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Nephrology Practice Guide Questions
- A 19-year-old man is evaluated for proteinuria discovered during a routine sports preparticipation evaluation. He has been asymptomatic, has no other medical problems, and takes no medications. On physical exam, temperature is 36.6˚C, blood pressure is 110/72mmHg, pulse rate is 60/min, and respiration rate is 12/min. BMI is 18. The funduscopic, car- diopulmonary, and skin findings are normal. No peripheral edema is present. Hemoglobin: 150g/L Albumin: 41g/L Total cholesterol: 3.4mmol/L Creatinine: 61.9umol/L Glucose: 5.1mmol/L Total protein: 65g/L Spot urine protein-creatinine ratio: 0.8mg/mg Urinalysis: urine dipstick - protein 2+, blood - negative, glucose - negative, microscopic - rare hyaline cast, no cells or crystals. Which of the following is the most appropriate next diagnostic test? A) 24h urine protein excretion B) Evaluate for orthostatic proteinuria C) Kidney biopsy D) Protein electrophoresis of the serum and urine: B)
- A 62-year-old woman is evaluated for acute oliguric renal failure. She was admitted to the hospital 7 days ago for sepsis due to methicillin-sensitive Staphylococcus aureus, intravenous cefazolin was begun and she quickly im- proved. Today, her urine output is 10mL/h.
2 / 153 On physical exam, temperature is 37.5˚C, blood pressure is 138/88mmHg, pulse rate is 78/min, and respiration rate is 12/min. A macular erythematous rash is present over her anterior chest and abdomen. The remainder of the physical exam is normal. Day 1: Blood urea nitrogen: 2.9mmol/L Creatinine: 53.0umol/L Urinalysis: normal Day 7: Blood urea nitrogen: 7.1mmol/L Creatinine: 159.1umol/L Urinalysis: dipstick - pH 5, protein +1, blood - negative, microscopic - 15-20 WBC per high power field, many leukocyte casts. Urine culture: no growth Renal ultrasonography shows normal kidney size without hydronephrosis. Which of the following is the most likely diagnosis? A) Acute interstitial nephritis B) Acute tubular necrosis C) Cholesterol crystal embolization D) Prerenal azotemia: A)
- A 65-year-old man comes for a follow-up office visit. Three weeks ago, he was admitted to the hospital for deep venous thrombosis of the left leg. He was treated with low-molecular-weight heparin followed by warfarin. He takes no other medications. He has a 30- pack-year history of cigarette smoking and currently smokes two packs of cigarettes daily.
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18,400U/L INR: 1.
Complete blood count, alkaline phosphatase, bilirubin, and albumin are nor- mal. Urine dipstick is 4+ positive for occult blood, negative for erythrocytes. Blood alcohol level is 174mmol/L. Toxicology testing is positive for opiates and cocaine. Bladder catheterization reveals only 30mL of brown urine. Which of the following is the most likely cause of the acute kidney injury? A) Hemolytic anemia B) Hemolytic-uremic syndrome C) Hepatorenal syndrome D) Rhabdomyolysis: D)
- A 72-year-old man is evaluated in the ER for a 2-day history of suprapubic abdominal pin. He has had difficulty urinating for the last 6 months, including urinary frequency and difficulty starting his urinary stream. He has nocturia four to five times per night. Medical history is otherwise nonsignificant, he takes no medications. On physical exam, the patient is uncomfortable. Temperature is 37.0˚C, blood pressure is 162/90mmHg, pulse rate is 92/min, and respiration rate is 12/min. Suprapubic fullness to palpation is noted. Blood urea nitrogen: 10.7mmol/L Creatinine: 194.5umol/L Sodium: 136mmol/L Potassium: 5.2mmol/L Chloride: 100mmol/L Carbon dioxide:
5 / 153 20mmol/L Which of the following is the best diagnostic test for this patient? A) Kidney arteriography B) Kidney biopsy C) Kidney ultrasound D) Urine dipstick for protein: C)
- A 21-year-old woman is evaluated in the ER for a 2-day history of abdominal pain and bloody diarrhea. Before this episode she was healthy, and she takes no medications. On physical exam, she appears ill and pale; temperature is 38.5˚C, blood pres- sure is 97/70mmHg, pulse rate is 120/min, and respiration rate is 16/min. Bowel sounds are hyperactive, and the abdomen is tender without guarding. The remainder of the exam is normal.
7 / 153 Hemoglobin: 120g/L Leukocyte count: 8.4x 9/L Platelet count: 335x10 9/L Serum creatinine: 203.3umol/L (106.1umol/L 6 weeks ago) Urinalysis: specific gravity 1.011, pH 5.5, protein +1, no blood, 2- erythro- cytes/hpf, no leukocyte esterase.
8 / 153 Urine sediment findings are shown. Kidney ultrasound shows normal-sized kidneys and no hydronephrosis. Which of the following is the most likely cause of this patient's findings? A) Acute interstitial nephritis B) Acute tubular necrosis C) Thrombotic thrombocytopenia purpura D) Urinary tract obstruction: B)
- A 56-year-old woman is evaluated for a 1-week history of right upper-quad- rant abdominal pain, anorexia, nausea, and vomiting and a 3-day history of increasing lethargy and weakness. She also has dark-coloured urine and a decreased urine output. One year ago, she was diagnosed with stage IV breast cancer treated with mastectomy and hormonal and chemotherapy. Current medications are tamoxifen and trastuzumab. on physical exam, temperature is normal, blood pressure is 90/50mmHg, pulse rate is 100/min, and respiration rate is 18/min. Cardiopulmonary exam is nor- mal. The mucous membranes are dry. Abdominal exam reveals hepatomegaly. There is no edema. Sodium: 124mmol/L Potassium: 5.7mmol/L Chloride: 94mmol/L Bicarbonate: 12mmol/L Uric acid: 0.54mmol/L Phosphorus: 1.9mmol/L Calcium: 2.5mmol/L Blood urea nitrogen: 37.5mmol/L
10 / 153 On abdominal ultrasound, the right kidney is 9.6cm and the left kidney is 9.1cm. There is no hydronephrosis, and no renal calculi or focal solid masses are seen. There is hepatomegaly with multiple liver metastases. Which of the following is the most appropriate next management step? A) Dialysis B) Isotonic saline C) Midodrine and octreotide D) Rasburicase: B)
- A 65-year-old man with a history of stage 4 chronic kidney disease and hyper- tension comes for a follow-up exam. Two days ago, he was discharged from the hospital after a 4-day stay for pneumonia. During his hospitalization, his blood pressure averaged 130/70mmHg and he was not exposed to radiocontrast agents. He was treated with ceftrixone and azithromycin; on discharge, these agents were discontinued and he began oral levofloxacin. Since his discharge, he has had nausea, vomiting, and anorexia. He believes that his urine output over the past day has been less than 500mL. Additional medication are lisino- pril, calcium carbonate, and low- dose aspirin. On physical exam, temperature is 35.8˚C, blood pressure is 110/50mmHg standing and 100/80mmHg supine, pulse rate is 108/min standing and 96/min supine, and respiration rate is 16/min. The remainder of the exam is normal except for crackles heard at the base of the lungs bilaterally. Serum creatinine: 530.4umol/L (221.0umol/L in the hospital) Urinalysis: specific gravity 1.016, no protein or blood, occasional hyaline casts
11 / 153 Which of the following is the most likely cause of this patient's acute kidney injury? A) Acute interstitial nephritis B) Acute tubular necrosis
13 / 153 vomiting, weight loss, or itching. His medications are lisinopril, furosemide, low-dose aspirin, calcitriol, sevelamer, and ferrous
14 / 153 sulphate. He has several family members who are being evaluated as potential kidney donors. Estimated glomerular filtration rate (GFR) 2 months ago was 18mL/min/1.73m2. On physical exam, he is mentally alert. Temperature is 37.0˚C, blood pressure is 125/75mmHg, pulse rate is 75/min, and respiration rate is 14/min. Cardiac rhythm is normal without murmurs, extra sounds, or rubs. The estimated central venous pressure is 8cm H2O. The lungs are clear to auscultation. His abdominal exam is significant for large, contender bilateral flank masses. No bleeding, ecchymosis, or petechiae is evident. He scores 29/ on the Mini-Mental State Examination and no asterixis is evident. He has 1+ pretibial edema. Hemoglobin: 130g/L Albumin: 39g/L Blood urea nitrogen: 21.4mmol/L Calcium: 2.1mmol/L Creatinine: 433.1micromol/L Sodium: 140mmol/L Potassium: 5.3mmol/L Chloride: 100mmol/L Carbon dioxide: 21mmol/L Phosphorus: 1.7mmol/L Estimated GFR: 13mL/min/1.73m Which of the following is the most appropriate next step in the management of this patient's disease? A) Initiation of dialysis
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- A 35-year-old woman is evaluated for a 1-month history of progressive bilat- eral lower-extremity edema. She was diagnosed with type 1 diabetes mellitus 10 years ago. At her last office visit 4 months ago, the urine albumin-creatinine ratio was 40mg/g. Medications are enalapril, insulin glargine, insulin apart, and low- dose aspirin. On physical exam, vital signs are normal except for a blood pressure of 162/90mmHg (baseline 130/70mmHg). Cardiopulmonary and funduscopic ex- aminations are normal. There is 3+ pitting edema of the lower extremities to the level of the thighs bilaterally. HA1c: 6.8% Albumin: 30g/L Serum creatinine: 97.2umol/L Urinalysis: protein +3, blood +2, 8-10 dysmorphic erythrocytes/hpf, 2- 5 leuko- cytes/hpf, few erythrocyte casts Urine protein-creatinine ratio: 5.2mg/mg On kidney ultrasound, the right kidney is 12.2cm and the left kidney is 12.7cm. There is no hydronephrosis, and no kidney masses are seen. Which of the following is the most appropriate next step in this patient's management? A) Cytoscopy B) Kidney biopsy C) Spiral CT of the abdomen and pelvis D) Observation: B)
- A 33-year-old woman comes for follow-up examination for a left fibular fracture due to a fall 1 week ago. She has hypertension and stage 5 chronic kidney disease treated with home hemodialysis. Medications are lisinopril, sevelamer, epoetin alfa,
17 / 153 paricalcitol, and multivitamins. On physical exam, temperature is normal, blood pressure 130/70mmHg, pulse
19 / 153 C) Metabolic alkalosis and respiratory acidosis D) Respiratory acidosis and metabolic acidosis E)Simple metabolic acidosis: A)
- A 40-year-old woman is evaluated in the hospital for metabolic acidosis.
20 / 153 Arterial blood gases: pH 7.3, bicarb 36mmHg Electrolytes: Sodium: 140mmol/L Potassium: 3mmol/L Chloride: 113mmol/L Carbon dioxide: 17mmol/L Urine electrolytes: Sodium: 40mmol/L Potassium: 10mmol/L Chloride: 30mmol/L Which of the following is the most likely cause of this patient's acid- base disorder? A) Diabetic ketoacidosis B) Renal tubular acidosis C) Laxative abuse D) Viral gastroenteritis: B)
- A 61-year-old man is evaluated in the ER because of a 3-day history of cough productive of yellow sputum. He has chronic obstructive pulmonary disease and he routinely uses supplemental oxygen, 2L/min. He states that he is now short of breath at rest. Physical exam shows that he is using accessory muscles of respiration and pursed-lipped breathing. He has prolonged expiratory- to-inspiratory phase on exhalation and scattered wheezes. he has tachycardia and bilateral pitting edema of the extremities. His oxygen saturation is 91% on supplemental oxygen. Chest radiograph shows changes consistent with emphysema, but is otherwise unchanged from base- line. His arterial blood gas values
