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?
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 08/06/2018
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?
You are rounding on your patients in the dialysis unit and seeing a 65-year-old gentleman with ESRD due to chronic interstitial disease. He also has a history of diet-controlled diabetes mellitus and hypertension. His other past medical history is significant for dyslipidemia, coronary artery disease, hypothyroidism, gout and depression. He has been hospitalized in the recent past for swelling and pain of his right great toe. He was seen by the foot doctor, a scan was done and eventually the great toe had to be amputated. He has been on hemodialysis 3 times a week. His weekly Kt/V is 1.9. You are conducting the monthly blood work review for this patient. You note that his hemoglobin has been persistently low for past few monthly blood draws. He is currently on 100 mcg of Darbepoetin weekly on dialysis. On enquiry there is no history of blood loss in the form of hematemesis, melena, hematochezia or hemoptysis. His active medication list includes Losartan, Atorvastatin, Calcitriol, multivitamin supplements, paroxetine, allopurinol, aspirin.
His pertinent blood work is as follows:
Test
Result
WBC
4500 cells /cumm
Hemoglobin
8.2 g/dL
Platelet count
450 thousand /cumm
Reticulocyte count
Normal
Iron
55 (range 50-150)
Total iron binding capacity
250 g/dl (range 250-310)
Transferrin saturation
20%
Ferritin
1400 ng/ml (range 20-235)
Haptoglobin
400 mg/dl (range 83-267)
Lactate dehydrogenase
240 U/L (range 80-225)
Total bilirubin
1.0 mg/dl
Folate
7 ng/ml (range 1.8-9.0)
B12
500 pg/ml (range 200-800)
Peripheral blood smear.
Normal RBC morphology, few burr cells.
Which of the following is true about this patient’s anemia?
Correct Answer: Option C: This patient has chronically inflamed state which is contributing to his anemia.
Explanation:
10-15% of patients who have been receiving erythrocyte estimating agents (ESA) develop resistance. There are multiple reasons why ESRD patients develop resistance.
ESA resistance occurs due to the following reasons:
Iron deficiency.
Chronic inflammation.
Under-dialysis.
Hemolysis.
Folate and B12 deficiency.
Chronic blood loss.
Anti EPO antibodies.
Pure red cell aplasia.
Failed chronic renal allograft.
ACEI/ARB.
Aluminum overload.
Hyperparathyroidism.
Hematological disorders or malignancy.
Option A: Incorrect option. ESRD is associated with erythropoietin deficiency. Patient has been initiated on ESA already. There is no point in measuring EPO levels. There is no evidence of measuring EPO levels in management of anemia in CKD.
Option B: Incorrect option. ESRD is an inflamed state. In inflammatory milieu there is increased production of Hepcidin. The hepatic iron-regulatory hormone Hepcidin and its receptor, the cellular iron exporter Ferroportin, constitute a feedback-regulated mechanism that maintains adequate plasma concentrations of iron-transferrin for erythropoiesis and other functions, ensures sufficient iron stores, and avoids iron toxicity. In chronic kidney disease, inflammation and impaired renal clearance increases plasma hepcidin, inhibiting duodenal iron absorption and sequestering iron in macrophages. These effects of hepcidin can cause systemic iron deficiency, decreased availability of iron for erythropoiesis, and resistance to endogenous and exogenous erythropoietin.
Choice C: Correct option. Refer explanation for option B. He had pain, swelling of his right great toe, a foot doctor sees him, a bone scan is done and subsequently the amputation. All suggestive of an infective etiology probably osteomyelitis.There is a temporal relationship between patients’ anemia and underlying chronic inflammatory state.
The high ferritin is also suggestive of inflamed state.
Choice D: Incorrect option. Pure red cell aplasia, a form of severe ESA hypo-responsiveness mediated by anti-erythropoietin antibodies, was first reported with certain formulations of Epoetin alfa but has now been reported with all commercially available forms of ESA. This syndrome presents with rapid onset of severe anemia (hemoglobin <7 g/dl), severe reticulocytopenia (reticulocyte count <10,000/?l) and marked elevations in serum ferritin level (>1000 ng/ml) and transferrin saturation (>70%) resulting from low iron utilization. Pure red cell aplasia is unlikely given the absence of characteristic laboratory findings. Moreover, the patient did not receive Epoetin alfa.
Choice E: Incorrect option. Under-dialysis leads to anemia due the same mechanism mentioned earlier in option B. Under-dialysis worsens the uremic milieu which in turn leads to inflammatory state. This leads to anemia. Patient in this clinical vignette has been dialysed appropriately. His weekly Kt/V is 1.9, which is above the target goal of 1.7
Copyright © ABIM Exam World Created On: 10/22/2018 Last Modified: 04/17/2021
All of the following are helpful in predicting AV Graft stenosis EXCEPT:
Copyright © ABIM Exam World Created On: 09/23/2020 Last Modified: 01/28/2021
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
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?
Copyright © ABIM Exam World Created On: 09/14/2017 Last Modified: 08/06/2018
A 30 year-old man comes to your office for a painful rash on the neck. He has fever and malaise. He has history of HIV. He is currently taking Tenofovir, emtricitabine, and indinavir. The rash is suggestive of Herpes Zoster rash :
Physical examination does not reveal any oral cavity lesions. His current CD4 count is 250/mm3. His chemistry is normal. He is started on an intravenous medication for his rash. Two days later his chemistry is as follows:
Na 135 mEq/L
K 4.5 mEq/L
CL 100 mEq/L
HCO3 24 mEq/L
BUN 21 mg/dL
Cr 2.0 mEq/L
Glucose 95 mg/dL
Calcium 9.4 mg/dl
Urinalysis shows needle-shaped crystals in the sediment.
Which of the following is most likely the cause of his renal problem?
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 08/29/2018
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
Protein 100 mg/24 h
Red Blood Cells None
White Blood Cells None
Nitrites Negative
Chemistry:
BUN 13.5 mg/dL
Creatinine 0.9 mg/dL
Potassium 5.8 mEq/L
Bicarbonate 18.5 mEq/L
Chloride 112 mEq/l
Aldosterone 5 ng/mL
PRA <1.0ng/dl/hr
HbA1C 5.30%
S. Osmolality 282 mOsmol
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?
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 01/25/2021
As per the JNC VIII committee recommendation, for individuals that are part of the African American population, including those with diabetes, the initial treatment should include a thiazide type diuretic or calcium channel blocker (CCB).
Which of the following thiazide type diuretic is preferred as the initial antihypertensive therapy?
Copyright © ABIM Exam World Created On: 09/20/2017 Last Modified: 01/28/2021
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 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 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
Na 140 mEq/L
K 2.2 mEq/L
Cl 103 mEq/
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?
Copyright © ABIM Exam World Created On: 09/12/2017 Last Modified: 12/30/2017
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
14.2 gm/L
WBC count
6.8 X 103/cubic mm
241 X 103/cubic mm
Segmented Neutrophils
Lymphocytes
Monocytes
Band neutrophils
Eosinophils
Basophils
60%
36%
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?
The Correct Answer is Option D : eGFR equations like MDRD equation can be used predict hyper filtration.
Supra physiologic elevation in GFR is observed early in the natural history of type 1 and type 2 diabetes mellitus which is due to glomerular hyper filtration Pathogenesis of hyper filtration in diabetes is complex with a prominent role for hyperglycemia and distorted insulin levels especially in early diabetes and pre-diabetes. Dilatation of the afferent (pre-capillary) glomerular arteriole plays an important role in the hyper filtration response, by raising both the intra-glomerular pressure and renal blood flow.
Direct measurement of GFR is usually required to detect hyperfiltration because estimation equations, such as the Modification of Diet in Renal Disease (MDRD) usually underestimate the true GFR when it is normal or above normal.
Option A : A definite cut off of GFR is lacking. However, renal hyper filtration is typically defined as a GFR of between 120 mL/min and 150 mL/min/1.73m2, or greater than 2 standard deviations above the mean GFR in normal, healthy individuals.
Option B: Hyper filtration in diabetes precedes the onset of albuminuria and/or decline in renal function, and predisposes to progressive nephron damage by increasing glomerular hydraulic pressure
Option C : Hyper filtration per se does not seem to fully explain adverse renal outcome, as the risk for ESRD in transplant donors is very low. However, in type 1 diabetes Rapid GFR decline is associated with renal hyper filtration and impaired GFR and may predict progressive DKD prior to loss of renal function.
Copyright © ABIM Exam World Created On: 10/30/2018 Last Modified: 10/23/2020
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:
K 5.0 mEq/L
CL 105 mEq/L
BUN 19 mg/dL
Cr 1.3 mg/dL
HCO3 8 mEq/L
pH 7.3
pO2 90 mmHg
pCO2 22 mmHg
Measured serum osmolarity 320 mmol/L
What is the next step in management?
Copyright © ABIM Exam World Created On: 09/13/2017 Last Modified: 12/30/2017
Which of the following antihypertensive medications resulted in better blood pressure control and cardiovascular outcomes when combined with an ACE inhibitor?
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