Question 1

1. Question 1 A 69 y.o. male is evaluated during a routine physical examination. He has a history of HTN, dyslipidemia, DJD and smoking. Medications include HCTZ, atenolol, and simvastatin. Six months ago, urinalysis performed by another MD during evaluation for an upper respiratory tract infection showed 2+ blood without proteinuria. Prior UA�s were unremarkable. Labs show creatinine 1.1, 2+ blood 5-10 erythrocytes per high power field without casts. Which of the following is the most appropriate step in the evaluation of this patients hematuria? Repeat UA in 6 months Cystoscopy Ciprofloxacin Kidney biopsy

2. Question 2 A 44 y.o. man with a history of nephrolithiasis requests non-pharmacologic interventions for stone prevention. His last kidney stone (calcium oxalate) was 2 years ago. Prior labs have shown normal renal function and normal levels of calcium, phosphorus, and uric acid. Plain abdominal films show no nephrocalcinosis. In addition to increasing fluid intake to > 2 liters per day, which of the following is the best initial therapy for this patient? Increase dietary calcium Decrease dietary calcium Decrease dietary citrate Increase dietary animal protein Increase dietary sodium intake

3. Optimal Values of Urinary Constituents Volume > 2 liters Calcium Males < 300 mg Females < 250 mg Oxalate < 40 mg Uric acid Males < 800 mg Females < 750 mg Citrate > 320 mg Sodium < 200 mEq Phosphorus < 1100 mg pH > 5.5 or < 7

4. Question 3 A 65 y.o. male is referred for evaluation of edema and proteinuria. He complains of fatigue, but otherwise is asymptomatic. On exam the BP is 150/80. There is 1+ ankle edema. Labs show hemoglobin 10 (MCV 74, RDW 20); urine protein:creatinine ratio is 4.4 mg/gm, serum creatinine is 1 mg/dL, and cholesterol is 320 mg/dL. Serum complement levels are normal. Urinalysis shows 3+ protein, hyalofatty casts and oval fat bodies. Which of the following is the most likely cause of this patient�s renal symptoms? Minimal change glomerulopathy FSGS Membranous glomerulopathy IgA nephropathy ANCA-associated GN

5. Question 4 A 19 y.o. female is evaluated for sudden onset periorbital and pretibial edema. 3 weeks ago she was diagnosed with an URI that has since resolved. On PE the BP is 150/100. A soft S3 gallop is present. There are crackles at both lung bases. The liver is enlarged and tender. There is bilateral pitting pretibial edema. There is no rash. Labs show creatinine 1.5, albumin 3.8. C3 and C4 are low. Urinalysis shows rare dysmorphic red cells and trace protein. Which of the following is the most likely diagnosis? IgA nephropathy Goodpasture's syndrome ANCA vasculitis Postinfectious GN SLE nephritis

6. Question 5 A 29 y.o. female returns for routine follow up of SLE. She was recently found to have a rise in her serum creatinine from 0.9 to 1.4. Labs show low C3 and C4, and urinalysis shows 1+ protein and dysmorphic red cells. Kidney biopsy shows diffuse proliferative GN. In addition to corticosteroids, what else would you recommend? Monthly IV Cytoxan for 6 months followed by maintenance iv Cytoxan Monthly IV Cytoxan for 6 months followed by maintenance mycophenolate mofetil Oral Cytoxan Therapeutic plasma exchange

7. Question 6 A 51-year-old man with a history of chronic lymphocytic leukemia with transformation to prolymphocytic leukemia is hospitalized for chemotherapy with R-CHOP (cyclophosphamide doxorubicin vincristine prednisone rituximab). Before initiation of chemotherapy, he receives allopurinol and normal saline at a rate of 250 mL/h. One day later, his creatinine level is 2.3 mg/dL (previous creatinine is 0.8 mg/dL), and his urine output over the past 12 hours is 200 mL despite continued saline hydration. On physical examination, he is afebrile, pulse rate is 98/min, respiratory rate is 16/min, and blood pressure is 134/78 mm Hg. There is lymphadenopathy involving the cervical and submental chains and supraclavicular areas bilaterally, as well as bulky axillary and inguinal lymphadenopathy. Cardiac and pulmonary examinations are normal. The spleen is palpable approximately 3 cm to 4 cm below the left costal margin, and there is no hepatomegaly. There is no edema, cyanosis, or clubbing of the extremities. Labs show hematocrit 22%, leukocyte count 72,000/�L, platelet count 19,000/�L, BUN 63 mg/dL, uric acid 19 mg/dL, creatinine 2.3 mg/dL, potassium 5.5 meq/L, bicarbonate 17 meq/L, albumin 4.2 g/dL, calcium 7.5 mg/dL, phosphorus 11 mg/dL, urinalysis pH 5, numerous finely granular casts/hpf, no uric acid crystals Which of the following is the most appropriate next step in this patient�s management? A. Switch intravenous hydration to sodium bicarbonate B. Furosemide C. Rasburicase D. Hemodialysis E. Probenecid

9. Question 7 A 64-year-old woman is evaluated for progressive weakness, nausea, dyspnea, and acute renal failure of several weeks� duration. Her creatinine level is 4.6 mg/dL (last creatinine is 1.3 mg/dL 2 months ago). She has a history of type 2 diabetes mellitus and hypertension treated with metoprolol and hydrochlorothiazide. Other medications include aspirin and glipizide. On physical examination, the blood pressure is 110/70 mm Hg. Fundoscopic examination reveals arteriovenous nicking but no evidence of diabetic retinopathy. Cardiac examination shows a laterally displaced PMI and a grade I holosystolic murmur at the apex. On pulmonary examination, the lungs are clear to auscultation. There is no pedal edema. Hemoglobin 12.8 g/dL, leukocyte count 8000/�L, platelet count 311,000/�L, BUN 48 mg/dL, uric acid 11.6 mg/dL, creatinine 4.6 mg/dL, sodium 140 meq/L, potassium 4.3 meq/L, chloride 110 meq/L, bicarbonate 26 meq/L, total protein 8.4 g/dL, albumin 3.8 g/dL, calcium 10.5 mg/dL, phosphorus 5.6 mg/dL, lactate dehydrogenase 634 U/L; Urinalysis pH 6.5, trace protein, trace blood, 2 leukocytes/hpf, amorphous crystals. Urine sodium 60 meq/L, urine creatinine 90 mg/dL, urine protein�creatinine ratio 3 mg/g Renal ultrasound shows enlarged hyperechoic kidneys bilaterally measuring 14 cm in length. Chest radiograph reveals mild cardiomegaly but is otherwise unremarkable. Which of the following is the most likely diagnosis? A. Uric acid nephropathy B. Thiazide-induced acute renal failure C. Primary amyloidosis D. Myeloma cast nephropathy E. Lymphomatous infiltration of the kidneys

10. Question 8 A 56-year-old man with a history of end-stage renal disease due to type 1 diabetes mellitus is hospitalized for fever, night sweats, nausea, emesis of coffee-ground material, and abdominal pain. More than 1 week before admission, he also had dark, tarry stools. Six months ago, he underwent renal transplantation. Before transplantation, a cytomegalovirus antibody assay was positive and an Epstein�Barr virus (EBV) antibody assay was negative. The kidney donor had evidence of previous Epstein�Barr virus infection but no cytomegalovirus antibodies. Medications are tacrolimus, mycophenolate mofetil, and prednisone. Two days before admission, the patient also took several doses of ibuprofen for fever. On physical examination, temperature is 37.8 oC (100.1 �F), pulse rate is 80/min, and blood pressure is 136/80 mm Hg. Cardiac and pulmonary examinations are normal. There is bulky lymphadenopathy in the axillary and inguinal chains bilaterally. The liver is enlarged and spans 14 cm, and a spleen tip is palpable. There is no peripheral edema. Hemoglobin 9.2 mg/dL, leukocyte count 5100/�L, platelet count 240,000/�L, creatinine 1.6 mg/dL, lactate dehydrogenase 682 U/L (normal 338�610 U/L), cytomegalovirus viral load <50 copies/mL. Esophagogastroduodenoscopy shows multiple duodenal ulcers without active hemorrhage. Which of the following is the most likely diagnosis? A. Helicobacter pylori�induced peptic ulcer disease B. Cytomegalovirus-induced mucosal injury C. Nonsteroidal anti-inflammatory drug�induced peptic ulcer disease D. Post-transplant lymphoproliferative disease

11. Question 9 A 34 year old woman who underwent elective laparoscopic cholecystectomy develops severe headache and nausea the next morning. During the surgery, D5�NS was started and continued postoperatively at 125 mL/hr. She remained in recovery until late afternoon because she was too sedated to be discharged. Intravenous meperidine is administered with adequate relief of her pain. On physical exam the blood pressure is 130/80. She is afebrile. The heart and lung exams are normal. There is no peripheral edema. Neurologic exam is remarkable only for lethargy. Laboratory studies show sodium 128, potassium 3.4, chloride 86, bicarbonate 28, BUN 10, creatinine 0.8, glucose 86. Urine sodium 46, urine osmolality 453. Which of the following should be done next? Begin 0.9% NaCl at 200 mL/hr Begin 3% NaCl via infusion pump Emergent head CT to guide therapy Administer naloxone Discontinue D5 �NS and follow the serum sodium level and neurologic examination

14. Question 10 A 46 y.o. male is hospitalized for severe necrotizing pancreatitis. He is placed on NG suction and over the first 24 hours of hospitalization he receives 6 liters of NS and then NS at 100 mL/hour. Over the next 24 hours his urine output increases to > 3 liters per day and his plasma sodium concentration rises from 145 meq/L on admission to 153 meq/L. On exam the blood pressure is 140/90. Chest is clear . There is no edema. Labs show sodium 153, potassium 3, chloride 112, bicarbonate 24, BUN 49, creatinine 1.1, urine sodium 50, urine potassium 20, urine osmolality 500 mosm/kg. Which of the following is the most likely cause of this patient�s polyuria? Central diabetes insipidus Nephrogenic diabetes insipidus Post obstructive diuresis Solute diuresis

18. Question 11 A 58-year-old woman with a history of chronic alcohol abuse is admitted to the hospital for evaluation of abdominal pain and vomiting. A diagnosis of recurrent pancreatitis is made on the basis of the history of alcoholism, the presence of diffuse abdominal tenderness and decreased bowel sounds, and elevated serum amylase and lipase levels. Therapy is begun with intravenous fluids (0.9% saline and 5% dextrose in water at 75�mL/hr) and nasogastric drainage, which produces copious amounts of fluid. After five days of therapy, the patient's symptoms resolve and the following laboratory studies are obtained: BUN 21 mg/dL, serum creatinine 1.4 mg/dL, plasma glucose180 mg/dL, serum sodium 140 mEq/L, potassium 2.6 mEq/L, chloride 86 mEq/L, bicarbonate 38 mEq/L, urine pH 7.0, urine sodium 10 mEq/L, urine chloride 5 mEq/L Which of the following best explains the hypokalemia in this patient? (A) Renal potassium losses derived from decreased proximal tubule reabsorption (B) Potassium loss in the gastric aspirate (C) Intracellular redistribution of potassium is a major determinant of the hypokalemia (D) Increased aldosterone and distal nephron bicarbonate delivery causing renal potassium losses

22. Question 12 A 42 y.o. female is evaluated for minimal edema and a urinary protein excretion of 5 gm/24 hours. As a child she had frequent urinary tract infections and underwent a surgical procedure to reimplant the ureters to prevent reflux. On PE the BP is 140/95. There is trace peripheral edema. Labs show creatinine 1.5, albumin 3.4, Urinalysis shows 3 + protein and oval fat bodies. Chest x-ray is normal. Renal US shows a normal left kidney and the right kidney small and difficult to visualize. Which of the following is the most likely cause of the proteinuria? Minimal change disease Membranous nephropathy FSGS Membranoproliferative GN

26. Question 13 A 44 y.o. female with cirrhosis is admitted with fever and abdominal pain. Medications include spironolactone, furosemide, and lactulose. On exam the BP is 74/55, HR 72, T 38.3, RR 24. She is cachectic. The abdomen is tense and diffusely tender. There is 1+ leg edema. Labs show Serum sodium 128, potassium 5.1, chloride 104, bicarbonate 12, BUN 20, creatinine 1.3, glucose 84, albumin 1.4. ABG pH 7.25, pCO2 28, pO2 78. Which best describes the acid-base status of this patient? Mixed anion gap metabolic acidosis and respiratory alkalosis Mixed anion gap metabolic acidosis and respiratory acidosis Anion gap metabolic acidosis Hyperchloremic acidosis Mixed anion gap metabolic acidosis and hyperchloremic acidosis

28. Question 14 23-year-old Caucasian female referred for further evaluation of hypokalemic acidosis. She was in her usual state of excellent health with normal growth and development until her second month of pregnancy. She had a spontaneous miscarriage, and was found to have a serum potassium of 3.2 mEq/L and a bicarbonate level of 19 mEq/L during a hospitalization for a D and C. She was treated with oral potassium and bicarbonate supplements and then weaned these off after 4 months of therapy. Six weeks later, she developed myalgias and collapsed due to profound weakness. She was found to have a serum bicarbonate level of 14 mEq/L with a serum potassium of 1.9 mEq/L. 140 114 13 Calcium 9.1 1.9 14 1 Phosphorus 3.5 ABG-pH 7.29, PCO2 30, pO2 100 Urine K 46 Urine Na 36 Urine Cl 42 Urine Osm 580 UA ph 6.8 trace protein No casts 10-15 white cells per high power field Which of the following is the correct diagnosis? Type IV RTA Diarrhea Type I RTA Renal tubular alkalosis Proximal RTA

33. Question 15 A 32 y.o. male presents with paresthesias, perioral numbness, and generalized weakness. He is not on any medications. The BP is 120/88, and the physical exam is remarkable for dental caries. Earlier in the day he had attended a birthday party for his nephew. Labs show Na 139, potassium 2.8, chloride 90, bicarbonate 38. Urine sodium 28, urine potassium 38, urine chloride < 10, urine pH 6.2, urine calcium:creatinine ratio 0.2 (mmol/mmol). Is this: Barrter syndrome Vomiting Gitelman syndrome Hypokalemia periodic paralysis Licorice ingestion

35. Question 16 You are asked to evaluate a 42 year old woman because of hyponatremia. She has a history of schizophrenia and is currently hospitalized because of suicidal and homicidal ideation. Her admission laboratory studies obtained during a psychiatric hospitalization were normal. Current medications are haloperidol and benztropine mesylate. Physical exam shows pulse 92 supine, 100 standing, BP 112/82 supine and 108/88 standing. Occasional involuntary movements of the tongue and lips are noted. There is no edema. Labs show sodium 120 mEq/L, potassium 4.2 mEq/L, chloride 85 mEq/L, bicarb 27 mEq/L, BUN 8 mg/dL, creatinine 0.8 mg/dL, serum osmolality 250 mOsm/kg, TSH 3.8 microunits/mL, uric acid 3.2 mg/dL; Urine sodium 12, urine potassium 3, urine chloride 10, urine osmolality 55. Which of the following is the most likely cause of this patient�s hyponatremia? Primary polydipsia Mineralocorticoid deficiency Reset osmostat Diuretic abuse SIADH

36. Question 17 A 49 y.o. female is admitted to the hospital because of severe right sided abdominal pain requiring administration of narcotic analgesics. The patient is unable to provide a complete medical history, but reports that she has had seizures for as long as she can remember. Physical exam reveals papular skin lesions in the malar area. Bilateral flank masses are noted. There is a 2-cm periungual nodular lesion on the right great toe. Hematocrit is 25%. Serum creatinine is 5.5 mg/dL. CT of the abdomen without contrast reveals enlarged kidneys with bilateral renal cysts of varying size in the cortex and the medulla; several variably sized masses with densities identical to perinephric fat are also detected in areas not involved with cysts. Which if the following is the most likely diagnosis? ADPCKD Von Hippel-Lindau disease Medullary cystic kidney disease Tuberous sclerosis Bilateral renal dysplasia