative balance.

Answer 79

Normal anion gap Metabolic Acidosis

Question 80

renal tubular epithelial cells metabolize ___, generating ammonium that is excreted in the urine

Answer 80

glutamine to glutamate

Question 81

Carbonic anhydrase inhibitor (acetazolamide) effects on: ``` Na+ K+ Bicarb Calcium Uric acid ```

Answer 81

↓ Na+ ↓ K+ ↓ Bicarb — Calcium — Uric acid

Question 82

cocaine use causes ___kalemia

Answer 82

hypokalemia

Question 83

blocks binding of RANK-L to RANK and reduces formation of mature osteoclasts.

Answer 83

Osteoprotegerin

Question 84

Low ___ states cause osteoporosis by decreasing osteoprotegerin production, increasing RANK-L production, and increasing RANK expression in osteoclast precursors.

Answer 84

estrogen

Question 85

This patient has urinary frequency and urge incontinence in the setting of an overactive or spastic bladder due to the presence of an upper motor neuron lesion in the spinal cord.  Patients with ___ get this.

Answer 85

``` multiple sclerosis Bladder hypertonia (due to S2-S4 spinal cord lesion) ```

Question 86

___ can cause SIADH by increasing antidiuretic hormone (ADH) secretion and renal sensitivity to ADH.

Answer 86

Carbamazepine (causes ADH sensitivity– High urine osmolality: concentrated) *Lithium causes ADH resistance–Low urine osmolality: dilute)

Question 87

1. ____ for deficient (CDI) ADH – Polyuria 2. ____ for (SIADH) high ADH – Hyponatremia 3. ____ for (NDI) high ADH – Polyuria

Answer 87

1. Desmopressin 2. Salt tablets 3. Hydrochlorothiazide

Question 88

1. Polyuria, hyponatremia and high urine specific gravity. 2. Polyuria, Low urine specific gravity. 3. Polyuria, Low urine specific gravity.

Answer 88

(SIADH) high ADH (NDI) high ADH (CDI) low ADH

Question 89

Urinary urge incontinence is treated with an

Answer 89

antimuscarinic drug (targeting M3 receptors)

Question 90

Vasopressin/Desmopressin/ ADH cause decreased ___ clearance

Answer 90

urea

Question 91

Following desmopressin administration during the water deprivation test, urine osmolality increases to normal levels in

Answer 91

central DI

Question 92

Following desmopressin administration during the water deprivation test, urine osmolality does NOT increase much in

Answer 92

partial nephrogenic DI *none in complete

Question 93

ADH works on ___ section of CT

Answer 93

Medullary