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PROGRAM HIGHLIGHTS:• Obesity in CKD, Transplantation, and Beyond• Bedside Ultrasonography for the Nephrologist: Hands-On Workshop• CRRT: Hands-On Workshop• Allied Health Program• Opportunity to Present Abstracts

MAYO CLINIC ABIM MAINTENANCE OF CERTIFICATION LEARNING SESSION

OMNI AMELIA ISLAND PLANTATION RESORT AMELIA ISLAND, FLORIDA FEBRUARY 23-24, 2018

16th Annual Mayo Clinic Update in

NEPHROLOGY & TRANSPLANTATION

Only for use at the Mayo Clinic Learning Session held February 24, 2018.

Mayo ClinicMaintenance of Certification Learning Session

Mayo Clinic will host a Maintenance of Certification Learning Session that will feature the AmericanBoard of Internal Medicine (ABIM) Update in Nephrology medical knowledge module.

The Learning Session will be held on Saturday, February 24, 2018

2017-2018 Update in NephrologyA7-T Version 17-1

The primary purpose of the Learning Session is to facilitate completion of ABIM medical knowledge modules by board-certified internists and subspecialists of internal medicine in order for them to receive Maintenance of Certification credit. Learning Sessions are conducted in an interactive group setting with educational support and are led by ABIM-certified physicians.

Participants who are enrolled in ABIM’s Maintenance of Certification program can order a copy of the Update in Nephrology from ABIM’s website, www.abim.org, and transfer and submit the answers discussed during the Learning Session to ABIM for scoring. ABIM will send participants a score report that confirms whether or not the module was completed successfully. Those who complete the module successfully will receive 10 points per 30-question module, toward ABIM’s Self-Evaluation of Medical Knowledge requirement for Maintenance of Certification. In addition, CME credit for completing ABIM modules is available through a program jointly sponsored by ABIM and the American College of Physicians. Successful completion of the ABIM Update in Nephrology medical knowledge module qualifies for 2 AMA PRA Category 1 Credit(s)™. You must be enrolled in ABIM’s Maintenance of Certification program to submit completed medical knowledge modules for scoring, feedback reports, andeligibility to receive Maintenance of Certification and CME credit.

For additional information about the ABIM Maintenance of Certification program requirements, visit ABIM’s website, www.abim.org or call the ABIM Contact Center, 800-441-ABIM, extension 3598. To enroll in Maintenance of Certification go to your password-protected “Home Page” in the Physician Login (formerly On-Line Services) section of www.abim.org. Once enrolled, you will be able to order an ABIM medical knowledge module from your “Home Page.”

ABIM MOC INFORMATION

Availability of 2017-2018 Annual Updates: July 1, 2017, was the release date, and June 30, 2018 is the last day to order. Since their availability spans two calendar years, they are called the 2017-2018 Annual Updates.

Objective of Annual Updates: These activities are intended to support you in staying current with changing knowledge and practice within your discipline. They address recent advances in medical knowledge that have impacted “best practices” regarding diagnoses, treatments and other aspects of patient management; some questions may also address important clinical management principles that, even though they have not recently changed, should be reinforced in the practice community.


REGISTRATION INFORMATION

To participate in the Learning Session:

The Maintenance of Certification Learning Session is part of your course registration. If you are not enrolled in the ABIM MOC program through ABIM, then you may need to pay an additional fee to ABIM to access the official module to submit your answers for MOC credit. Please bring your laptop,tablet or smartphone with you to so that you can enroll in the ABIM MOC program and order the module at the beginning of the session on February 24, 2018. Course staff will be present during the session to assist with enrollment with ABIM as needed.

1) Mayo Clinic will provide you with a “Learner’s Copy” of the ABIM Update in Nephrology at the session on February 24, 2018.

2) To enroll in the ABIM MOC program visit the ABIM website: www.abim.org and go to the physician login tab in the upper right-hand corner. You will need your 6-digit ABIM ID. If you do not know your ID, follow the instructions on the screen. If this is your first time using the website, you will have to create an online account with a password.

3) Login to your account (you will need your 6-digit ABIM ID and your password). This will take you to your ABIM homepage.

4) Under “My Maintenance of Certification (MOC) Program,” order the “2017-2018 Update in Nephrology (A7-T 17-1).” You do not need to pay for the module if you are already enrolled in MOC. Once you order the module, it will show up in your ABIM homepage at the bottom.

5) If you were unable to bring a laptop, tablet or smartphone with you to the session to work through the questions live, please submit your answers to ABIM as soon as possible for MOC credit by completing and submitting your “official” internet copy (you must be connected to the internet in order for your answers to be successfully transmitted to ABIM). If you need assistance submitting your answers please call 800-441-ABIM.


2017-2018 Update in

Nephrology

Self-Assessment Module

A7-T 17-1

July 1, 2017

CONFIDENTIAL

WARNING: This Self-Assessment Module (SAM) is copyrighted work under the Federal Copyright Act. It is a federal criminal offense

to copy or reproduce this work in any manner or to make adaptations of this work. It is also a crime to knowingly assist someone else in the

infringement of a copyrighted work. No part of this work may be reproduced by any means or transmitted in any form or by any means

(electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the American Board of Internal

Medicine. The making of adaptations from this work also is strictly forbidden. In addition to criminal penalties, the Copyright Act, 17

U.S.C.§§101, et seq., provides a number of remedies for the infringement of a copyright, including injunctive relief, the award of statutory

and actual damages, the award of attorney fees and costs, and confiscation and destruction of infringing works and materials. It is the

policy of the Board to strictly enforce its rights to this copyrighted work.

Copyright © 2017 by American Board of Internal Medicine.

All rights reserved. Do not copy without permission.


Common Abbreviations

The following abbreviations may be used in this module:

A2 Aortic valve component of second heart sound

ACE Angiotensin-converting enzyme

ADPKD Autosomal dominant polycystic kidney disease

AIDS Acquired immunodeficiency syndrome

AKI Acute kidney injury

ALT Alanine aminotransferase

ANCA Antineutrophil cytoplasmic antibody

AST Aspartate aminotransferase

BMI Body mass index

BPM Beats per minute

BUN Blood urea nitrogen

C3 Complement C3

CKD Chronic kidney disease

CMV Cytomegalovirus

DOQI Disease Outcomes Quality Initiative

ELAIN Effect of Early vs Late Initiation of Renal Replacement

Therapy on Mortality in Critically Ill Patients with Acute

Kidney Injury (trial)

ELISA

ESRD End-stage renal disease

FSGS

GBM Glomerular basement membrane

GFR Glomerular filtration rate

HLA Human leukocyte antigen

HMG CoA Hydroxymethylglutaryl coenzyme A

IgAN Immunoglobulin A nephropathy


INR International normalized ratio

KDIGO Kidney Disease Improving Global Outcomes

KDOQI Kidney Disease Outcomes Quality Initiative

Kt/V

MDMA Methylenedioxymethamphetamine

NPH Neutral protamine hagedorn

PaCO2 Arterial partial pressure of carbon dioxide

PaO2 Arterial partial pressure of oxygen

PTFE Polytetrafluoroethylene

PTH Parathyroid hormone

RBCs Red blood cells

S3 Third heart sound (ventricular gallop)

S4 Fourth heart sound (atrial gallop)

TGF Transforming growth factor

WBCs White blood cells

WHO World Health Organization


Introduction

Copyright

Copyright ©American Board of Internal Medicine. All rights reserved. Do not copy without

permission.

Please read the following information carefully.

On successful completion of this module, you will receive 10 points of self-evaluation of medical

knowledge credit in the Maintenance of Certification Program; credit remains valid for 10 years.

Instructions

Read each one-best-answer question in the module and indicate your answer by clicking in the

appropriate box. You should use educational resources (e.g., online medical references, textbooks,

journal articles) to assist in answering the questions. Suggested resources are listed in the Education

Resources section of the CME information.

On each question screen, the Help button will provide you with technical information and instructions on

how to navigate through the module, including submitting your completed module. For common

abbreviations that may appear in this module, click the "Resources" button on the right side of the

screen.

CME information for this module, including CME expiration date, may be reviewed by clicking the

“CME Credit for the ABIM Maintenance of Certification Program” link in the left-hand column.

Laboratory Studies and Reference Ranges

Reference ranges for laboratory test reports are included in the text of the ABIM exam questions. As is

true in practice, interpretation of a particular patient’s test result in relation to the reference

range depends on the clinical context. For example, reference ranges for tests assessing lipid or

glucose metabolism may not be applicable in certain clinical settings; ABIM reference ranges should not

be confused with patient-specific targets for such tests.

Information on specific studies

The National Cancer Institute advises that there is no specific normal or abnormal level of prostate-

specific antigen (PSA) in the blood. Therefore, ABIM is reporting “no specific normal or abnormal

level” in place of the reference range for PSA.

The comprehensive metabolic panel contains the following assays: Albumin, alanine and aspartate

aminotransferases (ALT and AST), alkaline phosphatase, total bilirubin, blood urea nitrogen, calcium,

creatinine, electrolytes (sodium, potassium, chloride, and bicarbonate), glucose, and total protein.

Unless noted otherwise in examination questions:

• Arterial blood gas studies are done at sea level with the patient breathing room air

• Reticulocyte counts are uncorrected

• Tuberculin skin tests are done with purified protein derivative (PPD) at intermediate

strength (5 TU)

• Electrocardiograms are recorded at normal standard and speed

• Lung volumes are determined by body plethysmography


Illustrations and Multimedia (if applicable)

Some questions are accompanied by illustrations, such as radiographs, electrocardiograms, photographs

of physical or histologic findings, videos, and charts. All electrocardiograms are recorded at normal

standard and speed unless otherwise specified.

Criteria for successful completion

In order to successfully complete this module and receive Maintenance of Certification credit, you must

answer every question. Submission of this module will not be accepted until answers have been

provided for every question.


Page 1

1A 42-year-old man who has end-stage renal disease due to lupus nephritis has been undergoing in-center

hemodialysis three times per week for the past three years. The patient has been treated with ferric citrate due to

intolerance of other phosphate binders. His other current medications are rosuvastatin, iron sucrose per the

dialysis unit’s protocol, epoetin alfa per the dialysis unit’s protocol, atenolol, and lisinopril.

Physical examination is notable for a left radiocephalic arteriovenous fistula.

Laboratory studies:

Transferrin saturation 42% [20%–50%]

Serum ferritin 1180 ng/mL [20–235]

Serum calcium 9.3 mg/dL [8.6–10.2]

Serum phosphorus 5.1 mg/dL [3.0–4.5]

Serum intact parathyroid hormone 452 pg/mL [target: 130–585]

Which of the following best describes the effect of ferric citrate on the use of intravenous (IV) iron and

erythropoiesis-stimulating agent (ESA) in dialysis patients such as this one?

IV iron ESA

(A) Reduces the need Reduces the need

(B) Reduces the need Increases the need

(C) Increases the need Reduces the need

(D) Increases the need Increases the need


Page 2

2A 37-year-old man with autosomal dominant polycystic kidney (ADPKD) disease comes to your office for a

periodic health evaluation. His ADPKD was diagnosed 15 years ago by ultrasonography and family history.

For the past two years, his estimated glomerular filtration rate (eGFR) has remained stable at 48 mL/min/1.73

m2. For the past six years, he has been treated for hypertension. Current medication is enalapril, 20 mg daily.

On physical examination, heart rate is 70 beats per minute and blood pressure is 119/65 mm Hg. The patient

appears well. Cardiopulmonary examination is unremarkable. The abdomen is soft with mild fullness in the

flanks on deep palpation.

Laboratory studies:

Serum creatinine 1.76 mg/dL [0.70–1.50]

eGFR 48 mL/min/1.73 m2

Serum electrolytes:

Sodium 140 mEq/L [136–145]

Potassium 4.6 mEq/L [3.5–5.0]

Chloride 109 mEq/L [98–106]

Bicarbonate 23 mEq/L [23–28]

Urine albumin-to-creatinine ratio 18 mg/g [less than 30]

Urinalysis:

Specific gravity 1.003 [1.002–1.030]

Protein Negative

Glucose Negative

Blood Small

WBCs 0/hpf

RBCs 3/hpf

Which of the following would be the most appropriate treatment to help slow the loss of kidney function in this

patient?

(A) Continue current therapy

(B) Add losartan, 50 mg twice daily

(C) Increase enalapril dosage to 40 mg daily

(D) Add spironolactone, 50 mg twice daily

(E) Add sodium bicarbonate, 650 mg twice daily


Page 3

3A 67-year-old man is referred to the nephrology service for evaluation and management of chronic kidney

disease. Medical history is notable for type 2 diabetes mellitus, hypertension, hyperlipidemia, obesity, and

obstructive sleep apnea. Current medications are metformin, lisinopril, amlodipine, atorvastatin, and aspirin. He

regularly uses continuous positive airway pressure (CPAP).

Temperature is 37.5 C (99.5 F), heart rate is 88 beats per minute, respirations are 20 per minute, and blood

pressure is 130/84 mm Hg. The physical examination is notable for edema (1+) of the lower extremities.

Laboratory studies:

Hemoglobin 11.9 g/dL [14–18]

Hemoglobin A1C 6.5% [4.0%–5.6%]

(3 months ago: 6.4%)

Blood urea nitrogen 25 mg/dL [8–20]

(3 months ago: 28 mg/dL)


(3 months ago: 1.72 mg/dL)

Estimated glomerular

filtration rate 44 mL/min/1.73 m2

Serum electrolytes:

Sodium 141 mEq/L [136–145]




Plasma lactate 1.5 mmol/L [0.7–2.1]

Which of the following would be the most appropriate management now?

(A) Continue current therapy

(B) Monitor serum bicarbonate every 12 weeks

(C) Monitor serum lactate every 12 weeks

(D) Discontinue metformin; begin glipizide

(E) Discontinue metformin; begin pioglitazone


Page 4

4A 65-year-old man who has chronic kidney disease due to hypertension comes to your office for follow-up

evaluation six weeks after receiving the ferric carboxymaltose you prescribed for him for iron deficiency

anemia. He reports that he has tolerated the medication well, without adverse physical effects. The patient also

has coronary artery disease for which he previously underwent placement of two stents. Current medications are

lisinopril, carvedilol, atorvastatin, and aspirin.

Heart rate is 70 beats per minute, respirations are 12 per minute, and blood pressure is 135/85 mm Hg. Arterial

oxygen saturation is 100% on room air. The patient appears to be comfortable and in no distress. The physical

examination is normal.

Repeat laboratory studies:


Transferrin saturation 28% [20%–50%]

Serum ferritin 400 ng/mL [20–235]

As you review the results of the laboratory tests, you notice that one test result is different from the patient’s

usual baseline.

Which of the following would be the most likely laboratory test abnormality resulting from ferric

carboxymaltose administration in this patient?

(A) Hyperphosphatemia

(B) Hypophosphatemia

(C) Hyperkalemia

(D) Hypokalemia


Page 5

5A 25-year-old woman with sickle cell disease is seen for prenatal counseling at 10 weeks of pregnancy. Her

husband is healthy with no known medical history. Her medical history is remarkable for approximately one

vaso-occlusive crisis per year, not requiring hospitalization. Current medications are folic acid, 1 mg daily; a

prenatal vitamin, one tablet daily; and ibuprofen, 800 mg daily as needed.

Heart rate is 77 beats per minute, and blood pressure is 101/63 mm Hg. Physical examination is notable only for

a grade 2/6 systolic flow murmur.

Laboratory studies:




Serum total bilirubin 1.0 mg/dL [0.3–1.0]

Urinalysis:

Specific gravity 1.008 [1.002–1.030]

Protein Negative

Glucose Negative

Blood Negative

Bilirubin Negative

WBCs 1/hpf

RBCs 1/hpf

This couple's child is at increased risk for which of the following conditions in adulthood?

(A) Nephrolithiasis

(B) Chronic kidney disease

(C) Clear cell renal cell carcinoma

(D) Hypertension


Page 6

6A 67-year-old woman comes to your office for a periodic health evaluation. The patient has stage 3 chronic

kidney disease secondary to type 2 diabetes mellitus and hypertension, coronary artery disease with previous

stent placement, heart failure with grade 1 diastolic dysfunction, hyperlipidemia, and anemia secondary to iron

deficiency; she also previously had a stroke. Current medications are glipizide, losartan, extended-release

nifedipine, hydrochlorothiazide, extended-release metoprolol, simvastatin, aspirin, clopidogrel, and ferrous

sulfate.


pressure is 154/88 mm Hg. Physical examination is notable for an S3, the absence of an S4, and the presence of

edema (2+) in the lower extremities.

Laboratory studies:




Serum electrolytes:

Sodium 141 mEq/L [136–145]




Based on the EMPA-REG OUTCOME trial, which of the following may result from the initiation of

empagliflozin in this patient, compared with no treatment?

(A) Lower risk of bone fracture

(B) Lower risk of genital infection

(C) Slower progression of kidney disease

(D) Higher risk of thromboembolic event

(E) Higher risk of hyperkalemia


Page 7

7A 34-year-old Chinese man found to have IgA nephropathy by biopsy (Oxford Classification M1 E0 S0 T1)

eight years ago transfers his care to you. Originally, the patient was evaluated for gross hematuria, and

hypertension and chronic kidney disease were diagnosed. He was prescribed lisinopril and fish oil, and he

reports his home blood pressure typically ranges from 126/65 to 138/78 mm Hg. He has had no further episodes

of gross hematuria. Current medications are lisinopril, 20 mg daily, and omega-3 fish oil, 1g twice daily.

Heart rate is 68 beats per minute, and blood pressure is 130/72 mm Hg. Physical examination is notable for

bilateral tonsillar hypertrophy without exudate.

Laboratory studies:


(baseline for past 2 yr)


filtration rate (eGFR) 60 mL/min/1.73 m2

Serum potassium 4.6 mEq/L [3.5–5.0]

Serum bicarbonate 23 mEq/L [23–28]

Urine protein (on

adequate collection) 1400 mg/24 hr [less than 100]

Urinalysis:

Protein 2+

Blood Moderate

RBCs 8/hpf

Which of the following would be the best next step to preserve kidney function in this patient?

(A) Start an HMG-CoA reductase inhibitor

(B) Start corticosteroids

(C) Increase lisinopril to 40 mg daily

(D) Order tonsillectomy


Page 8

8A 67-year-old man is evaluated in the emergency department for fever and cough with purulent sputum

production. He has hyperlipidemia and hypertension. Current outpatient medications are simvastatin, low-dose

aspirin, and metoprolol.

Temperature is 39.1 C (102.3 F), pulse rate is 118 per minute, respirations are 18 per minute and labored, and

blood pressure is 112/64 mm Hg. Arterial oxygen saturation is 92% on room air. Physical examination is

notable only for crackles at the base of the left lung and abdominal obesity. At presentation, the patient’s serum

creatinine is 1.01 mg/dL [0.70–1.50]. A radiograph of the chest shows an infiltrate in the left lower lobe. He is

admitted to the hospital.

The patient is started on meropenem and vancomycin. Subsequently, he becomes progressively hypotensive and

is transferred to the medical intensive care unit. An indwelling urinary catheter is placed, and 15 mL of dark

urine is collected.

Laboratory studies:


Urinalysis:

RBCs 0/hpf

RBC casts 0/lpf

Granular casts 2–3/lpf

Both the intensivist and you judge the patient to be euvolemic.

Based on recent evidence, which of the following urinary tests would best predict progression of acute kidney

injury and the need for renal replacement therapy?

(A) Albumin-to-creatinine ratio (ACR)

(B) Fractional excretion of sodium (FENa)

(C) Furosemide stress test

(D) Neutrophil gelatinase-associated lipocalin (NGAL)


Page 9

9An asymptomatic 60-year-old woman was referred to you by her primary care physician for initial evaluation of

chronic kidney disease (CKD) after an elevated serum creatinine was found on routine laboratory studies. The

patient also has atrial fibrillation, gastroesophageal reflux disease, diabetes mellitus, and depression. Current

medications are rivaroxaban, 15 mg daily; omeprazole, 20 mg daily; dapagliflozin, 5 mg daily; and citalopram,

10 mg daily.

Body mass index is 28. On physical examination, the patient is afebrile. Heart rate is 80 beats per minute and

blood pressure is 125/75 mm Hg.

Laboratory studies:

Hemoglobin A1C 6.7% [4.0%–5.6%]




Serum electrolytes Normal

Which of the following medications could have potentially contributed to this patient’s CKD?

(A) Citalopram

(B) Rivaroxaban

(C) Omeprazole

(D) Dapagliflozin


Page 10

10A 63-year-old woman who has hypertensive chronic kidney disease comes to your office for follow-up of blood

pressure (BP) control. The patient also has hypercholesterolemia; previously, she had a myocardial infarction.

Current medications are aspirin, carvedilol, lisinopril, and rosuvastatin.

The patient’s pulse rate is 66 per minute. Her average BP is 147/92 mm Hg after three measurements. Physical

examination is remarkable only for trace peripheral edema.

Laboratory studies:




Serum low-density lipoprotein

cholesterol 98 mg/dL [optimal: less than 100]

Urine protein-to-creatinine ratio 0.8 mg/mg [less than 0.2]

Based on the results of a recent randomized controlled trial, which of the following blood pressure targets

should you use to reduce this patient’s risk of cardiovascular events?

(A) Diastolic BP less than 70 mm Hg

(B) Diastolic BP from 85 to 89 mm Hg

(C) Systolic BP less than 120 mm Hg

(D) Systolic BP from 135 to 139 mm Hg


Page 11

11A 55-year-old man comes to your office for follow-up evaluation of his recently diagnosed fibrillary

glomerulonephritis (GN) and to discuss what further testing may be required. On initial presentation, he had

nephrotic-range proteinuria, with 3500 mg on 24-hour urine collection, and elevated serum creatinine level. He

underwent a kidney biopsy, which revealed a fibrillary GN. He was started on corticosteroids after the biopsy

results were obtained. Medical history is otherwise not significant. Current medications are prednisone and

furosemide.

On physical examination, the patient is afebrile. Heart rate is 88 beats per minute, respirations are 12 per

minute, and blood pressure is 130/85 mm Hg. Arterial oxygen saturation is 100% on room air. Cardiopulmonary

examination is normal. The abdomen is soft, nontender, and nondistended. There is mild peripheral edema.

Laboratory studies:



Which of the following tests would be the most appropriate next step?

(A) Phospholipase A2 receptor (PLA2R) antibodies

(B) Myeloperoxidase (MPO) antibodies

(C) Hepatitis B serologic testing

(D) Evaluation for a paraprotein


Page 12

12An 85-year-old man with heart failure comes to the emergency department (ED) after experiencing two shocks

from his automatic implantable cardiac defibrillator (AICD). Five years ago, his heart failure with reduced

ejection fraction was diagnosed after he had an anterior wall myocardial infarction. Six months ago, the AICD

was placed after a decrease in left ventricular ejection fraction from 35% to 15% on routine echocardiography.

During this time, he has had stable New York Heart Association class III symptoms, without evidence of volume

overload, and has not been hospitalized. Current medications are lisinopril, 10 mg daily; furosemide, 40 mg

twice daily; spironolactone, 25 mg daily; carvedilol, 12.5 mg twice daily; patiromer, 8.4 g daily; atorvastatin, 20

mg daily; and aspirin, 81 mg daily.

Heart rate is 55 beats per minute, and blood pressure is 105/64 mm Hg. On physical examination, the patient

looks well but is mildly anxious. Right atrial pressure is estimated at 5 cm of blood. Hepatojugular reflux is

absent. The lungs are clear to auscultation. Cardiovascular examination demonstrates a soft S1 and S2 with a

grade 2/6 systolic murmur of mitral regurgitation, without an S3. Abdominal examination is normal, without

enlargement of the liver. There is no peripheral edema, and the extremities are warm and well-perfused.

Laboratory studies:



(unchanged from baseline)




Serum magnesium 1.4 mEq/L [1.6–2.6]

Serum cardiac troponin I 0.06 ng/mL [0–0.1]

Interrogation of the AICD in the ED reveals two episodes of ventricular tachycardia that were terminated by the

firing of the device. An electrocardiogram demonstrates normal sinus rhythm with prolonged QTc interval.

Which one of the following would most likely have contributed to the arrhythmia?

(A) Patiromer

(B) Spironolactone

(C) Lisinopril

(D) Carvedilol


Page 13

13A 61-year-old man is referred to you because of difficult-to-control hypertension. He also has hyperlipidemia,

obesity, obstructive sleep apnea, and benign prostatic hyperplasia. Current medications are lisinopril, 40 mg

daily; amlodipine, 10 mg daily; hydrochlorothiazide, 50 mg daily; atorvastatin, 20 mg daily; and aspirin, 325 mg

daily. The patient has a 20-pack-year smoking history but quit more than 10 years ago. He regularly uses

continuous positive airway pressure (CPAP). He does not exercise regularly.

Body mass index is 36. Temperature is 37.5 C (99.5 F), heart rate is 68 beats per minute, respirations are 20 per

minute, and blood pressure is 168/92 mm Hg. The physical examination is notable for edema (2+) of the lower

extremities.

Laboratory studies:




Serum electrolytes:

Sodium 141 mEq/L [136–145]




In addition to reinforcing the importance of lifestyle changes, the addition of which of the following would be

the most appropriate treatment?

(A) Hydralazine

(B) Losartan

(C) Clonidine

(D) Doxazosin

(E) Spironolactone


Page 14

14A 50-year-old man who has chronic kidney disease and hypertension comes to your office for a second opinion

regarding advice given to him by another nephrologist regarding the benefits of consuming vegetable-source

proteins. Current medications are losartan, verapamil, and atorvastatin.

Heart rate is 77 beats per minute, respirations are 20 per minute, and blood pressure is 130/78 mm Hg.

Laboratory studies:





Serum albumin 3.6 g/dL [3.5–5.5]

Serum sodium 138 mEq/L [136–145]


Serum chloride 100 mEq/L [98–106]



Serum phosphorus 5.5 mg/dL [3.0–4.5]

Serum uric acid 7.0 mg/dL [3.0–7.0]

Urine protein-to-

creatinine ratio 0.35 mg/mg [less than 0.2]

Consuming a ketoanalogue-supplemented vegetarian very-low-protein diet would most likely result in a

lowering of which of the following?

(A) Risk of mortality

(B) Serum bicarbonate level

(C) Serum potassium level

(D) Serum calcium and phosphorus levels

(E) Serum urea and uric acid levels


Page 15

15A 71-year-old man with stage 3B chronic kidney disease (CKD) with an estimated glomerular filtration rate

(eGFR) of 33 mL/min/1.73 m2 comes to your office for a periodic health evaluation. The patient also has type 2

diabetes mellitus, hypertension, and dyslipidemia. Current medications are atorvastatin, lisinopril, nifedipine,

aspirin, and glipizide.


pressure is 148/80 mm Hg. The lungs are clear. Cardiovascular examination shows a normal rate and regular

rhythm. The abdomen is soft and nontender. Bowel sounds are normal. Trace edema is noted in the lower

extremities.

Laboratory studies:







Urine protein-to-


Which of the following would be the most likely effect of adding spironolactone to this patient’s current

medication regimen?

(A) Decrease in the risk of cardiovascular events

(B) Decrease in the risk of death

(C) Decrease in proteinuria

(D) Delay in CKD progression

(E) Delay in the need for renal replacement therapy


Page 16

16A 59-year-old black man who has hypertension and has smoked one-half pack of cigarettes daily for the past 20

years comes to your office for a periodic health evaluation. The patient also has coronary artery disease;

previously he had a stroke, without residual deficits. Current medications are lisinopril, metoprolol, and

amlodipine.

Heart rate is 88 beats per minute, respirations are 20 per minute, and blood pressure is 133/80 mm Hg. Trace

edema is noted in the lower extremities.

Laboratory studies:







Urine protein-to-


The patient read on the internet that there has recently been some discussion about the benefits of intensive

blood pressure control. Being an African American, he would like to know how this strategy applies to him.

In this patient, which of the following outcomes would most likely be associated with targeting a strict systolic

blood pressure goal of less than 120 mm Hg?

(A) Decreased long-term risk of ESRD

(B) Decreased risk of death

(C) Increased risk of orthostatic hypotension

(D) Increased risk of falls


Page 17

17A 52-year-old man is admitted to the intensive care unit with sepsis related to underlying pneumonia.

The patient has a history of hypertension, dyslipidemia, chronic obstructive pulmonary disease, and chronic

tobacco use. The patient’s current outpatient medications include blood pressure medications, and these have

been withheld. He has been started on intravenous piperacillin-tazobactam, pantoprazole, and heparin.

Temperature is 38.7 C (101.7 F), heart rate is 106 beats per minute, and blood pressure is 90/60 mm Hg.

Rhonchi are heard in both lungs.

Laboratory studies:




(baseline: 0.91 mg/dL)

Serum albumin 2.5 g/dL [3.5–5.5]





Central venous pressure is 6 mm Hg.

Based on this patient’s presentation, which of the following resuscitation fluids should you administer in the

next 24 hours?

(A) Isotonic saline

(B) Lactated Ringer’s solution

(C) Sodium bicarbonate

(D) Hydroxyethyl starch

(E) Albumin


Page 18

18A 64-year-old woman who has had recurrent kidney stones is admitted to the intensive care unit for septic shock.

For six days prior to admission, she had intermittent left flank pain associated with dysuria and urinary urgency

and frequency.

On the day of admission, she is found to be confused and diaphoretic. Temperature is 38.9 C (102.1 F), heart

rate is 126 beats per minute, respirations are 26 per minute, and blood pressure is 88/42 mm Hg. Blood and urine

specimens are sent for culture, and the patient is initiated on broad-spectrum antibiotics. After receiving 4 L of

intravenous isotonic saline, she remains hypotensive. An intravenous infusion of norepinephrine is initiated.

Compared with norepinephrine administered early, which of the following vasopressors, when administered

early, has been shown to provide a similar survival benefit and number of days free from severe acute kidney

injury (stage 3) in patients such as this?

(A) Dopamine

(B) Fenoldopam

(C) Vasopressin

(D) Phenylephrine


Page 19

19A 55-year-old hypertensive man comes to your office for further evaluation of worsening kidney function. He

has stage 3 chronic kidney disease that had been attributed to a 10-year history of hypertension. An angiotensin-

converting enzyme inhibitor was previously discontinued because of angioedema. He has not had any new

symptoms. Current medications are metoprolol, amlodipine, hydralazine, and chlorthalidone.

On physical examination, heart rate is 82 beats per minute and blood pressure is 158/94 mm Hg. Cardiovascular

examination is unremarkable. There is no rash or signs of arthritis.

Serum creatinine measurements:

Today 5.01 mg/dL [0.70–1.50]

1 week ago 3.02 mg/dL

1 month ago 2.01 mg/dL

3 months ago 1.61 mg/dL

6 months ago 1.42 mg/dL

Urine studies:


Urine dipstick:

Protein 2+

Blood 3+

WBCs 0/hpf

RBCs 20–30/hpf

RBC casts Occasional/lpf

In this patient, testing for which of the following antibodies is most likely to be positive?

(A) Anti-myeloperoxidase

(B) Anti-histone

(C) Anti-proteinase 3

(D) Anti-double-stranded DNA


Page 20

20A 20-year-woman comes to your office seeking a second opinion on management of Gitelman syndrome.

Three years ago, she underwent evaluation for myalgias and difficulty competing with her peers in high school

athletics and was found to have Gitelman syndrome based on history and laboratory studies.

She has been on her current medication regimen for the past two and one-half years, composed of potassium

chloride, 40 mEq twice daily; magnesium oxide, 400 mg twice daily; and naproxen, 200 mg twice daily.

Body mass index is 18.5. Heart rate is 75 beats per minute, and blood pressure (BP) is 103/60 mm Hg. Physical

examination is otherwise unremarkable.

Laboratory studies:

At diagnosis At present

Blood urea nitrogen [8–20] 13 mg/dL 18 mg/dL

Serum creatinine [0.70–1.50] 0.71 mg/dL 0.92 mg/dL

Serum sodium [136–145] 137 mEq/L 137 mEq/L

Serum potassium [3.5–5.0] 3.2 mEq/L 3.5 mEq/L

24-Hour urine collection Hypocalciuria, —

inappropriate

kaliuresis

Which of the following physiologic changes would be most consistent with changing therapy from the

nonsteroidal anti-inflammatory drug to a mineralocorticoid receptor antagonist?

Serum Serum

sodium aldosterone eGFR BP

(A) Increased Increased Decreased Decreased

(B) Decreased Increased Increased Decreased

(C) Decreased Decreased Increased Increased

(D) Decreased Increased Decreased Increased


Page 21

21A 48-year-old man is brought to the emergency department for further evaluation of altered mental status. He

has a history of chronic alcohol abuse and his family reports that over the past three days he drank more than

forty 12-ounce cans of beer. He denies headache or nausea. Currently, the patient takes no medications.

Weight is 80.0 kg (176.2 lb). The patient is afebrile. Heart rate is 90 beats per minute, and blood pressure is

118/80 mm Hg. He appears disheveled and lethargic, but is arousable. His speech is slowed but intelligible.

Physical examination is otherwise unrevealing.

Laboratory studies:

Blood urea nitrogen 5.0 mg/dL [8–20]




Serum osmolality 230 mOsm/kg H2O [275–295]

Urine osmolality 330 mOsm/kg H2O [38–1400]

Blood ethanol level Undetectable [less than 0.005%]

The patient is administered intravenous 3% sodium chloride at 100 mL/hr.

Four hours later, serum sodium is 119 mEq/L [136–145] and urine output total is 2 L.

Intravenous administration of which of the following would be most appropriate at this time?

(A) Dextrose 5% in water

(B) Furosemide

(C) Conivaptan

(D) Desmopressin and dextrose 5% in water


Page 22

22A 25-year-old woman was brought to the emergency department after having had respiratory distress at a

nightclub. Her friends stated that earlier in the evening she had used Ecstasy

(3,4-methylenedioxymethamphetamine [MDMA]) and had complained of feeling thirsty. The patient does not

take any medications on a regular basis.

On physical examination, she is conscious but confused and dysarthric. Temperature 38.0 C (100.4 F), heart rate

is 105 beats per minute, respirations are 25 per minute, and blood pressure is 145/70 mm Hg. Pulmonary

examination shows tachypnea, and crackles at both lung bases. There is no lower extremity edema.

Laboratory studies:

Blood urea nitrogen 8.0 mg/dL [8–20]



A radiograph of the chest reveals a normal cardiomediastinal silhouette and bilateral alveolar infiltrates.

Which of the following is most likely the strongest risk factor for the development of hyponatremia due to use of

MDMA?

(A) Volume of water ingested

(B) Low body mass index

(C) Female gender

(D) Quantity of MDMA ingested


Page 23

23A 50-year-old woman with a five-year history of hypertension and diabetes mellitus had previously been able to

control her conditions and avoid medications through an intensive regimen of diet and exercise. However, for

the past six months she admitted to having been less stringent with her diet and exercise, and has gained 9.0 kg

(20.0 lb). You order laboratory tests and receive the following results:

Plasma glucose 130 mg/dL [70–99]

Hemoglobin A1C 7.2% [4.0%–5.6%]








These results prompted initiation of lisinopril, 5 mg daily; canagliflozin, 100 mg daily; aspirin, 81 mg daily; and

furosemide, 20 mg daily as needed for edema.

The patient returns to your office for a follow-up visit one month after the initiation of her medications. She

reports that she has been urinating more than usual. Over the past five days, she has been feeling lightheaded on

standing, and she almost passed out during her church gathering. She has been taking her medications regularly

except for the furosemide, which she has only taken twice over the past month.

Height is 167.6 cm (66 in.), and weight is 86.3 kg (190.0 lb). Temperature is 36.8 C (98.3 F), heart rate is 100

beats per minute, respirations are 12 per minute, and blood pressure is 110/60 mm Hg. The patient does not

appear to be in acute distress. Skin turgor is decreased. The neck is supple; there is no jugular venous pressure

elevation. The lungs are clear. Cardiovascular examination shows normal S1 and S2, with no murmurs, rubs, or

gallops. There is no peripheral edema.

Which of the following most likely led to this patient’s current presentation?

(A) Furosemide

(B) Lisinopril

(C) Canagliflozin

(D) Hyperglycemia


Page 24

24A 62-year-old man who received a living related kidney transplant from his sister 10 years ago for end-stage

renal disease secondary to hypertension comes to your clinic for a follow-up visit. He wants to discuss not only

his immunosuppression and care of his kidney transplant, but also his recent visit with his dermatologist, who

found two squamous cell carcinomas on the left cheek of his face and removed them. The patient asks you what

can be done to decrease his risk of development of further skin cancers. His only other medical problem is

osteoarthritis. He is up to date with his other health maintenance tests. Current medications are cyclosporine,

75 mg twice daily; mycophenolate mofetil, 1000 mg twice daily; prednisone, 5 mg daily; and amlodipine, 10 mg

daily.


pressure is 125/75 mm Hg. Arterial oxygen saturation is 100% on room air. The patient does not appear to be in

distress. Skin examination shows two healing, slightly erythematous areas on the left cheek of the face where

superficial skin has been surgically removed. Head, eye, ear, nose, and throat examination is unremarkable.

There are no enlarged cervical lymph nodes. Cardiopulmonary and abdominal examinations are unremarkable.

Laboratory studies:

Hemoglobin 13 g/dL [14–18]

Leukocyte count 4800/L [4000–11,000]

Platelet count 250,000/L [150,000–450,000]








Whole blood

cyclosporine (trough) 115 ng/mL [75–125]

Transition from cyclosporine to which of the following immunosuppression-based therapies would be the best

choice for decreasing this patient’s risk of future skin cancer?

(A) Tacrolimus

(B) Sirolimus

(C) Belatacept

(D) Azathioprine


Page 25

25You have been asked to evaluate a 55-year-old man three days after deceased donor kidney transplantation to

provide recommendations on a future maintenance immunosuppression regimen. The patient, a 3/6 HLA-

matched recipient, was cytomegalovirus (CMV) and Epstein-Barr virus (EBV) serotype unknown at the time of

transplant, but was tested and found to be both CMV and EBV seronegative. The donor was CMV seropositive

and EBV seropositive. Induction was with rabbit anti-thymocyte globulin, and current immunosuppression is

with belatacept, 10 mg/kg; mycophenolate mofetil, 1000 mg twice daily; and prednisone, 40 mg daily, with a

scheduled taper plan. After the procedure he had immediate graft function, and for the past three days his daily

urine output has been 1000 mL per day. He reports that he is feeling well. The first administration of the

planned prophylactic regimen of trimethoprim-sulfamethoxazole and valganciclovir is to occur prior to hospital

discharge. Previously, he had end-stage renal disease from diabetes mellitus and was on hemodialysis without

any native urine output at the time of being called in for transplantation. Prior to transplantation, he also felt

well and had no acute illnesses or recent hospitalizations. The patient also has hypertension and hyperlipidemia.

In addition to belatacept, mycophenolate mofetil, and prednisone, other current medications are insulin glargine,

20 units daily and 5 units with meals; and atorvastatin, 20 mg daily. He works as an accountant in an office

building.


beats per minute, respirations are 13 per minute, and blood pressure is 140/80 mm Hg. Arterial oxygen

saturation is 100% on room air. Head, eye, ear, nose, and throat, cardiovascular, pulmonary, and abdominal

examinations are unremarkable. The allograft is in the right iliac fossa; the incision is clean, dry, and intact. No

bruit is heard over the allograft site.

Laboratory studies:



Platelet count 159,000/L [150,000–450,000]

Plasma glucose 140 mg/dL [70–99]








Compared with a typical kidney transplant recipient, this patient would be at higher risk for developing which of

the following after transplantation?

(A) Pneumocystis jiroveci pneumonia

(B) Actinomyces infection

(C) Kaposi’s sarcoma

(D) Post-transplant lymphoproliferative disorder


Page 26

26A 40-year-old white woman comes to the clinic to be evaluated as a potential kidney donor for her sister, a 50-

year-old woman with end-stage renal disease (ESRD) secondary to IgA nephropathy and currently on peritoneal

dialysis. The potential donor states that she feels well and is eager to donate a kidney to her sister. The donor is

gravida 2, para 2, with two uncomplicated pregnancies that resulted in two healthy children. The donor has no

medical problems and has had no illnesses or hospitalizations except for the birth of her children. She takes no

prescribed medications, but does take a multivitamin supplement daily. She drinks one or two alcoholic

beverages per week, is a lifetime nonsmoker, and does not use illicit drugs.

Height is 167.6 cm (66 in.), and weight is 65.8 kg (145.0 lb). Body mass index is 23.4. Temperature is 36.9 C

(98.4 F), heart rate is 80 beats per minute, respirations are 14 per minute, and blood pressure is 114/68 mm Hg.

Arterial oxygen saturation is 100% on room air. The patient appears not to be in distress and is breathing

comfortably. Head, eye, ear, nose, and throat examination is unremarkable. Cardiovascular, pulmonary, and

abdominal examinations are normal. Neurologic examination yields grossly nonfocal findings. Psychologic

examination demonstrates appropriate mood and affect; the donor is open and motivated to donate and appears

to have made a noncoerced decision.

Laboratory studies:

Complete blood count Normal

Comprehensive metabolic panel Normal


Iothalamate glomerular filtration rate 115 mL/min/1.73 m2

Urine albumin-to-creatinine ratio 3.0 mg/g [less than 30]

She has been looking at various resources to determine her risk for ESRD after donation.

What is this potential kidney donor’s risk of developing ESRD by 15 years after donation?

(A) Less than 1%

(B) 5%

(C) 10%

(D) 15%


Page 27

27A 45-year-old woman has end-stage renal disease from autosomal dominant polycystic kidney disease (ADPKD)

and is being evaluated for kidney transplantation. At the time she started dialysis, seven years ago, she initially

underwent evaluation for transplantation but decided not to pursue transplant at that time because she felt well

and was concerned about the antirejection medications she would need to take. She now has again read about

the medications and is prepared to take all medications necessary for transplantation. Her father also had

ADPKD and died on dialysis. A brother had ADPKD and received a kidney from a healthy sister. There are no

other potential living donors, and so she plans to wait for a kidney on the waiting list. She also has hypertension

and hyperlipidemia. Current medications are amlodipine, 10 mg daily; and atorvastatin, 10 mg daily.


beats per minute, respirations are 12 per minute, and blood pressure is 138/84 mm Hg. Arterial oxygen

saturation is 100% on room air. Overall, the patient seems to be in no acute distress. Head, eye, ear, nose, and

throat examination is normal. Cardiovascular and pulmonary examinations are normal. The abdomen is soft

and nontender. Bowel sounds are normal. There is abdominal distention from an enlarged liver and kidneys.

Palpation over the costovertebral angle does not elicit tenderness. The kidneys appear to extend to just above

the anterior superior iliac spine. No peripheral edema is noted.

Laboratory studies:



Platelet count 190,000/L [150,000–450,000]

Comprehensive metabolic panel

notable for




The patient has been reading about the new kidney allocation system, and wants more information on wait time.

According to the new United Network for Organ Sharing organ allocation system, which of the following is the

amount of wait time that the patient would receive once she is put on the transplant waiting list?

(A) None; wait time will start to accumulate once she has been listed for transplant

(B) One year; wait time for having already been on dialysis at the time of evaluation

(C) Three and one-half years; wait time equivalent to half the time she has spent on dialysis

(D) Seven years; wait time equivalent to the time she has spent on dialysis


Page 28

28A 56-year-old woman with chronic kidney disease from lupus nephritis is being evaluated for a living related

kidney transplant. She has had some right leg pain, which her primary care physician thinks may be related to

claudication. She currently takes mycophenolate mofetil, 1000 mg twice daily; prednisone, 5 mg daily; ramipril,

20 mg daily; and furosemide, 40 mg twice daily.

Physical examination is notable for a malar rash, palpable posterior tibial and distal pedis pulses, and normal

capillary refill in the toes bilaterally.

Laboratory studies:




Urinalysis

pH 6.0 [4.5–8.0]

Protein Trace

Blood 1+

The transplant nephrologist requests contrast-enhanced magnetic resonance imaging in order to evaluate the

flow in the iliac arteries, in determining her suitability to receive a kidney transplant.

Based on recent evidence, which of the following would be a reasonable contrast agent for this patient?

(A) Ferumoxytol

(B) Gadodiamide

(C) Iodinated contrast

(D) Manganese nanoparticles


Page 29

29A 57-year-old man with chronic kidney disease due to diabetes mellitus and hypertension begins dialysis with an

estimated glomerular filtration (eGFR) of 12 mL/min/1.73 m2. He has a left brachiocephalic arteriovenous

fistula that is cannulated with 15-gauge needles. He is able to achieve a blood flow rate of 450 mL/min for

treatments. His in-center hemodialysis schedule is twice weekly, with the goal of preserving his ability to work.

Compared with standard initiation of dialysis, incremental dialysis is associated with which of the following?

(A) Worse markers of nutritional status

(B) More hospitalizations

(C) Faster loss of residual renal function

(D) Similar risk of mortality


Page 30

30A 63-year-old man with type 2 diabetes mellitus, hypertension, gout, and severe obesity comes to you for an

opinion regarding renal function. For the past ten years, the patient has had progressive loss of kidney function,

with a yearly loss of estimated glomerular filtration rate (eGFR) of approximately 2 to 3 mL/min/1.73 m2. He

previously had a renal biopsy that showed Kimmelstiel-Wilson nodules, glomerular basement membrane

thickening, and arteriolar hyalinosis. Current medications are irbesartan, 300 mg daily; metoprolol, 25 mg twice

daily; and furosemide, 80 mg twice daily.

Body mass index is 48.2. Pulse rate is 72 per minute, and blood pressure is 137/79 mm Hg. There is abdominal

obesity and trace pitting peripheral edema.

Laboratory studies:

Hemoglobin A1C 7.1% [4.0%–5.6%]

eGFR 42 mL/min/1.73 m2

Urine protein-to-


You refer the patient to the surgical weight loss clinic for consideration of bariatric surgery.

Which of the following best characterizes the effect of bariatric surgery on decline of renal function?

(A) No change in decline of renal function in patients with diabetes mellitus

(B) No change in decline of renal function in patients with hypertension

(C) Slowed decline of renal function in patients with glomerulonephritis

(D) Slowed decline of renal function in all patients

MC1489-41rev0218

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