Chronic Kidney Disease Anemia Management, Exams of Nursing

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AAFP Board Review - Renal

American Urological Association guidelines define asymptomatic microscopic hematuria as which one of the following in the absence of an obvious benign cause? (check one) A. ≥ 1 RBCs/hpf B. ≥ 3 RBCs/hpf C. ≥ 10 RBCs/hpf D. A positive dipstick reading for blood - Answer B. ≥ 3 RBCs/hpf The American Urological Association guidelines define asymptomatic microscopic hematuria (AMH) as ≥3 RBCs/hpf on a properly collected urine specimen in the absence of an obvious benign cause (SOR C). A positive dipstick does not define AMH, and evaluation should be based solely on findings from microscopic examination of urinary sediment and not on a dipstick reading. A positive dipstick reading merits microscopic examination to confirm or refute the diagnosis of AMH. A 70-year-old male sees you for a routine annual evaluation. He complains of fatigue but has no other symptoms. He has a history of hypertension but has not fully adhered to his drug regimen, which includes hydrochlorothiazide, amlodipine (Norvasc), and lisinopril (Prinivil, Zestril). Laboratory Findings Hemoglobin 9.0 g/dL (N 13.5-17.2) Serum creatinine 2.2 mg/dL (N 0.6-1.2) Glomerular filtration rate 26 mL/min/1.73 m Serum iron 30 g/dL (N 60-170) Total iron binding capacity 300 :g/dL (N 240-450) Ferritin 55 ng/mL (N 46-100) Mean corpuscular volume 77 :m3 (N 80-100)

One year ago the patient had a serum creatinine level of 2.0 mg/dL. A colonoscopy 6 months ago was unremarkable and a stool test for occult blood is negative. Which one of the following would be most appropriate at this point? (check one) A. An erythropoietin level B. Transfusion of packed RBCs C. Epoetin alfa (Procrit) D. Ferrous sulfate oral - Answer D. Ferrous sulfate orally CKD 5 Stage: Stage 1 is defined as a GFR >90 mL/min/1.73 m2, Stage 5 (kidney failure) GFR < mL/min/1.73 m2. Anemia is associated with all stages: Hgb: 13.5 g/dL in men or 12. g/dL in women. CKD anemia from decreased erythropoietin, but testing not needed, just CBC, reticulocyte, ferritin, B12, folate, transferrin serum ferritin level <25 ng/mL is indicative of low iron stores Treat: iron Patients with depleted iron stores will benefit from replenishment, which serves to correct an isolated iron orally with ferrous sulfate, 325 mg 3 times a day; repeat CBC, transferrin, ferritin in 1-3 mos For patients who do not respond to iron replacement, erythropoiesis-stimulating agents such as epoetin alfaor darbepoetin alfa should be used. The goal should be to relieve symptoms such as fatigue and to achievea hemoglobin level of 11-12 g/dL. Levels >13 g/dL increase the mortality rate, particularly from cardiovascular disease. A 72-year-old white male has new-onset hypertension with a current blood pressure of 190/110 mm Hg. Which one of the following agents can be used as part of a test for diagnosing renovascular hypertension, but would also increase the risk for azotemia if used for treatment? (check one) A. Captopril (Capoten) B. Metoprolol (Lopressor) C. Clonidine (Catapres) D. Furosemide (Lasix) E. Amlodipine (Norvasc) - Answer A. Catopril (Capoten)

• ACE inhibitors can significantly worsen renal failure in patients with hypertension caused by renovascular disease
• Captopril renography is a useful diagnostic screening test.
• Hyperkalemia is an associated problem
• other agents are safe to lower BP but raise creatinine level A 70-year-old male who recently moved to your area sees you for the first time. He has a previous history of myocardial infarction, has a pacemaker, and has hypertension that had been well controlled on hydrochlorothiazide and atenolol (Tenormin) for several years. About 6 months ago his previous physician had to add amlodipine (Norvasc) to his regimen. On examination he has mild arteriolar narrowing in his fundi and there is a

systolic bruit just to the right of his umbilicus. He has a log of home blood pressure readings that average 138/88 mm Hg for the past 2 months. His serum creatinine level has gone from 1.2 mg/dL to 1. mg/dL (N=0.6-1.2) in the past 2 months. Which one of the following would be most appropriate at this time? (check one) A. Referral for stent placement B. Scheduling an arteriogram C. A captopril renal scan D. Adding losartan (Cozaar) to his regimen E. Continued monitoring of serum cre - Answer E. Continued monitoring of serum creatinine - renal artery steosis

• 5% of patients with hypertension: in CAD/PVD, HTN w/ 4-5 meds, abd bruit, low potassium, renal insufficiency (low Cr)
• initiating therapy with an ACE inhibitor can all point toward renal artery stenosis as a diagnosis.
• if BP control esp w/ ACE/ARB, no testing needed other than watching Cr
• Catopril test not used anymore, screening tests: duplex ultrasonography, CT angiography, or MR cystography
• stenting does not help Sympathomimetic decongestants such as pseudoephedrine and phenylephrine can be problematic in elderly patients because they can (check one) A. decrease blood pressure B. cause bradycardia C. worsen existing urinary obstruction D. enhance the anticholinergic effects of other medications E. enhance the sedative effects of other medications - Answer C. worsen existing urinary obstruction Sympathomimetic agents can elevate blood pressure and intraocular pressure, may worsen existing urinary obstruction, and adversely interact with β-blockers, methyldopa, tricyclic antidepressants, oral hypoglycemic agents, and MAOIs. A 63-year-old female with community-acquired pneumonia is being treated with appropriate antibiotics. The only abnormality on a basic metabolic panel is a serum sodium level of 121 mEq/L (N 135-145). Her shortness of breath and cough are improving. She has no other complaints on a review of systems. On examination the patient is noted to have normal vital signs and mucous membranes are moist. She has crackles in her right lower lobe. Skin turgor is normal. The remainder of the physical examination is normal. Further testing reveals the following: Urine sodium.......................... 50 mEq/L Serum osmolality....................... 276 mOsm/kg (N 280-285) Urine osmolality....................... ..300 mOsm/kg

Which one of the following would be most appropriate at this point? (check one) A. Intravenous diuretics B. Intravenous hypertonic saline - Answer D. Fluid restriction Her urine sodium is high and her urine osmolality is low = syndrome of inappropriate secretion of antidiuretic hormone (SIADH) This is most likely related to her pneumonia, which is improving. A 66-year-old male has hypertension that has become difficult to manage after several years of good control on a stable medical regimen. On evaluation, his BUN level is 40 mg/dL (N 8-25) and his serum creatinine level is 2.1 mg/dL (N 0.6-1.5). Which one of the following tests would be best to evaluate this patient for renovascular hypertension? (check one) A. Duplex Doppler ultrasonography B. CT angiography C. Aortography D. Captopril (Capoten) renography - Answer A. Duplex Doppler ultrasonography

• Tests involving intravenous radiographic contrast material may cause deterioration in renal function. - Captopril renography: not reliable in the setting of poor renal function.
• Magnetic resonance angiography also could be considered: gadolinium contrast agents and nephrogenic systemic fibrosis in patients with renal dysfunction is a concern Which one of the following is a common cause of prerenal acute kidney injury? (check one) A. Acute tubular necrosis B. Diuretic overuse C. Glomerulonephritis D. Neurogenic bladder E. Prostate hypertrophy - Answer B. Diuretic overuse A 72-year-old female with longstanding diabetes mellitus presents to your office. During the review of systems, she complains of difficulty voiding and frequent "dribbling." A urinalysis is negative for infection and her post-void residual volume is 250 mL. Which one of the following is the most likely cause of this patient's urinary incontinence? (check one) A. Excess urine output due to hyperglycemia B. Atrophic vaginitis C. A grade II cystocele D. Asymptomatic bacteriuria E. Autonomic neuropathy - Answer E. Autonomic neuropathy
• Dribbling and increased post-void residual volume (>100 mL) are signs of overflow incontinence.
• Overflow incontinence can be caused by outflow obstruction (e.g., prostate hypertrophy, urethral constriction, fecal impaction)
• or by detrusor muscle denervation caused by diabetic or other neuropathies. not Excess urine output from hyperglycemia

• urgency not Atrophic vaginitis and cystoceles
• stress incontinence Not Asymptomatic bacteriuria
• no infection A 55-year-old female sees you because of a constant leakage of small amounts of urine. Her obstetric/gynecologic history includes two pregnancies, with vaginal deliveries. Her current medications include hydrochlorothiazide, metformin (Glucophage), and glyburide (DiaBeta). On examination she has mild diabetic retinopathy, decreased sensation to monofilament testing on her feet, and suprapubic fullness. The most appropriate initial treatment for this problem would be: (check one) A. tolterodine (Detrol LA) B. duloxetine (Cymbalta) C. estrogen replacement therapy D. bladder neck needle suspension E. a set schedule for urination - Answer E. A set schedule for urination - Neurogenic bladder
• can be caused by diabetes mellitus, multiple sclerosis, or spinal cord injury
• usually initially treated with a strict voluntary urination schedule, which may be coupled with Crede's maneuver.
• also adding bethanechol to the regimen
• intermittent self-catheterization of the bladder.
• Ultimately, the patient may require resection of the internal sphincter of the bladder neck. 4 types of urinary incontinence in women:

1. functional incontinence

• the patient's inability to ambulate or transfer results in loss of urine

2. urinary stress incontinence

• pelvic relaxation and is manifested as involuntary loss of urine with increases in abdominal pressure such as that which occurs with laughing, sneezing, or coughing

3. detrusor instability or overactive bladder

• urge to urinate is quickly followed by loss of urine, usually a large volume

4. neurogenic bladder, which is marked by constant leakage of small amounts of urine. A 44-year-old female is distressed because of incontinence. She reports frequent episodes of an immediate need to urinate, which cannot always be deferred. She admits to urinating more than 10 times a day, but denies any urine leakage with coughing, laughing, or straining. Which one of the following is the most appropriate initial treatment for this patient? (check one) A. Solifenacin (Vesicare) B. Oxybutynin (Ditropan XL) C. Tamsulosin (Flomax) D. Phenazopyridine (Pyridium)

E. Pelvic floor muscle training and bladder training - Answer E. Pelvic floor muscle and bladder training

• effective in urge incontinence or overactive bladder, as well as in stress and mixed incontinence
• In motivated patients, training may be more effective than medications such as oxybutynin and newer muscarinic receptor antagonists such as solifenacin.
• Tamsulosin is used in benign prostatic hypertrophy and phenazopyridine is a urinary tract anesthetic that has not been recommended for treating overactive bladder. A 70-year-old male presents to your office for a follow-up visit for hypertension. He was started on lisinopril (Prinivil, Zestril), 20 mg daily, 1 month ago. Laboratory tests from his last visit, including a CBC and a complete metabolic panel, were normal except for a serum creatinine level of 1.5 mg/dL (N 0.6-1.5). A follow-up renal panel obtained yesterday shows a creatinine level of 3.2 mg/dL and a BUN of 34 mg/dL (N 8-25). Which one of the following is the most likely cause of this patient's increased creatinine level? (check one) A. Bilateral renal artery stenosis B. Coarctation of the aorta C. Essential hypertension D. Hyperaldosteronism E. Pheochromocytoma - Answer A. Bilateral renal artery stenosis Classic clinical clues:

1. onset of stage 2 hypertension (blood pressure >160/100 mm Hg) after 50 years of age or no family history of hypertension
2. hypertension associated with renal insufficiency, especially if renal function worsens after the administration of an agent that blocks the renin-angiotensin-aldosterone system
3. hypertension with repeated hospital admissions for heart failure
4. drug-resistant hypertension (defined as blood pressure above the goal despite treatment with three drugs of different classes at optimal doses).

• The other conditions mentioned do not cause a significant rise in serum creatinine after treatment with an ACE inhibitor. A 48-year-old female with type 2 diabetes has been hospitalized for 4 days with persistent fever. Her diabetes has been controlled with diet and glyburide (Micronase, DiaBeta). You saw her 2 weeks ago in the office with urinary frequency, urgency, and dysuria. At that time a urinalysis showed 25 WBCs/hpf, and a urine culture subsequently grew Escherichia coli sensitive to all antibiotics. She was placed on trimethoprim/sulfamethoxazole (Bactrim, Septra) empirically, and this was continued after the culture results were reported. She improved over the next week, but then developed flank pain, fever to 39.5°C (103.1°F), and nausea and vomiting. She was hospitalized and intravenous cefazolin (Kefzol) and gentamicin were started while blood and urine cultures were performed. This urine culture also grew E. coli sensitive to the current antibiotics. Her temperature

has continued to spike to 39.5°C since admission, withou - Answer E. Order CT of the abdomen - Perinephric abscess

• collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota's fascia.
• Mortality rates 50% have been reported, usually from failure to diagnose the problem in a timely fashion
• The difficulty in making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes indolent course of this disease.
• The diagnosis should be considered when a patient has fever and persistence of flank pain.
• Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction.
• Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk.
• persistence of fever for more than 4 days after initiation of antibiotic therapy.
• CT. This can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic).
• Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition. A 77-year-old white male complains of urinary incontinence of more than one year's duration. The incontinence occurs with sudden urgency. No association with coughing or positional change has been noted, and there is no history of fever or dysuria. He underwent transurethral resection of the prostate (TURP) for benign prostatic hypertrophy a year ago, and he says his urinary stream has improved. A rectal examination reveals a smoothly enlarged prostate without nodularity, and normal sphincter tone. No residual urine is found with post-void catheterization. Which one of the following is the most likely cause of this patient's incontinence? (check one) A. Detrusor instability B. Urinary tract infection C. Overflow D. Fecal impaction E. Recurrent bladder outlet obstruction - Answer A. Detrusor instability most common cause of urinary incontinence in both men and women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy. Not UTI - no fever Not overflow - no residual urine Not outlet obstruction - urine stream ok, no residual urine A 72-year-old white female who is otherwise healthy complains of occasional incontinence. She reports that this occurs mainly at night when she awakens with an intense desire to void, and by the time she is able to get to the bathroom she has "wet herself." The most likely diagnosis is: (check one) A. Sphincter incompetence

B. Detrusor instability C. Detrusor hypotonia D. Uninhibited neurogenic bladder - Answer B. Detrusor instability

• uninhibited contractions of the detrusor muscle.
• causes an intense urge to void, which overcomes the patient's voluntary attempt to hold the sphincter closed
• hence, the common term urge incontinence. -Other common causes of incontinence:
• weak sphincter (sphincter incompetence), which leads to leakage associated with ordinary activities such as coughing or lifting (stress incontinence)
• overflow of urine from an abnormally distended, hypotonic, poorly contractile bladder (detrusor hypotonia).
• more common in males with longstanding obstruction due to prostatic hypertrophy. Spinal cord damage (rare)
• reflex incontinence
• patient unable to sense the need to void. A 70-year-old white female complains of two episodes of urinary incontinence. On both occasions she was unable to reach a bathroom in time to prevent loss of urine. The first episode occurred when she was in her car and the second while she was in a shopping mall. She is reluctant to go out because of this problem. The most likely cause of her problem is: (check one) A. overflow incontinence B. stress incontinence C. urge incontinence D. functional incontinence - Answer C. urge incontinence
• when patients sense the urge to void but are unable to inhibit leakage long enough to reach the toilet
• treatment: 1st behavioral, then anticholinergics Overflow incontinence
• when the bladder cannot empty normally and becomes overdistended Functional incontinence
• lower urinary tract function is intact but other factors such as immobility and severe cognitive impairment lead to incontinence. Which one of the following is the best radiographic test for confirming the diagnosis of renal colic? (check one) A. A KUB radiograph B. Ultrasonography C. CT D. Intravenous pyelography E. MRI - Answer C. CT - renal colic. Noncalcium stones may be missed by plain radiography but visualized by CT. MRI is a poor tool for visualizing stones.

A 45-year-old white male presents with severe intermittent right flank pain that radiates into his right groin area. You suspect a ureteral stone. Which one of the following would most reliably confirm your suspected diagnosis? (check one) A. A helical CT scan of the abdomen and pelvis without contrast B. Intravenous pyelography C. Abdominal ultrasonography D. A KUB plain film of the abdomen E. A urinalysis - Answer A. An unenhanced helical CT scan of the abdomen and pelvis

• A CT scan may also reveal other pathology, such as appendicitis, diverticulitis, or abdominal aortic aneurysm. Not abdominal ultrasonography
• sensitivity is much lower; thus, its use is usually confined to pregnant patients with a suspected stone. Not X-ray -only show with radiopaque stones For which type of renal calculus is acidification of the urine indicated? (check one) A. Cystine B. Uric acid C C. Calcium oxalate D. Calcium phosphate - Answer D. Calcium phosphate
• Urine should be acidified for prevention of calcium phosphate and struvite stones. Cranberry juice or betaine can lower urine pH
• Uric acid, cystine, and calcium oxalate stones tend to form in acidic urine
• struvite (magnesium ammonium phosphate) and calcium phosphate stones form in alkaline urine. A 44-year-old male sees you for evaluation of an episode of pink-tinged urine last week. He denies any flank or abdominal pain, as well as frequency, urgency, and dysuria. He has no prior history of renal or other urologic disease, and no other significant medical problems. He has a 24-pack-year smoking history. A urinalysis today reveals 8- RBCs/hpf. You refer him to a urologist for cystoscopy. Which one of the following would be the most appropriate additional evaluation? (check one) A. KUB radiography B. Transabdominal ultrasonography C. Voiding cystourethrography D. CT urography E. Magnetic resonance urography - Answer D. CT urography
• or intravenous pyelography is recommended by the American College of Radiology as the most appropriate imaging procedure for hematuria in all patients
• with the exception of those with generalized renal parenchymal disease, young women with hemorrhagic cystitis, children, and pregnant females.

A 45-year-old male sees you for follow-up after a pre-employment physical examination reveals blood in his urine. He brings a copy of a urinalysis report that shows 3- RBCs/hpf. He has not seen any gross blood himself. He is asymptomatic, is on no medications, and does not smoke. You perform a physical examination, with normal findings. A repeat urinalysis confirms the presence of red blood cells but is otherwise normal. Which one of the following would be most appropriate at this point? (check one) A. Observation and reassurance B. A repeat urinalysis in 6 months C. Urine cytology only D. Ultrasonography of the kidneys and urine cytology only E. Ultrasonography of the kidneys, urine cytology, and cystoscopy - Answer E. Ultrasound of kidneys, urine cytology, cystoscopy

• significant microscopic hematuria = ≥3 RBCs/hpf. - may be associated with urologic malignancy in up to 10% of adults.
• to exam upper urinary tract: no clear guidelines so intravenous urography, ultrasonography, or CT can be considered.
• to exam lower urinary tract: urine cytology and cystoscopy
• The AUA recommends that patients with microscopic hematuria have radiographic assessment of the upper urinary tract, followed by urine cytology studies.
• The AUA also recommends that all patients older than 40 and those who are younger but have risk factors for bladder cancer undergo cystoscopy to complete the evaluation.
• Cystoscopy is the only reliable method of detecting transitional cell carcinoma of the bladder and urethra. The test of choice for immediate evaluation of an acutely swollen scrotum is: (check one) A. a pelvic radiograph B. radionuclide imaging C. color Doppler ultrasonography D. CT E. MRI - Answer C. color doppler ultrasound
• avoid damage such as testicular torsion, or of life-threatening diseases such as testicular carcinoma.
• Color Doppler ultrasonography is the test of choice for immediate evaluation of scrotal masses (SOR B) because it can be done quickly and has a high sensitivity (86%-88%) and specificity (90%-100%) for detecting testicular torsion, which is a surgical emergency Not Radionuclide imaging
• involves too much of a time delay to be useful. Not CT and MRI
• only if ultrasonography is inconclusive or carcinoma is suspected
• useful for staging testicular tumors Not Pelvic radiographs
• not for scrotal masses. A 56-year-old male with diabetes mellitus, hypertension, and chronic renal insufficiency presents for follow-up of his chronic medical conditions. Results of his most recent

metabolic panel included an estimated glomerular filtration rate of 30 mL/min/1.73 m (N >60) and a calcium level of 10.4 mg/dL (N 8.5-10.2). Medication reconciliation reveals he is not taking the sevelamer (Renagel, Renvela) prescribed by the consulting nephrologist. You explain to the patient that he should be taking sevelamer to lower his serum calcium. The drug accomplishes this by? (check one) A. Blocking the effect of parathyroid hormone B. Blocking excessive vitamin D levels, thus decreasing intestinal calcium absorption and increasing renal calcium excretion C. Blocking intestinal absorption of phosphate, which lowers parathyroid hormone secretion D. Directly blocking excessive calcium absorption in the intestines E. Directly i - Answer C. Blocking intestinal absorption of phosphate

• Sevelamer is a newer synthetic agent in the therapeutic class of phosphate binders, which includes calcium acetate
• Decreasing serum phosphate lowers the feedback stimulation of parathyroid hormone secretion by the parathyroid gland, which is often excessive in chronic renal insufficiency. Normalizing parathyroid levels improves serum calcium levels. A 56-year-old male with a history of nephrolithiasis presents with a complaint of right flank pain. Further evaluation reveals a right ureteral calculus 4 mm in diameter. Laboratory tests reveal a serum calcium level of 12.1 mg/dL (N 8.5-10.5), a normal albumin level, and normal kidney and liver function tests. The patient takes no chronic medications. Which one of the following is most likely to reveal the cause of this patient's elevated calcium? (check one) A. A 24-hour urine calcium level B. A repeat serum calcium level in 4-6 weeks C. A serum 25-hydroxyvitamin D level D. A serum calcitonin level E. A serum intact parathyroid hormone level - Answer E. serum PTH level - Primary hyperparathyroidism and malignancy are the most common causes of hypercalcemia, accounting for about 90% of cases. - An intact parathyroid hormone (PTH) level should be obtained initially, as the results will indicate what kind of additional evaluation is needed. Not vitamin D and urine calcium studies
• useful in evaluating hypercalcemia
• but a PTH level should be obtained first. Not be appropriate to wait 4-6 weeks
• because this patient has nephrolithiasis and a calcium level 12 mg/dL i.e. need surgery Not Calcitonin levels
• not needed

Which one of the following is the best INITIAL management for hypercalcemic crisis? (check one) A. Intravenous furosemide B. Intravenous pamidronate (Aredia) C. Intravenous plicamycin (Mithramycin) D. Intravenous saline - Answer D. IV saline The initial management of hypercalcemic crisis involves volume repletion and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels over 14-15 mg/dL A 69-year-old female is unable to obtain adequate calcium from dietary sources. She is on long-term therapy with pantoprazole (Protonix) for peptic ulcer disease. Which one of the following would be the most appropriate calcium supplement for this patient? (check one) A. Oyster shell calcium B. Calcium carbonate C. Calcium lactate D. Calcium gluconate E. Calcium citrate - Answer E. Calcium citrate

• does not depend on stomach acid for absorption A 75-year-old female is admitted to the hospital with a change in mental status. The initial workup includes a chemistry profile that reveals a plasma potassium level of 6. mEq/L (N 3.7-5.2). Which one of the following should be given now to rapidly lower the plasma potassium level? (check one) A. Corticosteroids B. Albuterol C. Furosemide (Lasix) D. 0.45% saline - Answer B. Albuterol
• Severe hyperkalemia (>7.0 mEq/L) requires aggressive treatment.
• Calcium chloride or gluconate has no effect on the plasma potassium level, but it should be given first, as it rapidly stabilizes the membranes of cardiac myocytes, reducing the risk of cardiac dysrhythmias.
• Therapies that translocate potassium from the serum to the intracellular space should be instituted next, as they can quickly (albeit temporarily) lower the plasma concentration of potassium.
• These interventions include sodium bicarbonate, glucose with

1. insulin
2. albuterol. Total body potassium can be lowered with sodium polystyrene sulfonate, but this takes longer to affect the plasma potassium level than translocation methods. In the most severe cases, acute hemodialysis can be instituted. Which one of the following medications is most likely to cause hypokalemia? (check one)

A. Albuterol (Proventil, Ventolin) B. Doxazosin (Cardura) C. Erythromycin D. Felodipine (Plendil) E. Lisinopril (Prinivil, Zestril) - Answer A. Albuterol (Proventil, Ventolin) β-Agonists activate potassium uptake by the cells. This includes bronchodilators and tocolytic agents. Other agents that can induce hypokalemia include pseudoephedrine and insulin. Diuretics, particularly thiazides, can also cause hypokalemia as a result of the renal loss of potassium. A 55-year-old male is brought to the emergency department because of confusion and seizures. He has a history of hypertension and obstructive sleep apnea due to obesity. He is not conscious and no other history is available. An examination shows no focal neurologic findings, but a general examination is limited because of his size. Breath sounds are diminished, and heart sounds are difficult to hear. He has venous insufficiency changes on his lower extremities, with brawny-type edema. Laboratory testing reveals a sodium level of 116 mmol/L (N 135-145), but normal renal and liver functions. A chest radiograph shows mild cardiomegaly. A BNP level is pending, but immediate treatment is felt to be indicated. Which one of the following is the treatment of choice for this patient? (check one) A. Valsartan (Diovan) B. Furosemide C. Vasopressin (Pitressin) D. Hypertonic saline E. Conivaptan (Vaprisol) - Answer D. Hypertonic saline - severe hyponatremia manifested by confusion and seizures, a life-threatening situation warranting urgent treatment with hypertonic (3%) saline.

• The serum sodium level should be raised by only 1-2 mmol/L per hour, to prevent serious neurologic complications
• Saline should be used only until the seizures stop
• Some authorities recommend concomitant use of furosemide, especially in patients who are likely to be volume overloaded, as this patient is, but it should not be used alone.
• The arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic or hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or who are having seizures. A 45-year-old male was admitted to the hospital for nausea resulting from chemotherapy for colon cancer. He has no other chronic diseases and takes no routine medications. He was mildly dehydrated on admission and has been receiving intravenous fluids (D5 ½-normal saline with potassium chloride) at slightly higher than maintenance rates through an indwelling port for the last 24 hours. The nausea is being controlled by antiemetics, and his condition is improving. Results of routine blood work at the time of admission and from the following morning are shown below.

Admission Following Morning Glucose 109 mg/dL (N 65-110) 371 mg/dL BUN 13 mg/dL (N 7-21) 9 mg/dL Creatinine 0.9 mg/dL (N 0.6-1.6) 0.9 mg/dL Sodium 143 mmol/L (N 136-144) 129 mmol/L Potassium 3.7 mmol/L (N 3.6-5.1) 6.6 mmol/L Chloride 110 mmol/L (N 101-111) 108 mmol/L Total CO2 20 mmol/L (N 22-32) 22 mmol/L Which one of the following would be the most app - Answer B. order blood work from peripheral vein

• Patient's condition is improving but his lab is out of range
• his sugar is 371 but he has no diabetes, his potassium is so high he should be symptomatic
• likely the blood is from indwelling catheter w/out discarding the first few c.c. You are evaluating a 68-year-old male with obstructive urinary symptoms. Which one of the following medications may lead to falsely depressed levels of prostate-specific antigen (PSA)? (check one) A. Terazosin (Hytrin) B. Finasteride (Proscar) C. Tamsulosin (Flomax) D. Doxazosin (Cardura) E. Lycopene - Answer B. Finasteride (Proscar) Which one of the following is the most common secondary cause of nephrotic syndrome in adults? (check one) A. Diabetes mellitus B. Systemic lupus erythematosus C. Hepatitis D. NSAIDs E. Multiple myeloma - Answer A. Diabetes mellitus The most common cause of acute interstitial nephritis is: (check one) A. hypertension B. pyelonephritis C. collagen vascular disease D. dehydration E. hypersensitivity to medications - Answer E. hypersensitivity to medications - 85% of cases
• other cases are due to mechanisms such as an immunologic response to infection or an idiopathic immune syndrome
• Hypertension and dehydration do not cause interstitial nephritis.

A 62-year-old male is admitted to the hospital with acute renal failure. A renal biopsy confirms the diagnosis of acute interstitial nephritis (AIN). Infection and immune- associated causes are ruled out, and you consider medications as a potential cause. Which one of the following would be most likely to cause AIN? (check one) A. Chronic daily use of metoprolol (Lopressor) B. Twice-daily use of ibuprofen for 2 weeks C. Initiation of lisinopril (Prinivil, Zestril) therapy 1 week ago D. A 5-day course of azithromycin (Zithromax) 6 months ago E. Intermittent use of acetaminophen, up to 4 g/day - Answer B. Twice daily use of ibuprofen x 2 wks

• all NSAIDs are known to be associated with AIN
• usually approximately 2 weeks after starting a medication and is not dose-related.
• Other medications strongly associated with AIN include various antibiotics (particularly cephalosporins, penicillins, sulfonamides, aminoglycosides, and rifampin), diuretics, and miscellaneous medications such as allopurinol. The most common cause of proteinuria in children is: (check one) A. Acute postinfectious glomerulonephritis B. Lupus glomerulonephritis C. Hydronephrosis D. Orthostatic proteinuria E. Reflux nephropathy - Answer D. Orthostatic proteinuria accounts for up to 60% of all cases of asymptomatic proteinuria reported in children, with an even higher incidence in adolescents. A 25-year-old male who came to your office for a pre-employment physical examination is found to have 2+ protein on a dipstick urine test. You repeat the examination three times within the next month and results are still positive. Results of a 24-hour urine collection show protein excretion of <2 g/day and normal creatinine clearance. As part of his further evaluation you obtain split urine collections with a 16-hour daytime specimen containing an increased concentration of protein, and an 8-hour overnight specimen that is normal. Additional appropriate evaluation for this man's problem at this time includes which one of the following? (check one) A. Serum and urine protein electrophoresis B. Antinuclear antibody C. Serum albumin and lipid levels D. Renal ultrasonography E. No specific additional testing - Answer E. No more testing
• Persons younger than 30 years of age who excrete less than 2 g of protein per day and who have a normal creatinine clearance should be tested for orthostatic proteinuria
• This benign condition occurs in about 3%-5% of adolescents and young adults.
• increased protein excretion in the upright position, but normal protein excretion when the patient is supine.
• diagnosed using split urine collections as described in the question (daytime vs night)

• a benign condition with normal renal function, no further evaluation is necessary. During a comprehensive health evaluation a 65-year-old African-American male reports mild, very tolerable symptoms of benign prostatic hyperplasia, rated as a score of 7 on the American Urological Association Symptom Index. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8ng/mL. Based on current evidence, which one of the following treatment options is most appropriate at this time? (check one) A. Observation, with repeat evaluation in 1 year B. Saw palmetto C. An α-receptor antagonist D. A 5-α-reductase inhibitor - Answer A. Observation, with repeat in 1 year - mild benign prostatic hyperplasia (BPH). 5 alpha-reductase inhibitors
• PSA levels >2.0 ng/mL for men in their 60s (correlate with a prostatic volume >40 mL) Alpha antagonist
• for severe symptoms A 72-year-old female is admitted to the hospital after having surgery for a hip fracture. Her previous medical history is significant for hypertension and type 2 diabetes mellitus. Two days after admission the orthopedic surgeon consults with you because the patient has had several hours of fever to 39°C (102°F); tachycardia, with a pulse rate of 120 beats/min; and systolic blood pressures of 91-97 mm Hg (baseline 120-140 mm Hg with medication). When you examine the patient she says she feels weak and chilled but she is alert. Her oxygen saturation is excellent on room air, and a physical examination is normal except for the sinus tachycardia and low blood pressure. A urinary catheter is in place, but there has been little output over the last 4 hours. Her renal function was normal prior to her hospitalization. A chest radiograph is normal. Her electrolyte levels are normal, but laboratory tests reveal the follow - Answer A. high rate IV fluid - sepsis syndrome due to urinary infection.
• The renal failure that has resulted is almost certainly due to low perfusion of the kidneys (prerenal azotemia).
• This condition requires aggressive intravenous fluids to halt and reverse the reduction in nephrologic function.
• underperfusion can result in acute tubular necrosis (an intrinsic renal dysfunction) that may prevent excretion of any excess fluid, so the patient's fluid status should be monitored carefully. - Metabolic acidosis will likely reverse with appropriate hydration, and sodium bicarbonate should be reserved for severe acidosis (<10-15 mmol/L) or for those with chronic kidney disease. Not Low-dose dopamine

• proven to be ineffective in acute renal failure, and this patient does not have an indication for dialysis. Not Intravenous furosemide
• contraindicate A 45-year-old white male is admitted to the intensive-care unit after being pinned in a car wreck for 2 hours. He has sustained several broken bones and crush injuries to both thighs. On admission his urine is clear but the next morning it is burgundy colored. Some fresh urine is drawn from his Foley catheter and sent for analysis, with the following results: Specific gravity............1. pH............6. Protein............30 mg/dL (N 1-14) Glucose............negative Hemoglobin............4+ Urobilinogen............0.1 Ehrlich Units (N 0.1-1.0) Bile............negative RBCs............1-2/hpf WBCs............0-2/hpf Occasional hyaline casts You immediately order a CBC which shows his hematocrit to have dropped 4 percentage points overnight. Visual inspection of the serum shows it is light yellow. The color of his urine is most likely due to (check one) A. myoglobinuria B. hematuria from trauma to the ur - Answer A. myoglobinemia - from broken down muscle
• A positive dipstick for hemoglobin without any RBCs in the urine sediment = free hemoglobin or myoglobin in the urine
• fresh sample so significant RBC hemolysis within the urine would not be expected Not transfusion reaction
• haptoglobin binds enough hemoglobin to turn serum pink
• Only when haptoglobin is saturated will the free hemoglobin be excreted in the urine. Not trauma
• there would be many RBCs visible on microscopic examination of the urine. Not Free hemoglobin resorption
• does not occur Not Porphyria
• urine maybe be burgundy colored
• not associated with a positive urine test for hemoglobin A 72-year-old male with a serum creatinine level of 1.8 mg/dL (N 0.6-1.5) requires a contrast dye study. Which one of the following is most effective when given prior to the

administration of contrast to reduce the risk for contrast-induced renal failure? (check one) A. N-acetylcysteine B. Mannitol C. Furosemide (Lasix) D. Methylprednisolone sodium succinate (Solu-Medrol) E. Diphenhydramine (Benadryl) Correct. - Answer A. N-acetylcysteine Current methods for reducing the risk of renal failure induced by contrast material include adequate hydration and the use of N-acetylcysteine. Neither mannitol nor furosemide has been shown to prevent contrast-induced renal failure. Corticosteroids and antihistamines are useful for the prevention of idiosyncratic reactions to contrast, but are not helpful in reducing the risk of renal failure.