Final renal quiz

A 55-year old man is admitted to hospital with hepatic failure and hyperammonemia. He is administered an agent which will decrease his gut flora and thus decrease his ammonia load. Which of the following was most likely administered?

Lactulose

An 18-year-old male consumes a relatively large quantity of lemon juice with a fatty meal. He experiences severe discomfort which results in presentation to the urgent care clinic, where vomiting is induced. Prior to that treatment, however, considerable acid absorption had already occurred within his intestinal tract. Which cells in his nephrons will specifically excrete some of this excess acid into the tubular lumen in order to eliminate it from his body?

Late distal tubule intercalated cells

A 44-year-old man has been experiencing hematuria, nausea, fatigue and flank pain. Upon physical examination he is found to have a varicocele and diagnosed with nutcracker syndrome. Which of the following vessels is being compressed causing this condition?

Left renal vein

A 50-year-old woman with a 6-year-history of chronic hepatitis B presents with a 1-day history of right flank pain and bloody urine. Over the past 2 weeks, she has also developed progressive lower extremity swelling and unintentional weight gain. On physical examination, she has periorbital, pretibial and pedal edema. The abdominal CT scan shows a large right kidney with abundant collateral vessels, and a filling defect in the right renal vein. Urinalysis shows 4+ protein and fatty casts. Which of the following is the most likely underlying cause of this patient's renal vein findings?

Loss of antithrombin III

A previously healthy 36-year-old woman presents with severe, right-sided, colicky flank pain that radiates to the groin. She drinks 2-3 energy drinks daily. An x-ray of the abdomen shows a 4-mm radiopaque mass in the right ureter. Microscopic examination of the urine shows envelope-shaped crystals. Which of the following is most likely to prevent future episodes of flank pain?

Maintain adequate hydration

A 60-year-old diabetic woman with a long history of non-compliance with her insulin treatment, is admitted to the hospital and you receive the following lab data: pH 7.26, PaCO2 34 mmHg, HCO3- = 17 mmHg. What is the most likely primary acid-base disorder?

Metabolic acidosis

Which of the following adverse effects of a drug that alkalinizes the urin, is likely to occur in this patient?

Metabolic acidosis

A 36-year-old business executive, non-smoker, presents with persistent vomiting, nausea, and weakness for 3-4 weeks. He has been diagnosed with peptic ulcer disease in the past and has been on a variety of histamine receptor 2 blockers, antacids, and anti-reflux medications for several years. Upon examination, he is ill-looking and pale. His vitals are as follows BP 110/70 mmHg, PR 110/min, RR 24/min. There is diffuse abdominal tenderness, but no other abnormalities. Laboratory tests reveal: Na 130 mEq/L, K 2.4 mEq/L, Cl 88 mEq/L, HCO3- 36 mEq/L, BUN 23 mg/dL, creatinine 1.6 mg/dL, pH 7.48, PaCO2 50 mmHg, PaO2 95 mmHg; Hb 13.6 g/dL, WBC 12 600/mm3, ESR 10 mm in 1h. What is the acid-base disorder that most likely explains this presentation?

Metabolic alkalosis with compensatory respiratory acidosis

A 56-year-old man presents with fatigue and progressively worsening swelling of his ankles. He reports a weight gain of 4 kg over the past 4 months. His blood pressure is 140/90 mmHg, and he has 2+ pitting edema in the lower extremities. Neurologic examination shows diminished two-point discrimination in the fingers and toes. Laboratory studies show a hemoglobin A1c concentration of 7.9% and a serum creatinine concentration of 1.9 mg/dL. A urine sample is noted to be foamy. A biopsy specimen of the kidney is most likely to show which of the following?

Nodular glomerulosclerosis

A 6-year-old boy presents with facial swelling for 5 days. He had a sore throat two weeks ago, which resolved spontaneously. His vitals are normal. Examination shows periorbital edema and pitting edema of the upper and lower extremities. The abdomen is mildly distended. Laboratory studies show: Serum Albumin 2.1 g/dL Total cholesterol 290 mg/dL Triglycerides 210 mg/dL Urinalysis Blood negative Glucose negative Protein 4+ Leukocyte esterase negative A renal biopsy of this patient is most likely to show which of the following findings?

Normal light microscopy findings

.A 57-year-old man comes to the physician with a 3-month history of right flank pain. Urinalysis shows 60 RBC/hpf. Renal ultrasound shows a 3 cm, well-defined mass in the upper pole of the right kidney. A photomicrograph of a section of the resected mass is shown. Which of the following is the most likely diagnosis?

Oncocytoma

A 70-year-old man comes to the physician because of several episodes of dark urine over the past 2 months. He has had a 6 kg unintentional weight loss over the past 3 months. He has smoked a pack of cigarettes daily for 30 years. A CT scan shows a heterogeneous enhancing mass arising from the left renal pelvis. Pathologic examination of the lesion is most likely to show which of the following findings?

Pedunculated tumor comprised of pleomorphic urothelial cells with severe nuclear atypia

Which congenital condition is related to a failure of the developing kidney to migrate from its initial location?

Pelvic kidney

A 33-year-old female has been experiencing dysuria, a frequent urge to urinate, cloudy urine with a strong odor and pain in her hypogastric abdominal region. She is diagnosed with a lower urinary tract infection. What nerve carries the visceral sensory fibers back to her central nervous system from the affected organ?

Pelvic splanchnic

A 1-year-old boy presents with swelling around the eyelids for 2 weeks. He was born at term after an uncomplicated pregnancy and has been growing well. His blood pressure is 132/84 mm Hg. Physical examination shows an empty scrotal sac and a left-sided abdominal mass. Ophthalmologic examination shows no abnormalities. Urinalysis shows proteinuria of 4+, Maltese-shaped crystals and fatty casts. Abdominal ultrasound shows a hyper-vascular mass at the upper pole of the left kidney. Which of the following best describes the pathogenesis of this patient's disease?

Point mutation of the WT1 gene

A 55-year-old man with end stage renal disease undergoes allogeneic kidney transplantation. One hour after surgery his serum creatinine is 1.4 mg/dL and 2 hours after surgery it is 2.4 mg/dL. Ultrasound of the donor kidney shows diffuse tissue edema. At this point, dialysis is initiated. Which of the following is the most likely cause of this patient's symptoms?

Preformed antibodies against class I HLA molecules

A 12-year-old boy presents with a 3-month history of progressive fatigue, urinary frequency and difficulty concentrating at school. Laboratory studies show: Serum Na 130 K 2.5 Phosphorus 1.8 Albumin 2.0 Bicarbonate 17 Urine Na Increased Bicarbonate Increased Glucose Positive Altered function of which of the following structures is the most likely cause of this patient's abnormal laboratory studies?

Proximal convoluted tubule

A 30-year-old woman is brought to the emergency department because of severe headache and vomiting that started after she was hiking in the mountains at high altitude. She normally lives in a city that is close to sea level. Therapy is initiated with a drug that alkalinizes the urine. Which of the following is the most likely site of action of this drug in the kidney?

Proximal convoluted tubule

A 75-year-old man with HTN presents with left knee pain for the past 8 hours. He does not remember any trauma to the right knee. His HTN is well-controlled on a diuretic. On physical examination, the skin above his left knee is erythematous and the joint tender to palpation and on passive movement. Analysis of the synovial fluid under polarized light microscopy shows negatively birefringent needle-shaped crystals. Which of the following parts of the nephron is the site of action of the patient's diuretic?

Proximal convoluted tubule

An 80 y-o woman with HTN and CAD presents with hearing loss 5 days after a hospital admission for congestive cardiac failure. During the admission she was treated with an intravenous diuretic. What is the site of action of the diuretic this patient most likely received during her admission?

Proximal convoluted tubule

A 75-year-old man comes to the physician because of abdominal pain and nausea over the past 2 weeks and a 1-month history of pain in his knees and hips. He has smoked one pack of cigarettes daily for 30 years. Physical examination shows decreased muscle strength. Laboratory studies are shown: Ultrasonography of his abdomen shows a 6-cm mass in his right kidney. Nephrectomy is performed. A photograph of the resected specimen is shown. The patient's tumor most likely originated from which of the following locations?

Proximal convoluted tubules

A 24-year-old patient presents at her obstetrician's office for her first prenatal visit. She has no medical history and has had an uncomplicated pregnancy. Her examination is normal other than glycosuria noted on the urine dipstick. The obstetrician diagnoses the glycosuria as a normal physiologic response to the increased glomerular filtration rate (GFR) of pregnancy. Where in the renal glomerulus-tubule structure is glucose reabsorbed via secondary active transport?

Proximal tubule

At a 20-week screening ultrasound of a 31-year-old G1P0 woman, the technician finds bilateral renal aplasia. While discussing the findings with the expectant parents, the physician notes that this condition leads to which of the following?

Pulmonary hypoplasia

A 40-year-old man with a history of total thyroidectomy for papillary thyroid cancer six days ago presents with nausea, abdominal discomfort, diarrhea, and progressive numbness around the mouth for the past 24 hours. His only medication is a multivitamin supplement. He appears fatigued. The vitals are normal. While measuring the patient's blood pressure, a spasm in the patient's hand is noted. Neck examination shows a well-healing surgical wound. Which of the following ECG findings are most likely in this patient?

QT prolongation

A 4700-g male newborn is delivered at term to a 30-year-old, G2P1 mother. Apgar scores are 7 at 1 min and 8 at 5 min. He appears pale. Temperature is 37°C, pulse is 170/min, and blood pressure is 90/60 mm Hg. Midfacial hypoplasia, infraorbital creases, and a large tongue are noted on examination. The right side of the body appears larger than the left. His abdominal organs protrude through the abdominal wall at the umbilicus and are covered by the amniotic membrane and the peritoneum. The liver is palpated 3 cm below the ribs. Serum glucose is 52 mg/dL. Ultrasonography of the abdomen shows enlarged kidneys bilaterally. In addition to surgical closure of the abdominal wall, which of the following is the most appropriate next step in management?

Regular abdominal ultrasound

Which of the following is most likely to decrease following treatment with a drug that alkalinizes the urine?

Renal ammonia excretion

A 63-year-old man presents with 4 episodes of red urine over the past week. He has also had recurrent headaches and intermittent blurry vision during the past month. He has benign prostatic hyperplasia. Current medications include tamsulosin. • He owns a convenience store at a gas station for 10 years. He has smoked one pack of cigarettes daily for the last 38 years. He does not drink alcohol. • The patient's BMI is 42 kg/m2. His temperature is 37.6°C, pulse is 86/min, and blood pressure is 156/96 mm Hg. Examination shows a flushed face. Cardiopulmonary and abdominal examination shows no abnormalities. Digital rectal examination shows an enlarged, smooth prostate. • His hemoglobin concentration is 18.5 g/dL

Renal cell carcinoma

A first-year medical student was anxious about her performance on the first biochemistry test. She felt numbness around her mouth and tingling in her hands and went to the clinic. A workup revealed: pH 7.48, PaCO2 36 mmHg, HCO3- 21 mEq/L. What is the primary acid-base disorder?

Respiratory alkalosis

What change is depicted by the blue square?

SIADH

A 68-year-old man with a 10-year history of hypertension managed with ramipril presents with fatigue and swelling of the lower legs for 3 weeks. He does not smoke or drink alcohol. His blood pressure is 155/95 mm Hg. Examination shows 2+ pretibial edema bilaterally. The remainder of the examination shows no abnormalities. Laboratory studies show: Serum Na+ 138 mEq/L Cl− 105 mEq/L K+ 5.0 mEq/L Urea nitrogen 60 mg/dL Glucose 100 mg/dL Creatinine 3.9 mg/dL Albumin 3.6 g/dL Hemoglobin A1C 6.5% Urine Blood negative Glucose negative Protein 1+ WBC 0-1/hpf Which of the following is the most likely pathology underlying this patient's presentation?

Sclerosis in the capillary tufts and arterial hyalinosis

A 40-year-old man on combined antiretroviral therapy for HIV presents with progressive swelling of his legs and unintentional weight loss over the past 3 months. He also reports frequent numbness of the tips of his fingers and cramping in his back and leg muscles. His temperature is 37.0°C (98.6°F), pulse rate is 80/min, and blood pressure 150/90 mm Hg. Physical examination shows 3+ periorbital and lower extremity edema bilaterally. Sensation to pinprick and light touch is decreased around the mouth and along the fingers. Laboratory studies show: Serum Albumin 2.5 g/dL Total cholesterol 270 mg/dL HIV antibody positive Urine Blood negative Protein +4 RBC 1-2/hpf RBC casts negative A kidney biopsy is most likely to show which of the following findings under light microscopy?

Segmental sclerosis

After 14 days of being immobilized in the intensive care unit following a motorcycle accident, a 28-year-old man develops increased urinary urgency, burning during urination, and lower abdominal pain. Urine culture reveals gram-negative rods, which yield red-pigmented colonies while growing on MacConkey agar. What is the most likely organism causing these symptoms?

Serratia marcescens

A 25-year-old Hispanic female presented to the emergency department (ED) with two weeks of waxing and waning right-sided flank pain. She described the pain as a cramping discomfort that worsened over the two weeks and was only mildly relieved by acetaminophen. She also reported urinary frequency and urgency without dysuria or hematuria. Physical examination was notable for right upper quadrant tenderness. Urinalysis showed nitrite negative, leukocyte esterase positive urine with 685 white blood cells per high power field, 53 red blood cells per high power field, and appreciable bacteria. Abdominal radiography and CT were carried out - the images of which are shown below. Which anomaly is shown on the images?

Staghorn calculus

A student in a clinical study had her normal diet changed to a diet high in potassium, but everything else remained normal. The student noted that she had gained nearly 3 lb. within a few days after starting the diet. Laboratory tests indicated a modest elevation in plasma K+. Interestingly, plasma levels of ADH and renin were depressed, consistent with volume expansion. What is the most likely reason for the hypervolemia?

Stimulation of aldosterone secretion by the high potassium diet leading to sodium and water retention

The kidneys receive sympathetic innervation from the least splanchnic nerves. Which of the following spinal cord segments contribute preganglionic sympathetic axons to these nerves?

T12

A 30-year-old Caucasian woman with recurrent episodes of joint pains presents with fatigue, lethargy, and swelling of the lower legs for 2 months. During the past year, she also had a rash on the face that was aggravated by exposure to sunlight. On physical examination, erythematous patches with scaling are noted on both cheeks, periorbital edema, as well as pitting pretibial and pedal edema. Laboratory studies show: Serum biochemistry BUN 36 mg/dL Creatinine 0.9 mg/dL Albumin 2.6 mg/dL Total cholesterol 295 mg/dL Triglycerides 215 mg/dL Urine Blood negative Glucose negative Protein 4+ WBC 0-1/hpf Fatty casts numerous A renal biopsy specimen is most likely to show which of the following?

Thickened capillary loops

A prospective cohort study planned to investigate the role of daily alcohol consumption in the etiology of renal cell carcinoma (RCC). The study results revealed a 5-year relative risk of RCC as 1.7 for people who consume alcohol daily compared to those who do not. Which of the following p-values is most consistent with the results described above?

0.03

A study of a new antihypertensive drug that affects glomerular filtration rate is being conducted. Infusion of drug X causes constriction of the efferent arteriole. After infusion of the drug, the following glomerular values are obtained from an experimental subject: hydrostatic pressure of the glomerular capillary (PGC) of 48 mm Hg, oncotic pressure of the glomerular capillary (πGC) of 23 mm Hg, hydrostatic pressure of Bowman's space (PBS) of 10 mm Hg, and oncotic pressure of Bowman's space (πBS) of 0 mm Hg. Which of the following best measures net filtration pressure in this participant?

15 mmHg

An investigator is studying the frequency of polycythemia in a population of a remote, mountainous region. A representative sample of 100 men shows a normal distribution of hemoglobin concentration with a mean concentration of 17 g/dL and a standard error of 0.1 g/dL. Which of the following best represents the probability that a subject will have a hemoglobin concentration greater than 18 g/dL?

15%

An investigator is studying the effect of antihypertensive drugs on cardiac output and renal blood flow. For comparison, an individual is given a continuous infusion of para-aminohippuric acid (PAH) to achieve a plasma concentration of 1 mg/ml. His urinary flow rate is 2 ml/min and the urinary concentration of PAH is measured to be 4 mg/ml. His hematocrit is 50%. Which of the following values best estimates renal blood flow (RBF) in this person?

16 ml/min

A 55-year-old alcoholic man with chronic kidney disease presents to his primary care provider, complaining of extensive hematuria (blood in urine). The physician tests his renal function, and the following measurements are obtained following the test: Plasma inulin concentration, 1 mg/mL. Urine inulin concentration, 40mg/mL. Urine flow rate: 0.5 mL/min Given the provided information, what is this patient's GFR?

20 ml/min

Ambitious to be chosen for the centrefold of a magazine, a body builder consumes 300 g of protein every day. Assuming he produces 2 L of urine per day, approximately how high is the concentration of urea in his urine?

5.0%

A 72-year-old woman undergoes an open repair of a ruptured abdominal aortic aneurysm, during which she receives 5 units of packed red blood cells. During the first 24 hours after the procedure her total urine output is 150 mL. She is afebrile, her pulse is 110/min, and blood pressure is 100/70 mm Hg. Serum studies show a creatinine concentration of 3.6 mg/dL (0.7 mg/dL on admission) and urea nitrogen concentration of 42 mg/dL (15 mg/dL on admission). Fractional excretion of filtered sodium (FeNa) 5%. Urinalysis is most likely to show which of the following sets of findings? Protein (mg/24 h) Casts A 100 Epithelial granular casts B 450 Red blood cell casts C 100 No casts D 100 White blood cell casts E 3500 Fatty casts F 450 Waxy casts

A

A 60-year-old man presents with a dull pain in the left portion of the midback for 2 weeks. He also has a 3-month history of fatigue and constipation. The pain persisted despite taking ibuprofen. The patient's father died of prostate cancer at 76 years of age. He has smoked one pack of cigarettes daily for 40 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses.

Abdominal CT scan

A 40-year-old man is hospitalized after a motor vehicle accident. He is noted to be hypotensive and is given a transfusion with packed red blood cells, after which he is transferred to ICU. On the second day from admission, the patient develops edema and oliguria. He is afebrile and his blood pressure is 130/80 mmHg. On physical examination, periorbital edema is noted. The remainder of the examination is normal. His BUN is 50 mg/dL, creatinine is 6 mg/dL, FENa is 4% and urinalysis shows numerous muddy brown epithelial and granular casts. What is the most likely cause of this presentation?

Acute tubular necrosis

A 55-year-old previously healthy woman presents with flank pain and reduced urine output. Two weeks ago, she had a lobar pneumonia that was treated with intravenous cefuroxime. Laboratory test results show eosinophilia, serum BUN of 30 mg/dL and serum creatinine of 3.0 mg/dL. Urine Na concentration is 50mEq/L and FENa is 3%. Eosinophils and eosinophil casts are noted on urinalysis. What is most likely cause of this patient's presentation?

Acute tubule-interstitial nephritis

A 50-year-old man presents with lethargy and confusion for the past 24 hours. For the past year has had a productive cough and has lost 6 Kg. For the past 30 years, he has smoked two packs of cigarettes daily. He drinks two beers every day after work. He appears lethargic and is not oriented to person, place, or time. His vitals are normal. Physical examination shows scattered wheezing bilaterally. Deep tendon reflexes cannot be elicited. Laboratory studies show:•An x-ray of the chest shows a central lung mass. Which of the following is the most appropriate next step in management?

Administer hypertonic saline

A 42-year-old man recovering from abdominal surgery is noted to have decreased urinary output. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure 3 hours ago. He is afebrile, his pulse rate is 98/min, and his blood pressure is 122/64 mmHg. There is a patent urinary catheter that flushes easily. Cardiopulmonary examination shows no abnormalities. His hemoglobin is 14.2 g/dL, BUN is 38 mg/dL, creatinine is 1.4 mg/dL and FENa is 0.9%. Which of the following is the most appropriate next step in management?

Administer intravenous fluids

As a physician-scientist, you are studying the characteristics of filtrate flow through nephron ultrastructure. In a stepwise fashion, which one of the following sequences of blood flow through the nephron ultrastructure would you observe?

Afferent arteriole, glomerular capillary, efferent arteriole, peritubular capillary, renal vein

A 32-year-old woman presents with a 2-day history of flank pain, myalgia, and "pink" urine for the past 2 days. The previous week she had an ear infection, for which she was prescribed Amoxicillin. She is otherwise healthy and is on no chronic medications. Her temperature is 37.6°C, her pulse is 70/min, and her blood pressure is 128/70 mm Hg. Examination of the mouth and pharynx shows no abnormalities. The abdomen is soft and there is no costovertebral angle tenderness. There is a faint maculopapular rash over the trunk and extremities. Serum creatinine is 2.4 mg/dL. Urinalysis shows: Protein 2+ Blood 2+ RBC 30/hpf WBC 20/hpf Bacteria none Which of the following is the most likely diagnosis?

Allergic interstitial nephritis

A 70-year-old woman complained to her physician of headache, nausea and vomiting, vertigo, tinnitus, and progressive loss of hearing. The woman had been receiving an antibiotic for 2 weeks to treat a urinary tract infection apparently due to Serratia marcescens. The drug used was most likely a member of which of the following antibiotic classes?

Aminoglycosides

A 46-year-old man presents with fatigue, thirst and increased urination for 5 months. At the previous visit 6 months ago, he had elevated blood pressure, but due to work commitments he did not return for follow up. He has a busy work schedule as an accountant and his diet consists primarily of fast food. He does not smoke or drink alcohol. His BMI is 34 kg/m2 and his blood pressure is 158/100 mmHg. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin A1c 8.1% Serum Glucose 280 mg/dL Creatinine 1.0 mg/dL Total cholesterol 270 mg/dL HDL cholesterol 50 mg/dL Triglycerides 180 mg/dL Urine Blood negative Glucose 2+ Protein 1+ Ketones negative Which of the following is the most appropriate next step in management?

Angiotensin-converting enzyme (ACE) inhibitor therapy

A 32-year-old woman has been vomiting to the point where he has become hypovolemic, as evidenced by an accompanying decrease in blood pressure and a feeling of light-headedness. The kidneys respond by reducing urinary volume flow, thus limiting the potential extent of hypovolemia. Increases in the plasma levels of which of the following hormones will bring about the MOST DRAMATIC DECREASE in urinary volume flow rate?

Anti-diuretic hormone (ADH)

A 50-year-old woman comes to the physician because of a 3-month history of a non-pruritic rash, fatigue, dark urine and decreased urination. Physical examination shows multiple erythematous, purpuric, non-blanching papules on trunk and extremities. Serum creatinine is 3.7 g/dL and serum complement levels are decreased. Urinalysis is positive for red blood cells, red blood cell casts and protein. Renal biopsy shows subendothelial immune complex deposits with granular immunofluorescence and tram-track basement membrane splitting. Further laboratory evaluation of this patient is most likely to show the presence of which of the following antibodies?

Anti-hepatitis C antibodies

A 68-year-old man comes to the physician for a follow-up examination. He has type 2 diabetes mellitus, hypertension, and chronic kidney disease. Medications include insulin, metoprolol, and atorvastatin. Physical examination shows pitting edema of both ankles. Serum creatinine concentration is 4.5 mg/dL. Parathyroid hormone (PTH) Vitamin D Calcium Phosphorus A Decreased increased increased increased B Increased decreased decreased increased C Increased decreased increased decreased D Increased decreased decreased decreased E Decreased decreased decreased increased

B

A 55-year-old woman presents to the emergency department with a 2-day history of increasing back pain and pain during urination. She states that was treated for a UTI 2 years ago; since she knew what the symptoms were, whenever she started to suspect she was having a UTI, she took cranberry capsules. Physical examination reveals pain over the lower left costovertebral angle. Physical examination is notable for a temperature of 38.8 C. Urinalysis is notable for 20 WBC/mL, 10 RBC/mL, white cell casts, and crystals resembling rectangular prisms. After 48 hours, urine cultures are positive for growth of a Gram-negative, oxidase-negative, rod growing as clear colonies on MacConkey with a characteristic swarming motility. Which of the following contributed to the formation of crystals?

Bacterial enzymes that break down urea into ammonia

A 65 y-o man with a history of type 2 DM presents with recurrent episodes of gross hematuria throughout micturition, for the past 3 months. There are no associated symptoms. His diabetes is wellcontrolled with metformin. He is married for 40 years and has recently retired after working for 33 years at a rubber manufacturing plant. He only traveled to Germany several times to visit his family. His vitals are normal. The BMI is 35 kg/m2. There are no abdominal masses on deep palpation. Serum chemistry reveals a creatinine of 1.2 mg/dL. Which is the most likely diagnosis?

Bladder cancer

A previously healthy 35-year-old man presents with acute onset of left flank pain radiating to his inner groin and scrotum. The pain started 2 hours ago and is now associated with nausea. He reports that his urine is bright red, with few blood clots. His only medication is a multivitamin, and his diet is vegetarian. He appears in pain. He is afebrile, pulse rate is 104/min, and blood pressure is 136/80 mm Hg. Physical examination shows marked tenderness in the left costovertebral area, without any other abnormalities. Laboratory studies show: Serum Calcium 9.1 mg/dL Phosphorus 4.0 mg/dL Creatinine 0.8 mg/dL Urea nitrogen 15 mg/dL Urine pH 6.5 RBCs 50-60/hpf, normal morphology A CT scan of the abdomen shows a 4-mm stone in the left distal ureter. Intravenous fluid resuscitation is begun and treatment with tamsulosin and ketorolac is initiated. Five hours later, he passes the stone. Metabolic analysis of the stone is most likely to show which of the following?

Calcium oxalate

Which of the following enzymes represents the key regulated point of urea synthesis?

Carbamoyl phosphate synthetase

A newborn girl develops severe seizures 3 days after birth. Blood tests show a glycine level that is 8 times above the upper limit of normal. Blood glucose and ketone bodies are in the normal range. Which of the following is normally produced by the enzyme that is missing in this patient?

Carbon dioxide and ammonia

A 65-year-old man presents with a 4-week history of hematuria, urinary frequency, dysuria and weight loss. He has no significant past medical history or family history and he recently retired after a 30- year career as a house painter. His pulse is 88/min, blood pressure 116/78 mmHg, temperature 37.0oC, respirations 16 /min. His BMI is 18.50 kg/m2. Abdominal examination reveals a soft abdomen with tenderness over the suprapubic region with no palpable masses. His computerized tomography (CT) scan is shown. What is the most likely diagnosis?

Carcinoma of the bladder

A 33-year-old woman with a history of recurrent urinary tract infections presents with a 5-month history of intermittent flank pain. She reports no recent trauma. She is sexually active with her husband and uses condoms consistently. Her blood pressure is 150/88 mm Hg. Physical examination discloses bilateral, nontender, lobular flank masses. Lungs are clear to auscultation. Cardiac examination shows a high-frequency, mid-to-late systolic murmur that is best heard at the apex. Serum BUN of 30 mg/dL and serum creatinine concentration of 1.7 mg/dL. Urinalysis shows 1+ protein and 10 RBC/hpf. Renal ultrasonography shows enlarged kidneys with multiple parenchymal anechoic masses. This patient should be counseled that she is at greatest risk for which of the following?

Cerebral bleeding due to rupture of a saccular aneurysm

A 70-year-old female with hypertension and hyperlipidemia presents with bilateral lower extremity weakness and cramps for about 2 months. She also complains of waking up two or three times every night to urinate. Her current medications are enalapril, furosemide, metoprolol, aspirin, isosorbide dinitrate and simvastatin. Her vitals are normal and the physical examination reveals no cardiopulmonary abnormalities and no edema. Which of the following is the next best step in the management of this patient?

Check serum electrolytes

A renal physiologist is studying the effect of various substances on renal arteriole tone and glomerular filtration rate (GFR). Which of the following results will be obtained after administration of HIGH dose angiotensin II?

Choice C

A 60-year-old man complains of lower back ache for a week, which does not respond to OTC analgesics. He also passed red urine several times. He denies urinary frequency and dysuria. Physical examination shows localized tenderness over the lumbar spine. • A CT scan shows multiple osteolytic lesions in the body of the lumbar vertebrae. • Cystoscopy shows a 4-cm mass in the right lateral wall of the bladder. • A photomicrograph of a biopsy specimen is shown.

Cigarette smoking

A 46-year-old woman complained of burning on urination and bladder pain. Her medical history was significant for recurrent urinary tract infections and for a congenital long QT syndrome detected during a routine visit 1 year ago. A clean catch midstream urine sample showed many Gram -negative rods. Which of the following antibiotics would be contraindicated for this patient?

Ciprofloxacin

A 38-year-old woman presents increased thirst and frequent urination two days after undergoing transsphenoidal removal of a pituitary macroadenoma. The surgery was uncomplicated. Neurologic examination shows no abnormalities. Serum Na is 156 mEq/L and fasting serum glucose is 90 mg/dL. Which of the following findings in the nephron best describes the tubular osmolality, compared with serum, in this patient?

Collecting duct is hypotonic

E. coli is isolated from a previously healthy 36-year-old woman with a 2-day history of dysuria. What is the most likely source and mode of transmission for this urinary bacterial isolate?

Contamination with perianal and bowel flora

A 56-y-o man with HTN is started on a second antihypertensive drug. After 2 months he presents with breast enlargement. Which is the site of action of this new medication?

Cortical collecting duct

A patient suffering from diabetes mellitus has recently developed hypertension. His doctor suspects that the patient may be developing renal insufficiency that is leading to reduced glomerular filtration and, as a result, hypervolemia and hypertension. The physician wishes to evaluate kidney function by measuring the glomerular filtration rate (GFR). The physician can estimate GFR best by performing a urine clearance study of which of the following substances?

Creatinine

An investigator is attempting to assess the glomerular filtration rate (GFR) of a healthy adult volunteer. The volunteer's inulin clearance is evaluated under continuous inulin infusion and urine collection and compared to the creatinine clearance. It is found that the estimated GFR based on the volunteer's creatinine clearance is 129 mL/min and the estimated GFR calculated using the inulin clearance is 122 mL/min. Which of the following is the best explanation for the difference in these measurements?

Creatinine can be actively secreted

A 59-year-old woman reports to her primary care provider complaining of mild pain in the joints of the hands, hips, knees, and lower back. The pain has progressively gotten worse for the past two years. Following physical exam and laboratory work, the physician diagnosis her with mild osteoarthritis. To help control the inflammation and pain in her joints, the patient is asked to take NSAIDs. What effect would this drug intervention have on glomerular capillary hydrostatic pressure?

Decrease hydrostatic pressure by constricting afferent arterioles

What is the effect of a medication that inhibits Na reabsorption by the thick ascending limb of the loop of Henle?

Decreased ability to maximally concentrate urine

A 49-year-old man, recently diagnosed with stage C heart failure, started a treatment with captopril, metoprolol and furosemide. Which of the following actions most likely contributed to the therapeutic effect of furosemide in the patient's disease?

Decreased preload

An investigator is studying patients with acute decompensated congestive heart failure. He takes measurements of a hormone released from atrial myocytes, as well as serial measurements of left atrial and left ventricular pressures. The investigator observes a positive correlation between left atrial pressures and the serum level of this hormone. Which of the following is most likely the mechanism of action of this hormone?

Decreases sodium reabsorption at the collecting tubules

A 7-year-old boy presents with a 24 hour-history of red urine and edema. This is the second episode in the past 2 years. Three months ago he had a flu-like illness that was treated with acetaminophen. Last year, he was diagnosed with mild bilateral sensorineural hearing loss. His maternal uncle died of complications of a progressive kidney disease at the age of 23. The child appears pale. He is afebrile, pulse is 70/min, and blood pressure is 145/85 mm Hg. Slit lamp examination shows a conical protrusion of both lenses. Laboratory studies show: Hemoglobin 11 g/dL Serum Urea nitrogen 40 mg/dL Creatinine 2.4 mg/dL Urine Blood 2+ Protein 1+ RBC 5-7/hpf RBC casts rare Which of the following is the most likely underlying cause of this patient's symptoms?

Defective type IV collagen

A previously healthy 32-year-old woman presents with frequent urination for the past 3 months. She has been voiding every 1-2 hours during the day and wakes up to urinate 2-3 times during the night. She says she is drinking a lot of water to compensate for any dehydration. She takes no medications. She is concerned she may have high blood sugar, like her mother. Laboratory studies show: Serum Na+ 149 mEq/L Glucose 94 mg/dL Osmolality 308 mOsmol/kg H2O Urine Osmolality 205 mOsmol/kg H2O A water deprivation test is conducted. After 2 hours of fluid restriction, her plasma osmolality is 317 mOsmol/kg H2O, and her urine osmolality is 208 mOsmol/kg H2O. One hour after an antidiuretic hormone (ADH) analog injection, her plasma osmolality is 280 mOsmol/kg H2O, and her urine osmolality is 430 mOsmol/kg H2O. Which of the following is the most appropriate therapy?

Desmopressin

A 56-year-old woman with CAD and rheumatoid arthritis presents with congestive heart failure and is started on intravenous furosemide. After 2 hours, urine output is 0.4 mL/kg/h. Concomitant treatment with which of the following drugs is most likely to have contributed to this development?

Diclofenac sodium

A 67-year-old man comes to the physician because of urinary frequency, dysuria, and blood in his urine. He has also had a 4.5-kg (10-lb) weight loss over the past 3 months and has been feeling more fatigued than usual. He smoked one pack of cigarettes daily for 40 years but quit 2 years ago. A urinalysis shows 3+ blood. Cystoscopy shows an irregular mass on the bladder wall; a biopsy is taken. Which of the following histologic findings would indicate the worst survival prognosis?

Dysplastic cells extending into the lamina propria

Which cells of the distal tubule and collecting ducts are least permeable to water under all conditions?

Early distal tubule epithelium cells

A 23-year-old woman presents with dark urine and decreased urine output for the past 2 days. Three weeks ago, she had a skin infection that required antibiotic treatment, but stopped the antibiotics early. Her blood pressure is 146/92 mm Hg. Physical examination shows bilateral periorbital edema. Light microscopy of a renal biopsy specimen is shown. Further evaluation of this patient is most likely to show which of the following findings?

Elevated anti-streptococcal antibodies

A 57-year-old man with a history of gastroesophageal reflux disease (GERD) and recurrent back ache presents with bilateral flank pain and blood-tinged urine since the previous night. Over the last 2 days, he has also had progressive fatigue, myalgia, and a generalized itchy rash. His current medications are pantoprazole for GERD, which he started 1 month ago, and acetaminophen as needed for the back pain. His vital signs are within normal limits. Examination shows a generalized, diffuse blanching maculopapular rash. The remainder of the examination shows no abnormalities. His serum creatinine is 4.1 mg/dL and BUN is 34 mg/dL. Which of the following findings is most likely going to be present on further evaluation?

Elevated levels of eosinophils in urine

A 27-year-old man reports to his primary care provider complaining of chronic productive cough, nausea, tremors, depressed mood and irritability. The patient was eventually diagnosed with a form of pulmonary malignancy that resulted in release of ADH-like agents from the cancerous cells, causing a large spike in levels of this hormone (syndrome of inappropriate antidiuretic hormone). Which of the following is most likely to be seen in this patient?

Elevated urine sodium osmolarity

A 50-y-o patient with HTN presents with muscle cramps and weakness 4 weeks after starting hydrochlorothiazide. The precordial leads of a 12-lead ECG are shown. The addition of which of the following drugs is most likely to have prevented this patient's condition?

Eplerenone

A 65-y-o man presents with painless hematuria. He is now retired but worked in a textile factory for 40 years. He smokes 1 pack of cigarettes daily since age of 20. His BMI is 40 kg/m2. Hemoglobin concentration is 18.9 g/dL. What is the most likely cause for this presentation?

Excessive eryrthropoietin synthesis

A 55-year-old male has end stage renal disease caused by diabetic nephropathy and is scheduled to undergo renal transplantation. The renal artery from the donor kidney is most commonly connected to what vessel in the patient receiving the transplanted kidney?

External iliac artery

A 1-year-old boy is brought to the emergency room by his parents because of inconsolable crying and diarrhoea for the past 6 hours. As the physician is concerned about acute appendicitis, she consults the literature base. She finds a paper with a table that summarizes data regarding the diagnostic accuracy of multiple clinical findings for appendicitis. Based on the table, the absence of which clinical finding would most accurately rule out appendicitis in this patient?

Fever

A 24-year-old man presents with a 1-week history of cough, cola-colored urine and decreased urination. The cough was initially nonproductive, but yesterday he has coughed up small amounts of blood-tinged sputum with clots. He has not had any fevers, chills, or weight loss. He has smoked one pack of cigarettes daily for 5 years. Pulse is 110/min and blood pressure is 120/70 mm Hg. Physical examination shows dried blood around the lips. Serum studies show a creatinine of 4.9 mg/dL. A biopsy specimen of the kidney is most likely to show which of the following light microscopy findings?

Fibrin crescents in Bowman space

A 27-year-old woman presents to an urgent care facility with a 1-day history of nausea, weakness, painful urination, and pain along her left flank. She has been previously healthy and takes no medications. She is sexually active with 2 male partners, uses an oral contraceptive, and uses condoms inconsistently. Her temperature is 38.4C. Physical exam reveals costovertebral angle tenderness. Pelvic examination is normal. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following contributed to ability of the organism most likely causing this patient's symptoms to establish infection?

Fimbriae

A 70-y-o woman with a background of cirrhosis and HTN is diagnosed with ascites and is started on appropriate medication. Four days later, her laboratory test results are as follows. Which of the following treatments is most likely responsible for this patient's presentation?

Furosemide

A 7-year-old boy is brought to the physician by his parents because of a 4-day history of arthralgia, abdominal pain, and non-blanching erythematous skin lesions on his arms and legs. Last week he had an upper respiratory tract infection for which he received treatment with acetaminophen. A photograph of his right leg is shown. Further evaluation is most likely to show which of the following?

Hematuria

A 14-year-old boy presents with severe colicky left flank pain and nausea for 3 hours. The pain radiates toward his left groin. He has had similar episodes of abdominal pain in the past. His maternal uncle has a similar history of abdominal pain. He drinks multiple glasses of iced tea every day and his diet is well-balanced. His vitals are normal. Left costovertebral angle tenderness is present on physical examination. The abdominal x-ray shows no abnormalities. A urinary cyanide nitroprusside test is positive. Further evaluation of this patient is most likely to show which of the following?

Hexagonal crystals on urinalysis

A 37-year-old schoolteacher has been found unconscious at home and is admitted to the ICU. He has a history of depressive illness. He is on tricyclic antidepressants. A suicide note and several empty medicine bottles are found in his home. He is not verbal, but responds to painful stimuli. He is hyperventilating and appears dehydrated. His vitals are: BP 90/70 mmHg; puse rate 130/min; respiratory rate 36/min, with deep respirations. Laboratory test results: Na 140 mEq/L, K 4.6 mEq/L, Cl 104 mEq/L, HCO3- 6 mEq/L; BUN 17 mg/dL; creatinine 1.1 mg/dL; glucose 90 mg/dL; ABG: pH 7.06; PaCO2 18 mmHg; PaO2 95 mmHg. What is the most likely acid-base disorder?

High AG metabolic acidosis with compensatory respiratory alkalosis

Which of the following is (are) directly responsible for maintenance of a high glomerular filtration rate (GFR)?

High blood hydrostatic pressures in the glomerular capillaries and High hydrostatic pressure of the fluid in the Bowman's capsule

A new biomarker is being tested for early diagnosis of renal cell carcinoma (RCC). Test results of 400 healthy volunteers and 175 diagnosed (RCC) patients are presented below. The initial diagnostic test used the cut-off value of 200 IU/dL. (solid vertical line). If researchers lower the cut-off to 190 IU/dL. (dashed vertical line), which of the following would most likely be observed?

Higher sensitivity

Which of the following changes stimulates the rate of aldosterone secretion?

Hyperkalemia

A 46-year-old woman with type 2 diabetes mellitus and hypertension with end-stage renal disease on hemodialysis for 3 months was started on erythropoietin. Which are the most likely complications that may occur after starting this treatment?

Hypertension worsening

A 60-year-old man with a history of metastatic carcinoma presents with 4-day history of persistent vomiting. He finished his chemotherapy round a week previously. His vitals are normal. Examination shows decreased skin turgor and dry mucous membranes. The abdomen is soft; there is no guarding or rebound. Serum studies show: Urea nitrogen 36 mg/dL Creatinine 1.1 mg/dL Glucose 100 mg/dL Osmolality 320 mOsmol/kg Arterial blood gas analysis on room air shows: pH 7.51 PCO2 52 mm Hg PO2 80 mm Hg HCO3- 40 mmol/L Which of the following additional findings is most likely in this patient?

Hypokalemia

What happens to K and the acid-base status after administration of aldosterone?

Hypokalemia and metabolic alkalosis

A 62-year-old woman with a long history of heart failure was admitted to the emergency department in acute distress with extreme breathlessness, marked sweating, wheezing, cyanosis and cough with pink, frothy sputum. Drugs taken by the patient upon admission were: captopril, furosemide, metoprolol and spironolactone for heart failure, omeprazole for heartburn and high dose ibuprofen for a recently diagnosed rheumatoid arthritis. Further exams led to the diagnosis of pulmonary edema and a standard dose of furosemide was given intravenously with negligible effect. Ten minutes later a second dose was given and a quick improvement of the clinical picture was observed. The cardiologist thought that a drug taken by the patient was counteracting the hemodynamic action of furosemide. Which of the following was most likely the culprit drug?

Ibuprofen

A 14-year-old boy presents with mild fever, sore throat and difficulty swallowing for 2 days. He also reports having passed a pink urine this morning. He has no pain with urination or changes in urinary frequency. He has had two similar episodes involving a sore throat and pink urine over the past 2 years. His temperature is 38.0°C, pulse is 80/min, and blood pressure is 120/76 mm Hg. Oral examination shows an erythematous pharynx and enlarged tonsils, with no exudates. The remainder of the examination shows no abnormalities. Laboratory studies show: CBC Hemoglobin 13.6 g/dL Leukocyte count 20,000/mm3 Platelet count 256,000/mm3 Serum Urea nitrogen 8 mg/dL Creatinine 1.4 mg/dL Urine Blood 3+ Protein 1+ RBC 15-17/hpf with dysmorphic features RBC casts numerous Ultrasonography of the kidneys shows no abnormalities. A renal biopsy is most likely to show which of the following findings?

IgA mesangial deposition

A researcher is studying the effects of a new antihypertensive medication on urine osmolality. She first measures urine osmolality in different parts of the nephron of a healthy human control. The findings are shown below: Which of the following is the most likely explanation for the urine osmolality in the ascending limb of the loop of Henle?

Impermeability to water

Which of the following is true about glucose reabsorption in kidney tubules?

In the absence of Na+ in the fluid in the lumen of kidney nephrons, no glucose can be reabsorbed.

A 50-year-old man with HTN is started on chlorthalidone. Which of the following serum laboratory changes is expected in this patient?

Increased calcium

What factors increase the PCT fluid reabsorption? (more than 1 answer may be applicable)

Increased oncotic pressure in peritubular capillaries, and Decreased hydrostatic pressure in the peritubular capillaries

Further evaluation of this patient is most likely to show which of the following findings?

Increased serum aldosterone concentration

A 56-y-o woman is admitted after the intentional ingestion of 50 tablets of chlorthalidone. What are the most likely changes observed in the serum parameters set out in the table?

Increased, decreased, increased, decreased

A 60-year-old woman complained to her physician of swollen legs. The woman had been suffering from stage C heart failure presently treated with captopril, metoprolol and furosemide. The physician suspected that the patient's edema was related to furosemide resistance and added another diuretic to her therapy. Which of the following was most likely the added diuretic?

Indapamide

A 10-year-old Caucasian female with Turner's syndrome underwent an abdominal imaging study and was discovered that the poles of her kidneys were fused inferiorly. Normal ascent of kidney during embryological development would be prevented by which of the following anatomical structures?

Inferior mesenteric artery

A 67-year-old man, previously diagnosed with low-output systolic heart failure, was admitted to the emergency department because of severe dyspnea and lower limb edema. Pertinent plasma lab results show a glomerular filtration rate (GFR) of 20 mL/min. Which of the following is most likely to occur when the patient's edema is treated with the appropriate diuretic?

Inhibition of Na+ sensing by the macula densa

A 72-year-old man with a history of hypertension on amlodipine presents with no urination for almost 24 hours. He also experiences severe pain localized in lower abdominal pain for the past 2 hours. He has no fever or chills. He has a history of hay fever and took a tablet of diphenhydramine the previous morning. He smokes 10 cigarettes daily. He appears restless. He is afebrile and his blood pressure is 134/82 mm Hg. Abdominal examination shows a tender palpable suprapubic mass. Digital rectal examination shows a mildly enlarged, nontender prostate without any palpable masses. The remainder of the examination shows no abnormalities. A bedside ultrasound scan confirms an enlarged prostate. Which of the following is the most appropriate initial step in management?

Insert transurethral Foley catheter

A 28-year-old woman is hypovolemic after running a full marathon on a hot day. Following excessive sweating, her plasma ADH levels are elevated rapidly, and urine volume is drastically reduced. This effect of ADH on water excretion predominantly occurs by ADH-induced activation/inhibition of which of the following steps/processes?

Insertion of aquaporin channels in the apical membrane of collecting duct

Which of the following biological processes is (are) involved in the regulation of glomerular filtration rate (GFR)?

Juxtaglomerular apparatus Change in afferent arteriole tone Change in efferent arteriole tone NaCl levels at the macula densa

Remnants of embryological structures can often be found in the adult. Which structure represents the caudal end of the mesonephric ducts that are incorporated into the urinary bladder?

Trigone

A 50-year-old man currently treated with Amphotericin B for a systemic fungal infection is evaluated because of a 3-day history of headache, nausea, and decreased urination. Laboratory studies show: Serum Na+ 136 mEq/L K+ 3.2 mEq/L Cl- 115 mEq/L Mg2+ 1.4 mg/dL ABG pH 7.28 HCO3- 14 mEq/L Urine pH 7.0 Which is the most likely cause for the acid-base findings?

Type 1 renal tubular acidosis

An African-American couple gives birth to a boy after an uneventful pregnancy. The child is fair skinned and has almost white hair. His pupils are red. A postnatal enzyme screen is likely to reveal a deficiency in which of the following enzymes?

Tyrosinase

A 40-year-old woman is undergoing rehabilitation following a spinal cord injury and pelvic fracture sustained in a motorcycle accident. She reports frequent dribbling of urine, but she has no urge to urinate. Her BMI is 26 kg/m2 and vitals are normal. Physical examination shows 2/5 muscle strength in the bilateral lower extremities, decreased sensation in the lower extremities, decreased rectal tone, and a palpable suprapubic mass. Genital examination shows no abnormalities. After transurethral catheterization, she no longer dribbles urine for the next few hours, but then the problem recurs. Urinalysis is normal. Which of the following is the most likely underlying cause for this patient's urinary incontinence?

Underactivity of detrusor muscle

A 67-year-old female has been experiencing severe pain in her lower right back, emesis, nausea, hematuria and a fever. Urinalysis and a CT scan reveal she has a 6mm renal calculus which is partially obstructing her urinary tract. A lithotripsy procedure is scheduled. Which of the following locations is the likely site of the obstruction?

Ureteropelvic junction

A 26-year-old G1P0 mother is in the delivery room in labor. Her unborn fetus is known to have a patent urachus. Which of the following abnormalities would you expect to observe in the infant?

Urine discharge from umbilicus

A 69-year-old presents with a 1- week history of fatigue, loss of weight and blood in the urine. He also has had a 3-kg weight loss during the past month. Physical examination shows pallor and cachexia. A nontender right flank mass is palpated. Chest, abdomen, pelvis CT scan: 5-cm right renal mass and several pulmonary lesions. A biopsy specimen of an affected area of the lung is obtained. A photomicrograph of the biopsy specimen is shown.

VHL gene deletion

A 6-year-old male was recently referred to your clinic for further evaluation and management of vesicoureteral reflux, which had first been diagnosed when the child was 1-year of age following repeated urinary tract infections. An image of their radiological investigation is shown below. What was the imaging method used to confirm the diagnosis of vesicoureteral reflux?

Voiding cystourethrography