Nephrotube, Aki End Of Module Exam
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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
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Placement of a colonic tube for continuous suction by gastroenterology
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Crystalloid infusion to a central venous pressure of 15 mmHg
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Paracentesis
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Decompressive laparotomy
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Bilateral thoracenteses
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NephroTube, AKI End of Module Exam
26 MCQs
80 minutes
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- 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?
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Determination of the fractional excretion of sodium (FENa)
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Infusion of 250 ml of 5% albumin solution
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Measurement of the central venous pressure
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Examination of the urinary sediment for casts and cells
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Measurement of complement factor 3 (C3)
Correct Answer
A. Examination of the urinary sediment for casts and cellsExplanation
Answer D: Examination of the urinary sediment for casts and cells
This patient has developed AKI based on the rise in serum creatinine level of >0.3 mg/dl and the development of oliguria. This patient has important risk factors for AKI including CKD, diabetes, and recent angiography, as well as coronary artery bypass surgery complicated by postoperative hypotension. The major diagnostic consideration is to determine whether the AKI is due to renal hypoperfusion (prerenal azotemia) that will improve with volume expansion or other measures to enhance renal perfusion versus acute tubular necrosis (ATN) related to renal ischemia that will not reverse promptly with such measures.
The presence of renal tubular epithelial cells and/or granular casts has a strong positive predictive value for ATN. A low FENa (Rate this question:
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- 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
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Initiation of hemodialysis
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Add vancomycin and piperacillin-tazobactam
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Vasoconstrictor therapy, infusion of albumin, and large-volume paracentesis
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Add pentoxifylline
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Transjugular intrahepatic portosystemic shunt (TIPS)
Correct Answer
A. Vasoconstrictor therapy, infusion of albumin, and large-volume paracentesisExplanation
Answer C: Vasoconstrictor therapy, infusion of albumin, and large-volume paracentesis
Large-volume paracentesis with infusion of albumin coupled with institution of vasoconstrictor therapy is the most appropriate management for this patient with tense ascites, hypotension, and acute oliguric kidney injury. Leading considerations in the differential diagnosis for this patient include prerenal azotemia, evolving acute tubular necrosis (ATN), or type I hepatorenal syndrome (HRS). A therapeutic trial of albumin 1 mg/kg at least over the initial 48 hours may ameliorate prerenal azotemia. Patients admitted to the intensive care unit with hypotension also benefit from norepinephrine titrated to raise the systolic blood pressure approximately 10 mmHg. Midodrine and octreotide (or terlipressin when available) is used rather than norepinephrine for patients managed outside of the intensive care unit. Comprehensive management includes large-volume paracentesis with the infusion of albumin to relieve intra-abdominal hypertension. The diagnosis of type I HRS would be supported by persistent kidney dysfunction despite optimization of renal perfusion in the absence of many muddy brown casts in the urine sediment. Distinguishing HRS from ATN is often difficult because epithelial cell and granular casts may be seen in the setting of hyperbilirubinemia, and the fractional excretion of sodium is oftenRate this question:
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- 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?
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Intravenous isotonic sodium bicarbonate or sodium chloride
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Oral volume expansion
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Administration of intravenous N-acetylcysteine
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Use of iodixanol, an iso-osmolar contrast agent
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Hemodialysis after contrast administration
Correct Answer
A. Intravenous isotonic sodium bicarbonate or sodium chlorideExplanation
Answer A: Intravenous isotonic sodium bicarbonate or sodium chloride
Recent data support the use of either intravenous isotonic sodium bicarbonate or sodium chloride infusions to decrease the risk of contrast-induced AKI. Although several randomized controlled trials showed superiority of sodium bicarbonate, these trials were underpowered, and three appropriately powered randomized trials demonstrated no difference in outcomes.
Individual studies and a pooled meta-analysis have failed to demonstrate decreased risk of contrast-induced AKI with the iso-osmolar agent iodixanol relative to “low” osmolar contrast media (600–850 mOsm/kg), whereas high osmolar contrast agents are clearly more nephrotoxic. High osmolar contrast agents are no longer used or available.
Evidence regarding the benefit of N-acetylcysteine has been equivocal, and use of intravenous N-acetylcysteine is not recommended due to the risk of anaphylaxis associated with intravenous administration. Kidney Disease Improving Global Outcomes recommends use oral N-acetylcysteine, together with intravenous isotonic crystalloids, in patients at increased risk for contrast-induced AKI, although the N-acetylcysteine guideline was a level 2D recommendation (“We suggest” with very low-quality evidence).
Hemodialysis has been shown to be of no additional benefit over intravenous crystalloid administration for preventing contrast-induced AKI, and there is risk for potential harm when it is used for prevention of contrast-induced AKI.
Enteral (oral) administration of fluid to achieve volume expansion may also provide a benefit but has not been studied rigorously and is not appropriate for an individual who is poised to have an emergency procedure.Rate this question:
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- 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?
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Intravenous isotonic sodium bicarbonate in 5% dextrose at 250 ml/h
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Intravenous calcium gluconate infusion
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Furosemide infusion
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Intravenous 0.9% saline at 500 ml/h
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Hemodialysis
Correct Answer
A. Intravenous 0.9% saline at 500 ml/hExplanation
Answer D: Intravenous 0.9% saline at 500 ml/h
Aggressive volume administration with isotonic saline is the best initial treatment for this patient with rhabdomyolysis. The treatment of rhabdomyolysis involves aggressive fluid administration to reduce the risk of intratubular cast formation and prevent AKI. The choice of fluids is controversial. There is a theoretical benefit to giving intravenous bicarbonate to maintain a urine pH of >6.5. Increased urine pH may prevent precipitation of the Tamm-Horsfall protein-myoglobin complex and potentially limit the reduction-oxidation cycling of myoglobin, decreasing tubular injury from lipid peroxidation. However, evidence of clear benefit is lacking. Furthermore, in patients with severe hypocalcemia, administration of high-dose bicarbonate could substantially reduce ionized calcium levels, increasing the likelihood of symptomatic hypocalcemia. Bicarbonate also promotes the deposition of calcium phosphate in the renal tubules and should be used with caution in patients with hyperphosphatemia.
Hemodialysis is not effective at removing creatine kinase and is reserved for patients with severe AKI or intractable hyperkalemia. Loop diuretics may be indicated if there was evidence of marked volume expansion.
Hypocalcemia in this setting is due to sequestration of calcium in damaged muscle cells. Rebound hypercalcemia often occurs and is exacerbated by exogenous calcium treatment. Severe vascular and visceral calcification has been reported in individuals in whom hypocalcemia was treated following an episode of rhabdomyolysis. Therefore, calcium should only be given in cases where the patient is symptomatic or where there is severe hyperkalemia with risk of arrhythmia.Rate this question:
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- 6.
Which ONE of the following statements regarding the epidemiology of AKI is correct?
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The incidence of AKI is increasing, and the absolute mortality rates of AKI are decreasing
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Both the incidence of AKI and the mortality rates associated with AKI are decreasing over time
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The increased risk of AKI over time is restricted to the setting of sepsis in intensive care unit (ICU) patients
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Crude mortality rates associated with AKI have decreased only in patients who do not require dialysis
Correct Answer
A. The incidence of AKI is increasing, and the absolute mortality rates of AKI are decreasingExplanation
Answer A: The incidence of AKI is increasing, and the absolute mortality rates of AKI are decreasing
Recent trend analysis derived from cardiac surgery settings suggests that the incidence of AKI is increasing. The analysis also indicated that although the absolute mortality rates in AKI may have decreased over time, the attributable risk of death continues to increase. Therefore, A is the correct choice. Both B and D are incorrect as the incidence and mortality in AKI are not decreasing, nor is the reduction in mortality restricted to the non-dialysis subjects. Choice C is also incorrect because the rising incidence of AKI and associated mortality have been demonstrated in multiple clinical settings including cardiac surgery and after nonsurgical percutaneous coronary interventions.Rate this question:
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- 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?
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Isotonic, crystalloid fluid
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0.45% saline
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Low molecular weight hetastarch
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0.9% saline plus 5% albumin
Correct Answer
A. Isotonic, crystalloid fluidExplanation
Answer A: Isotonic, crystalloid fluid
Isotonic and not hypotonic intravenous fluids should be used for volume resuscitation. Therefore, A is correct, and B is incorrect. Low molecular weight hetastarch solutions have been associated with an increased rate of complications, including acute kidney injury; therefore, C is incorrect. Finally, adding albumin to normal saline is not associated with any statistically significant benefit in terms of clinical outcomes, hence D is incorrect.Rate this question:
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- 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?
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Infuse 50 ml of 25% albumin intravenously, then reevaluate central venous pressure and central venous oxygen saturation.
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Transfuse 1 unit packed red blood cells.
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Administer 80 mg furosemide intravenously.
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Transfuse 1 unit packed red blood cells and administer 80 mg furosemide intravenously.
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Infuse boluses of isotonic saline until the central venous pressure is 8 to 12 mmHg, then recheck central venous oxygen saturation.
Correct Answer
A. Infuse boluses of isotonic saline until the central venous pressure is 8 to 12 mmHg, then recheck central venous oxygen saturation.Explanation
Correct Answer E: Infuse boluses of isotonic saline until the central venous pressure is 8 to 12 mmHg, then recheck central venous oxygen saturation.
This patient has septic shock complicated by respiratory and renal failure, and should receive early goal directed therapy. Saline boluses to achieve the target central venous pressure range of 8-12 mmHg is the best approach (Choice E). There is no proven advantage of albumin or other colloids in this setting (Choice A), even with hypoalbuminemia and acute lung injury with early pulmonary edema. There is no indication for blood transfusion at this point (Choices B and D), but this would be indicated if central venous oxygen saturation remained below 70% with a hemoglobin below 10 grams/dl when the target central venous pressure of 8-12 mmHg is achieved. Diuresis alone (Choice C) is contraindicated at this point in resuscitation
of this patient.Rate this question:
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- 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?
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Intravenous crystalloid, initiated before hospital arrival.
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Mannitol.
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Dopamine.
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Furosemide.
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N-acetyl-cysteine
Correct Answer
A. Intravenous crystalloid, initiated before hospital arrival.Explanation
Answer A: Intravenous crystalloid, initiated prior to hospital arrival
Several strategies have been proposed to prevent or attenuate the development of AKI in rhabdomyolysis. The most important is aggressive volume replacement. In patients with traumatic rhabdomyolysis, fluid resuscitation should be initiated in the field, even before the crushed extremity is released. Urinary alkalinization has been advocated as a means to increase the solubility of heme proteins within the tubule. It has also been suggested that alkalinization may decrease the redox cycling of myoglobin thereby reducing the generation of reactive oxygen species. The use of mannitol has also been advocated, however it has not been shown to have greater efficacy than volume expansion with saline alone. No benefit has been demonstrated for dopamine, furosemide or N-acetylcysteine in this setting.Rate this question:
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- 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?
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Acyclovir.
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Adefovir.
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Cidofovir.
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Foscarnet.
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Zidovudine.
Correct Answer
A. Zidovudine.Explanation
Answer E: Zidovudine
Rhabdomyolysis is seen with increased frequency in association with HIV infection. Several factors contribute to this including a high rate of alcohol and substance abuse in this population, muscle involvement and direct drug toxicity. Although myopathy is a common complication of HIV infection, it usually does not produce severe enough muscle injury to cause myoglobinuric AKI. The antiretroviral drug zidovudine has been associated with severe myopathy and rhabdomyolysis as a result of mitochondrial DNA depletion in myocytes. None of the other agents listed are associated with rhabdomyolysis.Rate this question:
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- 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?
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He should be listed for a combined liver kidney transplant.
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He should not be considered a candidate for liver transplantation.
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A trial of therapy with vasopressin analogues or octreotide and midodrine should be initiated before liver transplantation
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He should undergo liver transplantation only if his renal function improves after placement of a transjugular intrahepatic portosystemic shunt (TIPS).
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Renal replacement therapy is contraindicated.
Correct Answer
A. A trial of therapy with vasopressin analogues or octreotide and midodrine should be initiated before liver transplantationExplanation
Correct Answer C: A trial of therapy with vasopressin analogues or octreotide and midodrine should be initiated before liver transplantation.
In this patient with hepatorenal syndrome (HRS) due to chronic hepatitis C infection, a trial of therapy with terlipressin (a vasopressin analogue) or combination therapy with octreotide and midodrine should be initiated prior to liver transplantation Liver transplantation is not contraindicated in patients with HRS, although HRS is associated with an increase in peri-operative and 1-year mortality (choice A is incorrect). In a case control study, normalization of renal function with terlipressin prior to transplantation resulted in similar post-transplant outcomes as patients with normal renal function. Although terlipressin is not available in the United States, combination therapy with midodrine and octreotide is associated with similar improvement in renal function. Combined liver-kidney transplantation is not indicated in this setting as the majority of patients will recover renal function following successful liver transplantation (choice B is incorrect). The use of
transjugular intrahepatic portosystemic shunt (TIPS) may also improve renal function in patients with HRS, but is not a prerequisite to transplantation (choice D is incorrect). Although it may be appropriate to withhold renal replacement therapy in patients with HRS who are not candidates for liver transplant, renal replacement therapy is not contraindicated in patients who are active transplant candidates (choice E is incorrect).Rate this question:
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- 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?
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Urine pH
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Volume depletion
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Preexisting renal disease
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Increased uric acid excretion
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All of the above
Correct Answer
A. All of the aboveExplanation
The answer is E
All of the above choices are correct (E). Uric acid is the end product of purine metabolism. It has a pKa of 5.75. At a physiologic pH of 7.4, uric acid exists as urate anion. In clinical setting, the importance of uric acid lies in its solubility. In general, uric acid is less soluble than urate, and an acidic environment reduces uric acid solubility. At a pH of 5.0, the saturation of uric acid occurs at a concentration of 7.0, the saturation occurs at a concentration of >150 mg/dL. In the distal renal tubule, the pH isRate this question:
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- 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?
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Allopurinol
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Colchicine
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Losartan
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Rasburicase
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Febuxostat
Correct Answer
A. RasburicaseExplanation
The answer is D
Allopurinol is used prophylactically with hydration prior to chemotherapy. It inhibits xanthine oxidase, which converts xanthine to uric acid. Thus, uric acid formation and serum levels of uric acid are lowered. However, allopurinol has no direct effect on uric acid conversion to more soluble allantoin. Therefore, initiation of allopurinol in this patient does not lower uric acid levels. Thus, option A is incorrect. Colchicine reduces inflammation in gouty patients, and does not reduce uric acid levels in this patient. Also, colchicine is not indicated in tumor lysis syndrome. Thus, option B is incorrect. Losartan is an angiotensin receptor blocker, and has uricosuric properties. In this patient with elevated serum creatinine levels (acute kidney injury), losartan may not have any beneficial effect. Also, it is not the drug of choice in this patient. Therefore, option C is incorrect. Febuxostat is a novel nonpurine xanthine oxidase inhibitor, which is
recommended for prevention of hyperuricemia and gout. So far, no clinical trial results are available for its use in tumor lysis syndrome. Thus, option E is incorrect. Rasburicase is a recombinant urate oxidase. This enzyme converts urate into allantoin, which is excreted.
Human subjects lack this enzyme. Since the patient has high uric acid levels, the use of rasburicase seems appropriate in this patient, as it converts urate into allantoin. Either a single dose (0.2 mg/kg) or daily dose for 5 days lowers uric acid levels within few hours in children, adults, and elderly. Therefore, option D is correct. Rasburicase should be avoided in patients with glucose-6-phosphate dehydrogenase deficiency, as it may generate hydrogen peroxide and causes hemolytic anemia and methemoglobinemia.Rate this question:
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- 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
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Continuous arteriovenous hemodiafiltration (CAVHDF) is associated with improved survival compared with intermittent hemodialysis.
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Continuous venovenous hemodialysis (CVVHD) provides better solute control than continuous venovenous hemofiltration (CVVH).
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Sustained low-efficiency dialysis (SLED) and extended daily dialysis (EDD) are associated with improved survival compared with intermittent hemodialysis.
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Continuous venovenous hemofiltration (CVVH) is associated with improved survival as compared with peritoneal dialysis.
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Sustained low-efficiency dialysis (SLED) and extended daily dialysis (EDD) are associated with improved survival as compared with continuous venovenous hemofiltration (CVVH).
Correct Answer
A. Continuous venovenous hemofiltration (CVVH) is associated with improved survival as compared with peritoneal dialysis.Explanation
Answer D: Continuous venovenous hemofiltration (CVVH) is associated with improved survival as compared to peritoneal dialysis
In a study comparing CVVH to PD in 70 adult patients with infection-associated AKI (48 patients with severe falciparum malaria, 22 patients with sepsis), the mortality rate in patients treated with peritoneal dialysis was 47 % as compared to a mortality rate of 15% in patients treated with CVVH. In studies comparing CRRT to intermittent hemodialysis, no consistent survival benefit has been observed for CRRT. In the largest randomized controlled trial, CRRT was associated with a higher mortality, although this study was flawed by unbalance randomization that resulted in a higher acuity of illness in the CRRT group. There are no data to compare outcomes with either SLED or EDD to outcomes with intermittent hemodialysis or any form of CRRT. Although the mechanism of solute removal differs between CVVH (predominantly convective clearance) and CVVHD (predominantly diffusive clearance), similar degrees of solute control for urea and other low molecular weight solutes can be achieved with either modality.
• Phu NH, Hien TT, Mai NTH, et al. Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. N Engl J Med 347:895-902; 2002
• Swartz RD, Messana JM, Orzol S, Port FK. Comparing continuous hemofiltration with hemodialysis in patients with severe acute renal failure. Am J Kidney Dis 34:424-432; 1999
• Mehta R, McDonald B, Gabbai F, Pahl M, Pascual MTA, et al. A randomized clinic trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 60:1154-1163; 2001
• Kellum JA, Angus DC, Johnson JP, Leblanc M, Grinnin M, et al. Continuous versus intermittent renal replacement therapy: a meta-analysis. Intensive Care Med 28:29-37; 2002Rate this question:
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- 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?
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90–105 mg/dL
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110–149 mg/dL
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150–180 mg/dL
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90–110 mg/dL
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100–160 mg/dL
Correct Answer
A. 110–149 mg/dLExplanation
The answer is B
In ICU patients with sepsis and other conditions, hyperglycemia develops due to stress-induced insulin resistance. Intensive insulin therapy lowers glucose. Studies have shown that intensive glucose control reduces the intensity and severity of AKI. However, the degree of intensity that avoids severe hypoglycemia has not been established. Following an extensive review of literature, the KDIGO guideline recommends maintenance of serum glucose between 110 and 149 mg/dL. Thus, B is correct.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int (Suppl). 2:1–138, 2012.Rate this question:
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- 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?
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Measure eGFR and preoperative and postoperative albuminuria (0–6 hours after surgery)
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Measure eGFR and preoperative albuminuria
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Measure eGFR only
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Measure eGFR and postoperative albuminuria (0–6 hours after surgery)
Correct Answer
A. Measure eGFR and preoperative and postoperative albuminuria (0–6 hours after surgery)Explanation
Answer A: Measure eGFR, preoperative and postoperative albuminuria (0-6 hours after surgery)
Two separate cohort studies have shown that measurement of preoperative as well as postoperative albuminuria (measured between 0 to 6 hours after surgery) has a graded association with AKI in patients undergoing cardiac surgery. Both of these studies show that the addition of both preoperative and postoperative albuminuria improved the accuracy of prediction of AKI independent of the preoperative estimated GFR. Hence, A is the correct answer and choices B, C, and D are incorrect.
Coca SG, Jammalamadaka D, Sint K, Thiessen Philbrook H, Shlipak MG, Zappitelli M, Devarajan P, Hashim S, Garg AX, Parikh CR, Translational Research Investigating Biomarker Endpoints in Acute Kidney Injury: Preoperative proteinuria predicts acute kidney injury in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 143: 495-502, 2012
Molnar AO, Parikh CR, Sint K, Coca SG, Koyner J, Patel UD, Butrymowicz I, Shlipak M, Garg AX: Association of postoperative proteinuria with AKI after cardiac surgery among patients at high risk. Clin J Am Soc Nephrol 7: 1749-1760, 2012Rate this question:
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- 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?
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Her creatinine increase is only 1.0 mg/dL, and additional volume administration is needed to improve AKI
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She needs 5 % albumin to improve creatinine levels and AKI
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Her elevation in creatinine is actually an underestimation in view of her weight gain
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There is no relationship between volume expansion and creatinine level
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None of the above
Correct Answer
A. Her elevation in creatinine is actually an underestimation in view of her weight gainExplanation
The answer is C
Several studies have shown that volume expansion (fluid overload) underestimates serum creatinine levels, and delay the initiation of diagnosing AKI and renal replacement therapies. Positive fluid balance increases the volume of creatinine distribution and lowers its levels. Both in children and adults, fluid overload (>10 %) was found to be associated with increased mortality. This patient gained 8 kg (>10 %), which underestimates her serum creatinine. Thus, C is correct.Rate this question:
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- 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?
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The incidence of AKI in patients with renal cancer is approximately 44 %
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The incidence of AKI is at least threefold higher in patients with cancer compared to those without cancer
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Sepsis is the most common cause of AKI in critically ill patients with cancer
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Chemotherapeutic agents are least likely causes of AKI
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Medication-induced mucositis may limit oral intake and may precipitate prerenal AKI
Correct Answer
A. Chemotherapeutic agents are least likely causes of AKIExplanation
The answer is D
All of the above statements are correct except for D. Indeed, most of the chemotherapeutic agents do cause AKI by a variety of mechanisms. A large Danish study reported the highest incidence of AKI in patients with renal cancer at 44 % (A is correct), followed by 33 % in patients with multiple myeloma, 31.8 % in liver cancer patients. A number of studies reported the incidence of AKI is at least threefold higher in cancer patients than in patients without cancer (B is correct). Sepsis seems to be leading cause of AKI in critically ill cancer patients (C is correct). Volume depletion due to poor oral intake causes prerenal azotemia in those with mucositis due to chemotherapeutic drugs (E is correct)Rate this question:
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- 19.
Which one of the pathophysiologic mechanisms is IMPLICATED in hepatorenal syndrome (HRS)?
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Splanchnic vasodilation
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Translocation of bacterial flora from intestine to mesenteric lymph nodes
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Activation of vasoconstrictor system and nonosmotic release of antidiuretic hormone (ADH)
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Renal cortical vasoconstriction
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All of the above
Correct Answer
A. All of the aboveExplanation
The answer is E
Although the exact mechanisms leading to HRS are incompletely understood, the available studies so far implicate all of the above mechanisms (A–D). Thus, E is correct. Of these mechanisms, splanchnic vasodilation is widely accepted mechanism for HRS. In the initial stages of cirrhosis, inflammation of hepatocytes leads to hepatic stellate cells located in the perisinusoidal space to secrete collagen and deposition in the sinusoids, leading to portal vein resistance. With progression of liver disease, the increase in portal resistance/hypertension causes release of vasodilators such as nitric oxide (NO) by shear stress. Also, vasodilators such as cannabinoids and carbon monoxide are released. Increased shear stress also causes development of collaterals in mesenteric arteries, resulting in profound splanchnic vasodilation.
Splanchnic vasodilation causes a reduction in systemic vascular resistance because the splanchnic circulation is a major part of the peripheral circulation. In early cirrhosis, cardiac output increases with maintenance of arterial volume and BP. With advancing cirrhosis, this cardiac output may increase further, but not sufficient because of severe reduction in systemic vascular resistance. Effective circulating arterial blood volume also decreases. The result is a further increase in cardiac output, which is related to activation of sympathetic nervous system, renin-AII-aldosterone system, and nonosmotic release of ADH. Not only Na+ but also water is reabsorbed, resulting in edema and ascites. Relative hypotension develops because of increased splanchnic vasodilation despite adequate salt and water retention. Thus, circulatory dysfunction occurs in cirrhosis (A, C are correct).
Bacterial translocation from intestinal lumen to mesenteric lymph nodes occurs in cirrhotic patients. These bacteria cause inflammation and release of inflammatory cytokines such as tumor necrosis factor-α and interleukin-6. These cytokines stimulate the production of vasodilaters such as NO with accentuation of splanchnic vasodilation and further cardiac dysfunction. Thus, B is correct.
Renal cortical (arcuate and interlobular) vasoconstriction in HRS has been clearly demonstrated by imaging studies, resulting in AKI. Intense renal vasoconstriction is the result of splanchnic vasodilation and activation of sympathetic nervous and renin-AII-aldosterone system. Although the vasoconstrictive effect of sympathetic nervous and renin-AII-aldosterone system is less effective in splanchnic bed because of severe vasodilation, their effect is more pronounced on renal arteries. As a result, a decrease in renal blood flow and GFR is seen in patients with HRS (D is correct). Thus, HRS is a hemodynamically mediated abnormality rather than an intrinsic kidney disease.Rate this question:
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- 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?
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Discontinue lisinopril now
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Discontinue lisinopril immediately before surgery
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Continue lisinopril throughout the perioperative period
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Increase the lisinopril dose
Correct Answer
A. Discontinue lisinopril nowExplanation
Answer A: Discontinue lisinopril now
Recent data from the Translational Research Investigating Biomarker Endpoints in AKI (TRIBE-AKI) cohort suggest that perioperative exposure to ACEI/ARB increases the risk of functional, or prerenal, AKI (1). This prospective cohort included 1594 patients undergoing cardiac surgery who were classified as high risk for AKI based on the presence of one or more of the following: SCr > 2 mg/dl, diabetes, age > 70 years, ejection fraction 2 mg/dl and diabetes mellitus), discontinuing lisinopril now (A), during the month before CABG, would expose the patient to the lowest risk of functional AKI. Further studies are required to define effects on morbidity and mortality, before making more definitive recommendations regarding the perioperative use of angiotensin blockade. The remaining choices (B, C, and D) are associated with increased risk of AKI and are thus incorrect.
• Coca SG, Garg AX, Swaminathan M, Garwood S, Hong K, Thiessen-Philbrook H, Passik C, Koyner JL, Parikh CR; TRIBE-AKI Consortium: Preoperative angiotensin-converting enzyme inhibitors and angiotensin receptor blocker use and acute kidney injury in patients undergoing cardiac surgery. Nephrol Dial Transplant 28: 2787-2799, 2013Rate this question:
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- 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?
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She should receive blood products for volume resuscitation.
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She should receive hetastarch for volume resuscitation.
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She should receive crystalloid for volume resuscitation.
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Because colloid remains in the intravascular space, it is as cost-effective to volume resuscitate her with colloid as crystalloid.
Correct Answer
A. She should receive crystalloid for volume resuscitation.Explanation
Answer C: She should receive crystalloid for volume resuscitation
Randomized clinical trials and a Cochrane meta-analysis of colloid versus crystalloid administration for fluid
resuscitation that have suggested that there is no benefit to colloid administration, and in general colloids are
more expensive than crystalloid solutions (D is incorrect). Furthermore, certain colloids, such as hetastarch,
have been associated with an increased rate of AKI (B is incorrect). Blood products are not routinely used for
volume resuscitation, and with a hematocrit of 37%, this patient does not meet criteria for transfusion based on
published early goal directed therapy algorithms or based on randomized clinical trials of transfusion targets in
critically ill patients (A is incorrect). Therefore, the best choice of fluid for resuscitation in this patient is an
isotonic crystalloid solution (C is correct).
1. Brunkhorst, FM, Engel, C, Bloos, F, Meier-Hellmann, A, Ragaller, M, Weiler, N, Moerer, O, Gruendling,
M, Oppert, M, Grond, S, Olthoff, D, Jaschinski, U, John, S, Rossaint, R, Welte, T, Schaefer, M, Kern, P,
Kuhnt, E, Kiehntopf, M, Hartog, C, Natanson, C, Loeffler, M, Reinhart, K: Intensive insulin therapy and
pentastarch resuscitation in severe sepsis. N Engl J Med 358:125-139, 2008Rate this question:
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- 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?
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Normal saline at 100 ml/h
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NAC 1200-mg intravenous bolus every 6 hours for four doses
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Isotonic sodium bicarbonate infusion at 100 to 150 ml/h
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Packed red blood cell transfusion to target hemoglobin of 10 g/dl
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Mannitol 1 g intravenously every 6 hours
Correct Answer
A. Isotonic sodium bicarbonate infusion at 100 to 150 ml/hExplanation
Answer C: Isotonic sodium bicarbonate infusion at 100 to 150 ml/hour
N-acetylcysteine has no proven benefit for the prevention or treatment of AKI (or hemolysis) (Option B is
incorrect). Although her oliguria may respond to a volume challenge (her CVP is only 6 mmHg), the finding of
pink urine with presumed hemoglobinuria (to be confirmed with urine dipstick, and discrepancy with microscopic
urinalysis) suggests greater potential benefit with urinary alkalinisation combined with volume loading (sodium
bicarbonate), rather than the use of saline alone (Option A is incorrect, and Option C is correct) [1, 2]. If
transfusion is required, there is no indication to use of Hb threshold or target above 7 g/dl (Option D is incorrect).
Mannitol would potentially exacerbate hypovolemia, and has no proven benefit in this setting (Option E is
incorrect).
1. Vermeulen-Windsant, I, Snoeijs, M, Hanssen, S, et al: Hemolysis is associated with acute kidney injury
during major aortic surgery. Kidney Int 77:913-920, 2010Rate this question:
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- 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?
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ANP
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Fenoldopam
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Erythropoietin
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Dopamine
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Norepinephrine
Correct Answer
A. NorepinephrineExplanation
Answer E: Norepinephrine
This patient urgently requires vasopressor therapy to achieve an adequate systemic (and renal) perfusion pressure. Norepinephrine is superior to dopamine for this purpose (Option D is incorrect, and Option E is correct) . Fenoldopam has not been proven beneficial for this purpose, and is furthermore contraindicated in the presence of profound vasodilatory shock (Option B is incorrect). ANP has not been shown to improve renal function or outcomes in septic shock, and drug-induced hypotension would also be a concern in this patient if ANP were administered (Option A is incorrect). Erythropoietin therapy has not been proven to improve renal function in patients with AKI, even with early administration (Option C is incorrect) .
1. De Backer, D, Biston, P, Devriendt, J, Madl, C, Chochrad, D, Aldecoa, C, Brasseur, A, Defrance, P, Gottignies, P, Vincent, JL: Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 362: 779-789, 2010
2. Endre, ZH, Walker, RJ, Pickering, JW, et al: Early intervention with erythropoietin does not affect the outcome of acute kidney injury (the EARLYARF trial). Kidney Int 77:1020-1030, 2010Rate this question:
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- 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?
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Give intravenous boluses of 200 mg of furosemide with 500 mg of chlorothiazide, and increase furosemide infusion to 40 mg/h.
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Start a nesiritide infusion.
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Initiate slow continuous ultrafiltration.
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Give a mannitol bolus and infusion.
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Initiate continuous venovenous hemofiltration (CVVH).
Correct Answer
A. Initiate continuous venovenous hemofiltration (CVVH).Explanation
Answer: E. Initiate continuous venovenous hemofiltration (CVVH).
Initiation of RRT with CVVH is the most appropriate choice of intervention for this hemodynamically unstable patient with renal insufficiency, diuretic refractory oliguria, and severe volume overload. Volume overload is contributing to pulmonary dysfunction, inability to achieve sternal wound closure (with increased risk for mediastinitis), and possibly even right-sided cardiac dysfunction and shock. Even with maximal response, it is highly unlikely that diuresis can correct volume overload in a timely manner, particularly in someone refractory to furosemide infusion of 20 mg/h. Slow continuous ultrafiltration will not correct metabolic acidosis or provide therapy for evolving azotemia (GFR in this patient with anuria is 0). Mannitol
and nesiritide are of no proven benefit in this scenario and have the potential for harm by causing pulmonary edema or hypotension. Although serum creatinine has not yet increased significantly to reflect evolving acute-on-chronic renal failure in this patient, there is a strong rationale to initiate RRT at this time. Cardiac surgery patients commonly develop oliguria, acidosis, or azotemia in the perioperative period, and many groups claim superior outcomes with aggressive use of RRT in this setting. There are no adequate controlled trials to guide the timing of RRT initiation in patients with AKI after cardiac surgery, which remains a matter of clinical judgment.
● Bent P, Tan HK, Bellomo R, Buckmaster J, Doolan L, Hart G, Silvester W, Gutteridge G, Matalanis G,
Raman J, Rosalion A, Buxton BF: Early and intensive continuous hemofiltration for severe renal failure after
cardiac surgery. Ann Thorac Surg 71: 832–837, 2001Rate this question:
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- 25.
In which ONE of the following patients with hypoalbuminemia is intravenous albumin proved to decrease the incidence of AKI?
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Patient with cirrhosis and spontaneous bacterial peritonitis
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Patient with nephrosis and anasarca
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Patient with acute decompensated heart failure
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Patient with septic shock
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Patient with closed head trauma
Correct Answer
A. Patient with cirrhosis and spontaneous bacterial peritonitisExplanation
Correct answer is A: Cirrhotic patient with spontaneous bacterial peritonitis.
The use of intravenous albumin in the management of hypoalbuminemic patients has been controversial.
Albumin infusions have only been shown to decrease the incidence of AKI in a very limited number of clinical situations; including initial treatment of cirrhotic patients with spontaneous bacterial peritonitis (SBP) (choice A is correct) and in association with large-volume paracentesis in patients with diuretic resistant ascites. In a randomized controlled trial of 126 patients with cirrhosis and SBP the addition of intravenous albumin infusion to standard antibiotic therapy was associated with a decrease in the incidence of AKI from 33% to 10% (p=0.002) and in in-hospital mortality from 29% to 10% (p=0.01). No reduction in the incidence of AKI has been demonstrated in the settings of nephrotic syndrome, septic shock, decompensated heart failure or closed head trauma (choices B, C, D and E are incorrect).
In patients with traumatic brain injury fluid resuscitation with albumin was associated with increased mortality as compared to saline.
• Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del-Arbol L, Castells L, Vargas V, Soriano G, Guevara M, Ginès P, Rodés J: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 341:403-409; 1999.
• Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline
for fluid resuscitation in the intensive care unit. N Engl J Med 350:2247-2256; 2004.
• Myburgh J, Cooper DJ, Finfer S, Bellomo R, Norton R, Bishop N, Kai Lo S, Vallance S. Saline or
albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 357:874-884;
2007.Rate this question:
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- 26.
A 69-yr-old man develops multisystem organ failure with oliguric AKI as a complication of community- acquired pneumonia. He requires support with mechanical ventilation for respiratory failure and is on a norepinephrine infusion to maintain a mean arterial BP of 60 to 65 mmHg. Which ONE of the following RRT modalities is associated with the highest probability of 28-d survival?
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Intermittent hemodialysis.
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CVVHDF.
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“Hybrid” modality of renal support (e.g., sustained low-efficiency dialysis (SLED)).
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No single modality of RRT is associated with an increased probability of 28-d survival.
Correct Answer
A. No single modality of RRT is associated with an increased probability of 28-d survival.Explanation
Correct answer is D: No single modality of RRT is associated with an increased probability of 28-d survival.
Multiple randomized controlled trials have been published in the last six years comparing survival in patients with AKI treated with intermittent hemodialysis and CRRT. To date, none of these studies have demonstrated survival benefit associated with modality of renal replacement therapy. No studies have been performed comparing survival with the “hybrid” modalities (e.g., SLED) to outcomes with either intermittent hemodialysis or any modality of
CRRT. Thus, current data does not support an increased probability of 28-d survival with any single modality of RRT (choice D).
• Uehlinger DE, Jakob SM, Ferrari P, Eichelberger M, Huynh-Do U, Marti HP, Mohaupt MG, Vogt B, Rothen HU, Regli B, et al: Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 20:1630-1637, 2005
• Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, Pallot JL, Chiche JD, Taupin P, Landais P, Dhainaut JF: Continuous venovenous hemodiafiltration versus intermittent hemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomized trial. Lancet 368:379-385, 2006Rate this question:
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