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RENAL PATHOPHYSIOLOGY
RENAL PHARMACOLOGY
RENAL PATHOLOGY
FINAL EXAMINATION
December 13, 2005
__________________________
Student's name
INSTRUCTIONS
This examination is composed of multiple choice questions. Write your name on
both the question booklet and the answer sheet. The answers are to be written on the
answer sheet preferably in pencil, since it is easier to change your answer. For each
multiple choice question there is only one correct response, so write only one letter
as an answer. At the end of the test, the answer sheet should be stapled to the
question booklet and they both must be handed in.
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NORMAL LABORATORY VALUES
Test
Blood, Serum or Plasma
blood glucose
Scr
BUN
BUN/Scr ratio
Osmolality
Na+
K+
H+
pH (arterial)
ClHCO3pCO2 (arterial)
Albumin
Anion gap
Calcium
Phosphate (as phosphorus)
Daily Urinary Excretion
Creatinine
GFR or Ccr
Protein
Water (average)
Na+ (average)
K+ (average)
H+ (average)
Osmoles (average)
Normal Range
67-109 mg/dl
<1.5 mg/dl
<20 mg/dl
10-15
280-290 mOsm/kg
135-145 mEq/L
3.5-5 mEq/L
38-43 nEq/L
7.37-7.42
95-105 mEq/L
22-28 mEq/L
37-43 mmHg
4-5 gm/dl
8-12 mEq/L
8.5-10.5 mg/dl
2.5-5.0 mg/dl
1.0-2.0 gm/day
80-150 ml/min (115-216 L/day)
<150 mg/day
0.5-12L
(1.5L)
150 mEq/day
60-120 mEq/day
60-120 nEq/day
600 mOsm/day
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Renal Pathophysiology Questions:
1. Which of the following is least likely to be filtered freely through the glomerulus?
a) glucose
b) amino acids
c) hippuric acid
d) ammonia
e) sodium
2. Renal sodium handling can be affected by changes in:
a) cardiac output
b) interstitial volume
c) ADH
d) sodium concentration
e) total body potassium content
THE FOLLOWING TWO QUESTIONS REFER TO THE NEXT CASE
A 67-year-old man is admitted to the intensive care unit with a fever of 103 F, tachycardic and
hypotensive with a blood pressure of 80/40. He is tachypneic with a respiratory rate of 32. CXR
reveals a left lower lobe pneumonia. He becomes obtunded and requires intubation. He is very
agitated and continues to breathe with RR of 32 above the ventilator respiratory rate setting of
12. He is immediately given isotonic saline for volume resuscitation.
He remains febrile for the next day with a peak temperature of 105F, persistent tachypnea and
hypotensive requiring pressor support, despite aggressive volume repletion with 7 liters of 0.9%
saline (isotonic) over the past couple of days.
Laboratory data on the second day: Na 149 mEq/L, K 4.5 mEq/L, Cl 116 mEq/L, HCO3 12
mEq/L, BUN 28 mg/dl, Creat 1.3 mg/dl.
Urinalysis: specific gravity 1.015/ pH 5/ no cells or casts.
3. Hypernatremia occurs because:
a)
b)
c)
d)
e)
ADH is stimulated because of hypotension.
total body sodium content has increased.
aldosterone production increases sodium retention
large insensible losses of water occurs
metabolic acidosis promotes sodium retention
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4. An ABG is obtained with pH of 7.29, pCO2 25, pO2 60 (mmHg). Which of the following
explanations best explains how physiological pH range (7.20-7.70) is maintained?
a) intracellular shift of K in exchange for H
b) HCO3 is reclaimed primarily in the ascending loop of henle
c) chloride is an important extracellular buffer
d) CO2 is lowered through increased respirations
e) HCO3 is not filtered through the glomerulus due to decline in GFR
5. Glomerular filtration rate (GFR) can be estimated using urinary clearance of a substance.
Which of the following is true?
a) BUN is the best endogenous marker of GFR because when GFR falls the BUN rises to a
greater degree than creatinine
b) the gold standard measure for GFR is creatinine clearance.
c) inulin is an endogenous substance (sugar), which is usually used to measure GFR.
d) hippuric acid is a small positively charged molecule, which is freely filtered without
reabsorption or secretion.
e) serum creatinine exponentially rises with decline in GFR.
6. All of the following patients present to the emergency room with nausea, general malaise, and
are found to have an elevated creatinine of 6.4 mg/dl. Which of the following patients has the
poorest prognosis for recovery to normal renal function?
a) 76-year-old man with recently diagnosed prostate cancer complains of difficulty
maintaining urine stream over the last 2 weeks. He notes some decline in urine volume
over the last 3 days and is found to have a post-void residual urine volume of 300 ml.
b) 45-year-old female complains of flu-like symptoms and subsequent hemoptysis over the
last 3 weeks. Urine sediment shows red blood cell casts and many dysmorphic appearing
red blood cells.
c) 32-year-old woman with difficult to control hypertension was started on an ACE inhibitor
(lisinopril) and diuretic (furosemide) a month ago. On exam, blood pressure in the sitting
position is 154/98, which does not change with standing. She has an abdominal bruit.
d) 56-year-old male with osteoarthritis of the knees has been taking ibuprofen 800 mg tid
for the last 3 weeks. Urine sediment reveals white blood cells and white blood cell casts.
e) 74-year-old woman has hypotension, fever and confusion. Urine and blood cultures both
grow E. Coli. Over the next 24 hours she becomes anuric.
7. A 57-year-old woman presents with nausea and vomiting for the last 5 days. Her medical
history includes diabetes mellitus and hypertension.
Medications: Metoprolol 25mg bid, lisinopril 10 mg daily and insulin.
Physical Exam: T 98.7 F, BP 120/60 sitting and 90/40 standing, HR 120, RR 12. No JVD, heart
and lungs unremarkable, diffusely tender abdomen with hypoactive bowel sounds and no lower
extremity edema.
She is found to have an elevated creatinine of 2.0 mg/dl.
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Which of the following laboratory findings is most consistent with her presentation?
a) BUN 12
b) urine pH 7
c) urine specific gravity 1.030
d) urine Na 56 mEq/L, urine creat 8 mg/dl, serum Na 140 mEq/L
e) serum Na 160
8. A 58-year-old male with benign prostatic hypertrophy develops acute renal failure with a
BUN 50, creatinine of 3.4 mg/dl. Renal ultrasound reveals hydronephrosis. He is immediately
sent to the emergency room for foley catheter placement, after which 5 liters of urine drains into
the collection bag. In 2 days, you will most likely see:
a)
b)
c)
d)
e)
urine sediment with muddy brown casts
urine specific gravity of 1.001
hyponatremia
metabolic alkalosis
hyperkalemia
9. A 58-year-old woman with hypertension, CAD, COPD presents with shortness of breath. On
exam, BP is 150/90, she has worsening lower extremity edema and lung exam reveals crackles
and decreased breath sounds in right lower lobe region. She is found to have diffuse alveolar
opacities, vascular congestion and a right lower lobe infiltrate on chest X-ray. For this she is
given furosemide and started on amoxicillin. Her current medications also include metoprolol,
lisinopril and albuterol.
During her follow-up visit 2 weeks later, she complains of fever, rash, persistent malaise and
fatigue. T 100.1 F, BP is 138/86 sitting and standing. Exam reveals resolution of crackles and
improvement of edema. Diffuse fine erythematous rash on trunk and abdomen.
Laboratory data reveal a WBC of 10.6, hemoglobin 11, hematocrit 33, platelet 238, Na 136, K
4.8, Cl 102, HCO3 20, BUN 21, creat 3.2. Dipstick urinalysis reveals specific gravity 1.010, pH
5, trace protein, 1+ leukocyte.
Her elevated BUN and creatinine can be best explained by:
a) acute volume depletion resulting in hypoperfusion to the kidney from overly aggressive
diuresis
b) hypotension from sepsis with resultant ATN
c) urinary tract infection involving the kidneys (pyelonephritis)
d) nephrotoxicity from the lisinopril causing ATN
e) tubular inflammation from antibiotic induced acute interstitial nephritis
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10. The evolution of acute tubular necrosis is best described by;
a) once necrosis of the tubules occurs, local vasoconstriction allows for shunting of plasma
flow away from the injured nephron.
b) the renal cortex is most prone to ischemic injury due to the hairpin loop structure of the
vasa recta.
c) reperfusion just after an ischemic event is the time during which most of the tubular
healing occurs.
d) hypoperfusion of the kidney in the setting of volume depletion is not considered a cause
of acute tubular necrosis.
e) toxic injury of the tubule is minimized in the collecting duct where ADH is turned off to
further dilute the urine.
11. Which of the following can mediate a reduction in plasma flow across the glomerular
barrier?
a) prostaglandins
b) angiotensin ii
c) aldosterone
d) macula densa
e) renin
THE FOLLOWING TWO QUESTIONS REFER TO THE NEXT CASE
A 42-year-old obese woman has diabetes mellitus, retinopathy and neuropathy. She reports that
she is feeling well without any urinary symptoms including polyuria, dysuria or nocturia. On
exam, BP is 146/88, HR 88. Moist mucous membranes; no JVD; Heart and lung exams are
unremarkable. Lower extremities with trace edema. Left heel with shallow ulcer.
Laboratory data: BUN 20 mg/dl, creat 1.2 mg/dl, albumin 3.8 g/dl.
Urinalysis by dipstick reveals specific gravity 1.020, pH 5, glucose 1+, protein negative,
leukocyte negative, blood negative
12. What are your recommendations to her with regard to her risk of developing chronic kidney
disease?
a) If she controls her diabetes mellitus adequately, she will not develop chronic kidney
disease
b) She will not develop chronic kidney disease as there is no evidence for it at present
c) Her blood pressure is optimally controlled, which will help prevent progression of kidney
disease
d) The absence of nephrotic syndrome suggests there is no glomerular pathology
e) A 24-hour urine protein should be assessed.
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13. Assuming she has diabetic nephropathy, you would recommend the following:
a) ACE inhibitors or Angiotensin receptor blockers should be avoided as they will cause
acute renal failure
b) blood pressure should be maintained at a lower goal of 130/80
c) continue current management of diabetes mellitus which appears to be adequately
controlled as evidenced by the minimal glucosuria
d) greater fluid intake should be encouraged given her high urine specific gravity suggesting
volume depletion.
e) exercise should be avoided as this can increase proteinuria which has been shown to
exacerbate chronic kidney disease
14. Bone disease (renal osteodystrophy) as a result of chronic kidney disease occurs because;
a) hyperparathyroidism promotes calciuria
b) renal osteodystrophy occurs to due to poor filtration of phosphorus
c) poor conversion of cholesterol to 25-OH vitamin D
d) decline in GFR results in hypercalcemia with resultant “metastatic” calcification in
tissues
e) activated vitamin D stimulates PTH
15. A 21-year-old Hispanic female has had an 8-lb weight gain, fatigue, low-grade fevers and
achy joints for a month. Blood pressure is 123/72 mmHg, a rash is present on the face, there is
no jugular venous distention, lungs are clear and legs have 1+ edema.
Lab tests show:
BUN
Serum creatinine
Albumin
Total cholesterol
C3,C4 and CH50
ANA
Blood culture
ANCA
aGBM antibody
Urinalysis
24 hour urine protein
10 mg/dL
0.8 mg/dL
2.3 gm/dL
255 mg/dL
all low
positive -1:320
negative
negative
negative
clear, yellow, S.G. 1.013, protein 500 mg/dL, 1 RBC/hpf
3.6 gm
The most likely diagnosis is:
a) microscopic polyarteritis
b) membranous form of lupus nephritis
c) proliferative form of lupus nephritis
d) idiopathic crescentic glomerulonephritis
e) focal segmental glomerulosclerosis
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16. The above patient experiences sudden pleuritic chest pain, hemoptesis and shortness of
breath. You suspect that she is experiencing:
a) antibody-mediated pulmonary hemorrhage
b) pulmonary embolism
c) pulmonary edema
d) pulmonary vasculitis
e) fractured rib
17. A 19-year-old man is seen for a 5-day episode of gross hematuria occurring during an upper
respiratory infection. A similar episode happened one year earlier. Blood pressure is 146/97.
The physical examination is otherwise normal. Laboratory studies show:
BUN
Serum creatinine
Albumin
C3,C4 and CH50
ANA
ASLO titer
ANCA
aGBM antibody
Urinalysis
14 mg/dL
1.3 mg/dL
4.1 gm/dL
normal
negative
negative
negative
negative
tea-colored, S.G. 1.019, protein 100 mg/dL, RBC/many, red cell
casts
A renal biopsy shows increased cellularity of the glomeruli and immunofluorescence shows:
a) mesangial IgM deposition
b) IgG immune complex deposition
c) negative staining
d) linear capillary staining for IgG
e) mesangial IgA deposition
18. For the past month a 40-year-old man with chronic dyspepsia and heartburn has been taking sodium
bicarbonate dissolved in water for relief. Serum electrolytes show Na 141 mEq/L, K+ 3.0 mEq/L, Cl- 103
mEq/L and HCO3- 25 mEq/L. Serum potassium is low most likely because:
a) alkalosis shifts potassium into cells.
b) high sodium intake inhibits catecholamine release.
c) high sodium intake inhibits the renin axis.
d) bicarbonate is a non-reabsorbable anion.
e) potassium follows sodium in the urine.
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THE FOLLOWING TWO QUESTIONS REFER TO THE NEXT CASE
You have a 68-year-old diabetic woman with chronic renal failure and hypertension. The patient now has
muscle weakness of the lower extremities and cannot walk. Medications include a beta-blocker, an ACE
inhibitor, a thiazide diuretic and a salt substitute. The blood pressure is 130/75 mmHg. The lower
extremities have reduced muscle strength. Serum creatinine is 2.0 mg/dL, Na+ 141 mEq/L, K+ 7.8 mEq.L,
Cl- 105 mEq/L and HCO3- 18 mEq/L.
19. A major threat to this patient is:
a) fatal arrhythmia
b) a serious fall
c) hypovolemic shock
d) severe diarrhea
e) respiratory alkalosis
20. The hyperkalemia is caused by all of the following EXCEPT:
a) salt substitute
b) low renin state
c) thiazide diuretic
d) ACE inhibitor
e) beta-blocker
21. 59-year-old male presents to your office for evaluation of his third calcium oxalate kidney
stone. You advise increased fluid intake (2.5-3L per day) and plan a 24 hour urine collection to
evaluate his risk factors for further stone formation. Which of the following is most likely to be
an additional dietary recommendation?
a) low calcium diet
b) low oxalate diet
c) increased sodium intake
d) high fiber diet
e) high protein diet
22. If a patient presents to the emergency room with a 15mm kidney stone in the proximal ureter
causing complete obstruction of one of the kidneys, the most appropriate acute management
would be:
a) increase fluid intake to >3l per day to reduce risk of further stone formation
b) consult a urologist to arrange for stone removal
c) prescribe a thiazide diuretic to reduce urinary calcium excretion
d) start antibiotics to guard against pyelonephritis
e) initiate a 24 hour urine collection to investigate risk for stone formation
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23. The physical exam finding that most strongly correlates with hypervolemia is:
a) lower extremity edema
b) tachycardia
c) bilateral rales on chest exam
d) moist mucous membranes
e) decreased skin turgor
24. Which of the following mechanisms directly enhance reabsorption of sodium in the
proximal nephron?
a) ADH (antidiuretic hormone)
b) aldosterone
c) decreased GFR
d) increased sympathetic tone
e) countercurrent mechanism
25. A 25-year-old male presents with a 5-day history of nausea, vomiting and diarrhea. On
physical examination he has the following
Pulse: 110 BP 94/56
Reduced skin turgor, dry mucous membranes
He also has the following labs
Sodium: 141 meq/L
Chloride 105 meq/L
Bicarbonate 24 meq/L
BUN 29 mg/dL
Creatinine 1.0 mg/dL
Hemoglobin 15g/dL
Hematocrit 45%
The most appropriate resuscitation fluid would be:
a) 0.9% NaCl (154meq/L sodium, 154meq/L chloride)
b) Gatorade (18meq/L sodium, 3meq/L potassium, 21meq/L chloride)
c) red blood cell transfusion
d) albumin
e) 0.45% NaCl (77meq/L sodium, 77meq/L chloride)
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26. A 21-year-old cocaine user is found on the kitchen floor. The physical examination shows a
lethargic young man with a temperature of 100.0 F, a pulse rate of 110/min, and a blood
pressure of 175/100 mm Hg. There are multiple venipuncture sites in the skin of his left
forearm. The oropharynx is clear. The heart is regular in rhythm and no murmur or rub
appreciated. The lungs are clear. The abdomen is benign. There is diffuse tenderness to
palpation over buttocks and posterior aspects of legs.
The laboratory studies are as follows:
Hemoglobin
16
g/dl
Leukocyte count
10,750 /l
BUN
25
mg/dl
Creatinine
3.8
mg/dl
Potassium
4.9
meq/L
Creatine phosphokinase
50,350 U/L
Urine:
pH
5.0
Specific gravity
1.012
Protein
trace
Blood
4+
Urine sediment:
Erythrocytes 1-2 per high power field
Leukocytes 1-3 per high power field
Casts
numerous granular casts
What is the most likely cause of this patient’s renal disease?
a) prerenal azotemia
b) chronic glomerulonephritis
c) HIV nephropathy
d) rhabdomyolysis
e) acute interstitial nephritis
27. Which of the following casts found upon microscopic examination of urine sediment are
most suggestive of glomerulonephritis?
a) red blood cell casts
b) white blood cell casts
c) granular brown casts
d) hyaline casts
e) waxy casts
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28. A 76-year-old man with type 2 diabetes, HTN, CAD and chronic kidney disease from
diabetic nephropathy. His kidney function has been relatively stable today with a creatinine of
2.4 mg/dl. Urinary protein is 1.3 g/day increased from 0.6 g/day 4 months ago while on
Lisinopril for the last 3 years. Review of systems is unchanged with no chest pain, shortness of
breath or edema, except for a recent fall on the ice while walking resulting in lower back pain for
the last 3 weeks. Medications: Lisinopril (ACE inhibitor), ASA, Metoprolol (beta-blocker),
Insulin, Ibuprofen. Blood pressure is 150/90, HR 68. Lungs are clear, no lower extremity edema.
You increase the lisinopril from 20 mg daily to 40 mg daily for the increased proteinuria and
hypertension. Follow-up laboratory data (2weeks later) reveal BUN 64 mg/dl, creatinine 3.4
mg/dl and K 5.5 mEq/L. Urinalysis with specific gravity 1.010, pH 5.5, 2+ protein, no blood,
leukocytes, glucose or ketones.
The laboratory abnormalities:
a) Could be from the pain medications, which causes vasoconstriction at the afferent
arteriole.
b) Are unlikely from Lisinopril as he has been on the medication for many years
c) Are from his worsening diabetic nephropathy and hyporeninemic hypoaldosteronism
d) Should improve with initiation of a diuretic
e) Arose from volume depletion in the setting of osmotic diuriesis
29. You are in the emergency room when an elderly man is brought to see you in severe distress.
He has recently traveled to Kidneystan, the remote country of his origin, and he was prescribed
several bottles of an unknown medication, which he took. While you are scrambling to find a
Kidneystani translator, to determine the identification of his medications, you review his
bloodwork, which shows a Na+ of 128 mEq/L, a K+ of 3.5 mEq/L, an HCO3- of 14 mEq/L, a
Cl- of 104 mEq/L, and an arterial pH of 7.25, and a pCO2 of 28 mmHg. Which of the following
medications is most likely responsible for his illness?
a) aspirin
b) milk of magnesia (a potent cathartic, causing diarrhea)
c) hydrochlorothiazide
d) theophylline (a bronchodilator)
e) ipecac (causes vomiting)
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30. A 6-year-old girl is brought to the emergency room after collapsing; on initial presentation
she is unresponsive. Her parents are not available and for the moment, no other history is
available. She has a blood pressure of 74/30, a heart rate of 118/minute, and her mucous
membranes are dry, her lungs are clear, and his abdomen is soft and non tender. There is no
edema. An arterial blood gas shows a pH of 7.16 and a pCO2 of 80. The Na+ is 140 mEq/L, the
K+ is 4.7 mEq/L, the Cl- is 105 mEq/L, and the HCO3- is 28 mEq/L. Of the following, which is
the most likely cause of her acid-base disturbance?
a) overdose of sleeping pills
b) severe vomiting
c) diabetic ketoacidosis
d) diarrhea
e) overdose of salicylates
31. A 20-year-old woman comes to see you because she is not feeling well. Her medical history
is unremarkable, she takes no medications, and her examination is notable for a blood pressure of
138/84, a heart rate of 100/minute, and clear lungs, a normal abdomen, and no edema. Arterial
pH is 7.33, Na+ is 135 mEq/L, K+ is 4.8 mEq/L, Cl- is 92 mEq/L, and HCO3- is 15 mEq/L. The
pCO2 is 29 mmHg. Of the following, which is the most likely diagnosis?
a) adrenal insufficiency
b) early pregnancy
c) surreptitious intake of diuretics
d) renal failure
e) pulmonary embolism
32. A 49-year-old alcoholic man is admitted to the hospital with a two week history of no
appetite and continuous vomiting. His bicarbonate level is 40 mEq/L and the pH is 7.52 of the
following, the major mechanism for development of the abnormal bicarbonate level is
a) increased respiratory excretion of CO2
b) increased renin effect on the medullar collecting tubule
c) increased HCO3- reabsorption in the proximal tubule
d) decreased aldosterone effect on the proximal and distal tubules
e) increased HCO3- filtration in the glomerulus
THE NEXT TWO QUESTIONS REFER TO THE FOLLOWING CASE.
A 72 year old woman has severe congestive heart failure from ischemic heart disease. She is on
hydrochlorothiazide and furosemide, two diuretics. Her exam shows a blood pressure of 128/76,
heart rate of 90 that is irregularly irregular, bilateral rales, an S3 gallop, and ascites and 3+
peripheral edema. A chest x ray shows pleural effusions and pulmonary vascular congestion.
Her Na+ is 121 mEq/L. Her creatinine level is 1.2 mg/dL. Her BUN is 45 mg/dL. Her K+ is
3.7 mEq/L, the Cl- is 78 mEq/L, and the HCO3- is 38 mg/dL. The pH is 7.51 and the pCO2 is 49
mmHg.
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33. The single most important explanation for her hyponatremia is :
a) an increased ADH effect on the collecting duct
b) osmotic diuresis and urine sodium loss
c) a low sodium diet and decreased sodium intake
d) high level of aldosterone affecting the cortical collecting duct
e) decreased filtration of sodium and water in the glomerulus
34. What is contributing to the abnormal pH?
a) increased aldosterone effect on the cortical collecting duct
b) increased proximal tubular reabsorption of sodium
c) increased proximal tubular reabsorption of HCO3d) increased H+ secretion from the intercalated cells of the cortical collecting duct
e) all of the above
THE NEXT TWO QUESTIONS REFER TO THE FOLLOWING CASE
A 39 year old woman has focal and segmental glomerulosclerosis, and her kidney function has
been steadily worsening. When you see her in your clinic, she has a blood pressure of 200/80,
she is pale and fatigued, and she has bilateral rales, an S3 gallop, and 1+ edema. She has
excoriated skin lesions, from excessive itching. Her BUN is 124 mg/dL, and the creatinine is
17.2 mg/dL. The Na+ is 120 mEq/L, the K+ is 6.1 mEq/L, the Cl- is 85 mEq/L, and the HCO3is 10 mEq/L. Her arterial pH is 7.16.
35. What is the principal reason for her low serum Na+ level?
a) the serum Na+ is only falsely low because of the very high BUN level
b) decreased glomerular filtration of water
c) increased renal tubular secretion of sodium
d) decreased oral intake of sodium
e) increased effect of ADH on the cortical collecting tubule
36. Why is her blood pressure elevated?
a) psychological stress associated with her illness
b) increased release of renin from the juxtaglomerular apparatus of the kidney
c) decreased glomerular filtration of sodium
d) direct effect of BUN and creatinine on vascular smooth muscle
e) a cardiac arrhythmia associated with a high K+ level.
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37. A 59-year-old woman has breast cancer with metastases to the brain. She is given a
diagnosis of the syndrome of inappropriate ADH secretion. Which of the following laboratory
tests would you expect to see in her condition?
a) a urine Na+ of 72 mEq/L
b) a urine specific gravity of 1.002
c) a urine osmolality of 55 mOsm/L
d) a creatinine level of 2.3 mg/dL
e) a serum sodium level of 149 mEq/L
38. A 26-year-old male medical student takes a 5 mile jog on a hot day in July, and does not eat
or drink during exercise. At the conclusion of the run, he doesn't feel well, and at a visit to the
infirmary, his blood pressure is 100/70, heart rate is 110, and he is sweating, has clear lungs, and
no edema. His Na+ is 146 mEq/L, K+ is 3.9 mEq/L, Cl- is 118 mEq/L, HCO3- is 26 mEq/L, and
BUN is 23 mg/dL, with a creatinine of 1.0 mg/dL. Which of the following statements is likely to
be correct?
a) He has a modest increase in his total body sodium content
b) He probably has developed lactic acidosis.
c) He has a very high circulating level of ADH
d) His Cl- level is high because of increased proximal tubular reabsorption
e) The high serum Na+ level has suppressed renin production.
39. A 71-year-old man with a negative medical history develops fever, nausea, vomiting, and
diarrhea and has a profound decrease in his appetite. He visits his physician who notes his
temperature to be 100 degrees, BP to be 82/60, heart rate to be 110/min, respiratory rate is
28/min, and he has decreased skin turgor, dry mucous membranes, and clear lungs. The abdomen
is mildly tender. Labs show a Na+ of 123 mEq/L, K+ of 3.4 mEq/L, Cl- of 88 mEq/L, and
HCO3- of 21 mEq/L. The urine specific gravity is 1.030, and the urine osmolality is 1080
mOsm/kg H20. Of the following choices, what is the principal reason that the serum sodium
level is low?
a) loss of sodium from the skin and respiratory tract
b) increased sodium loss from the kidneys due to osmotic diuresis
c) shift of Na+ into cells
d) increased tubular reabsorption of water
e) increased aldosterone effect
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40. A 31-year-old man comes to see you for a physical examination. He has no history of prior
medical problems, takes no medications, does not smoke cigarettes, has 1 - 2 alcoholic beverages
per week, and has a negative family history for hypertension or cardiovascular disease. He jogs
or plays squash almost every day, and has a BMI of 24 (overweight > 25). He has three blood
pressure readings taken, which are 138/78, 132/86, and 120/88. His physical examination is
normal.
Which of the following statements is true?
a) He has stage I hypertension
b) His pulse pressure is between 95 and 100 mmHg.
c) He has a higher chance of developing end stage renal disease and a myocardial
infarction over his lifetime than someone with an average blood pressure of 110/70.
d) He should be worked up for renal artery stenosis, hyperaldosteronism, and a
pheochromocytoma
e) He is healthy, should be reassured, and his blood pressure needs no further attention.
41. A 52-year-old man has a history of schizophrenia and lives in a group home; he is on a
variety of psychotropic medications. He develops a sore throat and comes to the emergency
room where a physical exam shows a blood pressure of 128/80, and no obvious abnormalities
other than pharyngitis. Labs show a serum Na+ of 147 mEq/L, K+ of 3.9 mEq/l, Cl- of 114
mEq/L, and HCO3- of 24 mEq/L. The serum creatinine is 1.1 mg/dL.The urine analysis shows a
specific gravity of 1.001, and the urine osmolality is 60 mOsm/L. What is the most likely
explanation for his serum sodium abnormality?
a) increased ingestion of water due to his psychiatric illness
b) increased reabsorption of water in the medullary collecting duct
c) increased intake of sodium rich foods
d) impaired activity of ADH on renal tubular cells
e) decreased sodium excretion by the kidney
42. A 42-year-old African American man with a history of hypertension walks into your office
not feeling well, with a headache and blurred vision. On exam, his blood pressure is 220/136.
Which of the following abnormalities is most likely to be present?
a) elevated serum glucose level
b) proteinuria on urine dipstick
c) elevated hemoglobin level (above 15 gm/dL)
d) increased arterial pH
e) elevated serum calcium level
17
Path Renal Questions
The glomerulus below has been subjected to an immunofluorescent stain for IgA.
43. Of the 2 photos below which is most likely to represent the corresponding H&E stain of
a glomerulus from the same nephritic patient, A or B?
2 points
A
B
18
Match A and B, photos of small arteries, with the following scenarios:
A
B
44. A comatose 27 year old African-American man with a history of a severe headache
preceding loss of consciousness. He has a stiff neck and the blood pressure is 250/140.
45. A 69 year old man, with blood pressure of 160/95. He is on antihypertensives.
19
Note the light microscropic photo below. EM showed diffuse thickening of the basement
membrane with subepithelial deposits. A silver stain revealed irregular spikes protruding from
the basement membrane.
2 points
A. Idiopathic rapidly progressive glomerulonephritis
B. Membranous glomerulopathy
C. Post-streptococcal glomerulonephritis
46. Which is the most likely diagnosis, A, B, or C?
20
This gross renal photo might be from a patient with sickle cell disease.
47. Other conditions associated with the pathological entity illustrated include all of the
following except:
2 points
A.
B.
C.
D.
Obstruction
Diabetes mellitus
Renal artery embolism
Analgesic nephropathy
21
A patient with bacterial endocarditis is being treated with IV methicillin. He develops renal
failure.
48. Based on the biopsy shown above, he is given a diagnosis of:
2 points
A.
B.
C.
D.
Acute tubular necrosis
Drug-induced interstitial nephritis
Post-infectious glomerulonephritis
End stage kidney disease
49. A young woman develops acute renal failure and a microangiopathic hemolytic anemia
with thrombocytopenia. There is a history of diarrhea and ingestion of rare hamburger. She has
had slight confusion and restlessness but no seizures or loss of consciousness. Which is the most
likely diagnosis, A, B, or C?
A. Adult hemolytic-uremic syndrome
B. Thrombotic thrombocytopenic purpura
C. Acute tubular necrosis
22
50. The gross appearance of this diagrammatic kidney is most consistent with:
2 points
A.
B.
C.
D.
E.
Chronic glomerulonephritis
Renal infarcts
Chronic pyelonephritis
Renal artery stenosis
Sickle cell disease
23
A
B
Which of the above renal tumors, A or B, is associated with the features below?
51.A childhood tumor (a blastoma)
_______
52.Risk factors include tobacco smoking, obesity, and estrogen use
_______
53.An adult presenting with metastases and hypercalcemia
_______
54.WAGR, deletion 16p13 – WT1
55.Histologically triphasic
_______
_______
24
Match the adult structure with its embryological precursor (use each only once)
A.
B.
C.
D.
E.
Müllerian (paramesonephric) duct
Mesonephric (wolffian) duct
Coelomic epithelium
Urogenital sinus
Metanephric mesoderm
56.Peritoneal mesothelium
_______
57.Fallopian tubes
_______
58.Prostate gland
_______
59.Renal pelvis
_______
60.Glomerulus
_______
61.Which of the following developmental defects is least likely to be associated with the
oligohydramnios sequence?
A.
B.
C.
D.
E.
Bilateral renal agenesis
Tracheoesophageal fistula
Autosomal recessive polycystic kidney disease
Cystic-dysplastic kidneys
Prune belly syndrome
62.A young previously healthy man is hypovolemic for three hours after suffering severe
trauma with blood loss. One complication which develops is acute tubular necrosis. Which of
the following is least likely to be an additional complication?
A.
B.
C.
D.
E.
Subendocardial myocardial infarction
Transmural myocardial infarction
Centrolobular hepatic necrosis
Diffuse alveolar damage (ARDS)
Cerebral hypoxia
25
True (A) or (B) false:
63. Urothelial carcinoma of the bladder is much more common than squamous cell
carcinoma of the bladder, is more frequent in males than in females, and has an association with
tobacco smoking.
64. The juxtaglomerular apparatus consists of the glomerular cells in the efferent arteriole
and the macula densa in the adjacent proximal convoluted tubule.
65. In using the term “focal segmental glomerulosclerosis”, “segmental” refers to a segment
of the kidney and “focal” refers to a focal point in the glomerulus
66. In considering mechanisms of glomerular injury, an example of injury due to reduction
in GBM polyanion is the nephrotic syndrome associated with minimal change disease.
67. In crescentic glomerulonephritis the crescent is formed by mesangial cells and matrix.