A 20 year-old-male was at a party where after dancing he ate a lot of cake because it was “delicious”. After 2-3 hours he developed sudden onset of weakness in all 4 limbs. He has had two similar episodes in the past. He was rushed to the nearest ER. On examination: P: 88/min, BP: 140/96 mm Hg, Pallor+, No thyroid enlargement. He is alert and oriented. There is no cranial nerve involvement and no neck muscle weakness. Motor power is grade 2-3 in all extremities, reflexes sluggish to absent. Sensory exam is normal. Laboratory results reveal the following:

pH   7.4

pCO2    40 mm Hg

paO2  98 mm Hg

HCO3  24 mEq/L

O2 saturation  98%

Na  140 mEq/L

K   2.2 mEq/L

Cl   103 mEq/

BUN  10 mg/dl

S.Cr  0.8 mg%

S. Ca  10.2 mg/dl

PO4  2.5 mg/dl

Mg   2.2 mg/dl

Urine Electrolytes

Urine Na  100 mEq/L

Urine K  15 mEq/L

Which of the following is the MOST likely diagnosis?

A 19-year-old woman, African American descent, comes to clinic for follow up visit. She has been found to have type 1 diabetes mellitus since the age of 12 years of age. She has been using insulin pump for the last 5 years. She reports no hypoglycemic symptoms and has been monitoring blood sugar using flash glucose monitor. She reports infrequent hypoglycemic episodes all being self-managed. She met with an ophthalmologist for eye screening and has no retinopathy. She exercises regularly for 30 mins. Her vitals recording shows BP of 127/66 mmHg. Her BMI is 22.2.  Systemic  examination is unremarkable. 

Her laboratory investigation is as follows.

Characteristic	value
Hemoglobin	13.2 gm/L
WBC count	7.8 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	136 mEq/L
Sr. Potassium	4.2 mEq/L
Sr. Creatinine	0.6 mg/dL
eGFR using CKD-EPI	153.1 ml/min/1.73m2
Sr. Bicarbonate	24 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	8.2%
Sr. Calcium	10 mg/dL
Urine dipstick	pH- 5.4 Albumin-nil  no blood  no WBCs
24-hour urinary protein	86 milligrams/day

 

What is the MOST LIKELY False statement regarding renal hyper filtration stage of Diabetic Kidney Disease in this patient?

A 15 year-old boy is brought to the ER by his foster mother who states that when she got home from work she noticed he was acting very strange. He had slurred speech and seemed confused. He appeared to be very uncoordinated and she was not sure if he fell or hit his head. She states that he is somewhat a troubled boy but doesn’t know much about his history as he has been in and out of the foster care system out of state. On physical exam, he is tachycardic and has tachypnoea. Pupils are dilated, but there is no nystagmus. A fundoscopic exam shows hyperemia of the optic disk. He is relatively uncooperative but not aggressive or hostile. When asked about suicidal thoughts he responds only with inaudible mumbling. His foster mother left for work 10 hours prior and assumed he left for school. She is not sure when these symptoms began or what may have initiated them. P is 105/ min, BP is 140/90 mm Hg, RR is 28/min, and T is 97.1 F. Laboratory examination is as follows: 

Na   135 mEq/L                                            

K   5.0 mEq/L

CL   105 mEq/L

BUN  19 mg/dL

Cr   1.3 mg/dL         

HCO3  8 mEq/L  

Glucose  100 mg/dL         

pH   7.3          

pO2   90 mmHg

pCO2  22 mmHg

Measured serum osmolarity  320 mmol/L

What is the next step in management?

Which of the following antihypertensive medications resulted in better blood pressure control and cardiovascular outcomes when combined with an ACE inhibitor?

A 60 year-old with recently diagnosed colon cancer and diabetes presents with bilateral pedal edema, BP is 120/80 mm Hg, Urinalysis showed  4+ protein, no RBCs or WBCs, and 8-10 Hyaline casts. His BUN is 20, Creatinine is 1 mg/dL, and albumin is 2 grams/dL. 24 hour urine collection showed 10 grams protein. The patient undergoes kidney biopsy. The EM is shown below :

What is the most likely diagnosis?

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?

50-year-old female patient whos group B is being evaluated for kidney transplant surgery. She had ESRD secondary to analgesic nephropathy and is on hemodialysis for last 5 years. She has had multiple sensitization events in the form of 3 pregnancies and several blood transfusions. Her current calculated PRA against class I antigen is 97% and against class II antigen is 99%. She has been enrolled in the national highly sensitized recipient program.

Her husband who is blood group matched came forward as a potential kidney donor but she had positive Flow B and T Cell Cross match against him. Single antigen bead assay demonstrated that she has donor specific antibodies against class II across DQB*15 and DPB*14. This transplant did not materialize as patient declined desensitization protocol. Now her younger brother comes forward as a potential donor. He is blood group A and the flow B and T cell cross match is negative with no demonstrable donor specific antibodies against this donor.Patient wants to know more about ABO incompatible transplant.

Which of the following statements about the ABO incompatible transplant is correct?

A 36 year-old female was diagnosed as having membranous nephropathy secondary to SLE. Her 24 hour protein excretion was 7.5 gms/day. Her serum creatinine was 0.9mg/dl. She was started on 500 mg of cyclophosphamide IV every 15 days (Euro-Lupus) and prednisolone 1 mg/kg orally per day. After 3 months of therapy, she presented with decreased urine output, puffiness of face, and oedema feet. On physical examination, her temperature is 37 C, blood pressure is 160/100 mm Hg, pulse is 90/min, and respiration rate is 20/min. She is anemic and there is puffiness of the face and oedema of the feet. On systemic examination air entry was decreased in the bases of both the lung fields and heart sounds are distant and feeble. Chest X-Ray reveals bilateral pleural effusions. Echocardiogram reveals mild to moderate pericardial effusion. Laboratory examination is as follows: 

Hemoglobin   10.0 g/dL

Hematocrit   34%

Platelet Count   150,000 mm3

WBC    8,000 mm3

Differential count P  80% L 12% E 6% M 2%

ESR    50.8 mm/h

Urinalysis: 

Protein  1450 mg/24 h

Glucose  None

RBCs  70-80/HPF dysmorphic

WBCs  5-8/HPF

Leukocyte Esterase Negative

Nitrites  Negative

 BUN   35 mg/dL

Creatinine  3.9 mg/dL

Sodium   140 mEq/L

Potassium  5.2 mEq/L

Bicarbonate  15.5 mEq/L

Calcium   9.2 mEq/L

Phosphorus  5.6 mg/dL

Glucose   100 mg/dL

Uric Acid   5.3 mg/dL

C3 & C4 decreased 

ANA   positive

dsDNA   positive

Repeat biopsy shows:

Which of the following is the most appropriate therapy for her current condition?

You are the nephrologist on call. The  ER calls you for an 18 year-old female who complaining of vomiting and diarrhea. Her serum sodium is 116 mEq/L and Serum potassium is 5.9 mEq/L. On physical examination the patient is drowsy, Pulse is 126/min, BP is 90/60 mm of Hg, and RR is  32/min. Her chest is clear. Her heart sounds are normal, and no murmur is visible. The patient is drowsy but arousable and there was no focal neurological deficit. Laboratory findings are as follows:

Hb    16 gm/dl 

WBC   12,800/cmm 

Polymorph  46% 

Lymphocytes  16% 

Eosinophils  4%

Monocytes  4%

Platelets   2,40,000/cmm.

CL    70 mEq/L

BUN  10 mg/dl

Creatinine  0.5 mg/dl

Na    116 mEq/L

K    5.8 mEq/L

Urinalysis:

pH    6.4

Protein  trace

Glucose  absent

microscopic occasional WBCs & RBCs

Urinary Na  90 mEq/L

Urinary K         20 mEq/L

ABG    

PH                   7.32

PCO2   36 

HCO3   20 mEq/L

PaO2   92

O2 saturation  98%

S. Cortisol  6.00 mg/dl

TSH   3.5 IU/m (Normal 0-5 IU/m ).

Both plasma Renin and Aldosterone are high. 

Which of the following conditions is most likely with these findings?

Cyclosporine nephrotoxicity in a renal transplant recipient is associated with all the below renal biopsy findings EXCEPT:

(THIS PICTURE BELOW IN LOW POWER SHOWS ONE OF THE CLASSICAL FINDINGS IN CSA TOXICITY)

The ACCOMPLISH trial is the first major trial addressing the issue of combination therapy in 11,506 patients who were at high cardiovascular risk. The goal blood pressure was less than 130/80 mm Hg in the patients with diabetes or impaired renal function, and less than 140/90 mm Hg in the patients with prior cardiovascular disease.

Which of the following combinations of blood pressure medications was the best in reducing cardiovascular events and slowing the progression of nephropathy in patients with hypertension who were at high risk for such events?

A 28-year-old gentleman, Caucasian descent, comes to clinic for follow up visit. He has been found to have type 1 diabetes mellitus since the age of 12 years of age. His cousin brother has the same disease. He reports no symptoms. He has been using insulin pump using insulin Aspart. He has been monitoring blood sugar using flash glucose monitor and uses carbohydrate count for boluses. He reports infrequent hypoglycemic episodes particularly 2 hours into post lunch, but, manages by himself. He exercises at least at least 60 minutes per day. His vitals recording shows BP of 118/66 mmHg. His BMI is 23.2.  System examination is unremarkable.

His laboratory investigation is reported as follows.

Characteristic	Value
Hemoglobin	14.2 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	4.4 mEq/L
Sr Creatinine	0.6 mg/dL
eGFR using CKD-EPI	136.8 ml/min/1.73m2
Sr Bicarbonate	24 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	7.9%
Sr Calcium	10 mg/dL
Urine dipstick	pH- 5.4 Albumin-nil  no blood  no WBCs
24-hour urinary protein	76 milligrams/day

What is the MOST LIKELY incorrect statement regarding hyperfiltration stage of Diabetic Kidney Disease in this patient?

A 56 year-old male was brought to the emergency room with drowsiness and lethargy. He has been experiencing these for the last 2 days. He complains of a recent history of anorexia, nausea, and vomiting, He has diabetes mellitus and is on glimepiride 1 mg daily for the last 4 years. One week ago he had decreased vision with redness in his right eye. He was treated by his ophthalmologist with drops which seem to have resolved the problem. He currently takes cholecalciferol weekly for osteoporosis. On physical examination his pulse is 80/min, blood pressure is 140/90 mm Hg, respiratory rate is 20/min, and temperature is 97.7 F. The patient appears drowsy but shows no focal neurological deficits. Review of systems is otherwise unremarkable. Urinalysis is positive for glucose and negative for proteinuria, WBCs and RBC casts. A 24 hour urinary protein collection is significant for proteinuria of 3.5 g/day. Further labs reveal:

Hemoglobin  8 gm%

Hct    24%

MCV   85

WBC   7800/ml

PMN   80%

Lymphocytes  20%

ESR   80 mm/hr

Na    145 mEq/L

BUN   80 mg/dL

Cr    1.8 mg/dL

CL    115 mEq/L

HCO3   25 mEq/L

Uric acid   5.8 mg/dL

Ca    14 mg/dl

PO4    2.8 mg/dL

Total Protein  7.8 gm/dL

Albumin   3.5 mg/dL.

Vitamin D  40 ng/ml

PTH   10 pg/ml

Which of the following is most likely the cause of his hypercalcemia?

A 32 year-old male is brought to renal clinic with history of hematuria, oedema feet, and puffiness of face. He gives a history of fever and sore throat a week ago. He also complains of breathlessness on exertion and oliguria. Physical examination shows: Pulse 100/min, BP 150/100 mm Hg, and Temp. 37.4 C. He is pale. He has puffiness of face and oedema feet. Systemic examination-unremarkable. Laboratory examination is as follows:

Hb   10.5 g/d

Hct   34%

Platelet 250,000 mm3

WBC  8,000 mm3

Differential count P 80% L 12% E 6% M 2%

ESR  9.8 mm/h

Urinalysis:

Protein   3000 mg/24 h

Glucose   None

RBC   50-60/hpf Dysmorphic

WBC   occasional

Leukocyte Esterase Negative

Nitrites   Negati

BUN   40 mg/dL

Creatinine  3.9 mg/dL

Sodium   140 mEq/L

Potassium  4.2 mEq/L

Bicarbonate  25.5 mEq/L

S. protein  5.5 g/dl

S. Albumin  2.5 g/dl

Calcium   9.2 mEq/L

Phosphorus  3.2 mg/dL

Glucose   100 mg/dL

Uric Acid   5.3 mg/dL

C 3    Low

C4     normal

HBsAg /HIV   Neg

ANA    Neg

Kidney Biopsy: Shows enlarged Glomeruli, lobular accentuation, mesangial hypercellularity, endo-capillary proliferation and double contour along the capillary wall. IF shows bright C3 in mesangium and capillary wall with absent immunoglobulin staining. 

Electron Microscopy: Suggestive of dense deposits.

What is the BEST treatment option for this patient?

A 68 year-old African American male with known history of diabetes mellitus,  hyperlipidemia, CVD, and GERD presents to the ER with chest pain and shortness of breath. Patient says the pain is a crushing pain and radiating to his left arm. It woke him from sleep 30 minutes ago. He took his antacids and 4 tablets of nitroglycerin, and the pain got better. His current medications include low dose aspirin, metoprolol, glyburide, pioglitazone, lisinopril, simvastatin, and omeprazole. He recently suffered an upper respiratory infection for which he was given Levofloxacin. Vitals show: BP 160/95 mm Hg, T 98.1, and HR 110. He has no edema legs and no jugular venous distention. EKG shows LVH by voltage criteria with isoelectric ST segment. Serial troponin levels are normal. A stress test showed evidence of stress inducible ischemia in the anterior leads. He is scheduled for cardiac catheterization the next day. Laboratory results are as follows:

Serum Chemistry:

Na   143 mEq/L

K   3.5 mEq/L

Cl   101 mEq/L

HCO3  22 mEq/L

BUN   35 mg/dL

Cr   3.0 mg/dL

Glucose  110 mg/dL 

What would you do to PROTECT the kidneys before doing the cardiac catheterization?

A 25 year-old female is referred by her primary care provider for evaluation of hypertension and hypokalemia. The primary care provider has already started her on oral potassium, despite therapy her Potassium being 2.8 meq/L. Her blood pressure despite treatment with amlodipine and Lisinopril 154/96 mm of Hg. There is no renal bruit. Systemic and fundus examinations are normal. Her mother was also diagnosed with hypertension at an early age. Her brother died of a cerebrovascular accident 2 years ago. Laboratory findings are as follows:

Na   140 

Potassium 2.8 

Chloride   100 

HCO3    26

BUN   15 

Creatinine  0.8 

Glucose    110

TSH and Cortisol are normal

ACTH    elevated

Renin   0.7 (Low)

Aldosterone  48 (elevated)

Urinalysis:

Sodium   240 mEq/D

Potassium  98 mEq/D

Urinary 18-OH Cortisol and 18-oxocortisol are elevated.

The most appropriate treatment for this patient is:

A 35 year-old Caucasian male presents with persistent swelling of both legs associated with dark colored urine for two months. He went to an emergency room 2 months ago for these complaints and was told that he has some protein and blood in the urine. He was treated with 3 days of levofloxacin. There is no other past medical history. No history of skin rash or joint swelling. On examination the blood pressure was 130/85 mm Hg and there was bilateral 1+ pedal edema. Rest of the physical examination was normal. Urine analysis showed 3+ proteinuria, 10-15 RBCs per high-power field, and occasional RBC cast. The BUN was 10 mg/dL, serum creatinine was 0.9 mg/dL. Antistreptolysin was negative, C3 level is decreased and C4 level is normal. Antinuclear antibodies, ANCA, hepatitis B and C serology were negative. 24-hour urine collection showed 2 g proteinuria and a kidney biopsy was performed. On light microscopy, kidney biopsy showed increase in the mesangial matrix and cellularity and glomerular basement membrane appeared irregularly thickened. Silver stain revealed duplication of glomerular basement membrane in multiple glomeruli. Immunofluorescence showed positive staining for C3, but negative for IgG, IgM and IgA. Electron microscopy revealed electron-dense deposits in the mesangium and sub-endothelial area. 

What is the most likely diagnosis?

An 18 year-old male is brought to the renal clinic for evaluation of hypertension. There is no history of edema of the feet, puffiness of the face, hematuria, oliguria ,or recurrent urinary tract infections. He is an active football player, but lately he complains of weakness and muscle cramps. His blood pressure for the last 3-4 years has always been borderline high and during this visit was as noted below.

Physical examination shows: Pulse 100/min, all peripheral pulsations are well felt. BP 150/100 mm Hg, Temp. 37.4 degrees C. He is pale. His growth is stunted. His cognitive function is normal and no focal neurological deficits are noted. Other systems are unremarkable. Laboratory examination is as follows:

Hemoglobin   13.5 g/dL

Hematocrit   42%

Platelet Count   150,000 mm3

White Blood Cells  8,000 mm3

Urinalysis: 

Protein     100 mg/24 h

Glucose       None

Red Blood Cells      None

White Blood Cells     None

Leukocyte Esterase   Negative

Nitrites     Negative

Chemistry: 

BUN   13.5 mg/dL

Creatinine  0.9 mg/dL

Sodium   140 mEq/L

Potassium  5.8 mEq/L

Bicarbonate  18.5 mEq/L

Chloride   112 mEq/l

Calcium   9.2 mEq/L

Phosphorus  3.2 mg/dL

Aldosterone  5 ng/mL

PRA    <1.0ng/dl/hr

Glucose   100 mg/dL

HbA1C    5.30%

S. Osmolality   282 mOsmol

Uric Acid   5.3 mg/dL

ESR    9.8 mm/h

ABG: 

pH   7.25

PCO2  32 mm Hg

HCO3 16 mEq/L

PO2   90 mm Hg

USG  Normal size kidneys, no hydronephrosis 

Considering the history and the laboratory findings, which of the following is most likely the cause of hypertension in this patient?

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

A 25 year-old male comes to the physician complaining of flank pain and hematuria.  He says the pain is constant and dull. There is no frequency, urgency or dysuria.  He has a history of mental retardation and seizures. On physical exam his blood pressure is 140/90 mm Hg, and his pulse is 80 bpm. He has multiple yellow papules across his nose and cheeks and numerous areas of blanched skin spots on his face. A 2-3 cm hypopigmented macule is noted on the right arm. CT scan of the head was done as patient presented with seizures. CT head was reported normal. CT scan of the abdomen shows bilateral hypodense fat containing renal masses and cysts. 

What is the MOST likely diagnosis associated with these findings?

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 ?