ABIM Qbank Demo

In a CKD and ESRD patient, Vitamin D seems to protect against cardiovascular disease events by controlling secondary hyperparathyroidism. The OPERA trial evaluated the effect of paricalcitol Vitamin D analog in CKD stages 3-5 with left ventricular hypertrophy. The study observed the effect on left ventricular mass and function.

Which of the following statements is true about the effect of paricalcitol in CKD and ESRD patients?

		A. Paricalcitol treatment reduced LV mass
		B. Paricalcitol treatment preserved LV ejection fraction
		C. Paricalcitol treatment improved pulse wave velocity and arterial stiffness
		D. Paricalcitol treatment improved blood pressure control
		E. Paricalcitol treatment significantly reduced PTH and alkaline phosphatase

Explanation:

The correct answer is E

Paricalcitol treatment significantly reduced PTH and alkaline phosphatase

Explanation:

Vitamin D Rx DOES NOT reduce LV mass OR LV ejection fraction OR arterial stiffness

Vitamin D seems to protect against cardiovascular disease, but the reported effects of vitamin D on patient outcomes in CKD are controversial.

OPERA trial was a prospective, double blind, randomized, placebo-controlled trial to determine whether oral activated vitamin D reduces left ventricular (LV) mass in patients with stages 3-5 CKD with LV hypertrophy.

Subjects with echocardiographic criteria of LV hypertrophy were randomly assigned to receive either oral paricalcitol (1 ?g) one time daily (n=30) or matching placebo (n=30) for 52 weeks.

The primary end point was change in LV mass index over 52 weeks, which was measured by cardiac magnetic resonance imaging. Secondary end points included changes in LV volume, echocardiographic measures of systolic and diastolic function, biochemical parameters of mineral bone disease, and measures of renal function.

Change in LV mass index did not differ significantly between groups (median [interquartile range], -2.59 [-6.13 to 0.32] g/m(2) with paricalcitol versus -4.85 [-9.89 to 1.10] g/m(2) with placebo).

Changes in LV volume, ejection fraction, and tissue Doppler-derived measures of early diastolic and systolic mitral annular velocities, and ratio of early mitral inflow velocity to early diastolic mitral annular velocity did not differ between the groups.

Paricalcitol treatment significantly reduced intact parathyroid hormone (P<0.001) and alkaline phosphatase (P=0.001) levels as well as the number of cardiovascular-related hospitalizations compared with placebo.

52 weeks of treatment with oral paricalcitol (1 ?g one time daily) significantly improved secondary hyperparathyroidism but did not alter measures of LV structure and function in patients with severe CKD and ESRD.

OPERA and PRIMO are two recent randomized clinical trials in patients with CKD, which evaluated paricalcitol for slowing the progression of left ventricular mass. Both these trials were found to have negative results.

Copyright © ABIM Exam World
Created On: 09/20/2017
Last Modified: 08/06/2018

A 40 year-old pleasant African man with ESRD secondary to FSGS started automated peritoneal dialysis. His prescription includes 2.5 L and 3 exchanges over 8 hours at night with a last fill of 2 L. He has a urine output of 1000 mL/day. A typical ultrafiltration on cycler is used at 1000 mL. Average drain volume of the day dwell was 1500 mL prior to going on the cycler at night.

He came with complains of lower abdominal wall edema extending to the scrotum over the past 5 days. Without any change in the dialysis prescription, his drain volume before going on the cycler dropped to 900 mL, and the ultrafiltration volume on the cycler came down to 100 mL. He reports no pain with fill or drain.

What is the next step?

		A. Chest X ray PA and lateral view
		B. Drain the fluid middle of the day to reduce the dwell time
		C. PD catheter manipulation
		D. Abdominal CT scan with contrast in the dialysate
		E. Switch to hemodialysis
		E. Pleurodesis

Explanation:

The correct answer is D

Abdominal CT scan with contrast in the dialysate

Explanation:

Typical ultrafiltration failure from peritoneal membrane failure presents gradually. More frequently, we see an apparent ultrafiltration failure from other reasons.

Catheter malfunction can present with problem with inflow, outflow or both. A kink in the catheter poses problem with inflow and outflow.

Omentum or blood clots clogging the catheter can cause only outflow problem. Fibrin clots, constipation with loaded rectum, and displaced PD catheter also cause outflow obstruction. X ray KUB is very helpful in diagnosing displaced catheter.

FLUID LEAK leak into the abdominal wall causes swelling in the lower abdomen extending down to the scrotum or mons pubis and decrease in the drain volume. Usually this can be treated by temporarily doing low volume PD or transferring to HD for about 6 weeks. Such leaks starting few years after initiating PD usually do not respond to this approach and often requires placement of a new PD catheter.

A patent tunica vaginalis testes will cause UNILATERAL OR BILATERAL SCROTAL SWELLING without much swelling of the abdominal wall sometimes associated with decrease in the drain volume. A CT scan of the abdomen with ‘IV’ contrast into the peritoneal fluid can help in diagnosing the leak into the abdominal wall and scrotal leak. Patent tunica vaginalis testes requires surgery. Generally hemodialysis is not required after the surgery and low volume peritoneal dialysis can be resumed. This patient presents with signs of leak of fluid into the abdominal wall. A chest X ray is not required, so (Choice A) is wrong.

Draining during the middle of the day helps if the membrane is very permeable with very high D/P creatinine ratio on PET. This does not help in abdominal wall leak of dialysate. Therefore, (Choice B) is also wrong.

PD catheter manipulation (Choice C) is wrong because this patient does not have displaced PD catheter from the information given.

(Choice D) is the correct answer. If the clinical presentation is very convincing, most patients are treated with reducing the dialysate volume and if possible keeping the abdomen dry during the day. Sometimes these patients need to be switched to hemodialysis for 4-6 weeks before PD is resumed. Hence temporary switch to HD would be a correct answer, but unqualified switch to HD as is stated in answer E would be a wrong choice. Therefore, (Choice E) is the wrong or less appropriate answer.

ABDOMINAL ADHESIONS cause decrease in the drain volume as well and require surgical treatment with low volume PD or temporary HD after that.

DIAPHRAGMATIC LEAK into the pleural space presents with cough and shortness of breath without peripheral signs of fluid overload few weeks after starting peritoneal dialysis (not the presentation in this patient). Usually, such patients present with right sided pleural effusion clinically and on chest X ray PA and lateral view. These patients can be treated with temporary transfer to HD, pleuridesis and return back to PD 4-6 weeks later. Permanent switch to hemoidialysis without pleurodesis is another option.

TREATMENT OPTIONS OF VARIOUS ABDOMINAL/CHEST PROBLEMS AS MENTIONED ABOVE IN PATIENTS ON PERITONEAL DIALYSIS IS FREQUENTLY TESTED ON BOARDS. PLEASE KNOW THE TREATMENT OPTIONS.

Copyright © ABIM Exam World
Created On: 09/14/2017
Last Modified: 08/06/2018

All of the following are helpful in predicting AV Graft stenosis EXCEPT:

		A. Hyperpulsatility of the AV Graft
		B. Reduced pulse augmentation
		C. Increased bleeding and clots
		D. Decreased KT/V
		E. Decreased Blood Flow rate
		E. Surveillance of the graft

Explanation:

The correct answer is F

Surveillance of the graft

Explanation:

Intra-graft or venous outflow stenosis – A strong pulse in the AV graft - HYPERPULSATILITY suggests an increase in resistance as occurs with a venous stenotic lesion. The intensity of this pulse is directly proportional to the severity of the stenosis. For this reason, in an AV graft Hyperpulsatility can be considered as an indicator of impending AV graft stenosis.

Arterial stenosis – REDUCED PULSE AUGMENTATION suggests inflow stenosis due to stenosis of the arterial anastomosis or of the feeding artery. Although pulse augmentation is commonly performed, it is less sensitive for the detection of inflow stenosis in AV grafts compared with AV fistulas.

INCREASED BLOOD CLOTS, DECREASED KT/V, and DECREASED BLOOD FLOW RATE are all suggestive of impending AV graft stenosis. Often patients are seen with dilated, collateral veins over the arm and chest wall (very important to examine your hemodialysis patients after taking off their shirts) suggestive of central venous stenosis - The classic physical finding in a patient with a significant central venous stenosis is diffuse upper extremity edema. Subcutaneous collateral veins are frequently evident over the chest. Swelling and collateral veins are caused by generalized venous hypertension of the extremity, which occurs in central, but is rare with peripheral lesions.

SURVEILLANCE does not predict AV Graft stenosis. It is not a sensitive or specific modality to detect the same accurately.

Copyright © ABIM Exam World
Created On: 09/23/2020
Last Modified: 01/28/2021

All of the following are helpful in predicting AV Graft stenosis EXCEPT:

		A. Hyperpulsatility of the AV Graft
		B. Ruduced pulse augmentation
		C. Increased bleeding and clots
		D. Decreased KT/V
		E. Decreased Blood Flow rate
		E. Surveillance of the graft

Explanation:

The correct answer is F

Surveillance of the graft

Explanation:

Intra-graft or venous outflow stenosis – A strong pulse in the AV graft - HYPERPULSATILITY suggests an increase in resistance as occurs with a venous stenotic lesion. The intensity of this pulse is directly proportional to the severity of the stenosis. For this reason, in an AV graft Hyperpulsatility can be considered as an indicator of impending AV graft stenosis.

Arterial stenosis – REDUCED PULSE AUGMENTATION suggests inflow stenosis due to stenosis of the arterial anastomosis or of the feeding artery. Although pulse augmentation is commonly performed, it is less sensitive for the detection of inflow stenosis in AV grafts compared with AV fistulas.

INCREASED BLOOD CLOTS, DECREASED KT/V, and DECREASED BLOOD FLOW RATE are all suggestive of impending AV graft stenosis. Often patients are seen with dilated, collateral veins over the arm and chest wall (very important to examine your hemodialysis patients after taking off their shirts) suggestive of central venous stenosis - The classic physical finding in a patient with a significant central venous stenosis is diffuse upper extremity edema. Subcutaneous collateral veins are frequently evident over the chest. Swelling and collateral veins are caused by generalized venous hypertension of the extremity, which occurs in central, but is rare with peripheral lesions.

SURVEILLANCE does not predict AV Graft stenosis. It is not a sensitive or specific modality to detect the same accurately.

A 68-year-old gentleman, Caucasian descent, comes to clinic for follow up visit. He is known to have type 2 diabetes mellitus for the past 18 years. His father had diabetes from 40 years of age and developed kidney disease requiring dialysis after 15 years of diabetes. He reports no symptoms. He has been having hypertension and coronary artery disease with history of PCI 2 years ago. He has non-proliferative diabetic retinopathy. His medications are sitagliptin, gliclazide and metformin in addition to losartan and hydrochlorothiazide. He has been monitoring blood sugar at home and reports no hypoglycemia. He exercises at least at least 30 minutes per day. His vitals recording shows BP of 168/66 mm Hg. His BMI is 29.2. Systemic examination is unremarkable.

His laboratory investigation is reported as follows.

Characteristic	value
Hemoglobin	12.2 gm/L
WBC count	6.8 X 103/cubic mm
Platelet count	241 X 103/cubic mm
Segmented Neutrophils Lymphocytes Monocytes Band neutrophils Eosinophils Basophils	60% 36% 2% 0% 2% 0%
Sr. Sodium	139 mEq/L
Sr. Potassium	4.9 mEq/L
Sr. Creatinine	1.2 mg/dL
Sr. Bicarbonate	22 mEq/L
Sr. Chloride	101 mEq/L
Total Bilirubin	1.0 mg /dL
AST	16 U/L
ALT	18 U/L
Sr. Albumin	4.0 g/dL
HBA1C	7.8%
Sr. Calcium	10 mg/dL
Urine dipstick	pH- 5.4 Albumin-trace no blood no WBCs
24-hour urinary albumin	200 milligrams/day

What is the MOST LIKELY correct statement regarding clinical diagnosis of Diabetic Kidney Disease in this patient ?

		A. Diabetic Kidney Disease previously called as diabetic nephropathy can be diagnosed clinically with renal biopsy only.
		B. Presence of microalbuminuria is adequate for clinical diagnosis of Diabetic Kidney Disease.
		C. Presence of hematuria without non-diabetic kidney disease is impossible in Diabetic Kidney Disease as diabetic kidney disease is a non-proliferative glomerular disease.
		D. Family history of Diabetic Kidney Disease is associated with renal involvement in Diabetes.

Explanation:

The Correct Answer is Option D: Family history of Diabetic Kidney Disease is associated with renal involvement in Diabetes.

Explanation:

Familial studies have demonstrated clustering of diabetic nephropathy. Patients with DM with a first-degree relative with T1/T2DM and diabetic nephropathy have more risk for developing diabetic nephropathy than those without an affected relative. This familial clustering has also been well documented in the Pima Indian population. The candidate genes identified are glucose transporter 2(GLUT2), transforming growth factor beta (TGF- ?), and endothelial nitric oxide synthase (eNOS).

Option A: Diabetic nephropathy is a clinical syndrome characterized by the following:

· Persistent albuminuria (>300 mg/d) that is confirmed on at least 2 occasions 3-6 months apart

· Progressive decline in the glomerular filtration rate (GFR)

· Elevated arterial blood pressure

Hence kidney biopsy is not a mandatory investigation to diagnose diabetic kidney disease.

Option B: If the amount of urine albumin exceeds 30 mg/d and is less than 300 mg/d it is called microalbuminuria, and if it is greater than 300 mg/d it is called macro albuminuria or overt albuminuria. Microalbuminuria is present in 5-7% of normal individuals and is associated with cardiovascular mortality and morbidity. It is marker of endothelial dysfunction in type 2 diabetes mellitus. Presence of microalbuminuria alone with diabetes cannot be clinically diagnostic of diabetic kidney disease.

Option C: Micro hematuria has been demonstrated in biopsy studies with isolated diabetic nephropathy. Red blood cell casts have also been described in patients with diabetic nephropathy. However, it is important to rule out other glomerular and extra-glomerular causes of hematuria.