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Nephrology Test For R2 Board Exam..

1. A 60-year-old man presents to the ED with a 6-week history of fatigue, myalgias, weight loss, and shortness of breath. Past medical history is significant for hypertension for 10 years. Urine output and blood pressure are normal. There is no skin rash, hepatomegaly, splenomegaly, or peripheral edema.

1. Laboratory testing reveals a hemoglobin level of 10 g/dL (normal, 13-18 g/dL), BUN of 68 mg/dL, and serum creatinine level of 4.5 mg/dL. Serum electrolytes are normal. Serum creatinine 1 year ago was 0.9 mg/dL. Urinalysis shows 2+ protein, 15 to 20 red blood cells, 5 to 10 white blood cells, and a few erythrocyte casts and granular casts per high-power field. Complement levels are normal. Ultrasound of the kidneys reveals 11cm kidneys bilaterally with no hydronephrosis.

1. Chest radiograph reveals patchy infiltrates in both lungs suggestive of bilateral multilobar pneumonia. The patient received 2 L of normal saline with no improvement in serum creatinine. Results of testing for serum antiGBM antibodies, ANCA, and antinuclear antibody, serum protein electrophoresis, and urine electrophoresis are pending. What is the next step in the management of this patient?

1.A. B. C. D. Emergent renal biopsy Lung biopsy Nasal and sinus biopsies Wait for results of serologic testing and continue supportive therapy

RPGN Anti-GBM Immune-complex mediated GN IgA nephropathy MPGN APSGN LN Cryoglobulinemia Pauci-immune GN (ANCA-associated)

2. A 37-year-old man presents to the ED with painless swelling in both ankles and a 10lb weight gain over the past 3 months. During a physical examination 1 year prior, 2+ protein was noted on dipstick urinalysis, but the patient denied further evaluation because he felt well. There is no family history of renal disease.

2. Blood pressure is 120/80 mm Hg. Physical examination is notable for edema in his legs up to the mid thighs. Laboratory testing reveals a hemoglobin level of 14 g/dL, hematocrit of 42%, serum glucose level of 80 mg/dL, serum creatinine level of 1.1 mg/dL, BUN of 28 mg/dL, albumin level of 2.6 g/dL, serum total cholesterol level of 325 mg/dL (normal, < 200 mg/dL), and serum triglyceride level of 800 mg/dL (normal, < 160 mg/dL)..

2. Serum complement levels are within normal limits. Urinalysis demonstrates 4+ protein on dipstick. Urine microscopy reveals 0 to 2 erythrocytes, hyaline casts, oval fat bodies, and fatty casts. A spot protein/creatinine ratio is 6 g/mg. The patient undergoes a renal biopsy What is the most likely biopsy finding?

2.A. B. C. D. Acute postinfectious glomerulonephritis Alport s syndrome Crescentic glomerulonephritis Membranous nephropathy

Nephrotic syndrome IgM nephropathy Membranous nephropathy FSGS Minimal change disease Infection Drugs Tumor LN Amyloidosis

3. Renal biopsy results are as suspected. A careful inquiry into the use of nonsteroidal anti-inflammatory drugs and other drugs is negative. Serologic testing for hepatitis B and C is negative. An age-appropriate work-up for malignancy is negative. What is the next step in this patients management?

3.A. Furosemide and an angiotensinconverting enzyme (ACE) inhibitor B. Monthly albumin infusions C. Oral prednisone D. Warfarin

Secondary MN Drugs Infection Malignancy LN

Primary membranous nephropathy ACEI/ARB Look proteinuria < 4 gm/day : wait and see 4 8 gm/day > 6 months : treat > 8 gm/day > 3 months : treat Cr rising : treat Renal vein thrombosis : treat

4. A 36-year-old Asian man with a history of asthma presents with a complaint of red urine. He describes 5 days of nasal congestion and dry cough. He notes no sore throat, fever, chills, myalgias, arthralgias, or flank pain. He has no family history of renal disease.

4. A urine study indicates 1+ protein, and no bacteria, leukocyte esterase, or nitrates. Thirty to 50 erythrocytes are observed, but no leukocytes are present. His serum creatinine level is normal. Which one of the following is the most likely diagnosis?

4.A. B. C. D. E. IgA nephropathy Nephrolithiasis Transitional cell carcinoma of the bladder Wegener s granulomatosis Postinfectious glomerulonephritis

5. A 64-year-old Caucasian man with a history of hypertension, hyperlipidemia, and nephrolithiasis presents with a complaint of dark-colored urine. He felt well until 2 days ago when he noted increasing fatigue and muscle weakness. Dipstick urinalysis shows a specific gravity of 1.020, no protein, and large blood. Neither leukocyte esterase nor nitrates are identified in the urine. The sediment reveals no erythrocytes or leukocytes. Which of the following diagnostic procedures is appropriate at this point?

5.A. Cystoscopy to evaluate for urologic cancer B. Flank computed tomography (CT) to evaluate for recurrent nephrolithiasis C. Kidney biopsy to delineate the disease process D. Serum analysis to evaluate the level ofcreatine phosphokinase (CPK)

Dont use with statin Erythromycin Clarithromycin Protease inhibitor Ketoconazole Itraconazole Posaconazole Gemfibrozil Cyclosporin A Danazol

Caution of simvastatin dosage 10 mg Amiodarone Diltiazem Verapamil 20 mg Amlodipine

6. A 15-year-old boy is evaluated for hypertension after his blood pressure was elevated on multiple occasions. He also reports generalized weakness and fatigue. His family history is positive for hypertension. Physical examination reveals a blood pressure of 185/110 mm Hg and a pulse of 91 bpm. Heart, lung, abdominal, and extremity examinations are unremarkable. The patient has no thyromegaly or abdominal/flank bruits.

6. Results of a laboratory evaluation are as follows: serum sodium, 140 mEq/L; serum potassium, 2.1 mEq/L; serum chloride, 98 mEq/L; serum bicarbonate, 34 mEq/L; thyrotropin, 2.5 U/mL; free thyroxine, 1.3 ng/dL; plasma renin activity (supine), 0.15 ng/mL/hour; plasma renin activity (upright), 0.2 ng/mL/hour; plasma aldosterone (supine), 2.1 ng/ dL; plasma aldosterone (upright), 2.4 ng/dL; urine aldosterone, 5 g/24 hours; urine potassium, 54 mEq/L. Which of the following is the most likely etiology of severe hypokalemia and hypertension in this patient?

6.A. Adrenal adenoma B. Fibromuscular dysplasia of the renal arteries C. Glucocorticoid remediable aldosteronism D. Liddle s syndrome

hypoK and met. alkalosis Renin , aldosterone Renin secreting tumor, renal artery stenosis, malignant hypertension Renin , aldosterone Primary hyperaldosteronism, GRA Renin , aldosterone Cushing syndrome, nonmineralocorticoid excess, Liddle syndrome, AME, CAH

7. An 80-year-old woman with a history of depression presents to the emergency department (ED) with weakness and dizziness. She takes furosemide 20 mg daily for lower extremity edema. She reports that her primary care physician prescribed hydrochlorothiazide for elevated blood pressure 1 week ago. The patient denies fevers, chills, nausea, or vomiting. She claims to be more thirsty than usual and has been drinking apple juice in response.

7. Her blood pressure is 100/60 mm Hg lying down and 84/40 mm Hg sitting, and her weight is 60 kg. Lungs are clear with no lower extremity edema. Laboratory studies reveal a serum osmolality of 260 mOsm/kg, serum sodium of 125 mEq/L (normal, 135-154 mEq/L), serum potassium of 3.4 mEq/L (normal, 3.5-5.0 mEq/L), and serum creatinine level of 0.8 mg/dL (normal, 0.6-1.2 mg/dL). Urinalysis reveals a sodium level of 50 mEq/L (normal, 0-300 mEq/L) and urine osmolality of 200 mOsm/kg

7. Which of the following is this patients most likely diagnosis? A. Adrenal insufficiency B. Furosemide-induced hyponatremia C. Hydrochlorothiazide-induced hyponatremia D. Syndrome of inappropriate antidiuretic hormone (SIADH) E. Thyroid disease

8. A 28-year-old obese woman presents to her doctors office with persistent headache and malaise. She is otherwise healthy. Blood pressure measured in the office is 190/110 mm Hg. Serum electrolytes demonstrate hypokalemia (serum potassium, 3.0 mEq/ L) and metabolic alkalosis (serum bicarbonate,32 mEq/L) with normal kidney function. Urinalysis reveals no proteinuria, cylinduria, or casts.

8. A secondary cause of hypertension is considered. Renal ultrasound shows normal echogenicity, with the right kidney 12.0 cm and the left kidney 10.5 cm in length. Doppler examination is technically limited by her obesity. A renal angiogram reveals significant stenosis (90%) of the left renal artery due to fibromuscular dysplasia. What is the best management option for this patient at this point?

8.A. Perform renal artery bypass B. Serial ultrasonography to assess kidney size C. Perform percutaneous angioplasty of the stenotic lesion D. Start an angiotensin-converting enzyme (ACE) inhibitor and titrate to control blood pressure

9. A 35-year-old healthy man is referred for hypertension. His blood pressure is190/105 mm Hg and laboratory tests show hypokalemia (serum potassium, 2.1 mEq/L) and metabolic alkalosis (serum bicarbonate, 36 mEq/L) with normal renal function. Given his age, there is concern for secondary causes of hypertension.

9. The plasma renin activity (PRA) level is low (0.5 ng/mL per hour), the plasma aldosterone concentration (PAC) is high (22.5 ng/dL), and the PAC:PRA ratio is 45. After 3 days of oral salt loading, the patient collects a24hour urine sample that reveals an elevated aldosterone concentration(> 14 mg/day). What is the next step in the workup of this patient s hypertension?

10.A. Bilateral renal vein sampling B. Captopril renal scan C. Computed tomography (CT) scan of the abdomen D. Renal artery angiogram

11. A 61-year-old woman with hypertension, type 2 diabetes mellitus, ischemic cardiomyopathy, and chronic renal insufficiency reports pain i