Nephrotube, Aki End Of Module Exam

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Nephrotube, Aki End Of Module Exam - Quiz

NephroTube, AKI End of Module Exam26 MCQs80 minutesGood luckJoin NephroTube on facebook www. Facebook. Com/groups/NephroTubeVisit NephroTube website: www. NephroTubeCNE. Com


Questions and Answers
  • 1. 
    A 50-year-old man is admitted to the intensive care unit for management of hypotension, leukocytosis, and respiratory failure requiring mechanical ventilation following partial colectomy for a colonic neoplasm. Despite antibiotics and volume expansion with crystalloid, he remains hypotensive and requires vasopressor support, sedation, paralysis, and ongoing mechanical ventilation. On day 3, his fraction of inspired oxygen is increased to 0.9, and he has elevated peak airway pressures. The central venous pressure is 12 mmHg; there is abdominal distention and diffuse edema. He also has progressive oliguria and azotemia. His net fluid balance is 15 L positive relative to admission, yet the urine sodium concentration is
    • A. 

      Placement of a colonic tube for continuous suction by gastroenterology

    • B. 

      Crystalloid infusion to a central venous pressure of 15 mmHg

    • C. 

      Paracentesis

    • D. 

      Decompressive laparotomy

    • E. 

      Bilateral thoracenteses

  • 2. 
    A 70-year-old man with underlying diabetes mellitus, hypertension, and stage G3 CKD is seen 2 days following coronary artery bypass grafting for symptomatic coronary artery disease. He presented 1 week ago with angina and underwent diagnostic coronary angiography, which showed severe three-vessel coronary artery disease. The intraoperative course was uneventful, but postoperatively, he has required mechanical ventilatory support and vasopressors for persistent hypotension. The urine output has fallen to 300 ml/24 h, despite treatment with furosemide. Cumulative fluid balance since the time of surgery is positive 10 L. The blood pressure is 90/50 mmHg and his pulse is 100 beats/min. The extremities are cool. There is mild generalized edema. Breath sounds are diminished in the lung bases. Bowel sounds are hypoactive; no bruits are appreciated. There is no rash. The rest of the examination is unremarkable. The serum creatinine level has increased from 2.23 to 2.6 mg/dl. Echocardiography shows no evidence of cardiac tamponade. Which ONE of the following is the MOST appropriate strategy to determine the etiology of the AKI?
    • A. 

      Determination of the fractional excretion of sodium (FENa)

    • B. 

      Infusion of 250 ml of 5% albumin solution

    • C. 

      Measurement of the central venous pressure

    • D. 

      Examination of the urinary sediment for casts and cells

    • E. 

      Measurement of complement factor 3 (C3)

  • 3. 
    A 70-year-old woman with hepatic cirrhosis related to hepatitis C infection presents with hematemesis. The blood pressure is 60/30 mmHg and pulse is 100 beats/min. Physical examination reveals jaundice, stigmata of cirrhosis; mild asterixis, diminished basilar breath sounds, a nontender, but tense and markedly distended abdomen with shifting dullness; and severe lower extremity edema. Laboratory data include a hemoglobin level of 7 g/dl, serum creatinine level of 1.5 mg/dl, and serum sodium level of 128 mEq/L. Variceal bleeding is identified and treated endoscopically. Packed red blood cells are transfused, the hemoglobin level improves to 9 g/dl, and the blood pressure rises to 90/55 mmHg. Despite this, the creatinine level rises to 2.3 mg/dl, and the urine output falls to 400 ml/24 h. The urine sodium level is
    • A. 

      Initiation of hemodialysis

    • B. 

      Add vancomycin and piperacillin-tazobactam

    • C. 

      Vasoconstrictor therapy, infusion of albumin, and large-volume paracentesis

    • D. 

      Add pentoxifylline

    • E. 

      Transjugular intrahepatic portosystemic shunt (TIPS)

  • 4. 
    A 65-year-old man is evaluated in the emergency department for chest pain and is found to have an acute myocardial infarction. He has a history of hypertension, type 2 diabetes mellitus, and stage G4 CKD (eGFR, 24 ml/min per 1.73 m2). He is to undergo an emergent cardiac catheterization, and you are consulted to help mitigate the risk of contrast-induced AKI. Medications are losartan, furosemide, aspirin, and insulin glargine. On physical examination, his blood pressure is 136/80 mmHg and his pulse is 88 beats/min. The lungs are clear, and an S4 extra-heart sound is present. There is no peripheral edema. Which ONE of the following is the MOST effective intervention to minimize the risk of contrast-induced AKI in this patient?
    • A. 

      Intravenous isotonic sodium bicarbonate or sodium chloride

    • B. 

      Oral volume expansion

    • C. 

      Administration of intravenous N-acetylcysteine

    • D. 

      Use of iodixanol, an iso-osmolar contrast agent

    • E. 

      Hemodialysis after contrast administration

  • 5. 
    A 21-year-old man is evaluated for right arm pain and weakness. The previous night, he had consumed a large quantity of alcohol and fell asleep on the floor with his right arm draped across a suitcase. He awoke in the same position 10 hours later. Over the last several hours, he notes onset of pain, swelling, numbness, and severe weakness of the right arm. Physical examination shows normal vital signs. There is mild swelling of the right upper arm with normal distal pulses. Deep palpation of the biceps muscle elicits pain, and there is flaccid paralysis of the right arm with absent deep tendon reflexes. Laboratory tests reveal a sodium level of 136 mEq/L, potassium level of 5.2 mEq/L, chloride level of 103 mEq/L, total CO2 of 16 mmol/L, BUN level of 15 mg/dl, creatinine level of 1.5 mg/dl, calcium level of 6.8 mg/dl, phosphorus level of 5.9 mg/dl, and creatinine kinase level of 90,000 IU/L. Electrocardiogram is normal. Which ONE of the following is the MOST appropriate next step in management?
    • A. 

      Intravenous isotonic sodium bicarbonate in 5% dextrose at 250 ml/h

    • B. 

      Intravenous calcium gluconate infusion

    • C. 

      Furosemide infusion

    • D. 

      Intravenous 0.9% saline at 500 ml/h

    • E. 

      Hemodialysis

  • 6. 
    Which ONE of the following statements regarding the epidemiology of AKI is correct?
    • A. 

      The incidence of AKI is increasing, and the absolute mortality rates of AKI are decreasing

    • B. 

      Both the incidence of AKI and the mortality rates associated with AKI are decreasing over time

    • C. 

      The increased risk of AKI over time is restricted to the setting of sepsis in intensive care unit (ICU) patients

    • D. 

      Crude mortality rates associated with AKI have decreased only in patients who do not require dialysis

  • 7. 
    A 79-year-old woman with sepsis due to influenza A and a secondary bacterial pneumonia is hypotensive and requires intravenous fluid for volume resuscitation. On physical examination, the BP is 70/50 mmHg and the pulse is 120/min. The lung examination shows crackles and bronchial breath sounds at the right base. There is no leg edema. Laboratory studies show sodium 132 mEq/L, potassium 3.8 mEq/L, chloride 95 mEq/L, total CO2 18 mmol/L, BUN 45 mg/dl, and SCr 1.3 mg/dl. Which ONE of the following fluid resuscitation choices is associated with the lowest risk of AKI for this patient?
    • A. 

      Isotonic, crystalloid fluid

    • B. 

      0.45% saline

    • C. 

      Low molecular weight hetastarch

    • D. 

      0.9% saline plus 5% albumin

  • 8. 
    A 60-yr-old Caucasian patient presents with septic shock, a BP of 90/60 mmHg, a central venous pressure 4 mmHg, oliguria (urine output 10 ml/h), a central venous oxygen saturation of 60%, a transcutaneous pulse oximeter saturation of 98% on room air, a respiratory rate of 18/min, bilateral interstitial edema on chest x-ray, a serum creatinine concentration of 2 mg/dl, a serum albumin concentration of 2 g/dl, and a hemoglobin concentration of 9 g/dl. Which ONE of the following options is the BEST choice for treatment of this patient?
    • A. 

      Infuse 50 ml of 25% albumin intravenously, then reevaluate central venous pressure and central venous oxygen saturation.

    • B. 

      Transfuse 1 unit packed red blood cells.

    • C. 

      Administer 80 mg furosemide intravenously.

    • D. 

      Transfuse 1 unit packed red blood cells and administer 80 mg furosemide intravenously.

    • E. 

      Infuse boluses of isotonic saline until the central venous pressure is 8 to 12 mmHg, then recheck central venous oxygen saturation.

  • 9. 
    A 24-yr-old construction worker has his legs pinned under a pile of rubble in a construction accident. He is extricated after 5 h. Upon arrival in the emergency room, he is found to have a creatinine phosphokinase of 23,000 U/L and a serum creatinine of 1.9 mg/dl. Which ONE of the following treatments would be associated with a decreased risk of AKI in this patient?
    • A. 

      Intravenous crystalloid, initiated before hospital arrival.

    • B. 

      Mannitol.

    • C. 

      Dopamine.

    • D. 

      Furosemide.

    • E. 

      N-acetyl-cysteine

  • 10. 
    A 34-yr-old man receiving treatment for HIV infection presents with severe myalgias. His serum creatinine is 2.1 mg/dl, with a creatine phosphokinase of 7,400 U/L. His urinalysis is strongly positive for blood on dipstick, but he has only 2 to 4 red blood cells per high-powered field. Which ONE of the following medications is MOST likely to be associated with his AKI?
    • A. 

      Acyclovir.

    • B. 

      Adefovir.

    • C. 

      Cidofovir.

    • D. 

      Foscarnet.

    • E. 

      Zidovudine.

  • 11. 
    A 56-yr-old African-American man with endstage liver disease secondary to chronic hepatitis C infection develops hepatorenal syndrome while awaiting liver transplantation. Which ONE of the following statements regarding his management is correct?
    • A. 

      He should be listed for a combined liver kidney transplant.

    • B. 

      He should not be considered a candidate for liver transplantation.

    • C. 

      A trial of therapy with vasopressin analogues or octreotide and midodrine should be initiated before liver transplantation

    • D. 

      He should undergo liver transplantation only if his renal function improves after placement of a transjugular intrahepatic portosystemic shunt (TIPS).

    • E. 

      Renal replacement therapy is contraindicated.

  • 12. 
    A 36-year-old woman with lymphoma is treated with chemotherapy, and you are consulted to evaluate AKI. Her serum uric acid is 12.4 mg/dL. Which one of the following is a risk factor for uric acid nephropathy?
    • A. 

      Urine pH

    • B. 

      Volume depletion

    • C. 

      Preexisting renal disease

    • D. 

      Increased uric acid excretion

    • E. 

      All of the above

  • 13. 
    A 34-year-old woman with acute leukemia is admitted for tumor lysis syndrome with acute kidney injury, elevated serum [K+], phosphate, uric acid (16 mg/dL), and creatinine levels. Besides hydration with normal saline, which one of the following interventions is MOST appropriate for this patient?
    • A. 

      Allopurinol

    • B. 

      Colchicine

    • C. 

      Losartan

    • D. 

      Rasburicase

    • E. 

      Febuxostat

  • 14. 
    A 47-yr-old man develops multisystem organ failure with ARF in the setting of Klebsiella pneumoniae pneumonia and sepsis. His BP is 104/58 mmHg, with a heart rate of 96 beats per minute on 6 mcg/kg per min continuous infusion of dopamine. He is mechanically ventilated and has a PO2 of 74 torr while receiving 60% inspired oxygen. His pulmonary capillary occlusion pressure is 22 mmHg. His urine output is
    • A. 

      Continuous arteriovenous hemodiafiltration (CAVHDF) is associated with improved survival compared with intermittent hemodialysis.

    • B. 

      Continuous venovenous hemodialysis (CVVHD) provides better solute control than continuous venovenous hemofiltration (CVVH).

    • C. 

      Sustained low-efficiency dialysis (SLED) and extended daily dialysis (EDD) are associated with improved survival compared with intermittent hemodialysis.

    • D. 

      Continuous venovenous hemofiltration (CVVH) is associated with improved survival as compared with peritoneal dialysis.

    • E. 

      Sustained low-efficiency dialysis (SLED) and extended daily dialysis (EDD) are associated with improved survival as compared with continuous venovenous hemofiltration (CVVH).

  • 15. 
    A 55-year-old woman is transferred to ICU for hypotension and AKI following prolonged hip surgery. Her blood pressure is 70/40 mmHg with heart rate of 92 BPM. She received Ringer’s lactate during surgery, and in ICU she received normal saline. Clinically, she is adequately fluid resuscitated (trace edema). The intensivist started vasopressors. The patient, who is not a diabetic, develops hyperglycemia with serum glucose level of 242 mg/dL. Based on clinical studies, which one of the following glucose levels is considered APPROPRIATE?
    • A. 

      90–105 mg/dL

    • B. 

      110–149 mg/dL

    • C. 

      150–180 mg/dL

    • D. 

      90–110 mg/dL

    • E. 

      100–160 mg/dL

  • 16. 
    A 65-year-old woman is scheduled for elective cardiac bypass surgery. She has diabetes mellitus and hypertension. On physical examination, the BP is 150/90 mmHg and the pulse is 80/min. An S4 is heard on cardiac auscultation, but no murmurs are present. The remainder of the examination is normal. Which ONE of the following diagnostic testing strategies will best determine this patient’s risk for postoperative AKI?
    • A. 

      Measure eGFR and preoperative and postoperative albuminuria (0–6 hours after surgery)

    • B. 

      Measure eGFR and preoperative albuminuria

    • C. 

      Measure eGFR only

    • D. 

      Measure eGFR and postoperative albuminuria (0–6 hours after surgery)

  • 17. 
    A 62-year-old type 2 diabetic woman is admitted with urosepsis develops AKI 3 days after admission. Her systolic BP is 100 mmHg. The patient receives several liters of normal saline, and currently on norepinephrine. Her creatinine increased from 0.6 to 1.6 mg/dL. Her admission weight was 62 kg, and at time of consultation the weight was 70 kg (a gain of 8 kg). Regarding her creatinine level and AKI, which one of the following statements is CORRECT?
    • A. 

      Her creatinine increase is only 1.0 mg/dL, and additional volume administration is needed to improve AKI

    • B. 

      She needs 5 % albumin to improve creatinine levels and AKI

    • C. 

      Her elevation in creatinine is actually an underestimation in view of her weight gain

    • D. 

      There is no relationship between volume expansion and creatinine level

    • E. 

      None of the above

  • 18. 
    A 70-year-old man is admitted for abdominal pain and hematuria, and CT of abdomen is suggestive of renal cancer. His serum creatinine is 0.9 mg/dL. Regarding cancer and AKI, which one the following statements is FALSE?
    • A. 

      The incidence of AKI in patients with renal cancer is approximately 44 %

    • B. 

      The incidence of AKI is at least threefold higher in patients with cancer compared to those without cancer

    • C. 

      Sepsis is the most common cause of AKI in critically ill patients with cancer

    • D. 

      Chemotherapeutic agents are least likely causes of AKI

    • E. 

      Medication-induced mucositis may limit oral intake and may precipitate prerenal AKI

  • 19. 
    Which one of the pathophysiologic mechanisms is IMPLICATED in hepatorenal syndrome (HRS)?
    • A. 

      Splanchnic vasodilation

    • B. 

      Translocation of bacterial flora from intestine to mesenteric lymph nodes

    • C. 

      Activation of vasoconstrictor system and nonosmotic release of antidiuretic hormone (ADH)

    • D. 

      Renal cortical vasoconstriction

    • E. 

      All of the above

  • 20. 
    A 63-year-old man with stage 3 CKD due to type 2 diabetes mellitus is seen in consultation 4 weeks before elective coronary artery bypass grafting. His kidney function has been stable for the past year, with recent laboratory studies showing a SCr of 2.3 mg/dl and a urine albumin/ creatinine ratio of 460 mg/g. The patient has chronic stable angina, with recent angiography documenting three-vessel coronary artery disease. An echocardiogram shows well-preserved left ventricular function. Medications are aspirin 81 mg daily, atorvastatin 40 mg daily, lisinopril 20 mg daily, and metoprolol 25 mg twice daily. The physical examination shows a BP of 146/86 mmHg and a pulse of 68/min. The remainder of the examination is normal. WhichONE of the following alterations in lisinopril therapy is MOST likely to reduce the risk of functional perioperative AKI in this patient?
    • A. 

      Discontinue lisinopril now

    • B. 

      Discontinue lisinopril immediately before surgery

    • C. 

      Continue lisinopril throughout the perioperative period

    • D. 

      Increase the lisinopril dose

  • 21. 
    A 62-year-old woman with diabetes presents to the emergency department (ED) with abdominal pain. She has a fever to 103°F, has tachycardia with a heart rate of 115 bpm, and has hypotension with a BP of 75/50 mmHg. Her neck veins are flat when the head of the bed is at 30°. A computed tomography scan of the abdomen reveals a perforated gallbladder. Her current hematocrit is 37%. The ED staff begins volume resuscitation. Which ONE of the following statements is correct regarding the volume resuscitation prescription for this patient?
    • A. 

      She should receive blood products for volume resuscitation.

    • B. 

      She should receive hetastarch for volume resuscitation.

    • C. 

      She should receive crystalloid for volume resuscitation.

    • D. 

      Because colloid remains in the intravascular space, it is as cost-effective to volume resuscitate her with colloid as crystalloid.

  • 22. 
    An 80-year-old woman with a history of rheumatic heart disease and stage 3 CKD returns to the ICU intubated after a mitral valve replacement. You are asked to evaluate her because she is developing oliguria postoperatively. Her BP is 120/70 mmHg, her CVP is 6 mmHg, and she has pink urine. Which ONE of the following do you recommend now to reduce the risk for AKI?
    • A. 

      Normal saline at 100 ml/h

    • B. 

      NAC 1200-mg intravenous bolus every 6 hours for four doses

    • C. 

      Isotonic sodium bicarbonate infusion at 100 to 150 ml/h

    • D. 

      Packed red blood cell transfusion to target hemoglobin of 10 g/dl

    • E. 

      Mannitol 1 g intravenously every 6 hours

  • 23. 
    A 50-year-old African-American woman develops fluid-unresponsive shock (MAP 50 mmHg, persistent despite intravenous fluid infused to achieve a CVP of 10 mmHg) with oliguria and AKI (serum creatinine increase by 0.3 mg/dl in 12 hours) secondary to neutropenic sepsis after recent chemotherapy for breast cancer. In addition to the other components of early goal-directed therapy of septic shock, which ONE of the following would you recommend to reduce the severity of AKI in this patient?
    • A. 

      ANP

    • B. 

      Fenoldopam

    • C. 

      Erythropoietin

    • D. 

      Dopamine

    • E. 

      Norepinephrine

  • 24. 
    A 25-year-old Asian woman undergoes cardiac surgery for congenital heart disease with pulmonary hypertension and severe right heart failure, which is associated with chronic renal insufficiency (baseline serum creatinine 2.5 mg/dl). After 4 hours of cardiopulmonary bypass, it is difficult to wean her from bypass. She returns to the intensive care unit intubated and anuric on furosemide 20 mg/h. Her BP is 80/50 mmHg on vasopressin, dopamine, and norepinephrine infusions. She is mechanically ventilated and has an oxygen saturation of 90% on a fractional inspired oxygen of 0.6 with 15 cmH2O positive end-expiratory pressure and inhaled nitric oxide therapy. Central venous pressure (CVP) is 35 mmHg, and venous oxygen saturation is 50%. Her weight is increased 15 kg from preoperatively, and the sternal wound has not been closed because of massive edema. Her chest x-ray demonstrates bilateral pulmonary edema. Her serum creatinine is 2.8 mg/dl. Other laboratory tests include sodium of 135 mEq/L, potassium of 4.5 mEq/L, chloride of 100 mEq/L, total CO2 of 12 mEq/L, blood urea nitrogen of 70 mg/dl, and glucose of 80 mg/dl. Urinalysis is not available. The surgical team plans to transfuse 6 U of fresh-frozen plasma in preparation for return to the operating room for placement of a right ventricular assist device and sternal closure. You are asked to initiate emergent renal replacement therapy (RRT). Which ONE of the following interventions is MOST appropriate in this setting?
    • A. 

      Give intravenous boluses of 200 mg of furosemide with 500 mg of chlorothiazide, and increase furosemide infusion to 40 mg/h.

    • B. 

      Start a nesiritide infusion.

    • C. 

      Initiate slow continuous ultrafiltration.

    • D. 

      Give a mannitol bolus and infusion.

    • E. 

      Initiate continuous venovenous hemofiltration (CVVH).

  • 25. 
    In which ONE of the following patients with hypoalbuminemia is intravenous albumin proved to decrease the incidence of AKI?
    • A. 

      Patient with cirrhosis and spontaneous bacterial peritonitis

    • B. 

      Patient with nephrosis and anasarca

    • C. 

      Patient with acute decompensated heart failure

    • D. 

      Patient with septic shock

    • E. 

      Patient with closed head trauma

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