Clinical Renal Module Self Test Review Questions: Warren Kupin MD, FACP

Clinical Renal Module
Self Test Review Questions
Warren Kupin MD, FACP

Table of Contents
The
The Kidney
Kidney Acid
Acid Base
Base Disorders
Disorders
Acute
Acute Kidney
Kidney Injury
Injury
in
in Pregnancy
Pregnancy (General)
(General)
Chronic
Chronic Kidney
Kidney Herbal
Herbal and
and Heavy
Heavy Approach
Approach to
to Hematuria
Hematuria
Disease
Disease Metal
Metal Toxicity
Toxicity and
and Proteinuria
Proteinuria
Dialysis
Dialysis Pharmacology
Pharmacology UTI/Pyelonephritis
UTI/Pyelonephritis
Sodium
Sodium and
and Immunopathogenesis
Immunopathogenesis
Transplantation
Transplantation
Water
Water Disorders
Disorders of
of Glomerular
Glomerular Disease
Disease
Primary
Primary
Hepatorenal
Hepatorenal Syndrome
Syndrome Kidney
Kidney Stones
Stones
Glomerulonephritis
Glomerulonephritis
Table of Contents
Secondary
Secondary
Interstitial
Interstitial Nephritis
Nephritis Erectile
Erectile Dysfunction
Dysfunction
Hypertension
Hypertension
Viral
Viral Pathogenesis/
Pathogenesis/
Prostate
Prostate Cancer
Cancer
Glomerulonephritis Treatment
Treatment of
of Hypertension
Hypertension
Glomerulonephritis
Benign
Benign Prostatic
Prostatic Congenital
Congenital
Light
Light Chain
Chain Disease
Disease
Hypertrophy
Hypertrophy Renal
Renal Disease
Disease
Hypertension
Hypertension :: Urogenital
Urogenital tract
tract
Voiding
Voiding Dysfunction
Dysfunction
Epidemiology
Epidemiology Pathology
Pathology
Clinical
Clinical Anion
Anion gap
gap
Renal
Renal Masses
Masses Pathology of HTN
Metabolic
Metabolic Acidosis
Acidosis
Table of Contents
Clinical
Clinical
Metabolic
Metabolic Alkalosis
Alkalosis
Renal
Renal Tubular
Tubular Acidosis
Acidosis
Incorrect !
Try Again !
Correct !
Back to the Question

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AKI
• Which of these factors is not commonly used to
estimate renal function ?
A Sex
B Serum Creatinine
C Etiology of renal disease
D Weight
E Age
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AKI
• The best determinant of acute renal failure is the ….. ?
A Presence of granular casts in the urine
B Presence of hyaline casts in the urine
C Presence of white blood cell casts in the urine
D Presence of red blood cell casts in the urine
E Presence of waxy casts in the urine

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AKI
• Which of these conditions does not change the normal
range of the serum creatinine ?
A Pediatric patient
B Cirrhosis
C Pregnancy
D Elderly patient
E Obese patient
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AKI
• Which of these factors is the most important
determinant of chronic vs. acute renal disease ?
A Anemia
B Elevated phosphorous
C Acidosis
D Kidney size
E Low calcium
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AKI
• During renal autoregulation which of these factors does not
maintain intraglomerular pressure at a time of volume depletion ?
A Afferent arteriole dilation
B Efferent arteriole constriction
C Increased Angiotensin II
D Increased PGE2
E Increased sympathetic nerve activity

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AKI
• All of these findings indicate pre-renal azotemia except
which one ?
A FENA < 1%
B Urine sodium < 20 meq/l
C BUN / Cr > 20:1
D Urine specific gravity < 1.010
E Bland urinary sediment

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AKI
• What is the influence of the use of angiotensin
inhibitors/angiotensin blockers or NSAIDs on the renal
autoregulation curve ?
A Shifts the curve to the right
B Shifts the curve to the left
C No effect
D Shifts the curve upward
E Shifts the curve downward

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AKI
• The most common cause of AKI in the outpatient
setting is ……… ?
A Glomerulonephritis
B Diabetes
C Obstructive uropathy
D Pre-renal azotemia
E ATN
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AKI
• The most common cause of AKI in the inpatient setting
is ……… ?
A Glomerulonephritis
B Diabetes
C Obstructive uropathy
D Pre-renal azotemia
E ATN
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AKI
• Why is the outer medulla the most sensitive site for
ischemia ?
A Least amount of blood flow
B Highest metabolic activity
C Highest utilization of delivered oxygen
D Main site of action of angiotensin II
E Highest concentration of tubules

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AKI
• A 25 year male just finished running the miami marathon and he
collapses at the finish line – in the ER he had a foley catheter
placed and minimal amounts of urine were noted.
• He had the following urine studies done

– Urine creatinine 40 mg/dl
– Serum creatinine 2.0 mg/dl
– Urine sodium 50 meq/L
– Serum sodium 138 meq/L
– Specific gravity 1.010
– Urine potassium 60 meq/L
– Serum potassium 6.0 meq/L
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AKI
• What is the FENA ?
A 0.7 %
B 1.8%
C 3.0%
D 1.2%
E 2.7%
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AKI
• The specific gravity of 1.010 in this case means …………
A A dilute urine
B A concentrated urine
C It has no meaning
D The presence of pre-renal azotemia
E The presence of ATN

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AKI
• Life threatening Hyperkalemia should be treated by all
of the following interventions except ……….
A IV calcium
B Hemodialysis
C IV insulin and dextrose
D B-2 agonists
E K+ binding oral resins

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AKI
• Potassium affects which part of the action potential?
A Resting Membrane potential
B Threshold potential
C Peak level of depolaritzation
D Rate of depolarization
E No effect on the action potential

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AKI
• Calcium affects which part of the action potential?
A Resting Membrane potential
B Threshold potential
C Peak level of depolaritzation
D Rate of depolarization
E No effect on the action potential

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AKI
• The 4 phases of ATN typically in order are ……………
A B C D E
Initiating Oliguric Polyuric Initiating Injury
Polyuric Polyuric Oliguric Oliguric ATN
Oliguric Recovery Maintenance Polyuric Polyuric
Recovery Maintenance Recovery Recovery Recovery

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AKI
• On physical examination which of these findings does
not suggest volume depletion ?
A Dry mucous membranes
B HTN
C Rapid heart rate
D Poor skin turgor
E Absent jugular venous distension

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AKI
• Your patient has both granular casts, renal tubular cells and waxy
casts on the urinalysis – what does this mean ?
A Acute glomerulonephritis
B CKD
C Pre-renal azotemia
D AKI and CKD
E ATN
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AKI
• You are a primary care physician and take care of a 75 year woman. Her routine
laboratory screen shows a creatinine of 1.4 mg/dl (normal lab range < 1.5 mg/dl)
with a BUN of 12 mg/dl ( normal lab range < 20 mg/dl). What is your assessment ?
A Normal results – repeat in 1 year
B Abnormal results – possible pre-renal azotemia – increase hydration
C Normal results – repeat in 6 months
D Abnormal results – patient has CKD
Abnormal results – patient has a low GFR and followup testing is needed
E
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AKI
• The most common cause of death in ATN is …… ?
A Uremia
B Hyperkalemia
C Infection
D GI bleeding
E Stroke
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AKI
• Your patient has had gastroenteritis for the past few
days and has the following test results – what is the
most likely cause of kidney failure (choices on the next
page?
Medication Lab test

Class
Creatinine 2.5 Urinalysis Hyaline
Beta blocker casts
Calcium channel BUN 60
blocker FENA 2.7%
Loop Diuretic FEurea 20%
Calcium vitamins Calcium 8.0
phophorous 7.5 Urine Na 40

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AKI – Case Continued
A Pre- renal azotemia
B ATN
C CKD
D ATN superimposed on CKD
E Pre-renal azotemia superimposed on CKD

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AKI
• An ACEI or ARB is contraindicated in all these
situations except
A Pregnancy
B Hyperkalemia
C AKI
D CKD
E ACEI or ARB are contraindicated in all the above situations

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AKI
• A patient on an NSAID (nonsteroidal anti-inflammatory
drug) would have which of the following findings ?
Renin level Angiotensin II Aldosterone Afferent
Level level arteriole
low decreased decreased constricted
A
normal decreased normal dilated
B
high increased increased No change
C
low decreased normal constricted
D
normal normal decreased No change
E
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AKI
• Which patient has the worst kidney function ?

Diagnosis Creatinine Gender Age
Routine 1.2 male 25
A physical
Diabetes 2.0 female 25
B Cirrhosis 3.0 female 50
C ATN 3.0 male 50
Pre-renal 3.0 female 50
D Azotemia
E
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CKD
• When talking about the progression of chronic kidney
disease – which of these statements is true ?
A The same kidney disease in 2 different patients will progress at the same rate
The use of ACEI/ARB is only proven to be effective in diabetic renal disease

B
ACEI/ARB work by dilating the afferent arteriole and increasing
C intraglomerular pressure ot normal to maintain GFR
Angiotensin II predominantly vasoconstricts the afferent arteriole leading to
D a reduction in renal perfusion
The reduction of proteinuria by ACEI/ARB will actually reduce the rate of
E progression independent of blood pressure
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CKD
• Which maneuver does not slow the rate of progression
of renal disease ?
A Controlling blood pressure < 130/80
Reducing proteinuria
B
C Adding an ACEI or ARB
D Maintain a standard protein intake of 1 gm/kg/day
E Treat hyperlipidemia
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CKD
• You have a patient with Diabetic renal disease (creatinine 1.5 mg/dl) and
nephrotic proteinuria – you start an ACEI – 2 weeks later the patient
returns and the creatinine is now 4.1 mg/dl – What is your diagnosis ?
A Spurious increase in creatinine due to impaired tubular secretion of creatinine
Acute allergic interstitial nephritis from the ACEI

B
C ATN due to direct tubular injury from the ACEI
D Bilateral renal artery stenosis and acute renal failure due to the ACEI
E Acute bilateral renal vein thrombosis

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CKD
• Which of these hormones is not made in the kidney ?
A Erythropoietin
25-OH Vitamin D
B
C Renin
D Angiotensin II
E All of the above hormones are made in the kidney

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CKD
• Anemia in chronic kidney disease is associated with all
the following except ?
A Normochromic normocytic
The development of LVH

B
C Begins to develop with a creatinine > 2.5 mg/dl
D Due to erythropoietin deficiency
E Correlated with higher mortlaity

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CKD
• The primary adaptation in the nephron due to a loss of
renal mass is hyperplasia ?
A True
False
B
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CKD
• Anemia is a late complication of CKD usually
occurring in Stage 4 CKD ?
A True
False
B
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CKD
• Which describes the normal adaptation to CKD?
Intraglomerular Afferent Efferent Single
pressure Arteriole Arteriole Nephron GFR
Increased Dilated Dilated No change
A Decreased Dilated No change Decreased
B Increased Constricte Constricte Increased
d d
C No change Constricte Dilated Decreased
d
D Increased Dilated Constricte Increased
d
E
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CKD
• Which of these does not stimulate PTH secretion in
patients with CKD ?
A Hyperphosphatemia
Hypocalcemia
B
C 1.25 Vitamin D deficiency
D FGF-23
E All of the above stimulate PTH secretion

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CKD
• Which of these statements is true about renal
ammoniagenesis in CKD ?
A Increased activity which is beneficial in the long run to decrease acidosis
Decreased due to loss of nephron mass resulting in acidosis

B
Increased activity that is actually counterproductive and leads to interstitial
C inflammation and fibrosis
D No change occurs in CKD and acidosis progressively develops
Increased activity in Stage 3 but it gradually decreases with Stage 5 disease

E
resulting in systemic acidosis
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CKD
– Which of these statements is not true about
CKD/Uremia ?
A The leading cause of death in CKD patients is from cardiovascular disease
Pericarditis is a known complication of uremia

B
There is no direct correlation between the level of BUN and uremic
C symptoms
D The serum phosphorous level directly predicts mortality
E Once a patient reaches Stage 4 CKD, 80% go on to begin dialysis

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CKD
– After a living person donates a kidney to a family member or
friend – what happens to the other kidney ?
It stays completely the same and the GFR reflects the loss of 50% of the
A total renal mass
It increases in size due to an increase in the number of glomeruli from
B compensatory hyperfiltration
C The GFR returns to 70% of normal due to compensatory hyperfiltration
Compensatory hyperfiltration involves increased intraglomerular pressure

D by vasconstriction of the efferent arteriole
The degree of glomerular hypertrophy is strictly related to the amount of
E renal tissue damaged or removed and is not influenced by any other factors
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CKD
– Which of these changes is not typical of the renal
changes in CKD ?
A Decreased FENA
B Reduced total renal ammoniagenesis
C Impaired concentrating ability
Impaired diluting ability

D
E Increased FEK (fractional excretion of potassium)

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CKD
– Which of these factors are risk factors for
progression of CKD ?
A High protein diet
B Proteinuria
C Obesity
HTN
D
E All of the above

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CKD
– What is the effect of aging on the kidney ?
A Renal function remains stable throughout life with a GFR > 90 cc/min
B Most patients at 80 years will require dialysis
C There is a progressive decline in renal function that begins after age 65
D There is a progressive decline in renal function that begins after age 30
E Most patients are aware of the fact that they have CKD
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Transplantation
– All of the following are true about transplantation
except ?
A Increases quality of life compared to dialysis
B Increases survival compared to dialysis
C Not all ESRD patients are candidates for transplantation
It is better to go on dialysis first and when stable then proceed to

D transplantation
E Kidneys are allocated according to the most critically ill first

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Dialysis
• Which of the following is not an indication for

dialysis ?
A Hyperkalemia
B Intractable Fluid overload
C Severe Metabolic Acidosis
D Severe Hyperparathyroidism
E Uremia
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Dialysis
– Which of these statements about dialysis is true ?
A Hemodialysis patients have a better survival compared to peritoneal dialysis
B Hemodialysis is usually performed daily while peritoneal dialysis is 3X /week
C Hemodialysis is started usually when the GFR is < 10 cc/min
It is better to go on dialysis first and when stable then proceed to

D transplantation
E Kidneys are allocated according to the most critically ill first

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Dialysis
– Which of these statements about how dialysis works
is true ?
A Hemodialysis uses convective (conductive) techniques primarily for waste removal
B Peritoneal dialysis uses convective techniques primarily for waste removal
Peritoneal dialysis requires at least 2 liters of fluid to be infused into the retroperitoneal
C space 4 X/day or overnight
Highly protein bound molecules are equally well removed by hemodialysis and peritoneal
D dialysis
The dialysate that is used for hemodialysis is isotonic with plasma but has
E
no BUN or creatinine
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• The development of hepatorenal syndrome is associated with
which one of these clinical findings ?
Peripheral Splanchnic Renal Cadiac

vascular vascular vascular Output
resistance resistance resistance
A
B
C
D
E
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• The serum creatinine as a marker for renal function in patients
with cirrhosis is ………… ?
A A reliable marker for renal function
B Not a good marker because it is elevated by liver disease
C Not a good marker because it is decreased by ascites

Not a good marker because it is not absorbed well from the diet in
D patients with cirrhosis
E Not a good marker because of muscle wasting in cirrhosis

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• Which of these does not result in vasoconstriction in the
kidney ?
A PGE2
B Angiotensin II
C Thromboxane
D Sympathetic nervous system stimulation
E Decrease in nitric oxide

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• When making the diagnosis of HRS – which one of
these criteria does not belong ?
A Presence of cirrhosis without ascites
B Lack of improvement after IV albumin
C Absence of shock or nephrotoxins
D Serum creatinine > 1.5 mg/dl
E Proteinuria < 500 mg/day

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• Hepatorenal Syndrome can be treated by which of the
following except …….?
A Infusion of vasopressin analogues
B TIPS
C Dopamine and albumin infusion
D Midodrine and Octrotide
E Liver Transplantation
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• What is the difference in Type I vs. Type II HRS ?
A Type I HRS does not respond to any treatment
B The renal failure in Type II is faster in onset compared to Type I
C Type I requires a kidney biopsy for diagnosis
D Type II HRS is only associated with acute viral hepatitis
E Type I HRS has a higher mortality

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• Which one of these factors is not a precipitating event
that can cause the Hepatorenal Syndrome ?
A Blood transfusion
B Upper GI bleed
C Peritonitis
D Large volume paracentesis
E Hospital admission
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• The urinalysis in HRS would show ……. ?
A Granular casts
B Dysmorphic red blood cells
C Waxy casts
D Bland sediment
E Renal tubular cells

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• Which one of these findings would not be compatible
with a diagnosis of hepatorenal syndrome ?
A FENA < 1%
B Granular casts in the urine
C BUN/Cr ratio > 20:1
D Urine sodium < 20 meq/L
E Urine specific gravity > 1.015

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The Kidney in Pregnancy

• During a normal pregnancy which one of these
processes occurs in the kidneys
A The kidneys decrease in size by 1 – 1.5 cm
B Increased peripheral vascular resistance
C An increase in Blood pressure in the first trimester
D Increase in GFR throughout the pregnancy
E Decrease in renal blood flow as blood is shunted to the placenta

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• In a normal pregnancy which of these biochemical changes
is correct ?
Urine protein Serum Uric Hematocrit Serum

(24 hours) Acid Sodium
< 150 mg No change normal Normal
A
< 300 mg decreased decreased decreased
B
< 300 mg increased increased Normal
C
< 500 mg decreased decreased decreased
D
< 300 mg decreased normal decreased
E
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• In pre-eclampsia which of these biochemical changes is
correct ?
Urine protein Serum Uric Hematocrit Platelet Count

(24 hours) Acid
> 500 mg No change decreased Normal
A
> 150 mg decreased No change Low
B
> 300 mg increased increased High
C
> 500 mg decreased decreased Normal
D
> 300 mg increased increased Low
E
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• Gestational hypertension is characterized by all the
following except ?
A Development in the first trimester
B No significant proteinuria
C Return to normal by 3 months posttransplant
D Associated with a higher risk of fetal loss
E Classified as a BP > 140 mmHg systolic or 90 mmHg diastolic

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• If a woman is diagnosed with gestational Diabetes
Insipidus – this means ?
A She has a higher risk of diabetes mellitus later in life
B She has hyponatremia from excess ADH production
C She has hypernatremia from placental production of vasopressinase
D She has hyponatremia from placental production of vasopressinase
E She has a high risk for the osmotic demyelinating syndrome

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• What is the most typical acid base abnormality in
pregnancy?
A Anion gap metabolic acidosis
B Non- anion gap metabolic acidosis
C Respiratory acidosis
D Respiratory alkalosis
E There is no typical acid base disorder of pregnancy

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• Pre-eclampsia is characterized by all the following
except ?
A Leading cause of maternal and fetal mortality
B Primarily occurs in first pregnancies

Classified as a BP > 140 mmHg systolic or 90 mmHg diastolic and
C proteinuria > 3 gm/24 hours
D Often associated with multiple gestations
E Improvement of symptoms 7-10 days after delivery

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• A 24 year old pregnant woman wanted to know the sex
of her baby at 20 weeks- you get an ultrasound and the
report says 1) it’s a boy and 2) the kidneys have
hydronephrosis bilaterally – what do you do ?
A Call for an emergency urology consult due to obstruction
B Order an intravenous pyelogram to see where the obstruction is
C Repeat the test in one week to see if it improves with hydration
D Look for kidney stones with a CAT scan
E Check the creatinine and if it is normal no further treatment is needed

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• Pre eclampsia is characterized by which of the
following mechanisms ?
A Autoantibodies produced against the placenta
B Diffuse vasculitis
C Immune complex deposition in the kidneys
D Generalized endothelial dysfunction

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Herbal and Heavy Metal Toxicity
• Which of these statements is not true about herbal therapy

in the U.S. ?
A Herbs are plant parts used for medicinal purposes

The FDA (Food and Drug Administration) tests and approves all
B herbal products sold in the U.S.
Herbal therapy is a part of a group of therapies called alternative
C and complementary medicine
Herbal therapy is used mostly by upper socio-economic class, well
D educated patients
E Most patients do not tell their doctors they use herbal products
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• Chinese herb nephropathy results from……. ?
A Contamination of the herbs with lead and cadmium
B An allergic response in some patients to the herb Stephania
C Obstruction of the kidney due to oxalate kidney stones
D Glomerular injury from the herb Glycerrhiza Glabrata
E Interstitial and tubular injury from aristolochic acid

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• A major long term complication of Chinese herb

nephropathy is……… ?
A Renal cell carcinoma
B Osteoporosis
C Kidney stones
D Bladder cancer
E Neurologic damage - Dementia

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Herbal and Heavy

Metal Toxicity
• How does each agent affect the activity of the hepatic
P450 enzyme system ?
St. John’s Grapefruit
Wort Juice
decreased increased
A
No change decreased
B
Increased No change
C
decreased decreased
D
Increased decreased
E
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• Your patient with kidney failure has been taking Noni juice for a
vitamin supplement – what abnormality would you might find ?
A Hyperkalemia
B Oxalate stones
C Hypertension
D Hypokalemia
E None – it is perfectly safe

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• What is the renal lesion caused by lead and cadmium toxicity?
A FSGS
B Acute interstitial nephritis
C Membranous nephropathy
D Chronic interstitial nephritis
E ATN
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• Which of these toxicities can be treated by chelation therapy?
A Lead toxicity
B Ephedra toxicity
C Aristolochic acid toxicity
D Cadmium toxicity
E Glyzyrrhizic acid toxicity

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• Your patient takes all types of herbal therapy over many years. He
gets them from all over the world. He somes to you for an
evaluation with the following history and lab results – what is his
diagnosis
• Past medical history
A Cadmium toxicity
– Hypertension
– Gout
B Ephedra toxicity
– High cholesterol
Creatinine 2.1 C Aristolochic acid toxicity

Hgb 9.8
Potassium 5.0 D Lead toxicity
Urinalysis Waxy casts
E Glyzerrhizic acid toxicity
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• How does licorice cause toxicity?
Contains an aldosterone like analogue that directly binds to the

A aldosterone receptor causing the syndrome called AME
It precipitates in the tubules as crystals and may cause kidney stones
B and renal failure
Stimulates the enzyme 11-beta hydroxydehydrogenase which
C degrades cortisol and leads to overactive aldosterone activity
Inhibits the enzyme 11-beta hydroxydehydrogenase which degrades
D cortisol and leads to overactive aldosterone receptor activation
Inhibits the enzyme 11-beta hydroxydehydrogenase which degrades
E aldosterone and leads to overactive aldosterone receptor activation
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Pharmacology and Renal Disease

• What part of the kidney is most important for drug metabolism ?
A Glomerulus
B Proximal tubule
C Thick ascending limb of Henle
D Distal tubule
E Collecting duct
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• CKD affects the absorption of drugs by all the following mechanisms
except …….. ?
A Delayed gastric emptying
B Decreased activity of p-glycoprotein
C Decreased gastric pH
D Decreased activity of hepatic cytochrome p-450 system
E Binding with co-administered drugs for CKD

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• All of these characteristics of a drug may make it difficult to remove by

dialysis except ………?
A High protein binding
B High Vd (volume of distribution)
C Large molecular weight
D Hydrophilic
E High degree of receptor binding

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• Phenytoin is being prescribed for a dialysis patient due to seizures – what do

you do with the dosing of this drug
Keep it the same as in a normal patient because the drug is liver metabolized with no
A active metabolites
Increase the dose due to enhanced activity of the p-450 system in CKD patients
B
Decrease the dose due to enhanced absorption from a decrease in p-glycoprotein activity
C
Increase the dose due to increased dialyzer clearance during the dialysis
D procedure
E Decrease the dose due to reduced albumin binding in CKD

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• Take a look at the graph below describing a drug and its pharmacokinetics –
answer the questions on the next slide based on this graph -
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A This drug has zero order kinetics typical of most drugs
This drug has zero order kinetics which is unusual for most drugs
B
C This drug has first order kinetics typical of most drugs
This drug has first order kinetics which is unusual for most drugs
D
E I can not tell the kinetics from this graph

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What does first pass metabolism of a drug refer to ?
A A drug that gets completely filtered and excreted by the kidneys after its first filtration
The process of removal of a drug by the liver or kidneys after IV infusion of a set dose
B
C The degradation of a drug by the intestines after IV infusion
The degradation of a drug by both the intestines and the liver after oral intake
D
E The degradation of a drug by both the kidneys and the liver after oral intake
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How does CKD affect loop diuretics ?
A Increased effectiveness due to less protein binding
Decreased effectiveness due to increased protein binding

B
C Increased effectiveness due to enhanced tubular sensitivity
Decreased effectiveness due to increased tubular excretion

D
E Decreased effectiveness due to decreased tubular secretion

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• Your patient has Diabetes – which of these statements is true about insulin
therapy and CKD ?
Insulin is a large molecule that is not filtered due to its size and it builds up in the blood
A with CKD
Insulin is freely filtered and secreted by the kidney so it builds up in the blood with
B CKD
Insulin is liver metabolized so no changes are needed

C
Insulin is metabolized by the proximal tubules and it builds up in the blood with
D CKD
E Insulin is protein bound and is not affected by CKD

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How is Narcotic pain medication like demerol affected by CKD?
A Increased metabolism due to activation of the cytochrome P-450 system in the liver
Impaired excretion of the parent drug by the kidneys

B
C Impaired metabolism of the parent drug by the liver
Increased absorption of the drug orally due to increased gastric pH

D
E Impaired excretion of bioactive metabolites by the kidneys

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• During a drug poisoning – what is the role of urine pH – which is true ?
It is important to manipulate the urine pH in order to convert the drug to its non-ionic
A form in the urine to increase excretion
You alkalinize the urine for a weak acid and acidify the urine for a weak base in order
B to enhance excretion
Acidification of the urine is one of the treatments of choice for an aspirin overdose
C
Urine pH will affect protein binding of the drug in the urine and alkalinization
D will reduce this binding and enhance excretion
E There is no effect of urine ph on drug excretion by the kidneys

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Sodium and Water Disorders
• For the cellular response to hyponatremia, which statement

is correct -
The first adaptive response is to expel sodium and then later reduce the
A concentration of myoinositol
The first adaptive response is to expel myoinositol and then later reduce the
B concentration of potassium
The first adaptive response is to expel potassium and then later reduce the
C concentration of sodium
The first adaptive response is to expel potassium and then later reduce the
D concentration of myoinositol
The first adaptive response is to expel sodium and then later reduce the
E concentration of potassium
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• Overly rapid correction of the sodium concentration in

patients with hyponatremia is defined as -
A Increase in Na > 25 meq/24 hours
Increase in Na to a level of > 140 meq/L in 24 hours

B
C Increase in Na > 12 meq/L in 24 hours
Increase in Na to a level > 120 meq/L in 24 hours

D
E Increase in Na > 6 meq/L in 24 hours

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• Overly rapid correction of the sodium concentration in patients
with hyponatremia can result in which neurologic syndrome
A Progressive multifocal leukoencephalopathy
Osmotic demyelinating syndrome

B
C Alzheimer’s Disease
Parkinson’s disease
D
E Amytrophic lateral sclerosis

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• A patient comes to the ER with Na 125

the following lab results –
• On the next slide answer the K 5.5
question based on these results
- Cl 100
HCO3 15
BUN 120
Cr 8.2
Glucose 540
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• Which description of this patient is correct
A Hypotonic Hypo-osmolar hyponatremia
Isotonic Hyperosmolar hyponatremia

B
C Hypertonic Hyperosmolar hyponatremia
Hypertonic Hypo-osmolar hyponatremia

D
E Hypotonic Hyperosmolar hyponatremia

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• For the same patient in the previous slide – what are correct values for
the tonicity and osmolarity
Tonicity Osmolarity
320 280
A
280 320
B
290 310
C
280 250
D
290 320
E
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• In a patient with SIADH, which of these urine osmolarity values
would not be consistent with that diagnosis ?
A 1.010
1.015
B
C 1.020
1.025
D
E 1.030
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• Which of these events is not associated with SIADH ?
A Lung cancer
Antipsychotic use
B
C Oral hypoglycemic agents
Lithium use
D
E Surgery / pain
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• Which of these statements best describes the body’s ADH
response to increased osmolarity and decreased volume ?
A Both stimulate ADH production equally well
The ADH response to volume depletion is more powerful than similar changes
B in osmolarity
The ADH response to increased osmolarity is earlier in onset and more
C powerful than changes in volume
D The body will always protect osmolarity over volume with greater ADH production
The body will always protect volume over osmolarity with a greater ADH
E production
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• A patient has CHF and comes to the hospital with the following
findings
BP 200/100 P 80
Lungs – bilateral rales
Heart – S3 gallop
2+ edema of the lower extremity
Na 130
K 3.2
Cl 83 Questions on the next 5 slides
HCO3 35
BUN 40
Cr 1.5
Glucose 180
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• What type of disorder does this patient have ?
A Water balance disorder only
Sodium balance disorder only

B
C Water and Sodium balance disorders
D ECF disorder only
E Na concentration disorder only

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• For the same patient in the previous discussion what is the acid
base disorder ?
A Metabolic alkalosis
Metabolic acidosis
B
D Respiratory alkalosis
E I do not have enough information

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• For the same patient in the previous discussion what is the
tonicity ?
A 260 mosm/L
270 mosm/L
B
C 283 mosm/L
D 300 mosm/L
E 257 mosm/L
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• For the same patient which description best fits the clinical findings
FENA Urine Specific Aldosterone
Gravity levels
<1% 1.010 Low

A
<1% 1.015 Normal
B
> 3% 1.005 High
C
>3% 1.015 Low
D
<1% 1.015 High
E
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• Which description best fits with a case of osmotic diuresis?
Serum Sodium Serum Glucose Urine
Osmolality
154 90 50
A
130 600 500
B
145 600 600
C
140 100 250
D
140 100 300
E
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• You order D5 .45NS at 100 cc/hr and after 10 hours the patient has now received
1 liter of fluid – which description best fits where the fluid went in your patient?
Intracellular Intravascular Interstitial
space
667 166 500
A
333.5 90 166
B
667 600 375
C
333.5 166 501
D
250 100 251
E
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UTI / Pyelonephritis
• Which of these factors is not a typical defense mechanism for
preventing urinary infections ?
A Prostatic secretions
Urine composition which is antibacterial

B
C Expulsion of bacteria with normal urination
The highly alkaline environment of the vagina

D
E Rapid turnover of bladder cells through apoptosis

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• Which demographic group has the highest incidence of UTIs ?
A Pre-school girls
Pre-school boys
B
C Adult woman 25 – 60 years old
Adolescent and young adult woman 15 – 25 years old

D
E Elderly woman > 60 years old

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• Which of these are not typical features of a UTI ?
A Hematuria
Dysuria
B
C Frequency
Suprapubic pain
D
E All of the above are classic features of a UTI

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• Which of these laboratory tests is not commonly seen with a
routine UTI ?
A Positive leukocyte esterase test
Positive culture > 105 organisms

B
C Positive nitrite in the urine
Positive Dip-stick for hematuria

D
E Sterile pyuria
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• Please answer the following as True or False ?
A positive urine culture is defined as > 105 organisms T F

Fimbrae on the transitional cells prevent bacteria from
Attaching and prevent UTIs
T F
Asymptomatic bacteriuria should be treated in a
pregnant woman but not most other situations
T F
Polymicrobial bacteriuria is indicative of a very severe
infection and requires intensive antibiotic therapy T F
The most common cause of a UTI is e. Coli and the most common
T F
Cause of Pyelonephritis is Klebsiella
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Kidney Stones
• The most common stone type in the world is ………………
A Calcium phosphate
Calcium oxalate
B
C Uric acid
Magnesium ammonium phosphate

D
E Cystine
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Kidney Stones
• Which of these statements about stone disease is not

correct ?
Hypercalciuria is the most important risk factor for stone disease and should be treated
A even if patients have not yet had a stone
Hypocitraturia is a major risk factor for calcium oxalate stone disease

B
C Urease producing organisms result in the development of struvite stones
Cystine stones are usually bilateral

D
E Uric acid crystals are often found as a nidus for calcium oxalate stones
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Kidney Stones
• Which of these statements about stone disease is correct ?
Type of Stone Urine pH Radiology
Finding
Uric Acid 5.5 Radio-opaque
A
Calcium Phosphate 7.0 Radio-opaque
B
Magnesium 5.5 Staghorn
Ammonium
Phosphate
C
Cystine 7.0 Radio-opaque
D Calcium Oxalate 5.5 Radiolucent
E
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Kidney Stones
• What does the term epitaxy or heterogeneous nucleation

mean ?
A It means stones form attached to a foreign body like the renal papillae
It describes the growth of calcium and oxalate crystals as they initially form in
B the urine
It describes the interaction of the inhibitors citrate and magnesium with the
C promotors of stones : calcium and oxalate
It describes the growth of calcium and oxalate on top of a uric acid nucleus
D
E It describes the precipitation of dibasic amino acids to form stones

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Kidney Stones
• Which of these is not a valid treatment for calcium stone

disease ?
A Increase urine volume > 2 L /day
Reduce vitamin C intake

B
C Reduce purine intake
Reduce calcium intake

D
E Increase citrus product intake

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Kidney Stones
• Which of these is not a valid treatment for calcium stone

disease ?
A Increase urine volume > 2 L /day
Reduce vitamin C intake

B
C Reduce purine intake
Reduce calcium intake

D
E Increase citrus product intake

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Kidney Stones
• Which of these is statements is not true about patients with

cystinuria ?
A It is a disorder of dibasic amino acids
Treatment is focused on alkalinizing the urine

B
C Stones are usually solitary and occur in the 4th decade
The stones are radio-opaque

D
Can be treated with drugs like d-penicillamine which form a sulfur bond with
E
cystine and increase its urinary excretion
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Kidney Stones
• Which of these is statements is not true about patients with

struvite stones ?
The presence of urease producing organisms is essential in order to release phosphorous
A from urea and form stones
Common in patients with spinal cord injuries and long term indwelling
B urinary catheters
C May cause staghorn stones and shut down renal function
Consist of magnesium / ammonium / calcium and phosphate

D
Form in an alkaline urine
E
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Kidney Stones
• Which of these statements about calcium oxalate stone

disease is not correct ?
A After forming their first calcium oxalate stone most people will form another stone
Calcium oxalate stone disease occurs primarily among Caucasion middle age men
B
C Most people form one stone at a time for each episode
Unsuspected Hyperparathyroidism is a significant cause of calcium stone disease

D
E Vitamin C is a major source of oxalate

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Kidney Stones
• Which of these tests is not required for a patient with

calcium oxalate stone disease ?
A Ultrasound of the kidneys
B Blood calcium / phosphorous levels
C Urinalysis / urine culture
D 24 hour urine for calcium / oxalate
E All of the above are part of the standard workup of stone disease
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Acid Base Disorders
• All of the following are causes of a high anion gap except
A Lactic acidosis
B Hypercalcemia
C Diabetic ketoacidosis
D Uremia
E Ethylene glycol poisoning

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Acid Base Disorders
• All of the following are causes of a low anion gap except
A Lithium
B Hypercalcemia
C Hyperalbuminemia
D Multiple Myeloma (high immunoglobulins)
E Hypermagnesemia
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Acid Base Disorders

• All of the following are correct compensation changes except -
Primary Acid-Base Serum pCO2

Disorder HCO3
Metabolic Acidosis decreased decreased
A
Respiratory decreased decreased
Alkalosis
B Metabolic Alkalosis increased decreased
C Respiratory Acidosis increased increased
D Metabolic Acidosis decreased increased

with combined
Respiratory Acidosis
E
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Acid Base Disorders
• Name the acid base disorder -
Na 138 meq/L pH 7.30

K 4.0 meq/L pC02 30 mmHg
Cl 100 meq/L HCO3 15 meq/L
HCO3 15 meq/L
BUN 30 mg/dl
Cr 3.0 mg/dl
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Acid Base Disorders

Choice Primary Acid-Base Secondary Acid Base Choice Primary Acid-Base Secondary Acid
Disorder Disorder Disorder Base Disorder
Metabolic Acidosis None Respiratory Acidosis Metabolic Alkalosis
A H
Respiratory Acidosis None Respiratory Acidosis Metabolic Acidosis
B I
Metabolic Alkalosis None Metabolic Alkalosis Metabolic Acidosis
C J
Respiratory Alkalosis None Metabolic Alkalosis Respiratory
Alkalosis
D K
Metabolic Acidosis Respiratory Metabolic Acidosis Metabolic Alkalosis
Alkalosis
E L
Metabolic Acidosis Respiratory Metabolic Alkalosis Respiratory
Alkalosis Acidosis
F L
Metabolic Acidosis Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis
G L
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Acid Base Disorders
• Name the acid base disorder – it has been present for over 5 days

HCO3 20 meq/L
BUN 30 mg/dl
Cr 3.0 mg/dl
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Acid Base Disorders

A H
B I
C J
Alkalosis
D K
Alkalosis
E L
Alkalosis Acidosis
F L
G L
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Acid Base Disorders

HCO3 15 meq/L
BUN 15 mg/dl
Cr 1.0 mg/dl
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Acid Base Disorders

A H
B I
C J
Alkalosis
D K
Alkalosis
E L
Alkalosis Acidosis
F L
G L
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Acid Base Disorders

HCO3 20 meq/L
BUN 15 mg/dl
Cr 1.0 mg/dl
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Acid Base Disorders

A H
B I
C J
Alkalosis
D K
Alkalosis
E L
Alkalosis Acidosis
F L
G L
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Acid Base Disorders

HCO3 40 meq/L
BUN 15 mg/dl
Cr 1.0 mg/dl
Table
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Acid Base Disorders

A H
B I
C J
Alkalosis
D K
Alkalosis
E L
Alkalosis Acidosis
F L
G L
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Acid Base Disorders

HCO3 30 meq/L
BUN 30 mg/dl
Cr 3.0 mg/dl
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Acid Base Disorders

A H
B I
C J
Alkalosis
D K
Alkalosis
E L
Alkalosis Acidosis
F L
G L
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Acid Base Disorders
• Name the acid base disorder present - choices on the next slide

HCO3 18 meq/L
BUN 10 mg/dl
Cr 1 mg/dl
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Acid Base Disorders
Choices for the prior patient -
Primary Disorder Second Disorder Third Disorder
Metabolic Alkalosis Metabolic Respiratory

A Acidosis Acidosis
Respiratory None None
B Alkalosis
None None None
C Metabolic Acidosis Respiratory None
Alkalosis
D Metabolic Acidosis Respiratory Metabolic Alkalosis
Alkalosis
E
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Approach to Hematuria/Proteinuria
• The upper limit for the amount of protein in a 24 hour urine

sample is ……..
A < 50 mg
B < 150 mg
C < 300 mg
D < 500 mg
E < 1 gm
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• The most common protein in the urine other than albumin is ….
A Light chains
B Immunoglobulins
C Hormones i.e. insulin
D Tamm Horsfall
E Beta-2 microglobulin
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• On the urinalysis in CKD – which of these classification of findings is

correctCasts
? Cells Crystals Appearance
Waxy None None Clear
A
Granular Renal None Dark Brown
B Tubular
RBC Dysmorphic None Clear or Dark

C RBCs Brown
WBC WBCs Magnesium Cloudy

ammonium
D phosphate
Fatty / Oval fat None Cholesterol Foamy

E bodies
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• The glomerular basement membrane (GBM) is an important
barrier to prevent protein loss – which of these statements about
the barrier is not true ?
A The GBM exhibits both charge and size selectivity
B The GBM is covered by the podocytes that form foot processes
C The GBM is highly positively charged which prevents albumin loss

Fusion of the foot processes is commonly seen in minimal change disease
D
E The GBM is made up of type IV collagen

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• The most common cause of nephrotic syndrome in children is … ?
A FSGS
B Membranous
C IgA nephropathy
D Minimal change disease
E Diabetes
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• A patient with nephrotic syndrome has a pulmonary embolism –
which of these statements is not correct ?
The pulmonary embolism is not related to the nephrotic syndrome because they
A lose clotting actors in the urine and have a high risk of bleeding
B This patient is also at high risk of having an elevated cholesterol
C You would expect to find fatty casts in the urine
D There is a strong chance of finding renal vein thrombosis
E The patient will have edema and hypoalbuminemia

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• You have a patient with HTN and normal kidney function.
Somehow a microalbumin test was ordered and showed a level of
100 mg / 24 hours. What do you conclude ?
A It doesn’t mean anything because the patient is not diabetic
B This patient is at high risk of developing diabetes
C This patient is at high risk of developing kidney failure
D The patient needs a renal biopsy
E This patient has a high risk of cardiovascular disease

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• Patients with nephrotic syndrome have a high cholesterol because
……. ?
A They retain more lipids due to renal failure

The liver makes high levels of apolipoprotein due to the low intravascular
B volume from 3rd spacing of fluid
C The kidney makes high levels of cholesterol

The liver makes high levels of apolipoprotein due to the low oncotic
D pressure
E They eat too much at Au Bon Pan

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Immunopathogenesis of
Glomerular Disease
• Which statement of immune complexes is not true ?
Toxicity of immune complexes occurs when the concentration of

A antibody and antigen is equivalent
B Immune complexes may deposit in tissue based on their size / charge
C Red blood cells bind immune complexes by the C3b receptor
D Immune complexes consist of antigen bound to the Fc portion of antibody
E Complement levels decrease in response to immune complexes

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Glomerular Disease
• Which type of pattern best fits the alternate complement pathway activation ?
C3 C4 C1
A normal Low High

Low Normal Low
B
High Low Normal
C
Low Normal Normal
D
Low High Male
E
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Glomerular Disease
• Which statement best describes a murine chimeric
antibody ?
A Human light chain and mouse heavy chains
B Both heavy and light chains are of murine origin
C The light chains are murine and the heavy chains are human origin
D Both heavy and light chains are of human origin
E None of the above are correct

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Glomerular Disease
• All of the following are functions of the complement system except … ?
A Clear immune complexes
B Assists in the opsonization of bacteria
C Acts as an adjuvant
D Increases chemotactic and anaphylatoxin response
E Decreases the immune response

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Glomerular Disease
• When discussing the complement pathways – which statement is
not true
A The classic pathway requires antibody binding for activation
B The lectin pathway requires a sugar moiety on the bacterial cell surface or activation
C C3 activation is common to all 3 complement pathways
D C3a and C5a are anaphylotoxins that increases PMN migration
E C3b and C5b are opsonins that directly damage cell membranes
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Glomerular Disease
• When the kidney biopsy is stained and the flourescent pattern is
read as “granular” – what does that signify ?
The target of the antibodies are endogenous antigens in the basement

A membrane of the kidney
B Another name for this disease is Anti-GBM/Goodpasture’s disease
C This is consistent with FSGS
D The patient has immune complexes that have deposited in the kidney
E The patient has pauci-immune gloemrulonephritis

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Primary and Secondary

Glomerular Disease
• Which of these diseases is nephritic and not nephrotic ?
A Minimal change
B Focal Sclerosis (FSGS)
C IgA nephropathy
D Membranous
E Diabetes
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Glomerular Disease
• All the above are characteristics of the nephritic syndrome except
which one ?
A Edema
B Hematuria
C HTN
D Pyuria
E All of the above are found in the nephritic syndrome

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Glomerular Disease
• Match the mechanism of disease – Minimal change ?
A Immune Complex deposition
B No immune complexes
C Anti-GBM
D None of the above

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Glomerular Disease
• Match the mechanism of disease – Membranous ?
C Anti-GBM
D None of the above

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Glomerular Disease
• Match the mechanism of disease – Focal Sclerosis ?
C Anti-GBM
D None of the above

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Glomerular Disease
• Match the mechanism of disease – Goodpasture’s ?
C Anti-GBM
D None of the above

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Glomerular Disease
• Match the mechanism of disease – MPGN due to Hepatitis C ?
B No immune complexes (pauci-immune)
C Anti-GBM
D None of the above

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Glomerular Disease
• Match the mechanism of disease – Diabetes ?
C Anti-GBM
D None of the above

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Glomerular Disease
A 12 year girl had an upper respiratory infection (URI)– it went away
all by itself without therapy but 2 weeks later she presents with leg
swelling , HTN and hematuria – which of these statements about
her disease is true ?
A A biopsy will show IgA staining in the mesangium
B The serum complement levels will be normal
C Her disease could have been prevented with antibiotics for her URI
D This disease is very common in Asian patients
E Her urine should show waxy casts

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Glomerular Disease
Which of these diseases is not associated with an ANCA positive test ?
A Churg Strauss
B Wegener’s Granulomatosis
C Microscopic Polyangiitis
D Membranoproliferative Glomerulonephritis
E Isolated Pauci-immune Glomerulonephritis

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Glomerular Disease
Which of these statements about ANCA is not true ?
A ANCA activates lymphocytes and causes inflammation
B There are 2 main patterns of ANCA : C-ANCA and P-ANCA
C It is associated with a pauci-immune pattern on renal biopsy
D Crescents may be present on renal biopsy
E Can be associated with systemic disease

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Glomerular Disease
Systemic Lupus Erythematosis is characterized by all the following
except ?
A Positive ANA
B Classical complement pathway activation
C Systemic symptoms – rash / arthralgias / fever

Renal biopsy classically shows characteristic Focal Proliferative
D Glomerulonephritis
E Affects predominantly young women

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Glomerular Disease
Diabetes is a worldwide epidemic – which of these statements is true
regarding Diabetic Nephropathy ?
A It is the second most important cause of ESRD after HTN in the U.S.
B The risk of ESRD from diabetes is close to 30%
C Nephrotic syndrome is the first presentation of Diabetic Nephropathy
The risk of renal involvement from Diabetes increases with the

D duration of disease
Once kidney disease from Diabetes occurs there is no effective treatment to
E delay the development of ESRD
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Glomerular Disease
A patient has a renal biopsy and the report comes back stating
amyloidosis – what is not true about this disease ?
A Primary amyloid is due to the accumulation of Serum amyloid A protein
B Cardiac involvement is very common
C The biopsy will stain positive with congo red
It may be associated with multiple myeloma

D
E The patient most likely had nephrotic syndrome

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Viral Glomerulonephritis
• HIVAN – HIV associated Nephropathy is caused by……
A Immune complexes from the HIV virus
B An allergic response to the HIV virus causing interstitial nephritis
C Direct infection of the renal podocyte and tubular cells
D The production of cryoglobulins that deposit in the kidney
E The mechanism is not known

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• HIVAN occurs in which type of patient demographic -
Race Gender Age Stage of HIV
Infection
Caucasion Male < 20 yrs old early
A
Black Female > 65 years old advanced
B
Caucasion Female 20 -65 yrs old advanced
C
Black Male 20-65 yrs old advanced
D
Black Male > 65 yrs old early
E
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• What type of renal lesion is characteristic of HIVAN ?
A Membranous glomerulonephritis
B FSGS
C Membranoproliferative glomerulonephritis
D Chronic interstitial nephritis
E ATN
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• What of these is not a proven therapy for HIVAN ?
A Angiotensin converting enzyme inhibitors (ACEI)
B Steroids
C HAART
D Kidney transplantation or dialysis
E Interferon
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• A caucasion patient has HIV and co-existant infection with
both Hepatitis B and Hepatitis C. He presents with swollen
legs and has the following test results –
Na 140 meq/L Urine protein 430 mg/dl

K 5.6 meq/L Urine creatinine 80 mg/dl
Cl 100 meq/L
HCO3 20 meq/L C3 65 (normal > 80)
BUN 56 mg/dl C4 10 (normal > 20)
Cr 5.1 mg/dl Urinalysis – 3+ blood
4+ protein
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• Based on the case from the previous page – you can
deduce that the patient has ……… ?
A HIVAN
B MPGN due to Hepatitis C
C MPGN due to Hepatitis B
D Membranous due to Hepatitis C
E MPGN due to Hepatitis B

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• All these statements about Cryoglobulins are true
except …….?
A They precipitate in the cold and become soluble when warmed

The Rheumatoid Factor is a good indirect marker for the presence of
B cryoglobulins
C They activate the alternate complement pathway
D They are composed of an antibody against another antibody
E The most common antibody that makes up the cryoglobulin is IgM

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• Which pattern of antibody and antigen best describes
the immune complex for Hepatitis B – induced renal
disease ?
A Hepatitis B surface antibody – Hepatitis B surface antigen
B Hepatitis B core Antibody – Hepatitis B core antigen
C Hepatitis B surface antibody – Hepatitis e Antigen
D Hepatitis e Antibody – Hepatitis e Antigen
E Hepatitis B e Antibody – Hepatitis B surface antigen

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• Hepatitis B induced renal disease can best be described
by which statement ?
A Linear staining of IgG on the basement membrane
B Activation of the classical complement pathway
C Nephritic syndrome
D Oval fat bodies and fatty casts in the urinalysis
E Unresponsive to any medical treatment

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• A patient with Hepatitis C was doing well but now was
just diagnosed with lymphoma – which statement is
true about this scenario ?
They are 2 independent diseases and it is just an unfortunate coincidence that
A he has lymphoma
B The lymphoma is a result of unsuspected co-infection with HIV
C The lymphoma is a result of infection of B cells by the Hepatitis C
The Lymphoma most likely developed about 5 years after the infection
D with Hepatitis C
The treatment of the lymphoma can be accomplished using anti-viral
E therapy since it is due to Hepatitis C
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• Which pattern best describes the clinical course and
presentation of NSAID induced interstitial nephritis ??
Time of Onset after Proteinuria Eosinophilia Biopsy

drug exposure (24 hours)
7-10 days < 2 gm decreased Interstitial
A Nephritis
1 month Nephrotic No change Minimal Change
B
3 months Nephrotic present Membranous
C
7-10 days < 2 gm decreased FSGS
D
3 months Nephrotic absent Minimal Change
E
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• When comparing allergic interstitial nephritis (AIN)
from acute pyelonephritis, which statement is correct ?
A Fever is only present in acute pyelonephritis
B Only AIN has large kidneys on ultrasound
C Granular casts will be present only with AIN
D Acute pyelonephritis will have rbc casts in the urine and AIN will not
A biopsy in acute pyelonephritis will show PMNs instead of T cells in

E the interstitium
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• Which of these is not associated with chronic
interstitial nephritis ?
A Lithium
B Sulfonamide antibiotics i.e. Bactrim
C Cyclosporine
D Analgesics – acetaminophen/aspirin compounds
E Chinese Herbs
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• Which of these statements is not true ?
A Interstitial nephritis accounts for < 25% of cases of ESRD
B The renal medulla has the highest volume of interstitial space
C The interstitium provides structural support for the kidney
D The cells of the interstitium make ADH and erythropoietin

The degree of interstitial fibrosis is the best predictor of outcome for
E any type of kidney disease
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• What statement best describes Eosinophiluria ?
A Highly specific and sensitive only for allergic interstitial nephritis
B Commonly seen with NSAID induced interstitial nephritis
C Present in patients with UTI and prostatitis

Represent the most common cells seen on biopsy in allergic
D interstitial nephritis
E May be seen by microscopic evaluation in an un-stained urine

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• Which pattern best describes the laboratory pattern of
allergic interstitial nephritis??
Acid base disorder FENA Casts Urine specific

gravity
None >2% Waxy 1.010
A
Anion gap acidosis <1% Granular 1.015
B Non anion gap >2% Fatty 1.010
acidosis
C Non anion gap <1% Granular 1.015
acidosis
D Non anion gap >2% Granular 1.010
acidosis
E
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Light Chain Disease

• A patient with multiple myeloma has the following laboratory results -
Na 138 meq/L Urinalysis : 4+ albumin

K 4.0 meq/L 0-2 RBC
Cl 100 meq/L 0-2 WBC
HCO3 24 meq/L Oval fat bodies
BUN 30 mg/dl SSA test 4+
Cr 3.0 mg/dl
Albumin 2.0 g/dl (nl > 3.5 g/dl)

Cholesterol 300 mg/dl (nl < 200 mg/dl)
Uric acid 7.5 mg/dl (nl < 6.5 mg/dl)
Phosphorous 4.9 mg/dl (nl < 4.5 mg/dl)
Calcium 9.8 mg/dl (nl < 10.5 mg/dl
Question on next slide -
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Light Chain Disease

• Based on the test results – you can conclude ……….
A biopsy will show large casts filling the tubules that stain positive for
A kappa light chains
B The patient has Fanconi’s syndrome
C A biopsy will show acute interstitial nephritis
D A biopsy will show glomerular staining for lambda light chains

This patient has Focal Segmental Sclerosis unrelated to the Multiple
E Myeloma
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Light Chain Disease

• A patient with multiple myeloma has the following laboratory results -
Na 138 meq/L Urinalysis : 1+ albumin

K 4.0 meq/L 0-2 RBC
Cl 110 meq/L 0-2 WBC
HCO3 16 meq/L Hyaline casts
BUN 25 mg/dl SSA test 3+
Cr 1.8 mg/dl
Albumin 3.4 g/dl (nl > 3.5 g/dl)

Cholesterol 200 mg/dl (nl < 200 mg/dl)
Uric acid 2.1 mg/dl (nl < 6.5 mg/dl)
Phosphorous 2.0 mg/dl (nl < 4.5 mg/dl)
Calcium 9.8 mg/dl (nl < 10.5 mg/dl) Question on next slide -
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Light Chain Disease

• Based on the test results – you can conclude ……….
A The patient has ATN from lambda light chains damaging the distal tubule
B The patient has Fanconi’s syndrome
C The patient has orthostatic proteinuria
D A biopsy will show glomerular staining with congo red
E The patient has nephrotic syndrome

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Light Chain Disease

• Myeloma can cause all of the following except …….
A Type II RTA
B Hypercalcemia
C ATN
D High anion gap
E Primary amyloidosis
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Light Chain Disease
• A patient has multiple myeloma (MM) – which of these

statements is true ?
A MM is a common cause of hyponatremia

Kappa light chains cause specific damage to the distal tubule resulting in the
B development of Fanconi’s syndrome
C Light chains may lead to the development of secondary amyloidosis

The SSA test is used to confirm the presence of light chains after the
D urinalysis initially detects them
E MM is often diagnosed by a urine or serum electrophoresis

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Light Chain Disease
• A patient has amyloid – which of these statements is true ?
A Amyloidosis deposits primarily in the renal tubules

Dialysis patients are at risk of getting amyloid from the AA protein
B accumulation with CKD
C Only a kidney biopsy can confirm the presence of amyloidosis

Amyloidosis can occur as a distinct disease separate from multiple myeloma
D
E Amyloidosis is associated with granular casts in the urine

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Hypertension : Epidemiology
• What percent of people in the US are unaware that
they have HTN ?
A 75%
B 50%
C 25%
D < 10%
E All people that have HTN are aware and under treatment
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• Which of these statements about HTN is not correct ?
A Blood pressure increases with age
B Men have a higher incidence of HTN
C Black patients have a greater risk of end organ damage from HTN
D The pulse pressure decreases with aging
E Most patients with HTN are asymptomatic

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• Which of these is not a risk factor for strokes ?
A HTN
B Diabetes
C Smoking
D Obesity
E Triglyceride level
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• Which of these statements about HTN is not true ?
A Isolated systolic HTN occurs more frequently in people < 60 y/o

At any given level of systolic BP the risk of mortality from cardiovascular
B disease is higher in older patients
Both systolic and diastolic BP are equally important risk factors for
C atherosclerosis
Even if the diastolic BP is normal, an elevated systolic BP causes
D cardiovascular disease
E HTN usually occurs in the presence of other cardiac risk factors

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Secondary Hypertension
• Which of these criteria are not part of the definition of
secondary HTN ?
A Age of onset >60 and < 20 years old
B Unprovoked hyperkalemia
C Creatinine > 1.5 mg/dl
D Family history of renal disease
E Systemic symptoms i.e. flushing, palpitations, sweating etc

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• When discussing a pheochromocytoma - which of these
statements is not true ?
A Usually unilateral unless associated with a familial disorder
B Rarely malignant
C Orthostatic hypotension is an infrequent complication
D Patients may experience significant weight loss
E Majority have paroxysmal rahter than intermittant HTN

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• When discussing a pheochromocytoma - which of these
statements is not true ?
A Usually unilateral unless associated with a familial disorder
B Rarely malignant
C Orthostatic hypotension is a frequent complication
D Patients may experience significant weight loss
E Majority have sustained rather than intermittent HTN

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• When discussing primary hyperaldosternism - which
of these statements is true ?
Plasma Renin Age group Acid Base Gender
affected Disorder Distribution
normal < 20 yrs None M/F equal
A
decreased > 60 yrs Metabolic M>F
B alkalosis
increased 30-50 yrs Metabolic M/F equal
Acidosis
C
decreased 30-50 yrs Metabolic F>M
alkalosis
D
increased > 60 yrs None M/F equal
E
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• When discussing renal artery stenosis due to
atherosclerosis - which of these statements is true ?
Plasma Renin Location of the Age of onset Kidney size
lesion in the
renal artery
normal Distal 1/3 > 50 yrs Normal
A bilaterally
decreased Proximal 1/3 < 30 yrs Affected side
larger
B
increased Middle 30-50 yrs Affected side
smaller
C increased Proximal 1/3 > 50 yrs Affected side
smaller
D increased Distal 1/3 30-50yrs Affected side
larger
E
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• When discussing renal artery stenosis due to Fibromuscular
dysplasia which of these statements is true ?
Plasma Most common Serum Potassium Kidney size
Aldosterone site of disease
Normal Intimal Low Normal
A bilaterally
Increased Medial Low Affected side
B smaller
Decreased Periarterial Normal Affected side
C larger
Increased Medial High Normal
D bilaterally
Increased Periarterial Low Affected side
E smaller
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Associated with a risk of renal artery dissection/thrombosis
A Essential HTN
B Pheochomocytoma
C Primary Aldosteronism
D Renal artery stenosis - atherosclerosis
E Renal artery stenosis – fibromuscular dysplasia

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Often associated with acute renal failure when using an
ACEI for BP control
A Essential HTN
B Pheochomocytoma

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Not Associated with Hypokalemia -
A Glucocorticoid remediable HTN
B Pheochromocytoma

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Pathology of Hypertension
Benign Nephrosclerosis due to HTN is associated with
all of the following except ?
A Granular surface of the kidney
B Atrophic cortex
C Hyaline arteriosclerosis
D Hyperplastic arterioslcerosis
E Tubular and interstitial fibrosis

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Pathology of Hypertension
Malignant Nephrosclerosis due to HTN is associated
with all of the following except ?
A Fibrinoid necrosis
B Interstitial hemorrhage
C Hyperplastic arteriosclerosis
D “Flea bitten” surface appearance
E Hyaline arteriosclerosis
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Benign Prostatic Hypertrophy

• Which of these statements about the treatment of BPH is
true?
A Alpha agonists are indicated in the treatment of BPH
5 alpha reductase inhibitors block the testosterone receptor thereby decreasing

B gland size
Alpha blockers relieve the symptoms but do not shrink the prostate in BPH
C
D Alpha receptors are concentrated specifically in the prostate
E Beta agonists will relax the prostate and help with urine flow
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• All of the following are symptoms of BPH except ….. ?
A Hesitancy
Urgency
B
Decreased stream
C
D Nocturia
E All of the above are symptoms of BPH

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• Pathological findings in BPH are important – which of these is true ?
A Nodules on the prostate indicate progression to prostate cancer
Hyperplasia of the stroma and epithelium only is found

B
Starts in the peripheral zone and compresses inward on the urethra
C
D BPH shows the absence of basal cells which are characteristic of prostate cancer
E None of the above are true

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Prostate Cancer
• All of the following are true about prostate cancer except ….
A The incidence of prostate cancer increases with age and starts at age 50
B Race is an important risk factor with the risk being higher in Caucasions
The PSA level correlates with the risk of cancer

C
D Prostate cancer is the most frequent cancer in men
E Family history of prostate cancer is an important risk factor

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Prostate Cancer
• Which Zone is affected by Prostate cancer ?
A Transitional / peri-urethral zone
B Central zone
Anterior fibromuscular stroma

C
D Peripheral zone
E All zones are equally affected

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Prostate Cancer
• Which of the following statements about the treatment of prostate cancer is
true ?
A TURP (resection) is the first line of therapy for patients with localized prostate
A cancer
B Radiation therapy is used for patients with advanced metastatic disease
C Hormonal therapy is effective for localized disease if surgery is not considered
D Hormonal therapy consists of androgen supplements either topically or orally
E All prostate cancer cells are extremely sensitive to hormonal therapy

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Prostate Cancer
• Which of the following statements about prostate cancer is true ?
A The majority of prostate cancers are metastatic at the time of presentation
B Histologically the most common cell type is squamous cell
C The Gleason scoring system is used to predict the severity of disease
D A chromosomal mutation has never been linked to prostate cancer
E Most common cause of death in males in the U.S.

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Voiding Disturbances
• Which of these statements about bladder innervation is false ?
A Muscarinic receptors are present throughout the detrusor muscle
B The pudendal nerve and pelvic nerve share the same spinal origin of S2-S4
The hypogastric nerve is the primary parasympathetic nerve of the bladder

C
D Alpha receptors are present in the sphincter and prevent incontinence
E Beta receptors are not of significant function in the voiding process

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• A patient comes to you with leakage of urine. She states that without
warning she has the intense desire to void. Afterward everything is fine
and then it happens again multiple times a day- what is this woman’s
problem ?
A Neurogenic bladder – detrusor failure
B Too much coffee
Stress incontinence
C
D Urge incontinence
E Overflow incontinence
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• What is the best voiding treatment for a patient with spinal cord paralysis
and detrusor failure?
A Anticholinergics
B Antimuscarinics
Alpha blockers
C
D Beta blockers
E Intermittent catheterization
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• Urge incontinence is best treated by …….. ?
A Anticholinergics
B Nicotinic receptor antagonists
Alpha agonists
C
D Beta blockers
E Intermittent catheterization
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• Which of these is not in the definition of overactive
bladder syndrome ?
A Frequency
B Intense desire to void with high bladder volumes
Urgency with leak – urge incontinence

C
D > 8 micturitions / day
E Urgency
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• The treatment of Overactive bladder syndrome with
Oxybutynin is associated with many side effects – all of
the following are side effects of this drug except…….
A Blurred vision
B Constipation
Confusion
C
D Blurred vision
E Edema
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Renal Masses
• All of the following are characteristics of a simple cyst except……
A anechoic
B Smooth walled
C Solitary
D No posterior enhancement
E No treatment needed
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Renal Masses
• All of the following are characteristics of an angiomyolipoma
except……
A May cause massive hematuria
B Females affected more than males
C Unilateral in presentation
D Multifocal
E Benign lesions
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Renal Masses
True or False ?
• The Bosniak classification is used to grade the severity of renal cell
carcinoma
T F
• The Fuhrman classification is used to grade the severity of

Overactive Bladder Syndrome
T F
• The majority of renal masses are benign

T F
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Renal Masses
• All of the following are characteristics of an oncocytoma except……
A Malignant lesion
B Well defined
C Asymptomatic presentation
D Central stellate scar
E Requires surgical excision to distinguish from renal cell carcinoma

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Renal Masses
• All of the following are characteristics of a renal cell carcinoma
except……
A Males affected more than females
B Rarely bilateral
C Most common site of origin is the proximal tubule
D Most common histology is Papillary carcinoma
E Increased risk in smokers

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Renal Masses
• Renal cell carcinoma (RCC) may cause paraneoplastic syndromes –
which of these syndromes has not been associated with RCC ?
A Polycythemia
B Cushings disease
C Hypercalcemia
D Diabetes
E SIADH
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• The most common disorder of sexual function in men is …..
A Loss of interest
B Lubrication problems
Performance anxiety
C
D Premature ejaculation
E Erectile dysfunction
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• Erectile dysfunction is rare below the age of 50 – True or False
A True
B False
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• Which of these statements is not true about the innervation of the penis ?
A The pudendal nerve provides parasympathetic innervation of the penis
B The S2-S4 segments give rise to the pelvic nerves
The sympathetic plexus acts through the hypogastric nerves

C
The pelvic nerve plexus may be frequently injured during a TURP causing
D erectile dysfunction
The sympathetic nerves release norepinephrine causing cavernous smooth
E muscle contraction
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• Which of these statements is not true about the physiology of an erection ?
A The parasympathetic nerves are key factors in establishing an erection
B Nitric oxide causing relaxation of the cavernous smooth muscle
Acetylcholine stimulates the release of Nitric oxide from the endothelial

C cells
D Nitric oxide stimulates the production of cGMP
Phosphodiesterase inactivates the metabolism of Nitric Oxide resulting in a

E short half life
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• Which of these is a contraindication to the use of a phosphodiesterase
inhibitor for erectile dysfunction ?
A Kidney Failure
B ACEI inhibitor use
C History of CHF
D Nitrate use
Beta blocker use

E
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• Which of these factors is not associated with erectile dysfunction ?
A smoking
B Diabetes
C ACEI/ARB use
D Depression
All of the above cause ED

E
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Congenital Renal Disease

• In autosomal dominant polycystic disease – what
percent of the tubules are affected by cysts ?
A 75 - 100%
B 50 – 75%
C 25 – 50%
D 10 – 25%
E < 10%
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• In autosomal dominant polycystic disease – which of
these is not an associated finding ?
A Cerebral aneurysms
B Mitral valve prolapse
C Bone cysts
D Liver cysts
E Colonic diverticulosis
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• Which medication is not recommended for the
management of HTN in patients with ADPCKD ?
A Calcium Channel Bockers
B ACEI
C Diuretics
D Beta blockers
All o the above are used because control of the blood pressure is
E mandatory to slow the rate of deterioration
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• Where do the cysts come from in each case of polycystic
kidney disease ?
ARPCKD ADPCKD
Entire Nephron Distal Tubule

A
Collecting Duct Proximal Tubule
B
Distal Tubule Collecting Duct
C
Proximal Tubule Collecting Duct
D
Collecting Duct Entire Nephron
E
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• What percent of the children will be affected by cystic
renal disease when the father has ……… ?
Father with Father with
ARPCKD ADPCKD
50% 25%
A
0% 50%
B
25% 0%
C
50% 0%
D
50% 25%
E
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• In autosomal recessive polycystic disease which of these
findings does not occur ?
A Cerebral aneurysms
B Liver fibrosis
C End Stage Renal Disease
D Enlarged kidneys
E All occur in ARPCKD

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• A 25 year old man undergoes a kidney transplant and at 3 months
the creatinine increases – he has a biopsy that shows linear
staining of the GBM with IgG – what do you think his original
kidney disease was ?
A ADPCKD
B Diabetes
C MPGN
D Alports
E Membranous
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• Your patient is a 25 year old man that had a renal
biopsy for proteinuria and has Alport’s syndrome
-what is the typical hereditary pattern of this disease?
A X – linked
B Autosomal dominant
C Autosomal recessive
D Spontaneous mutation
E It is not a hereditary disease

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• What statement best describes the pathogenesis of
Alport’s syndrome ?
A Defect in Type II collagen
B Defect in Type I collagen
C Defect in Type IV collagen
D Defect in Type III collagen
E Defect in the polycystin gene

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• Anti-GBM disease can occur after kidney
transplantation in patients with which underlying
primary renal disease ?
A Autosomal Dominant Polycystic Disease
B Focal Segmental Glomerulonephritis
C Autosomal Recessive Polycystic Disease
D Systemic Lupus Erythematosis
E Alport’s Syndrome
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• Match the clinical finding with the syndrome -
ARPCKD ADPCKD MSK – MCD- Alport’s

Medullary sponge Medullary cystic
disease
Syndrome
kidney
Deafness decrease No decreased Normal

E
Ad B
change C D
No hereditary
transmission A
No B
decrease C
No change D E
Metabolic
change d acidosis
No risk of ESRD A
No B
increase C
increased D E
Respiratory
change d acidosis
Portal fibrosis A B C D E
decrease decrease decreased Respiratory
d d alkalosis
Salt wasting state A B C D E
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• Which are true or false about Fabry’s disease -
True False
decrease No
d
A change
B
X linked heredity
No decrease
Deficiency of Hexoaminidase B A
change Bd
No increase
Premature atherosclerosis A
change Bd
Associated with the Nephritic Syndrome A
decrease B
decrease
d d
No available treatment A B
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• Which of these findings is not associated with Potter’s
syndrome ?
A Unilateral renal agenesis
B Oligohydramnios
C Respiratory failure
D Limb defects
E All are associated with this syndrome

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• Which of these statements is not correct ?
A Renal Atrophy is an acquired condition usually due to infection

Renal Hypoplasia is a condition with a small under-developed kidney with a
B reduced number of lobes but no scars
C Renal Dysplasia is a pre-malignant lesion and needs close observation
D Bilateral Renal agenesis is incompatible with life
E All of the above are not correct

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• Which of these statements about Wilm’s tumor is not
correct ?
A It is the most common primary tumor of childhood
Nephrogenic rests are precursors of Wilm’s tumor

B
C Wilm’s tumor is always unilateral
D The gene has been identified and is called WT1
Arise from embryonal blastema

E
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Urogenital Tract Pathology

• Which of these statements is true regarding the histology of renal cell
carcinoma ?
Most common Second Third Least common
Clear cell Papillary Oncocytoma Chromophobe

A
Papillary Clear cell Medullary Chromophobe
B
Clear cell Papillary Chromophobe Medullary
C
Oncocytoma Papillary Clear cell Chromophobe
D
Clear cell Chromophobe Papillary Medullary
E
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• Which of these statements is true regarding the origin of renal cell
carcinoma ?
Clear Cell Papillary Chromophobe Medullary
Proximal tubule Collecting duct Distal Tubule Collecting duct

A
Proximal tubule Distal Tubule Proximal tubule Distal Tubule
B
Distal Tubule Collecting duct Collecting duct Proximal tubule
C
Collecting duct Proximal tubule Distal Tubule Collecting duct
D
Proximal tubule Proximal tubule Distal tubule Collecting duct
E
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• Bladder cancer is associated with all of the following except … ?
A Cigarette smoking
B Age 50-80 yrs old
C Most common in rural, non-industrialized regions
D Prior use of chemotherapy such as cyclophosphamide
E Infections that cause cystitis such as Schistosomiasis

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• Which of these statements about prostate lesions is not true ?
BPH starts in the periurethral zone and extends posteriorly to cause

A obstruction
Prostate cancer starts in the peripheral zone and may be detected by rectal
B exam
C BPH can be associated with an elevated PSA
Prostate cancer often metastasizes to bone

D
Prostate cancer is the most frequent type of cancer in men
E
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Clinical Anion Gap Metabolic Acidosis

• What role does albumin play in the evaluation of the anion gap?
A Albumin is an unmeasured cation and a low albumin makes the gap smaller
B Albumin is a neutral compound and has no effect on the anion gap
C Albumin is an unmeasured anion and a low albumin will make the gap larger
D Albumin is an unmeasured cation and a low albumin will make the gap larger
E Albumin is an unmeasured anion and a low albumin will make the gap smaller
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• How does Ethylene glycol cause kidney injury ?
A
A Development of an allergic interstitial nephritis
B Direct toxic effect of ethylene glycol on the tubules
C
C Immune complex formation with acute glomerulonephritis
D
D ATN due to oxalate deposition in the tubules
E Pre-renal azotemia from shock and hypotension

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• Which of these is true about ethylene glycol poisoning?
A
A An osmolar gap results from the accumulation of glycolic acid
Fomepizole is a competitive inhibitor of the enzyme aldehyde

B
dehydrogenase
C
C Alcohol is a direct inhibitor of the enzyme alcohol dehydrogenase
Start an alcohol drip or fomepizole is required when renal failure

D
D
develops
E Renal failure occurs late in the course of an overdose
F
F All of the above are false
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• Methanol poisoning is associated with which of the following ……?
A
A An osmolar gap from the accumulation of lactic acid
B Acute Kidney injury due to ATN
C
C Blindness due to formic acid accumulation
D
D A non-anion gap metabolic acidosis
E Oxalate crystal deposition in the tubules
F
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• Which statement is true about an aspirin overdose ?
A
A An osmolar gap results from the accumulation of salicylic acid
B Fomepizole is indicated for patients with severe acidosis
C
C A High anion gap metabolic acidosis is the most common finding
D
D Urinary alkalinization is effective to enhance drug elimination
E Untreated cases result in blindness
F
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• Which statement is true about Lactic Acidosis ?
A
A An osmolar gap results from the accumulation of Lactic acid
B Fomepizole is indicated for patients with severe acidosis
C
C A High anion gap metabolic acidosis is the most common finding
D
D Results from an overactive Krebs cycle producing excess lactic acid
E Untreated cases result in Acute kidney injury
F
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Urinalysis
Na 130 Sp 1.015
• A 45 year old male patient gravity
comes into the ER after binge
drinking alcohol for the last K 3.3 Blood negative
week. Now he complains of
abdominal pain and has not Albumin negative
CL 93
been eating or drinking for the
past 5 days. His vital signs
HCO3 15 Ketones 1+
were otherwise normal -
• The following test results were
obtained - BUN 50 Crystals none
Blood gas
Cr 1.7 Glucose negative
pO2 80
pH 7.30
pCO2 30 Glucose 68 Casts Hyaline
HCO3 15
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What is the cause of this patient’s acid-base disorder ?
methanol poisoning
A
A
B ethylene glycol poisoning
C
D
D Alcoholic ketoacidosis
E Lactic acidosis
F
F None of the above
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For this patient, what would the expected FEurea be ?
A < 1%
B 50%
C < 35%
D 2%
E < 20
F
F None of the above
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What would the dominant acid be for the case described ?

A
A Acetoacetic acid
B
B Acetone
C
C Salicylic acid
D
D Formic acid
E
E Beta- hydroxybutyric acid
F Oxalic acid
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Urinalysis
Na 130 Sp 1.010
gravity
• A 45 year old male patient who
K 5.0 Blood negative
is a known alcoholic comes into
the ER complaining of
abdominal pain. He is confused CL 93 Albumin negative
and unable to give any history.
• The following test results were HCO3 15 Ketones trace
obtained -
BUN 35 Crystals Calcium
oxalate
Blood gas
pO2 80
pH 7.30
Measured 300 Casts granular
pCO2 30
serum
HCO3 15 osmolality
Glucose 68
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What is the cause of this patient’s disorder ?

A
A methanol poisoning
B
C
D
D Alcoholic ketoacidosis
E
E Lactic acidosis
F None of the above

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For this patient, what would the expected FENA (fractional
excretion of sodium) be ?
A < 1%
A
B > 50%
C
C < 35%
D
D > 2%
E < 20
F
F None of the above
Table
Table of
of Contents
What is the most important first treatment for this patient ?

A Dialysis
A
B High IV infusion volumes of 0.9 NS
C
C High IV infusion volumes of sodium bicarbonate
D
D Fomepizole or alcohol infusion
E Insulin drip
F
F None of the above
Table
Table of
of Contents

Urinalysis
Na 130 Sp 1.015
gravity
• A 45 year old male patient who
K 4.5 Blood negative
is a known alcoholic comes into
the ER complaining of
abdominal pain and blurrd CL 93 Albumin negative
vision. He is confused and
unable to give any history. His HCO3 15 Ketones trace
physical exam is noteworthy for
edema of the optic disk.
BUN 20 Crystals none
• The following test results were
obtained -
Blood gas
pO2 80
pH 7.30
Measured 275 Casts none
pCO2 30
serum
HCO3 15 osmolality
Glucose 68
Table
Table of
of Contents

What is the cause of this patient’s disorder ?
A methanol poisoning
A
C
D
D Starvation ketosis
E Lactic acidosis
F
F None of the above
Table
Table of
of Contents

What is the name of the acid that accumulates in this
A
A
disease ?
Glycolic acid
B
Formic acid
C
C
Acetoacetic acid
D
D
Salicylic acid
E
Lactic acidosis
F
F
Beta hydroxybutyric acid
Table
Table of
of Contents
What is the most important first treatment for this patient ?

A Dialysis
B High IV infusion volumes of 0.9 NS
C High IV infusion volumes of isotonic sodium bicarbonate
D Fomepizole or alcohol infusion
E Insulin drip
F
F
None of the above
Table
Table of
of Contents

• You are treating a young 18 year patient with Type 1 Diabetes for DKA (diabetic
ketoacidosis) – you have started an insulin infusion and the blood glucose is
improving as shown – the measurement of urine ketones is noted –
• Why did the urine ketones get temporarily worse even though the patients blood
sugar and serum bicarbonate were improving with treatment ? (choices on the
next slide)
Serum 800 600 400 200 100
glucose
(mg/dl)
Serum 10 14 18 21 25
bicarbonate
(meq/L)
Urine 1+ 3+ 2+ 1+ negative
ketones
dipstick
Why did the urine ketones get temporarily worse
even though the patients blood sugar and serum
bicarbonate were improving with treatment ?
A a) You have missed a diagnosis of lactic acidosis
b) The urine ketone test measures only acetone so with treatment of the hyperglycemia the ketone
B body, acetoacetic acid, eventually converts to acetone and causes the positive ketone test
c) The urine ketone test measures only acetoacetic acid so with treatment of the hyperglycemia the
C ketone body, acetone, eventually converts to acetoacetic acid and causes the positive ketone test
d) The urine ketone test measures only acetoacetic acid so with treatment of the hyperglycemia the
D ketone body, betahydroxybutyric acid, eventually converts to acetoacetic acid and causes the
positive ketone test
e) The urine ketone test measures only betahydroxybutyric acid so with treatment of the
E hyperglycemia the ketone body, acetoacetic acid , eventually converts to betahydroxybutyric acid
and causes the positive ketone test
F
F f) The urine ketone test is a useless assay and should not even be measured
Table
Table of
of Contents

pH pCO2 HCO3
• A 35 year man took 25
tablets of aspirin in a
A 7.25 55 30
suicide attempt – after an A
A
hour had passed he had
B 7.50 25 20
second thoughts and B
rushed to the ER – they
C 7.25 30 15
did a blood gas – which of C
C
the following results
D 7.50 48 35
would be expected in this D
D
clinical situation ?
E 7.25 45 20
E
Table
Table of
of Contents

• Which of these conditions is not associated with an osmolar
gap ?
A Uremia
B Ethylene glycol overdose
C Methanol overdose
D Alcohol overdose
E Aspirin overdose
F
F All of the above have an osmolar gap
Table
Table of
of Contents
Renal Tubular Acidosis

• Which of these is not associated with a hyperchloremic non anion gap
metabolic acidosis ?
A
A Type IV RTA
B Type I RTA
C
C Type II RTA
D
D Vomiting
E Diarrhea
All of the above are associated with a hyperchloremic non anion gap
F
F
acidosis
Table
Table of
of Contents

• Carbonic anhydrase ………….? Fill in the best answer
A
A Is in the proximal tubule and regulates potassium secretion
B Is in the proximal tubule and regulates HCO3 reabsorption
C
C Is in the distal tubule and regulates H+ secretion
D
D Is in the distal tubule and regulates potassium secretion
E Is in the thick ascending loop of Henle and controls sodium reabsorption
F
F All of the above are associated incorrect
Table
Table of
of Contents

• A patient is taking topomax for seizures. Which of these lab results
would you expect ??
Na K Cl HCO3
135 4.0 100 25

A
140 6.0 110 15
B
135 3.0 100 15
C
140 3.0 100 30
D
140 3.0 110 15
E
Table
Table of
of Contents

• A patient is getting chemotherapy wit ha drug called ifosphamide – you
remember that this drug is similar to heavy metals like Lead and can
cause a ……….
A
A Type IV RTA
B Type I RTA
C
C Nephrogenic diabetes insipidus
D
D SIADH
E Interstitial Nephritis
F
F Type II RTA and Fanconi’s syndrome
Table
Table of
of Contents

• Which RTA is associated with a risk of stone disease ?
A
A Type IV RTA
B Type I RTA
C
C Type II RTA
D
D Both Type I and Type II
E Both Type I and Type IV
F
F None are associated wit hstones
Table
Table of
of Contents

• Which RTA is associated with an equilibrium Acidosis ?
A
A Type IV RTA
B Type I RTA
C
C Type II RTA
D
D Both Type I and Type II
E Both Type I and Type IV
F
F None are associated wit hstones
Table
Table of
of Contents

• Type IV RTA is associated with all the following except ………?
A
A ACEI
B ARB
C
C Beta blockers
D
D NSAIDS
E Aldosterone antagonists
F
F All are associated with Type IV RTA
Table
Table of
of Contents

c of these are his lab results ??
• A patient has an ileostomy – which
Na K Cl HCO3
135 4.0 100 25

A
140 6.0 110 15
B
135 3.0 100 15
C
140 3.0 100 30
D
140 3.0 110 15
E
Table
Table of
of Contents

• A patient has an artificial bladder made from the ileum – which of these
is their lab result??
Na K Cl HCO3
135 4.0 100 25

A
140 3.0 110 15
B
135 3.0 100 15
C
140 3.0 100 30
D
140 6.0 110 15
E
Table
Table of
of Contents
Metabolic Alkalosis
• The most common acid base disorder seen in hospitalized patients is
……
A
A Type I RTA
B Respiratory Alkalosis
C
D
D Metabolic acidosis
E Metabolic alkalosis
F
F Type II RTA
Table
Table of
of Contents
Metabolic Alkalosis
• Which of these statements about hyperaldosteronism and metabolic
alkalosis is correct ?
Directly increases the HCO3 absorption in the intercalated cells and increases na-K
A
A exchange in the principal cells
Increases K+ secretion by the intercalated cells and H+ secretion from the principal
B
cells
Causes movement of H+ into cells through the activation of the Na-K ATPase pump in the
C
C
cell membrane –this is called redistribution alkalosis
Increases K+ secretion from the principal cells and H+ secretion from the intercalated
D
D cells
There is no relationship between elevated aldosterone levels and the development of a

E metabolic alkalosis
Directly increases HCO3 absorption in the proximal tubule and stimulateds H+

F
F
secretion from the intercalated cells
Table
Table of
of Contents
Metabolic Alkalosis Urinalysis

Na 135 Sp 1.015
gravity
• A 45 year old male patient just
K 3.3 pH 7.5
developed the stomach flu and
has been vomiting day and night
Blood negative
for the past 3 days. In the ER he CL 93
vomits on the medical student
and remains weak and nauseous. HCO3 35
Albumin negative
Ketones trace
BUN 40
Crystals none
Blood gas
Cr 1.5
pO2 80
pH 7.50 Glucose negative
Measured 275
pCO2 48
serum
HCO3 35 osmolality Casts none
Glucose 68
Table
Table of
of Contents
Metabolic Alkalosis
• What is your diagnosis……
A
A ATN with Metabolic alkalosis
B Pre-renal azotemia with Respiratory alkalosis
C
C ATN and Respiratory alkalosis
D
D Pre-renal azotemia and Metabolic alkalosis
E ATN and Mixed respiratory alkalosis and metabolic alkalosis
F
F Pre-renal and Mixed metabolic alkalosis and respiratory acidosis
Table
Table of
of Contents
Metabolic Alkalosis
• In the same patient what would the following tests show ?
FENA Urine Na Urine Cl FE Urea
<1% < 20 < 20 < 35%

A
> 2% > 40 > 20 > 50%
B
< 1% < 20 < 20 > 50%
C
> 2% > 40 < 20 < 35%
D
> 2% < 20 < 20 < 35%
E
Table
Table of
of Contents
Metabolic Alkalosis
• The best treatment for this patient is ………
A
A Dialysis
B 0.45 NS infusion
C
C D5W infusion
D
D 0.9 NS infusion
E D5W with 3 ampules of bicarbonate /Liter infusion
F
F No fluids – just an NG tube and anti-emetics
Table
Table of
of Contents
Metabolic Alkalosis
• Which of these best describes Bartter’s Syndrome ?
Blood K Inheritance Serum Site of action

pressure Aldosterone
High 4.0 Autosomal High DCT
A Dominant
Low 3.0 X- linked Low TALH
B
Low 3.0 Autosomal High TALH
C recessive
Low 3.0 Autosomal High DCT
D recessive
High 5.0 Autosomal High TALH
E Dominant
Table
Table of
of Contents
Metabolic Alkalosis
• Which of these best describes Liddle’s Syndrome ?

High 3.0 Autosomal Low DCT
A Dominant
B
Low 3.0 Autosomal High TALH
C Dominant
D recessive
High 3.0 Autosomal Low TALH
E Dominant
Table
Table of
of Contents
Metabolic Alkalosis
• Which of these best describes Gitelman’s Syndrome ?

Low 3.0 Autosomal Low DCT
A Recessive
B
High 3.0 Autosomal High TALH
C Dominant
D recessive
Low 3.0 Autosomal Low DCT
E recessive
Table
Table of
of Contents
Metabolic Alkalosis
• NSAIDs are best used for the treatment of which disorder………
A
A Liddle’s syndrome
B Fanconi’s syndrome
C
C Gitelman’s syndrome
D
D Bartter’s syndrome
E Type IV RTA
F
F Are you kidding ??? NSAIDs are nephrotoxic – none of the above !

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Clinical Renal Module

Self Test Review Questions

Warren Kupin MD, FACP

Back to the Question

C Etiology of renal disease

A Presence of granular casts in the urine

B Presence of hyaline casts in the urine

C Presence of white blood cell casts in the urine

D Presence of red blood cell casts in the urine

E Presence of waxy casts in the urine

A Afferent arteriole dilation

B Efferent arteriole constriction

E Increased sympathetic nerve activity

B Urine sodium < 20 meq/l

C BUN / Cr > 20:1

D Urine specific gravity < 1.010

E Bland urinary sediment

A Shifts the curve to the right

B Shifts the curve to the left

D Shifts the curve upward

E Shifts the curve downward

A Least amount of blood flow

B Highest metabolic activity

C Highest utilization of delivered oxygen

D Main site of action of angiotensin II

E Highest concentration of tubules

• He had the following urine studies done

• The specific gravity of 1.010 in this case means …………

D The presence of pre-renal azotemia

E The presence of ATN

C IV insulin and dextrose

E K+ binding oral resins

A Resting Membrane potential

C Peak level of depolaritzation

E No effect on the action potential

A Resting Membrane potential

C Peak level of depolaritzation

E No effect on the action potential

Initiating Oliguric Polyuric Initiating Injury

Polyuric Polyuric Oliguric Oliguric ATN

Oliguric Recovery Maintenance Polyuric Polyuric

Recovery Maintenance Recovery Recovery Recovery

A Dry mucous membranes

C Rapid heart rate

D Poor skin turgor

E Absent jugular venous distension

D AKI and CKD

A Normal results – repeat in 1 year

B Abnormal results – possible pre-renal azotemia – increase hydration

C Normal results – repeat in 6 months

D Abnormal results – patient has CKD

Medication Lab test

phophorous 7.5 Urine Na 40

AKI – Case Continued

A Pre- renal azotemia

D ATN superimposed on CKD

E Pre-renal azotemia superimposed on CKD

E ACEI or ARB are contraindicated in all the above situations

• Which patient has the worst kidney function ?