Nephrotube Ckd Module End Exam

20 Questions | Total Attempts: 147

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Nephrotube Ckd Module End Exam

20 MCQs60 minGood LuckGawad


Questions and Answers
  • 1. 
    A 58-yr-old white man was diagnosed 2 yr ago with type 2 diabetes. His 46-yr-old sister also has type 2 diabetes and has recently had a myocardial infarction. He was initially treated with oral hypoglycemic agents but was started on insulin 2 mo ago because of poor blood glucose control. He continues to smoke 1 package of cigarettes per day. On physical examination, he is obese with a body mass index of 32 kg/m2. Blood pressure (BP) is 120/75 mmHg, and pulse is 110 beats per minute. Funduscopic exam revealed background retinopathy. Laboratory studies included a serum creatinine of 1.1 mg/dl, an albumin/ creatinine ratio of 200 mg/g (normal 17 mg/g), hemoglobin A1C is 9.8%, and serum cholesterol is 298 mg/dl. Which ONE of the following treatment choices should be recommended to the patient?
    • A. 

      Stop insulin treatment and begin a combination of oral hypoglycemic agents.

    • B. 

      Perform angiotensin-converting enzyme (ACE) polymorphism studies and start treatment with an ACE inhibitor if his genotype is DD.

    • C. 

      Start treatment with an angiotensin II receptor blocker (ARB).

    • D. 

      Start treatment with a beta-blocker.

    • E. 

      Monitor albumin/creatinine ratio every 6 mo and institute treatment with an ARB if he develops overt albuminuria (albumin/creatinine ratio 250 mg/g).

  • 2. 
    A 38-yr-old African-American woman is found to have microscopic hematuria on a routine physical examination. Her only significant history is a normal labor and delivery at age 22. Her mother and a maternal aunt are on hemodialysis for end-stage renal disease (ESRD) secondary to polycystic kidney disease (PKD). On physical examination, blood pressure (BP) is 145/95 mmHg, pulse is 80 beats/ min, and weight is 75 kg. Her serum creatinine is 1.2 mg/dl; her hemoglobin is 14.5 g/dl; urinalysis shows specific gravity of 1.017, no protein, trace blood, and 5 to 10 red blood cells/high power field. A spot urine protein/creatinine ratio is 150 mg/g (normal 200 mg/g), and urine sodium is 102 mEq/L. Renal ultrasound demonstrates multiple cysts in both kidneys. Which ONE of the following is true regarding her condition?
    • A. 

      She does not have chronic kidney disease (CKD) because her serum creatinine and protein excretion are both normal.

    • B. 

      Estimating glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) study equation is not accurate in PKD patients.

    • C. 

      She has CKD on the basis of the microscopic hematuria and abnormal renal ultrasound.

    • D. 

      On the basis of her current serum creatinine, she is unlikely to develop ESRD during her lifetime.

    • E. 

      GFR should be measured by 125I-iothalamate clearance to appropriately stage her CKD.

  • 3. 
    Reagrding to the case in MCQ 3, Which ONE of the following should be recommended for therapy?
    • A. 

      She should be advised to lower her salt intake with follow-up blood pressure (BP) and serum creatinine in 4 mo.

    • B. 

      She should be referred for laparoscopic deroofing of her renal cysts.

    • C. 

      Anti-hypertensive therapy should be started with a thiazide diuretic, and a beta-blocker could be added if needed.

    • D. 

      She should be placed on dietary protein restriction (0.6 g/kg per d).

    • E. 

      She should be treated with an angiotensinconverting enzyme (ACE) inhibitor to a target BP of 130/85 mmHg.

  • 4. 
    A 78-yr-old white man comes to your office for routine preventive care. He has a history of hypertension treated with a thiazide diuretic. He is currently asymptomatic. On physical examination, his blood pressure (BP) is 155/80 mmHg, his pulse is 80 beats/min and regular, and his weight is 75 kg. The remainder of his examination is unremarkable. Laboratory studies show the following: serum creatinine, 1.1 mg/dl; calculated glomerular filtration rate (GFR) using the abbreviated Modification of Diet in Renal Disease (MDRD) study equation, 69 ml/min per 1.73 m2; urinalysis is normal; spot protein-to-creatinine ratio, 130 mg/g (normal 200 mg/g). A renal ultrasound shows the right kidney is 11 cm and the left kidney is 11.5 cm in length without evidence for hydronephrosis. Which ONE of the following is true regarding his condition?
    • A. 

      The Cockcroft-Gault equation is more accurate than the MDRD equation for estimating GFR in patients 70-yr-old.

    • B. 

      A kidney biopsy is indicated to define the underlying renal pathology.

    • C. 

      On the basis of the urinary protein excretion rate and GFR, he has stage 3 chronic kidney disease (CKD).

    • D. 

      The low GFR is a consequence of aging, and he should not be classified as having CKD.

    • E. 

      The thiazide diuretic should be switched to a loop diuretic.

  • 5. 
    A 46-yr-old white woman is seen in your office for evaluation of elevated serum creatinine. She currently has hypertension. A kidney biopsy performed 2 yr ago showed membranous glomerulonephritis. There was severe tubulointerstitial disease, and 3 of 27 glomeruli were globally sclerosed. At that time, her serum creatinine was 2.1 mg/dl, her calculated glomerular filtration rate (GFR) by the abbreviated Modification of Diet in Renal Disease (MDRD) study equation was 27 ml/min per 1.73 m2, serum cholesterol was 320 mg/dl, and she had a 24-h urinary protein excretion of 8.6 g. Which ONE of the following is true regarding her risk of developing progressive kidney failure?
    • A. 

      White patients have a higher risk of progression compared with patients from other ethnic groups.

    • B. 

      Few glomeruli were globally sclerosed; therefore, her renal prognosis is good.

    • C. 

      The severity of tubulointerstitial disease is a good predictor of kidney disease progression.

    • D. 

      Proteinuria is not a risk factor for kidney disease progression.

    • E. 

      On the basis of the amount of proteinuria, she is unlikely to respond to an angiotensinconverting enzyme (ACE) inhibitor.

  • 6. 
    A 58-yr-old Asian man is seen in your office for assessment and treatment of his elevated serum creatinine. He was diagnosed by renal biopsy with immunoglobulin A (IgA) nephropathy 2 yr ago. Laboratory studies show serum creatinine of 2.0 mg/dl, calculated glomerular filtration rate (GFR) of 37 ml/min per 1.73 m2 by the abbreviated Modification of Diet in Renal Disease (MDRD) study equation, hemoglobin of 10.0 g/dl, hematocrit of 30%; urine protein-tocreatinine ratio of 2400 mg/g (normal 200 mg/g). Which ONE of the following is true regarding assessment of his anemia?
    • A. 

      Hematocrit is a more accurate way of defining anemia than hemoglobin.

    • B. 

      Erythropoietin levels are useful in deciding treatment.

    • C. 

      A bone marrow biopsy should be performed to rule out myelodysplastic syndrome.

    • D. 

      Serum iron, transferrin saturation, and ferritin should be measured to assess iron stores.

    • E. 

      Proteinuria is associated with a poor response to erythropoietin therapy.

  • 7. 
    Which ONE of the following is true regarding therapy?
    • A. 

      Treatment of anemia is associated with higher rates of hospitalizations.

    • B. 

      Treatment of anemia can prevent the development of left ventricular hypertrophy.

    • C. 

      Erythropoietin can accelerate the progression of kidney disease.

    • D. 

      Treatment with recombinant erythropoietin should only be initiated when the hemoglobin is 8 g/dl.

    • E. 

      Target hemoglobin levels with recombinant erythropoietin should be 11 g/dl.

  • 8. 
    A 62-yr-old white man with type 2 diabetes and chronic kidney disease (CKD) presents to your office for treatment recommendations. Coronary artery bypass surgery was performed 3 yr ago. He has hypertension that is being treated with furosemide, metoprolol, and lisinopril. His major complaint is fatigue. On physical examination, his blood pressure (BP) is 140/85 mmHg, and he has 1 peripheral edema. His serum creatinine is 2.2 mg/dl with a calculated glomerular filtration rate (GFR) of 32 ml/min per 1.73 m2 by the Modification of Diet in Renal Disease (MDRD) abbreviated formula. A spot protein-to-creatinine ratio is 4000 mg/g (normal 200 mg/g). His fasting blood glucose is 150 mg/dl. Which ONE of the following choices is most correct regarding this patient?
    • A. 

      At this stage in his kidney disease, glycemic control is likely to be beneficial in slowing the progression.

    • B. 

      He has a low risk of kidney disease progression.

    • C. 

      His target BP should not be lowered because it would increase his risk of sudden cardiac death (J point phenomenon).

    • D. 

      Addition of an angiotensin receptor blocker will further decrease the progression of his kidney disease.

    • E. 

      Lowering his target BP can slow the progression of his kidney disease.

  • 9. 
    Additional laboratory tests performed on the patient described in last MCQ case return and demonstrate a hemoglobin of 10.1 g/dl with a serum iron of 92 mg/dl, a transferrin saturation of 23%, and a ferritin of 130 ng/ml. Which ONE of the following should be done next?
    • A. 

      Carefully follow his hemoglobin and start recombinant erythropoietin therapy if it decreased to 8 g/dl.

    • B. 

      Check an echocardiogram and start recombinant erythropoietin therapy if left ventricular hypertrophy is present.

    • C. 

      Start oral iron and recheck hemoglobin level in 1 mo.

    • D. 

      Start recombinant erythropoietin 10,000 units subcutaneously once weekly along with oral iron.

    • E. 

      Transfuse 2 units of packed red blood cells.

  • 10. 
    A 48-yr-old African-American man is seen in your office for elevated serum creatinine. He has polycystic kidney disease (PKD). His blood pressure (BP) is 135/90 mmHg, his weight is 85 kg, and his exam is remarkable for palpable kidneys. Laboratory studies include serum creatinine of 2 mg/dl, serum calcium of 7.6 mg/dl, serum phosphorus of 5.1 mg/dl, serum albumin of 4.0 g/dl, serum intact parathyroid hormone of 280 pg/ml (normal 12 to 72 pg/ml), and calculated glomerular filtration rate (GFR) using the abbreviated Modification of Diet in Renal Disease (MDRD) study equation of 46 ml/min per 1.73 m2. Which ONE of the following is true regarding therapy?
    • A. 

      Dietary phosphorus should be restricted to 2 g/d.

    • B. 

      He should be treated with 0.25 g/d calcitriol.

    • C. 

      Calcium-containing phosphate binders should be avoided.

    • D. 

      Long-term therapy with aluminum hydroxide should be started at a dose of 15 ml orally with meals.

    • E. 

      Sevelamer therapy would be associated with an increased risk of development of osteomalacia and bone fractures.

  • 11. 
    A 23-yr-old white woman is seen in your office to discuss strategies to prevent the development of diabetic nephropathy. She was diagnosed as having type 1 diabetes at age 8 yr. Currently, she is normotensive and her glucose is well controlled on an insulin pump (HbA1C 5.0%). Her blood pressure (BP) is 120/70 mmHg. Laboratory studies include serum creatinine of 1.0 mg/dl and spot albumin-to-creatinine ratio of 200 mg/g (normal 25 mg/g). Which ONE of the following is true regarding therapy?
    • A. 

      Anti-hypertensive therapy is not indicated because she is normotensive, but she should have BP monitored every 3 mo.

    • B. 

      Therapy should be started with a dihydropyridine calcium channel blocker to prevent the development of diabetic nephropathy.

    • C. 

      Anti-hypertensive therapy is not indicated at the present time, but an angiotensin-converting enzyme (ACE) inhibitor should be started if her urinary albumin-to-creatinine ratio increases to 355 mg/g.

    • D. 

      ACE inhibitors have been demonstrated to reduce albuminuria and decrease the risk of progressing to overt diabetic nephropathy.

    • E. 

      Angiotensin receptor blockers have been demonstrated to reduce albuminuria and reduce the risk of progressing to overt diabetic nephropathy.

  • 12. 
    A 31-yr-old white man is referred to you from his primary care physician for recommendations regarding the management of his chronic kidney disease (CKD). He has biopsy-proven immunoglobulin A (IgA) nephropathy. His main symptoms are fatigue. He is currently taking an angiotensin receptor blocker for control of his hypertension. His sister is bloodgroup compatible and is interested in being a kidney donor for him. On physical examination, his blood pressure (BP) is 125/70 mmHg. Laboratory studies include serum creatinine of 4.1 mg/dl and 24-h urinary protein excretion of 6.2 g. His calculated glomerular filtration rate (GFR) using the abbreviated Modification of Diet in Renal Disease (MDRD) study equation is 18 ml/min per 1.73 m2. Which ONE of the following should you recommend for this patient?
    • A. 

      Continue on his present treatment and return when his serum creatinine is 6 mg/ dl.

    • B. 

      Once he starts on dialysis, he should be evaluated as a kidney transplant candidate.

    • C. 

      Vascular access for dialysis should be placed in preparation for needed dialysis.

    • D. 

      Preemptive living donor transplant if a donor is available.

    • E. 

      Start on a low-protein diet of 0.3 g/kg per d to delay the need for dialysis.

  • 13. 
    A 79-yr-old Asian man is seen in your office for evaluation of chronic kidney disease (CKD) secondary to type 2 diabetes. Over the past 2 yr, his glomerular filtration rate (GFR) has decreased from 47 ml/min per 1.73 m2 to a current GFR of 19 ml/min per 1.73 m2, despite good blood pressure (BP) control with an angiotensin- converting enzyme (ACE) inhibitor. Laboratory studies include serum creatinine of 4.1 mg/dl, potassium of 5.0 mEq/L, and bicarbonate of 17 mEq/L. An arterial blood gas confirms he has a compensated metabolic acidosis. Which ONE of the following is true regarding his acidosis?
    • A. 

      No adverse effects of acidosis are seen until the bicarbonate is 15 mEq/L.

    • B. 

      Acidosis stimulates albumin synthesis by the liver.

    • C. 

      Acidosis suppresses parathyroid hormone release.

    • D. 

      Acidosis increases calcium loss from bone.

    • E. 

      Acidosis stimulates skeletal muscle hypertrophy.

  • 14. 
    A 55-yr-old white woman has chronic kidney disease (CKD) from type 2 diabetes. Her current glomerular filtration rate (GFR) is 45 ml/ min per 1.73 m2. Which ONE of the following is true regarding alterations in bone and mineral metabolism in CKD?
    • A. 

      The most sensitive marker of abnormal mineral metabolism is decreased calcitriol production.

    • B. 

      Elevations in parathyroid hormone (PTH) secretion do not occur until GFR is 20 ml/min per 1.73 m2.

    • C. 

      Elevated serum phosphorus inhibits the 1-alpha hydroxylase enzyme in the kidney, leading to decreased calcitriol synthesis.

    • D. 

      An alteration in the set point for calcium occurs in the parathyroid glands, leading to increased PTH secretion for any increase in serum calcium.

    • E. 

      The most common bone abnormality is osteomalacia.

  • 15. 
    A 37-yr-old African-American woman presents with nephrotic syndrome. A kidney biopsy is diagnostic for focal and segmental glomerulosclerosis. Her current estimated glomerular filtration rate (GFR) by the abbreviated Modification of Diet in Renal Disease (MDRD) equation is 60 ml/min per 1.73 m2. Which ONE of the following is the BEST predictor of her risk of progressing to ESRD?
    • A. 

      The percentage of glomeruli with focal changes on biopsy.

    • B. 

      Angiotensin-converting enzyme (ACE) genotyping for polymorphisms.

    • C. 

      The extent of tubulointerstitial disease on biopsy.

    • D. 

      The level of plasma renin activity.

    • E. 

      A family history of hypertension.

  • 16. 
    Which ONE of the following is TRUE regarding cardiovascular disease in patients with CKD?
    • A. 

      Microalbuminuria is not a risk factor for cardiovascular disease.

    • B. 

      Most patients with chronic kidney disease will die of cardiovascular disease before they reach end stage renal disease.

    • C. 

      CKD is a risk factor for coronary artery disease but not for stroke or peripheral vascular disease.

    • D. 

      CKD is a risk factor for cardiovascular disease only when the serum creatinine is 3 mg/dl.

    • E. 

      A higher prevalence of traditional risk factors such as hypertension and dyslipidemia account for the increased risk of cardiovascular disease in patients with CKD.

  • 17. 
    A 74-yr-old Asian woman was admitted to the hospital with failure-to-thrive. She has a past medical history of diabetes mellitus, heart failure, osteoporosis and Alzheimer’s disease. She has lost 20 pounds over the past half year and weighs 70 pounds currently. On physical examination, she is cachectic and has 2 lower extremity pitting edema. Her serum creatinine is 1.0 mg/dl. Her serum albumin is 2.5 g/dl. A random spot urine protein/creatinine ratio on admission is 3.6 g/gm. A complete 24-h urine collected via Foley during the second day of hospitalization revealed 1.6 g of protein and 453 mg of creatinine. Which ONE of the following statements is TRUE?
    • A. 

      The patient has nephrotic range proteinuria.

    • B. 

      There is contradictory information presented regarding whether or not patient has nephrotic range proteinuria.

    • C. 

      There is insufficient information to determine whether or not the patient has nephrotic range proteinuria.

    • D. 

      The random spot urine protein/creatinine ratio is misleading because of the low creatinine production.

    • E. 

      It is not valid to use urine protein/creatinine ratio to assess proteinuria when the serum albumin level is low.

  • 18. 
    A 51-yr-old Caucasian male patient with autosomal dominant polycystic kidney disease developed renal failure requiring hemodialysis seven years ago. Two years ago, he received a cadaveric kidney transplant. He is currently maintained on cyclosporine, prednisone and mycophenolate mofetil. His stable estimated GFR is 70 ml/min/1.73m2. His dipstick urinalysis has trace protein that is persistent but no hemoglobin or other abnormalities. He has 300 mg of protein in a 24-h urine collection. According to the current National Kidney Foundation Chronic Kidney Disease classification, this patient has which ONE of the following stages of CKD?
    • A. 

      Stage 1.

    • B. 

      Stage 2.

    • C. 

      Stage 3.

    • D. 

      Stage 4.

    • E. 

      Stage 5.

  • 19. 
    A 59-yr-old Caucasian man with type 2 diabetes mellitus was admitted to the hospital with sepsis of unclear etiology. His baseline urine dipstick has 1 protein and his baseline serum creatinine is 1.2 mg/dl (MDRD equation estimated GFR 66 ml/min/1.73m2). Patient failed to improve with antibiotic therapy and was admitted to the intensive care unit when he developed hypotension requiring vasoconstrictors and hypoxia requiring mechanical ventilation. He received IV contrast for an abdominal CT scan. His serum creatinine was 1.2 mg/dl the morning he received the contrast and rose to 2.4 mg/dl the following morning. Which ONE of the following statements is MOST correct?
    • A. 

      The patient’s baseline CKD is unrelated to his acute renal failure.

    • B. 

      Intravenous contrast is not contraindicated in patients with CKD.

    • C. 

      The patient’s diabetes is not a risk factor for his acute renal failure.

    • D. 

      The patient’s GFR when his creatinine rose to 2.4 mg/dl is approximately 30 ml/ min/1.73m2.

    • E. 

      To measure the patient’s current creatinine clearance, a 24-h urine collection should be started the morning when his serum creatinine rose to 2.4 mg/dl.

  • 20. 
    Which of the following is the most common cause of resistant anemia in CKD patients?
    • A. 

      Iron deficiency

    • B. 

      Malignancy

    • C. 

      Trauma

    • D. 

      Drugs

    • E. 

      PRCA

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