Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed.

SECTION VII. Disorders of the Kidney and Urinary Tract

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

VII-1. Which of the following is a potential etiology for ischemic acute renal failure?

A.  Apoptosis and necrosis of tubular cells

B.  Decreased glomerular vasodilation in response to nitric oxide

C.  Increased glomerular vasoconstriction in response to elevated endothelin levels

D.  Increased leukocyte adhesion within the glomerulus

E.  All of the above

VII-2. A 47-year-old man with a history of diabetes mellitus, hyperlipidemia, tobacco abuse, and coronary artery disease undergoes emergency appendectomy. Which of the following conditions predisposes this patient to postoperative acute kidney injury?

A.  Abdominal procedure, emergency surgery, and hyperlipidemia

B.  Age greater than 40, abdominal procedure, and emergency surgery

C.  Age greater than 40, emergency surgery, and diabetes mellitus

D.  Coronary artery disease, tobacco abuse, and abdominal procedure

E.  Diabetes mellitus and emergency procedure

VII-3. A 57-year-old man with a history of diabetes mellitus and chronic kidney disease with a baseline creatinine of 1.8 mg/dL undergoes cardiac catheterization for acute myocardial infarction. He is subsequently diagnosed with acute kidney injury related to iodinated contrast. All of the following statements are true regarding his kidney injury EXCEPT:

A.  Fractional excretion of sodium will be low.

B.  His creatinine is likely to peak within 3–5 days.

C.  His diabetes mellitus predisposed him to develop contrast nephropathy.

D.  Transient tubule obstruction with precipitated iodinated contrast contributed to the development of his acute kidney injury.

E.  White blood cell casts are likely on microscopic examination of urinary sediment.

VII-4. Which of the following acute kidney injury patients is most likely to have evidence of hydronephrosis on ultrasound evaluation of the kidneys?

A.  A 19-year-old man with purpura fulminans associated with gonococcal sepsis

B.  A 37-year-old woman undergoing chemotherapy and radiation for advanced cervical cancer

C.  A 53-year-old man with E. coli 0157:H7 associated thrombotic thrombocytopenic purpura

D.  An 85-year-old nursing home resident with pyelonephritis and sepsis

E.  None of the above

VII-5. In evaluation for acute kidney injury in a patient who has recently undergone cardiopulmonary bypass during mitral valve replacement, which of the following findings on urine microscopy is most suggestive of cholesterol emboli as the source of renal failure?

A.  Calcium oxalate crystals

B.  Eosinophiluria

C.  Granular casts

D.  Normal sediment

E.  White blood cell casts

VII-6. A 54-year-old man is admitted to the medical intensive care unit with sepsis associated with pneumococcal pneumonia. He requires mechanical ventilation as well as norepinephrine to maintain a mean arterial pressure greater than 60 mmHg. Invasive hemodynamics show adequate left-heart filling pressures and he is not known to have left ventricular dysfunction. On the third hospital day, his urine output drops and his creatinine increases to 3.4 mg/dL. Acute tubular injury is diagnosed. Which of the following agents has been shown to improve outcomes associated with his acute tubular injury?

A.  Furosemide

B.  Bosentan

C.  Low-dose dopamine

D.  Insulin-like growth factor

E.  None of the above

VII-7. 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?

A.  Afferent arteriolar vasoconstriction

B.  Afferent arteriolar vasodilatation

C.  Efferent arteriolar vasoconstriction

D.  Proximal tubular toxicity

E.  Ureteral obstruction

VII-8. Preoperative assessment of a 55-year-old male patient for coronary angiography shows an estimated glomerular filtration rate of 33 mL/min per 1.73 m2 and poorly controlled diabetes. He is currently on no nephrotoxic medications, and the nephrologist assures you that he does not currently have acute renal failure. The surgery is due to begin in 4 hours, and you would like to prevent contrast nephropathy. Which agent will definitely reduce the risk of contrast nephropathy?

A.  Dopamine

B.  Fenoldopam

C.  Indomethacin

D.  N-acetylcysteine

E.  Sodium bicarbonate

VII-9. In stage 5 chronic kidney disease the glomerular filtration rate is below:

A.  50 mL/min per 1.73 m2

B.  25 mL/min per 1.73 m2

C.  15 mL/min per 1.73 m2

D.  5 mL/min per 1.73 m2

E.  0 mL/min per 1.73 m2 (anuria)

VII-10. What is the leading cause of death in patients with chronic kidney disease?

A.  Cardiovascular disease

B.  Hyperkalemia

C.  Infection

D.  Malignancy

E.  Uremia

VII-11. All of the following statements regarding the use of exogenous erythropoietin in patients with chronic kidney disease are true EXCEPT:

A.  Exogenous erythropoietin should be administered with a target hemoglobin concentration of 100–115 g/L.

B.  The use of exogenous erythropoietin is associated with improved cardiovascular outcomes.

C.  The use of exogenous erythropoietin is associated with increased risk of stroke in patients with concomitant Type 2 diabetes mellitus.

D.  The use of exogenous erythropoietin may be associated with faster progression to the need for dialysis.

E.  The use of exogenous erythropoietin is associated with an increased incidence of thromboembolic events.

VII-12. A patient is followed closely by her nephrologist for stage IV chronic kidney disease associated with focal segmental glomerulosclerosis. Which of the following is an indication for initiation of maintenance hemodialysis?

A.  Acidosis controlled with daily bicarbonate administration

B.  Bleeding diathesis

C.  BUN greater than 110 mg/dL without symptoms

D.  Creatinine greater than 5 mg/dL without symptoms

E.  Hyperkalemia controlled with sodium polystyrene

VII-13. A 27-year-old woman with chronic kidney disease is undergoing hemodialysis and is found to be hypotensive during her treatment. Which of the following are potential mechanisms for hypotension during hemodialysis?

A.  Antihypertensive agents

B.  Excessive ultrafiltration

C.  Impaired autonomic responses

D.  Osmolar shifts

E.  All of the above

VII-14. A 35-year-old woman with hypertensive kidney disease progresses to end-stage renal disease. She was initiated on peritoneal dialysis 1 year ago and has done well with relief of her uremic symptoms. She is brought to the emergency department with fever, altered mental status, diffuse abdominal pain, and cloudy dialysate. Her peritoneal fluid is withdrawn through her catheter and sent to the laboratory for analysis. The fluid white blood cell count is 125/mm3 with 85% polymorphonuclear neutrophils. Which organism is most likely to be found on culture of the peritoneal fluid?

A.  C. albicans

B.  E. coli

C.  M. tuberculosis

D.  P. aeruginosa

E.  S. aureus

VII-15. A 45-year-old woman begins hemodialysis for end-stage renal disease associated with diabetes mellitus. Which of the following is the most likely eventual cause of her death?

A.  Dementia

B.  Major bleeding episode

C.  Myocardial infarction

D.  Progressive uremia

E.  Sepsis

VII-16. The “dose” of dialysis is currently defined as:

A.  The counter-current flow rate of the dialysate

B.  The fractional urea clearance

C.  The hours per week of dialysis

D.  The number of sessions actually completed in a month

VII-17. Your patient with end-stage renal disease on hemodialysis has persistent hyperkalemia. He has a history of total bilateral renal artery stenosis, which is why he is on hemo-dialysis. He has electrocardiogram changes only when his potassium rises above 6.0 meq/L, which occurs a few times per week. You admit him to the hospital for further evaluation. Your laboratory evaluation, nutrition counseling, and medication adjustments have not impacted his serum potassium. What is the next reasonable step to undertake for this patient?

A.  Adjust the dialysate.

B.  Administer a daily dose of furosemide.

C.  Perform “sodium modeling.”

D.  Implant an automatic defibrillator.

E.  Perform bilateral nephrectomy.

VII-18. Which of the following statements is true regarding kidney transplantation?

A.  Five-year survival rates are similar for recipients of living donor kidneys and deceased donor kidneys.

B.  Deceased donor age does not influence graft survival.

C.  Renal transplantation offers no cost benefit compared to hemodialysis.

D.  When first-degree relatives are donors, the graft survival rate at 1 year is 5–7% greater than that for deceased donors.

E.  When followed for more than 20 years, renal complications in single kidney donors are common.

VII-19. All of the following are likely causes of glomerular damage leading to renal failure EXCEPT:

A.  Diabetes mellitus

B.  Fanconi’s syndrome

C.  Lupus nephritis

D.  Malignant hypertension

E.  Mutation of TRPC6 cation channel

VII-20. A 21-year-old man is diagnosed with post-streptococcal glomerulonephritis. Which of the following is likely to be found in his urine?

A.  Greater than 3 g/24-hour proteinuria without hematuria

B.  Macroscopic hematuria and 24-hour urinary albumin of 227 mg

C.  Microscopic hematuria with leukocytes and 24-hour urinary albumin of 227 mg

D.  Positive urine culture for Streptococcus

E.  Sterile pyuria without proteinuria

VII-21. 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:

Serum creatinine: 106 μmol/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

A renal biopsy demonstrates that 60% of the glomeruli have segmental scarring by light microscopy, with the remainder of the glomeruli appearing unremarkable (see Figure VII-21).

image

FIGURE VII-21

The most likely diagnosis is:

A.  Hypertensive nephrosclerosis

B.  Focal and segmental sclerosis

C.  Minimal-change (nil) disease

D.  Membranous glomerulopathy

E.  Crescentic glomerulonephritis

VII-22. Which of the following is an extrarenal manifestation of autosomal dominant polycystic kidney disease?

A.  Aortic regurgitation

B.  Aortic root dilation

C.  Colonic diverticulae

D.  Intracranial aneurysm

E.  All of the above

VII-23. A 21-year-old male college student is evaluated for profound fatigue that has been present for several years but has recently become debilitating. He also reports several foot spasms and cramps, and occasional sustained muscle contractions that are uncontrollable. He is otherwise healthy, takes no medications, and denies tobacco or alcohol use. On examination he is well developed with normal vital signs including blood pressure. The remainder of the examination is normal. Laboratory evaluation shows a sodium of 138 meq/L, potassium of 2.8 meq/L, chloride of 90 meq/L, and bicarbonate of 30 mmol/L. Magnesium level is normal. Urine screen for diuretics is negative and urine chloride is elevated. Which of the following is the most likely diagnosis?

A.  Bulimia nervosa

B.  Diuretic abuse

C.  Gitelman’s syndrome

D.  Liddle’s syndrome

E.  Type 1 pseudohypoaldosteronism

VII-24. A 28-year-old woman was recently diagnosed with autosomal dominant polycystic kidney disease after an episode of hematuria. She is concerned about her intracranial aneurysm risk. Which of the following statements is true regarding this risk?

A.  Family history of ruptured intracranial aneurysms does not increase risk of rupture.

B.  Prior intracranial hemorrhage does not increase risk of subsequent hemorrhage.

C.  The size of the aneurysm does not correlate with its risk of spontaneous rupture.

D.  There is no increased risk of intracranial aneurysm in this condition.

E.  Uncontrolled hypertension augments the risk of spontaneous rupture.

VII-25. A patient with a history of Sjögren’s syndrome has the following laboratory findings: plasma sodium 139 meq/L, chloride 112 meq/L, bicarbonate 15 meq/L, and potassium 3.0 meq/L; urine studies show a pH of 6.0, sodium of 15 meq/L, potassium of 10 meq/L, and chloride of 12 meq/L. The most likely diagnosis is:

A.  Type I renal tubular acidosis (RTA)

B.  Type II RTA

C.  Type III RTA

D.  Type IV RTA

E.  Chronic diarrhea

VII-26. A 16-year-old female star gymnast presents to your office complaining of fatigue, diffuse weakness, and muscle cramps. She has no previous medical history and denies tobacco, alcohol, or illicit drug use. There is no significant family history. Examination shows a thin female with normal blood pressure. Body mass index (BMI) is 18 kg/m2. Oral examination shows poor dentition. Muscle tone is normal, and neurologic examination is normal. Laboratory studies show hematocrit of 38.5%, creatinine of 0.6 mg/dL, serum bicarbonate of 30 meq/L, and potassium of 2.7 meq/L. Further evaluation should include which of the following?

A.  Urinalysis and urine culture

B.  Plasma renin and aldosterone levels

C.  Urine toxicology screen for opiates

D.  Urine toxicology screen for diuretics

E.  Serum magnesium level

VII-27. In which of the following cases would treatment for biopsy-proven interstitial nephritis with corticosteroids be most likely to impact long-term renal recovery?

A.  A 37-year-old woman with sarcoidosis

B.  A 48-year-old man with slowly progressing interstitial nephritis over 2 months with fibrosis found on biopsy

C.  A 54-year-old man with diabetes mellitus and recent salmonella infection

D.  A 63-year-old man with allergic interstitial nephritis after cephalosporin antibiotic use

E.  None of the above

VII-28. A 58-year-old woman undergoes a hysterectomy and postoperatively develops acute respiratory distress syndrome. She is treated with mechanical ventilation and broad-spectrum antibiotics. Aside from hypothyroidism, she has no underlying medical conditions. On day 5 of her hospitalization her urine output is noted to fall and her serum creatinine rises from 1.2 mg/dL to 2.5 mg/dL. Allergic interstitial nephritis from cephalosporin antibiotics is suspected. Which of the following findings will confirm this diagnosis?

A.  Hematuria

B.  Peripheral blood eosinophilia

C.  Urinary eosinophils on urine microscopy

D.  White blood cell casts on urine microscopy

E.  None of the above

VII-29. A 44-year-old obese woman undergoes elective cholecystectomy for cholelithiasis. Postoperatively she does well and is discharged after 3 days. Two days after discharge she develops altered mental status and fever, and is brought to the emergency department by her family. She takes an antidepressant, but is otherwise healthy. Her temperature is 103°F, pulse is 127 beats/min, blood pressure is 110/78 mmHg, and respiratory rate and oxygen saturation are normal. Examination is notable for confusion and a well-healed surgical incision. Routine chemistries are drawn and show normal electrolytes, BUN of 80 mg/dL, creatinine of 2.5 mg/dL, white blood cell count of 17.3 thousand/μL, hematocrit of 30%, and platelet count of 25 thousand/μL. A peripheral blood smear shows schistocytes and confirms low platelets without clumping. Which of the following statements regarding her condition is true?

A.  Low activity of the metalloprotease ADAMTS13 is likely present in her peripheral blood.

B.  Plasma exchange is unlikely to be helpful.

C.  This was likely caused by an occult E. coli 0157:H7 infection.

D.  This condition is more common in men than women.

E.  Untreated mortality from this condition is low.

VII-30. A 35-year-old female presents with complaints of bilateral lower extremity edema, polyuria, and moderate left-sided flank pain that began approximately 2 weeks ago. There is no past medical history. She is taking no medications and denies tobacco, alcohol, or illicit drug use. Examination shows normal vital signs, including normal blood pressure. There is 2+ edema in the bilateral lower extremities. The 24-hour urine collection is significant for 3.5 g of protein. Urinalysis is bland except for the proteinuria. Serum creatinine is 0.7 mg/dL, and ultrasound examination shows the left kidney measuring 13 cm and the right kidney measuring 11.5 cm. You are concerned about renal vein thrombosis. What test do you choose for the evaluation?

A.  Computed tomography of the renal veins

B.  Contrast venography

C.  Magnetic resonance venography

D.  99Tc-labeled pentetic acid (DPTA) imaging

E.  Ultrasound with Doppler evaluation of the renal veins

VII-31. A 48-year-old man with diabetes mellitus and hyperlipidemia presents to the emergency department for evaluation of right flank pain and groin pain that has been severe and present for approximately 3 hours. He is diagnosed with a kidney stone. Which of the following is most likely to be found as the constituent of his stone?

A.  Calcium

B.  Cysteine

C.  Oxalic acid

D.  Struvite

E.  Uric acid

VII-32. A 54-year-old woman with a history of colon cancer treated with resection 2 years prior and chemotherapy is admitted to the hospital after routine lab work at her primary care physician’s office showed a BUN of 65 mg/dL and a creatinine of 4.5 mg/dL. She reports mild fatigue and recent lower back pain, but otherwise feels well. She does admit to recent NSAID use, but has not taken more than the recommended quantity. Aside from stopping NSAIDs and avoiding nephrotoxins, which of the following studies should be ordered first?

A.  CT of the abdomen/pelvis with oral contrast

B.  Post-void residual volume of bladder

C.  Retrograde urography

D.  Ultrasound of the abdomen/kidney

E.  Urinary fractional excretion of sodium

VII-33. A 67-year-old man presents to the emergency department with severe abdominal distention and pain. He is found to have a palpable bladder, and after Foley catheter placement 1.5 L of urine passes. His prostate-specific antigen (PSA) is not elevated, but he does report that he has had difficulty passing his urine for several weeks, culminating in no urination for 2 days. His BUN is 89 mg/dL and creatinine is 6.4 mg/dL. Over the next 4 days of hospitalization, his BUN and Cr fall, but his urine output is found to be rising. He is not receiving intravenous fluids. He passes 6 L of urine on the third and fourth hospital days. Which is the most likely explanation for the increased urine output?

A.  Cerebral salt wasting

B.  Decreased medullary osmolarity

C.  Increased activation of the renin-angiotensin-aldosterone system

D.  Increased tubule pressure

E.  Postobstructive diuresis

VII-34. The patient in question VII-33 is at risk for which of the following complications?

A.  Erythrocytosis

B.  Hyperchloremic metabolic acidosis

C.  Hyperkalemia

D.  Prerenal azotemia

E.  Systemic hypertension

VII-35. The pain associated with acute urinary tract obstruction is a result of which of the following?

A.  Compensatory natriuresis

B.  Decreased medullary blood flow

C.  Increased renal blood flow

D.  Vasodilatory prostaglandins

VII-36. You are evaluating a 28-year-old man from Peru with abdominal pain. As part of the diagnostic workup, an abdominal ultrasound shows bilateral hydronephrosis and hydroureters. Which of the following conditions is least likely in this patient?

A.  Lymphoma

B.  Meatal stenosis

C.  Phimosis

D.  Retroperitoneal fibrosis