Nephrology Test For

R2 Board Exam. นพ.กิตติ์รวี กฤษฏิ์เมธาภาคย์

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 11-cm 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 anti-GBM 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. Emergent renal biopsy B. Lung biopsy C. Nasal and sinus biopsies D. 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 10-lb 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. Acute postinfectious glomerulonephritis B. Alport’s syndrome C. Crescentic glomerulonephritis D. 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 patient’s management?

3.

A. Furosemide and an angiotensin-converting 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. IgA nephropathy B. Nephrolithiasis C. Transitional cell carcinoma of the bladder D. Wegener’s granulomatosis E. 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)

Don’t 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 µU/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 µg/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 สูง, aldosterone สูง Renin secreting tumor, renal artery stenosis, malignant hypertension

•  Renin ต่ํา, aldosterone สูง Primary hyperaldosteronism, GRA

•  Renin ปกติ, aldosterone ปกติ 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 patient’s 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 doctor’s 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 a24-hour 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 in her right knee. Her blood pressure is 140/84 mm Hg, and her pulse is 70 bpm. Because of tenderness and effusion in the knee joint, the patient is prescribed celecoxib 200 mg once daily.

11.

•  After 14 days of therapy, she reports dyspnea, increased swelling in the lower extremities, and fatigue. Blood pressure is now 188/100 mm Hg, blood urea nitrogen (BUN) is 67 mg/dL (baseline, 41 mg/dL), and serum creatinine level is 3.9 mg/dL (baseline, 1.9 mg/dL). Which of the following is the most likely mechanism by which celecoxib caused acute renal failure?

11.

A. Acute papillary necrosis with renal obstruction B. Acute tubular necrosis from drug-induced

nephrotoxicity C. Drug reaction causing allergic interstitial

nephritis D. Hemodynamic renal insufficiency from loss of

compensatory prostaglandins induced by cyclooxygenase-2 inhibition of celecoxib

NSAID – induced nephrotoxicity

Hemodynamic effects •  Renal

vasoconstriction •  Salt/water retension •  Hyporeninemic

hypoaldosteronism

Structural effects •  Nephrotic syndrome

(MCD > MN) •  AIN •  CKD (IFTA)

12.

•  A 31-year-old man with a 4-year history of HIV infection who takes zidovudine and lamivudine begins receiving indinavir to further reduce the viral load. He also continues taking trimethoprim-sulfamethoxazole 3 times weekly. Over the next 12 weeks, he develops nausea with vomiting, anorexia, and an episode of gross hematuria.

12.

•  Urinalysis results show hematuria and pyuria. Urine sediment examination shows crystals in various starburst and plate-like patterns. Serum BUN (54 mg/dL) and serum creatinine (2.5 mg/dL) are elevated. Indinavir is discontinued, and the patient receives an intravenous infusion of 0.9‰ saline. Which of the following most likely caused his acute renal failure?

12.

A. Acute tubular necrosis caused by indinavir

B. Allergic interstitial nephritis caused by trimethoprim-sulfamethoxazole

C. Indinavir-associated crystal-induced renal failure

D. Obstructive uropathy from retroperitoneal nodes caused by HIV-associated lymphoma

13.

•  A 73-year-old woman with osteoarthritis and mild hypertension goes to her physician’s office with new-onset lower back pain and progressively worsening fatigue. Physical examination reveals normal blood pressure and pale conjunctivae. The lower lumbar spine (L4 - L5) is tender to palpation, and the ankles have 2+ pitting edema.

13. •  Laboratory measurements are hemoglobin,

6.2 g/dL and serum creatinine, 4.8 mg/dL. Bone marrow biopsy results are consistent with multiple myeloma; a 24-hour urine collection shows 6.5 g of albumin and 1.2 g of monoclonal kappa light chain. Renal biopsy employing light microscopy shows nodular lesions in the glomerulus. On electron microscopy, granular deposits are seen along the basement membranes and in the glomerular nodules. No fibrillar material is identified in the biopsy specimen.

13.

•  Which of the following most likely caused the patient’s renal disease?

A. Hypertensive arteriolonephrosclerosis B. Light-chain deposition disease in the

kidney C. Myeloma cast nephropathy D. Renal amyloidosis

MM & AKI

•  Vascular : hyperviscosity, hypercalcemia •  Glomerular : amyloidosis, light chain

deposition disease, cryoglobulinemia – induced MPGN type I

•  Tubular : myeloma cast nephropathy •  Interstitium : plasma cell infiltration,

hyperuricemia, recurrent UTI

14.

•  A 71-year-old man with type 2 diabetes mellitus, gout, hypertension, hyperlipidemia, and chronic renal insufficiency (serum creatinine, 2.8 mg/dL) has chest pain and electrocardiographic changes consistent with myocardial ischemia. Prior to cardiac catheterization, he is given fluids intravenously to reduce contrast-associated renal injury.

14.

•  He receives 120 mL of noniodinated, low osmolarity contrast during the procedure and develops transient hypotension. Over the next few days, he develops severe hypertension, purple toes on the right foot, and gastrointestinal bleeding. His serum creatinine level increases to 6.5 mg/dL, necessitating hemodialysis. Which of the following most likely caused his renal failure?

14.

A. Cholesterol embolization to the small arteries and arterioles in the kidney

B. Congestive heart failure with prerenal azotemia

C. Ischemic acute tubular necrosis caused by hypotension during catheterization

D. Radiocontrast-induced nephrotoxicity

Urine eosinophil (Hansel stain)

15.

•  63 yo factory worker presents with upper & lower extremity & diffuse muscle weakness over the past 2 wks. For the past 6 mos, he has had low back pain that was sufficiently severe to cause him to miss work several occasions. Buffered salicylate tx relieved the pain somewhat

15. •  Labs:

–  Hgb: 8 g/dl K 2.6meq/L –  HCT 24% Na 135meq/L –  PLT 106K/ul Cl 117meq/L –  BUN 10mg/dl Bicarb 15meq/L –  Cr 1.0mg/dl Glc 88mg/dl –  Osm 277mosmol/L Cal 11mg/dl

–  ABG: 7.30/31 (pCO2)

–  UA: neg for albumin; + by sulfosalicylic acid test

15.

•  What disease process best explains the acid-base disorder?

A.  Proximal RTA B.  Salicylate toxicity C.  ETOH-induced lactic acidosis D.  Ethylene glycol toxicity

16. 30 y/o M w seizure d/o previously well-controlled on

phenytoin. After a night of “partying”, he has another seizure. In the ED…

Na 140 Gluc 80 EtOH level 100 K 4.8 HCO3 12 Cl 100 BUN 10 Cr 1 ABG: pH 7.25 pCO2 28 pO2 100

U/A: (-) ketones measured serum Osm: 310

16.

•  What is the most likely cause of his acid-base disorder?

A.  Lactic acidosis B.  Alcoholic ketoacidosis C.  Salicylate poisoning D.  Methanol intoxication E.  Ethylene glycol intoxication

Wide gap metabolic acidosis

•  Renal failure •  Ketoacidosis •  Lactic acidosis •  Toxin : salicylate, methanol, ethylene

glycol

Serum osmolal gap

•  Measured – calculated serum osmole = 310 – (2 x 140 + 80/18 + 10/2.8 + 100/4.6) = 1 (< 10)

17.

What if his EtOH level = 0 and urine show +rbc’s + rectangular

crystals?

17.

17.

1.  Methanol intoxication 2.  Isopropyl Alcohol intoxication 3.  Ethylene Glycol intoxication 4.  Cyanide intoxication 5.  Salicylate intoxication

Glue sniffing

18.

•  43 yo woman presents with back pain and is evaluated for renal insufficiency. Infection with HIV was dx 2 yrs ago, and the patient began taking active antiretroviral tx with zidovudine, lamivudine, & indinavir 1 yr later because of decreasing CD4 count & development of oral candidiasis. Six mos ago, she developed fasting hyperglycemia and hypercholesterolemia and was treated with rosiglitazone and atorvastatin.

18. •  Exam: BP 130/85, HR 80/min, RR is 18/min, temp is 37.8, no orthostatic

changes. No JVD or HJR. The cardiac, pulmonary, & abdominal examinations are normal, but 2+ LE edema is noted.

•  Labs:

–  BUN 22 mg/dl K 6.0 meq/L –  Na 141 meq/L Cr 3.2 mg/dl –  Cl 101 meq/L Cal 7.2 mg/dl –  Bicarb 19 meq/L PO4 9.0 mg/dl –  Uric acid 9.0 mg/dl Cholesterol 177 mg/dl

•  FBS and AIC elevated. HCT 31%, MCV elevated. WBC 3300/ul, PLT normal.

•  UA: protein TR, 2+hematuria, No ketones, no glucose. Muddy brown casts and tubular epithelial cells seen. No crystals or erythrocytes.

Muddy brown granular cast

18.

•  What is the most probable dx? A.  Rhabdomyolysis caused by atorvastatin B.  Indinavir – induced nephrolithiasis C.  Indinavir – induced tubulointerstitial renal

disease D.  HIV-associated nephropathy E.  Diabetic nephropathy

19.

•  All the following forms of glomerulonephritis (GN) have associated normal serum complement C4 levels except

•  A. lupus nephritis stage IV B. poststreptococcal GN C. hemolytic-uremic syndrome D. membranoproliferative GN type II E. endocarditis-associated GN

Low C3, normal C4

•  APSGN •  MPGN type 2, 3 •  HUS •  Renal atheroembolism •  IE

20.

•  A 29-year-old man is admitted to the hospital with a severe asthma exacerbation. He is taken to the intensive care unit (ICU) and treated with continuous aerosolized -adrenergic agonists and glucocorticoids. He requires bilevel positive airway pressure mechanical respiration. After 18 h of this therapy, his respiratory status begins to improve.

20.

•  He begins to complain of fatigue and myalgias in his legs. He has difficulty ambulating and on neurologic examination he has three out of five symmetric weakness in the lower extremities. On the cardiac monitor, you notice flattened T waves, ST depression, and a prolonged QT interval. What is the cause of this patient's neurologic and cardiac findings?

20.

A.  Adrenal insufficiency B.  ICU psychosis C.  Medication effect D.  Myocardial infarction with congestive

heart failure E.  Todd's paralysis

21.

•  A 63-year-old male with a history of diabetes mellitus is found to have a lung nodule on chest radiography. To stage the disease further he undergoes a contrast-enhanced CT scan of the chest. One week before the CT scan, his BUN is 26 mg/dL and his creatinine is 1.8 mg/dL. Three days after the study he complains of dyspnea, pedal edema, and decreased urinary output. Repeat BUN is 86 mg/dL and creatinine is 4.4 mg/dL.

21.

The urinalysis is most likely to show A.  granular casts B.  red blood cell casts C.  urinary eosinophils D.  urinary neutrophils E.  white blood cell casts

22.

•  A 15-year-old girl complaining of profound weakness, occasional difficulty walking, and polyuria is brought to the pediatrician. Her mother is sure the girl has not been vomiting frequently. The girl takes no medicines. She is normotensive, and no focal neurologic abnormalities are found.

22.

•  Serum chemistries include Na+ 142 mmol/L, K+ 2.5 mmol/L, HCO3– 32 mmol/L, and Cl– 100 mmol/L. A 24-h urine collection on a normal diet reveals Na+200 mmol/d, K+ 50 mmol/d, and Cl– 30 mmol/d. Renal ultrasound demonstrates symmetrically enlarged kidneys without hydronephrosis. A stool phenolphthalein test and a urine screen for diuretics are negative. Plasma renin levels are found to be elevated.

22.

•  Which of the following conditions is most consistent with these data? A. Conn's syndrome B. Chronic ingestion of licorice C. Bartter's syndrome D. Wilms' tumor E. Proximal renal tubular acidosis

23.

•  A 32-year-old patient presents to your clinic complaining of right-sided flank pain and dark urine. He states that these symptoms began about a month ago. He denies any burning on urination and has had no fevers. He has not suffered any trauma and has not been sexually active recently.

23.

•  On review of systems he reports early satiety and describes a burning sensation in his chest when he lies down. An ultrasound of his right flank is performed and reveals >20 cysts of varying sizes in his right kidney. Which of the following statements is true?

23. A. Adult-onset polycystic kidney disease (PCKD) will lead to end-stage renal disease in 100% of patients by age 70. B. Aortic stenosis is present in 25% of patient with PCKD. C. 40% of patients with PCKD will have hepatic cysts by age 60. D. PCKD is inherited as an autosomal recessive trait in adults. E. There is a significantly increased risk of embolic stroke in patients with PCKD.

24.

•  In patients with chronic renal failure, which of the following is the most important contributor to renal osteodystrophy? A. Impaired renal production of 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] B. Hypocalcemia C. Hypophosphatemia D. Loss of vitamin D and calcium via dialysis E. The use of calcitriol

25.

•  Laboratory evaluation of a 19-year-old male who is being worked up for polyuria and polydipsia yields the following results: – Serum electrolytes (meq/L): Na+ 144, K+ 4.0,

Cl– 107, HCO3– 25 – BUN: 6.4 mmol/L (18 mg/dL) – Blood glucose: 5.7 mmol/L (102 mg/dL) – Urine electrolytes (mmol/L): Na+ 28, K+ 32 – Urine osmolality: 195 mosmol/kg water

25.

•  After 12 h of fluid deprivation, body weight has fallen by 5%. Laboratory testing now reveals the following: – Serum electrolytes (meq/L): Na+ 150, K+ 4.1,

Cl– 109, HCO3– 25 – BUN: 7.1 mmol/L (20 mg/dL) – Blood glucose: 5.4 mmol/L (98 mg/dL) – Urine electrolytes (mmol/L): Na+ 24, K+ 35 – Urine osmolality: 200 mosmol/kg water

25.

•  One hour after the subcutaneous administration of 5 units of arginine vasopressin urine values are as follows: – Urine electrolytes (meq/L): Na+ 30, K+ 30 – Urine osmolality: 199 mosmol/kg water

•  The likely diagnosis is

25.

A. nephrogenic diabetes insipidus B. osmotic diuresis C. salt-losing nephropathy D. psychogenic polydipsia E. none of the above

26.

•  Which of the following is the most potent stimulus for hypothalamic production of arginine vasopressin?

•  A. Hypertonicity B. Hyperkalemia C. Hypokalemia D. Hypotonicity E. Intravascular volume depletion

27.

•  It is hospital day 5 for a 65-year-old patient with prerenal azotemia secondary to dehydration. His creatinine was initially 3.6 mg/dL on admission, but it has improved today to 2.1 mg/dL. He complains of mild lower back pain, and you prescribe naproxen to be taken intermittently. By what mechanism might this drug further impair his renal function?

27.

A. Afferent arteriolar vasoconstriction B. Afferent arteriolar vasodilatation C. Efferent arteriolar vasoconstriction D. Proximal tubular toxicity E. Ureteral obstruction

28.

•  The condition of a 50-year-old obese female with a 5-year history of mild hypertension controlled by a thiazide diuretic is being evaluated because proteinuria was noted during her routine yearly medical visit. Physical examination disclosed a height of 167.6 cm (66 in.), weight of 91 kg (202 lb), blood pressure of 130/80 mmHg, and trace pedal edema. Laboratory values are as follows:

28.

– Serum creatinine: 106 mol/L (1.2 mg/dL) – BUN: 6.4 mmol/L (18 mg/dL) – Creatinine clearance: 87 mL/min – Urinalysis: pH 5.0; specific gravity 1.018;

protein 3+; no glucose; occasional coarse granular cast

– Urine protein excretion: 5.9 g/d

28.

•  A renal biopsy demonstrates that 60% of the glomeruli have segmental scarring by light microscopy, with the remainder of the glomeruli appearing unremarkable (see following figure)

28.

28.

•  The most likely diagnosis is A. hypertensive nephrosclerosis B. focal and segmental sclerosis C. minimal-change (nil) disease D. membranous glomerulopathy E. crescentic glomerulonephritis

29.

•  A 21-year-old man presented with progressive deafness and was found to have bilateral high-tone hearing loss.

•  Further investigations revealed chronic kidney disease stage 5.

•  No family history was available as he had been adopted as a baby.

29.

•  What eye abnormality is most likely to be present A anterior lenticonus B corneal deposits C lens dislocation D optic atrophy E retinitis pigmentosa

Anterior lenticonus

30.

•  A 43-year-old man who has had recurrent sinusitis during the past year comes to the emergency department because he has had shortness of breath and cough productive of green sputum for the past two weeks. Physical examination shows tenderness over the maxillary region. On auscultation of the chest, crackles are noted bilaterally in the lung bases. Trace edema of the extremities is noted.

30.

•  Chest x-ray study shows bilateral pleural effusions with apical opacities. Laboratory studies show serum creatinine level of 3.0 mg/dL and blood urea nitrogen level of 60 mg/dL. Result of antiglomerular basement membrane antibody test is negative and result of antineutrophil cytoplasmic antibody test is positive. Urinalysis shows pH of 5.5, specific gravity of 1.020, 2+ protein, and 2+ blood. Red blood cells are visible in the urine sediment.

30.

•  Which of the following is the most likely diagnosis (A) Allergic interstitial nephritis (B) Goodpasture syndrome (C) IgA nephropathy (D) Poststreptococcal glomerulonephritis (E) Wegener granulomatosis