renal exam 2006.doc

8/18/2019 Renal exam 2006.doc

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RENAL PATHOPHYSIOLOGYRENAL PHARMACOLOGY

RENAL PATHOLOGY

FINAL EXAMINATION

December 15, 2006

__________________________ Student's name

INSTRUCTIONS

This examinatin is !m"sed # mu$ti"$e !hi!e %uestins& (ite )u( name n

*th the %uestin *+$et and the ans,e( sheet& The ans,e(s a(e t *e ,(itten n the

ans,e( sheet "(e#e(a*$) in "en!i$- sin!e it is easie( t !han.e )u( ans,e(& F( ea!h

mu$ti"$e !hi!e %uestin there is only one correct response- s ,(ite n$) ne $ette(

1


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NORM! !"ORTOR# $!U%S

Test N(ma$ Ran.e

/$d- Se(um ( P$asma

*$d .$u!se 012345 m.6d$S!( 73&8 m.6d$/9N 7:4 m.6d$/9N6S!( (ati 34238Osm$a$it) :;42:54 mOsm6+.

Na< 3=823>8 mE%6L?< =&828 mE%6LH< =;2>= nE%6L"H @a(te(ia$ 1&=121&>:C$2 582348 mE%6L

HCO=2 ::2:; mE%6L

"CO: @a(te(ia$ =12>= mmH.

A$*umin >28 .m6d$ Anin .a" ;23: mE%6LCa$!ium ;&8234&8 m.6d$Phs"hate @as "hs"h(us :&828&4 m.6d$

Bai$) 9(ina() Ex!(etinC(eatinine 3&42:&4 .m6da)GFR ( C!( ;42384 m$6min @3382:30 L6da)P(tein 7384 m.6da)ate( @ae(a.e 4&823:L

@3&8L

Na


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1. A healthy 26-year-old woman takes a 10 kilometer run on a hot day. She does not takedrinking water with her and at the end of the run, she feels nauseated and vomits repeatedly, and

is unable to take in any food or fluids. She goes to a loal lini, where she is noted to have a

blood pressure of !!"#0 mm$g, and to have dry muous membranes, lear lungs, no edema.anddry skin. %abs show& 'a( 1)2 m*+"%, ( .1 m*+"%, $/- # m*+"%, l- 110 m*+"%, '

2 mg"d%, r 1.1 mg"d%. 3he p$ is .#6. . 4hih of the following is most likely to be true5

A. She has an elevation in her total body sodium. She has a very low level of A$

. $er urine osmolality is very high

. At the renal tubular level, she will have inreased water reabsorption in the asendingthik limb of the loop of $enle

*. $er tubular seretion of reatinine must be inreased

3$* 7/%%/48'9 34/ :*S38/'S ;*%A3* 3/ 3$* 7/%%/48'9 AS*

After traveling in Southeast Asia, a -year-old woman is admitted to the hospital with a si< day

history of diarrhea. /n e


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. 3here is inreased tubular seretion of sodium.

. 3here is an inreased synthesis of A$

. $e probably has entral diabetes insipidus*. 3here is an inreased glomerular filtration rate ausing inreased sodium filtration

). A worried set of parents bring their 1) year old high shool student daughter to see you beause she is not feeling well. $er parents report that she has been trying to diet to lose weight.

$er past medial history and the family history is negative, and you find no abnormalities on an

initial physial e


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. ethylene glyol overdose

. saliylate >aspirin? overdose

. diureti overdose*. diabeti ketoaidosis

=. A ! year old woman omes to see you in your lini, efore seeing her, you review her bloodwork. 3he 'a( is 1# m*+"%, the ( is #.# m*+"%, the l- is == m*+"%, and the $/- is

16 m*+"%. 3he arterial blood gas is .2! and the p/2 is 0 mm$g. 4hih of the following

diagnoses is the most likely5

A. pregnany

. distal renal tubular aidosis

. an aldosterone produing tumor . hroni obstrutive pulmonary disease

*. kidney failure

10. A )-year-old man is admitted to the hospital with worsening ongestive heart failure. $ehas been taking inreasing doses of diuretis--furosemide and metola@one, a thia@ide like agent,

as an outpatient. /n e


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. She should have serum and urinary ateholamines measured

*. She should begin therapy with antihypertensive mediations

1. A !0-year-old man has a long history of smoking and also has a history of two myoardial

infartions, a erebrovasular aident >stroke? and has reently had worsened hypertensionC the

blood pressure is now 200"110. A renal arteriogram shows severe left renal artery stenosis.4hih of the following laboratory tests is likely to be present in this ondition5

A. elevation in serum potassium. derease in serum biarbonate

. inrease in serum aldosterone

. derease in serum renin

*. inrease in serum A$ level

1#. A 6-year-old Afrian Amerian man has had hypertension for over 2) years, and has been

treated with varying mediations for that period of time, but beause of the ost of mediations

and side effets, he has not been optimally ompliant. /ver the past five years at least, his blood pressure has always been over 160"100. 4hen you see him on a routine visit, his blood pressure

is 1!0"110 and his heart rate is !2"minute. /f the following, what would most likely be presentif you perform a history, physial e


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1). 3he above photo represents a form of hypertensive vasular disease. 4hih of thefollowing statements about this lesion is true5 >2 points?

A. 3his lesion is harateristi of malignant nephroslerosis. 3he lesion is the result of antibodies formed against ollagen 8D

. 3he lesion is strongly assoiated with hypertension but an also be seen in diabetes

without hypertension. 3he lesion is almost always assoiated with membranoproliferative glomeruloslerosis

16. 4hih of the following hanges would be e


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*. eause he is unable to drink water, the fall in 97; will allow for prodution of dilute

urine.

20. A )-year-old female has vomiting and diarrhea for 2 days and is only able to keep fluidsdown for the last day. /n e


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2). A 1 year-old female presents with sudden onset edema with hypertension. idney funtion

is abnormal with a reatinine of 2.6 mg"dl and albumin is 2. g"dl. She reports urinary foaming,

but denies gross hematuria or other urinary symptoms inluding dysuria or fre+ueny.4hih of the following urinalysis and sediment is most onsistent with the above linial

presentation5

A. Speifi gravity 1.01)" p$ )" #( protein " no ells or asts

. Speifi gravity 1.010" p$ )" #( protein " 2)-)0 dysmorphi ;s" one ; ast

. Speifi gravity 1.020" p$ )" trae protein " ) ;s" )0-100 4s" no asts. Speifi gravity 1.020" p$ )" no protein " no ells or asts

*. Speifi gravity 1.020" p$ )" no protein " )-10 ;s" hyperpigmented >dark? granular

asts

>;I red blood ell, 4I white blood ell?

26. rine dipstik shows a speifi gravity of 1.01), p$ ).)" negative protein" no blood or

leukoyte esterase and sediment reveals no ells or asts. reatinine is 2.0 mg"dl. 3he following

linial presentation is most onsistent with the above urine findings&

A. 6#-year-old female with a 20 year history of diabetes mellitus and diabeti retinopathy. 2-year-old female diagnosed with lupus nephritis

. !-year-old female with dysuria, urinary fre+ueny and foul smelling urine

. #0-year-old male with no medial history now with septi shok ompliated by oliguri>1)0 ml"2# hr? aute renal failure

*. 6)-year-old male with bak pain, anemia and spine J-ray revealing lyti lesions

suggestive of multiple myeloma with tubular proteinuria >light hains?.

2. 4hih one of the following urine sediment findings is NOT orretly mathed5

A. $yaline ast- 3amm $orsfall Hrotein produed by tubular ells. ;ed blood ells- ladder aner

. oarse hyperpigmented granular ast- aute glomerulonephritis

. 4hite blood ell asts- aute interstitial nephritis*. 4hite blood ell asts- pyelonephritis

3$* '*J3 34/ :*S38/'S ;*7*; 3/ 3$* 7/%%/48'9 AS*

A 6-year-old female has a 1) year history of hypertension whih has been poorly ontrolledwith past medial history inluding hyperholesterolemia, A >oronary artery disease?, s"p

A9 >oronary artery bypass graft?, atrial fibrillation and ishemi ardiomyopathy.

reatinine measured 2 years ago is 1.! mg"dl. She is hronially on o


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2!. 4hih of the following statements best desribes the abnormal laboratory data5

A. 3he diureti is ontributing to her urinary protein loss resulting in a low albumin

. She has hyperphosphatemia due to vitamin defiieny

. $yponatremia ours due to the A* inhibitor . $yperkalemia arises due to hyperaldosteronism

*. reatinine is elevated as a result of progression of her underlying renal disease

2=. She is hospitali@ed numerous times over the nehypertension?. $e is found to have vessel oronary artery disease and is planned for

A9 >oronary artery bypass graft? ne


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rine 'a )0, rine reat ).

1. 4hih of following e


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#. 4hih of the photos below is most onsistent with the senario in the previous+uestion5 >2 points?

A

Antibody-antigen ompledense deposit?

). 8gA nephropathy

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6. Host-streptooal glomerulonephritis

. Kembranoproliferative glomerulonephritis, type 88

!. Kembranoproliferative glomerulonephritis, type 8

=. *ah of the following patients has a reatinine of 4.6 mg"dl. 4hih patient will most likely

have omplete renal reovery5

A. 2#-year-old female with lupus nephritis

. 6)-year-old male with obstrutive uropathy for the past 6 months. )6-year-old female with sepsis and hypotension resulting in A3'

. #6-year-old male with diabeti nephropathy

*. 6-year-old male with polyysti kidney disease

Kath the embryologial struture of origin with the definitive struture >1 point eah?

A. KOllerian dut. rogenital sinus

. Kesonephri dut. 'one of the above

#0. Hrostate >the maor portion?#1. terus

#2. rinary bladder

#. Hro


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#). 3he abnormality depited above is the result of& >2 points?

A. Abnormal migration of the metanephros

. Abnormal migration of the mesonephros

. *arly embryonal obstrution of the prostati urethra. A mutation in the H-1 gene

#6. A )!-year-old man is found to have old, yanoti toes and renal failure following a

proedure. 3he renal biopsy reveals the presene of emboli in branhes of the renal artery.

holesterol rystals are present. 4hih of the following is most likely to ause this senario5 >2 points?

A. Harado


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. Hlaement of a graft in the right ilia artery

#. 3he above blood smear is from a woman with renal failure oming on ) days after

delivery. 4hih of the following statements is true5 >2 points?

A. 8t is ertain that abruption, intrapartum hemorrhage, amnioti fluid embolism, or puerperal sepsis ourred

. 3he patient must have eaten ontaminated fresh spinah

. 3he blood smear shows shistoytes, spheroytes, and a defiient +uantity of platelets

. 3he patient almost ertainly does not have neurologial symptoms and signs

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3he above *K photo is of a glomerular apillary wall with the lumen lowermost. Kaththe labels, A >the large oval?, >the retangle?, >the small irle?, with the following

ultramirosopi strutures. >1 point eah?

#!. 7oot proess

#=. 7enestra in endothelium

)0. asement membrane

8ndiate whether the following statements are true >A? or false >?. >1 point eah?

)1. 3he onstellation of findings in von-$ippel-%indau syndrome inludes erebellar

hemangioblastomas and renal ell arinomas.

)2. 3he malignant ell in renal ell arinoma >lear ell type? is a round to polygonal ell withlear to granular ytoplasm.

). 4ilms tumor has a lassi biphasi histologial pattern and is most likely to present in theearly teen age period.

)#. 3he most important prognosti fator in 4ilms tumor is the degree of anaplasia seen

histologially.

)). 3he most likely senario to e2 points?

A. 3he patient suffers from merury poisoning.

17


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. 3he patient was treated three weeks ago with ampiillin and now has peripheral

eosinophilia.

. 3he patient is 1) years of age and had a reent streptooal throat infetion.. 3he patient reently underwent treatment whih inluded the use of an intraaorti

balloon.

)6. 4hih of the following interventions will have the greatest effiay at preventing future

alium o1=me+ 'a per %?. 4hih of thefollowing senarios is most likely to our as a result5

A. Suessful restoration of intravasular volume

18


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. $yponatremia from eA$? by the pituitary a


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6. A 0-year-old Afrian Amerian heroin user has been $8D positive sine 1==6, and had nottaken her $8D mediations in several years. She is admitted to the hospital with pneumoystis

pneumonia and high $8D viral titers. 8n addition, she has a urinalysis showing 1.010, ( protein

and hyaline asts, serum reatinine of 1.1mg"d%, serum albumin .2g"d%, and # normal, and

a 2#$ urine protein of 1g.

A renal biopsy would likely show whih of the following&

A

20


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6#. A )=-year-old man has had diabetes mellitus for 21 years ompliated by retinopathy and peripheral neuropathy. $e has also had hypertension, proteinuria and mild renal failure for

five years. $is mediations are amlodipine, doompared with 1.!mg"d% and ).#m*+"% si< months

earlier?. Serum gluose is 1! mg"d%.

3he potassium level is probably e


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A. 7urosemide & ototo


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1. A )-year-old woman weighs !0 kg >16 lb?, and her blood pressure is 1#0"=6 mm $g.She has pitting edema in both legs. $er physiian presribes e


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. se drug therapy to bring blood pressure below 10"!0

. %ook for left ventriular hypertrophy with an eletroardiogram

*. %ook for oronary alifiation with eletron-beam omputed tomography

6. 4hih lass of drugs redue heart rate, ardia output, peripheral vasularresistane and renin seretion5

A. iuretis

. β-blokers

. P1-blokers

. alium hannel blokers*. A* inhibitors

. A 62-year-old man has systoli heart failure and takes low doses of furosemide,

spironolatone, metoprolol, amlodipine and aptopril. lood pressure is 1#2"=). Serum potassium is ).6m*+"%. Bou should inrease the dose of whih drug to redue blood pressure5

A. 7urosemide. Spironolatone

. Ketoprolol

. Amlodipine

*. aptopril

!. 3he patient in the previous +uestion >immediately before this one? develops a dryough. %ungs sound lear. hest


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!0. A 6-year-old white male dialysis patient has diffiult-to-ontrol hypertension. $e

makes no urine. $is mediations inlude ma


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. 3he risk of respiratory depression is less than with intravenous opioids.

. 8t is tehnially easier to perform than patient ontrolled analgesia.

*. Bou get more seletivity for the type of opioid reeptor that is ativated

!). /J-2 inhibitors and nonsteroidal anti-inflammatory agents&

A. Should be avoided in patients with renal insuffiieny.. Are more potent analgesi agents than the most potent opiates

. Add little benefit when ombined with opioids for pain ontrol.

. ause respiratory depression.

*. Kust be administered intravenously.

!6. Hatients who have been reeiving opioids for e


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*. $e is ompensating for severe metaboli aidosis.

!=. 3he most likely e


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=. 3he ation of saliylate that best aounts for its severe to


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. Signifiantly greater than that reported in *urope

==. 4hih maor breakthrough aounted for the greatest improvement in transplantation

results5

A. 3he ability to reate a vasular anastomosis.

. 8mproved understanding of human leukoyte antigens >$%A? Q 3-ell reeptor omple<interations.

. 3he disovery of ylosporine.

. 3he appliation of ross math testing.

100. 4hih of the following statements about urrent immunosuppressive mediations is

true5

A. 3he mehanism of ation of prednisone is based on its ability to interfere with '7-T. 3arolimus bloks signal transdution from the 8%-2 reeptor.. Kyophenolate mofetil inhibits the prodution of pyrimidine nuleotides.

. 'one of the above.

101. ;egarding protein immunosuppressive drugs, whih is false5

A. 3hymoglobulin is a polylonal 8g9 that bloks 3-ell membrane proteins.

. asili8%-2; mAb? is a nondepleting antibody that lowers the risk of aute

reetion.

. A side effet of /3 is the ytokine-release syndrome.. Sine indution therapy is only used in the early period after transplantation, there is no

inreased long-term aner risk assoiated with these agents.

102. ylosporine is diffiult to use in kidney transplantation beause&

A. 3he primary adverse effet is nephrotoHrograf?, whih of the following statements is true5

A. 3arolimus is a yli peptide derived from soil fungus, whose primary ation is to limit

U-interferon prodution.

. linial side effets ommonly inlude neutropenia, stomah upset and diarrhea.. 3he maor advantage of tarolimus is inhibition of immunologi memory.

. $igh levels of tarolimus predispose to neuroto


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10#. After transplant a patient presents to lini with headahes, tremor and hyperkalemia.

3he blood pressure is 1!0"100. ;enal funtion is marginally worse with a reatinine of 1.!

mg"dl. 4hih drug most likely ontributes to this onstellation of omplaints5

A. A@athioprine

. 3arolimus . Kyophenolate mofetil

. Hrednisone

10). ;egarding sirolimus >;apamune?, whih statement is false5

A. inds to the immunophilin 7H.. *

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