Pharmacology Exam 7 Study Guide

Match the following crystalloid intravenous solutions with the correct statement: Most commonly used crystalloid for fluid resuscitation

0.9% NaCl (NS)

Except for 25% albumin, administering 500 mL of a colloid will result in about _______ mL of intravascular volume expansion. a.333 b.500 c.250 d.100

b

Select all that apply Identify the IV solutions in which 25% of the infused volume will remain in the intravascular space and 75% will distribute in the interstitial space. a.5% Albumin b.Lactated Ringers (LS) c.0.9% NaCl (NS) d.D5W

b,c

Hetastarch 6% and dextran IV products have been associated with which of the following adverse effects which have limited their widespread use? (select all that apply) a.liver dysfunction b.renal impairment c.increasead intracranial pressure d.coagulopathy

b,d

Which of the following is true regarding 25% Albumin (select all that apply) a.Is the preferred colloid for fluid resuscitation b.It is a hypotonic solution c.Has an oncotic pressure 5 times that of normal plasma d.Will cause a fluid shift from the intravascular space to the interstitial space

c

Which of the following patients is IV 25% albumin preferred? (select one) a.Patients who are undergoing surgical procedures associated with significant blood loss b.Patients who have ongoing renal insufficiency and need an increase in oncotic pressure c.Patients who do not require fluid resuscitation but who would benefit from a redistribution of fluid (e.g., ascites, pleural effusions) d.Patients with severe dehydration before NS

c

Many experts and practitioners avoid the IV administration of D5W for which of the following cases? (select all that apply) a.Conditions associate with hypoglycemia b.Elevated intracranial pressure (ICP) c.Severe dehydration d.Conditions associated with hyperglycemia

c,d

Colloids are too large to cross the capillary membrane; therefore, they will primarily remain in the ___________space.

intravascular

How does PTH influence Ca2+ and Pi levels?

↑Ca2+ reabsorption ↓Pi reabsorption

Chief Complaint "I feel very weak and tired." HPI Brandon O'Byrne is a 60-year-old man who presents to the ED with complaints of generalized weakness, fatigue, myalgias, and polyuria over the past 2 days. He states that recently he has felt bloated and has been taking extra doses of his "water pill." He also mentioned that he may have eaten something bad because he has thrown up three times since dinner last night. PMH Hypertension (diagnosed 15 years ago) HFrEF (diagnosed 3 years ago) Diabetes, type 2—diet controlled Dyslipidemia (diagnosed 3 years ago) FH Mother is alive with a history of HTN and dyslipidemia. Father is alive with HTN. Younger sister is alive with dyslipidemia. SH Patient reports he does not consume alcohol except a glass of wine "at special occasions." He denies tobacco or illicit drug use. Lives at home with his wife of 35 years and their two dogs. Meds Lisinopril 20 mg PO once daily Carvedilol 25 mg PO BID Furosemide 40 mg PO once daily Atorvastatin 40 mg PO once daily Last dose of all medications was this morning 3 hours before arriving at the ED All Codeine—patient reports "I get short of breath" ROS Denies unusual weight gain or loss. He denies fever, chills, or night sweats, but reports dizziness that has occurred off and on over the past week in addition to generalized fatigue and weakness. No reported chest pain, palpitations, shortness of breath, or cough. He denies diarrhea, constipation, or change in bowel habits. He reports a recent increase in thirst and urination, but no change in urine color. He reports myalgias and perioral numbness that began recently with the fatigue and weakness. Physical Examination Gen The patient is ill-appearing and feels warm to the touch. VS BP 93/62 mm Hg, HR 101, RR 20, T 37.9°C; Wt 176 lb (80 kg), Ht 5′7″ (170 cm); O2 sat 96% on RA Skin Soft, intact, warm, dry HEENT EOMI; PERRLA; no sinus tenderness; dry mucous membranes; no oral lesions; no nasal congestion present Neck/Lymph Nodes No JVD or bruits; no lymphadenopathy or thyromegaly Chest CTA bilaterally CV RRR; normal S1, S2; no S3 or S4; no murmurs, rubs, gallops Abd Soft, NTND; (+) bowel sounds GU/Rect WNL MS/Ext No CCE; feet are dry and wrinkled Neuro A&O × 3. CN II-XII intact. Labs Favorite Table | Download (.pdf) | Print Na 132 mEq/L Hgb 12.4 g/dL Alb 3.8 g/dL K 2.9 mEq/L Hct 36.7% AST 19 IU/L Cl 85 mEq/L Plt 324 × 103/mm3 ALT 16 IU/L CO2 39 mEq/L WBC 12.1 × 103/mm3 Alk phos 62 IU/L BUN 24 mg/dL Mg 1.7 mEq/L T. bili 0.4 mg/dL SCr 1.1 mg/dL Phos 3.6 mg/dL PT 11.3 s Glu 118 mg/dL Ca 7.6 mg/dL INR 0.96 ABG pH 7.54, PaCO2 46 mm Hg, PaO2 86 mm Hg, HCO3 38.3 mEq/L on RA UA Urine sodium 18 mEq/L; potassium 33 mEq/L; chloride 9 mEq/L, urine pH 6.1 Chest X-Ray Mild pulmonary congestion, otherwise unremarkable ECG Sinus tachycardia, rate 101, no acute ST-segment or T-wave changes Assessment Admit patient for hypotension, flulike symptoms, electrolyte and acid-base abnormalities. Clinical Course The patient was started on IV fluids, and labs were reassessed a few hours later. The patient is observed to have 1+ pitting edema in the lower extremities. Laboratory values are as follows: Favorite Table | Download (.pdf) | Print Na 140 mEq/L BUN 14 mg/dL ABG K 3.8 mEq/L SCr 0.8 mg/dL pH 7.46 Cl 103 mEq/L Mg 2.1 mEq/L PaCO2 39 mm Hg CO2 30 mEq/L PaO2 92 mm Hg HCO3 31 mEq/L

1) Assess pH of 7.54- Alkalosis 2) Assess CO2 of 46 mmHg- Acidosis 3) Assess HCO3 of 38.3 mmHg- Alkalosis 4) What matches your pH: Metabolic with partial respiratory compensation. Started on IV fluids, labs reassessed a few hours later 1+ pitting edema in BLE. Etiology: 1) Diuretic Over-use: Loop diuretics promote excretion of Na and K in the loop of henle. H+ excretion is stimulated by increased luminal flow rate and by intravascular volume contraction. Hypokalemia stimulates further acid excretion in the kidney. 2) Excessive vomiting caused a significant loss of HCl rich gastric fluid causing hypovolemia. Subjective info: vomiting, weakness, fatigue, myalgias, increased diuretic use. Objective info : elevated arterial blood pH, elevated arterial and serum HCO3, decreased Na, Cl, K, Mg, elevated urine pH, and decreased urine Cl. List of Problems and goals 1) Hypotension necessitating volume replacement. Plan: Normalize BP and maintain MAP> 65 mmHg, Achieve UOP>0.5 mL/kg/hour 2) Metabolic alkalosis secondary to excessive loop diuretic use Plan: Stop vomiting, correct blood pH, serum bicarb, serum chloride, and urine pH. 3) Electrolyte abnormalities necessitating correction Plan: correct serum K, Na, Ca, and Mg 4) HFrEF 5) Dylipidemia 6) Type II Diabetes Possible non drug cause of the pt's metabolic alkalosis: Excessive vomiting: Gastric contents are abundant in HCl. Signifcant losses of HCl can increase serum bicarb. Typically resolves by renal compensation: dumping excess serum bicarb in the urine. Nonpharmacological therapy: Hemodialysis, considered in patients with advanced renal failure, volume overload, resistant to acetazolamide (last line option). Pharmacotherapeutic options Chloride Resistant: Decrease dose of exogenous corticosteroid, decrease excess alkali intake, K supplementation if depleted, Spironolactone, Amiloride, or Triamterene for endogenous mineralocorticoid excess Chloride Responsive: IV fluid resuscitation (NS), Acetazolamide If persistent: acidifying agents (HCl, ammonium chloride, arginine monohydrchloride) What information should be provided to the patient? Diuretic adherence, daily weights, minimize sodium intake, potassium supplementation, follow-up for regular lab work. Follow up: Repeat ABG after fluid resuscitation, serum electrolytes 12-24 h, renal panel 12-24 hr, urine electrolytes when patient is euvolemic, monitor UOP, and assess for signs and symptoms of fluid overload. Follow up with PCP within 3 days of discharge and consider HF clinic referral.

How do you treat chronic hypocalcemia?

1-3g/day of elemental calcium Vitamin D Magnesium

What is the equivalent intravascular volume expansion (mL) for: 1000 mL D5W

100

What is a normal range of Phosphorus?

2.5-4.5 mg/dL

What is the normal range for Vitamin D? What levels constitute insufficiency and deficiency?

20-40 ng/mL Insufficiency: 12-20 ng/dL Deficiency: <12 ng/mL

Assuming a normal distribution of K+ between the EC an IC compartments, a 1-mEq/L reduction in plasma potassium represents as total body potassium deficit of ______________mEq of K+.

200-400

Pt BZ is a 35 yo F who presents with diabetic ketoacidosis. Her BG is 500 and she is complaining of polydipsia and polyuria. She weighs 75 kg. Her ABG yields pH 7.31, pCO2=36 mmHg and HCO3- is 18. What is her bicarbonate deficit? Given her presentation, would you expect her anion gap to be high or normal?

225 mEq/L, High

What is the equivalent intravascular volume expansion (mL) for: 1000 mL LR

250

What is the equivalent intravascular volume expansion (mL) for: 1000 mL NS

250

Match the IV solution with the correct osmolality: Lactated Ringers (LR)

273 mOsm/L

Match the IV solution with the correct osmolality: 5% Dextrose (D5W)

278 mOsm/L

Match the IV solution with the correct osmolality: 0.9% NaCl (NS)

287 mOsm/L

What is the equivalent intravascular volume expansion (mL) for: 100 mL 25% albumin

500

What is the equivalent intravascular volume expansion (mL) for: 500 mL Albumin 5%

500

What is the equivalent intravascular volume expansion (mL) for: 500 mL Hetastarch 6%

500

For D5W infusion, _______% will distribute into the intracellular space and ______% in the extracellular space. Of the distribution to the extracellular space, ______% will remain in the intravascular space, and ______% will distribute to the interstitial space.

60, 40, 25, 75

1. A malignancy associated with hypercalcemia from PTH-related protein is: A. Breast B. Prostate C. Leukemia D. Cervical E. Sarcoma

A

10. What mechanism may cause drug-induced hypocalcemia from bisphosphonates? A. Blocked bone resorption B. Increased sensitivity to CaSr C. Decreased PTH sensitivity D. Induction of hypomagnesemia

A

11. A 45-year-old male with CKD category 3b (eGFR of 42 mL/min/1.73 m2) is seen in the nephrology clinic. His labs today show the following: Hb 8.5 g/dL (85 g/L; 5.28 mmol/L) (down from 10.5 g/dL [105 g/L; 6.52 mmol/L] three months ago), TSat 34% (0.34), serum ferritin 610 ng/mL (mcg/L; 1370 pmol/L). He reports feeling tired and less able to do his activities of daily living. Work-up shows no signs of active bleeding. Should this patient be started on an erythropoietic-stimulating agent (ESA) and what is the rationale? A. Yes, his Hb is below 10 g/dL (100 g/L; 6.21 mmol/L) and the extent of decline indicates a high likelihood of needing a blood transfusion. B. Yes, an ESA is indicated to enhance his quality of life and decrease mortality risk. C. Yes, his Hb is below 12 g/dL (120 g/L; 7.45 mmol/L) and the goal is to normalize the Hb in nondialysis CKD patients. D. No, an ESA will not be effective since his iron indices are low and iron should be administered first. E. No, his Hb is above 8 g/dL (80 g/L; 4.97 mmol/L) and he has not had a large decline in Hb since his last visit.

A

12. A 31-year-old man presents with lethargy, weakness, labored respiration, and confusion. He has had diabetes for 15 years, and has been suffering from the "intestinal flu" for a day or so, for which he has been avoiding food to help prevent further vomiting and "make his stomach ache go away." Since he stopped eating, he thought that it would be a good idea to stop taking his insulin. When seen in the emergency department his urine dipped positive for both glucose and ketones and his breath had a strange sweet, fruity smell. The following arterial blood gas data was obtained: pH 7.27, PCO2 23 mm Hg (3.1 kPa), and HCO3− 10 mEq/L (mmol/L). His most recent serum chemistries are as follows: Na 132 mEq/L (mmol/L), Cl 83 mEq/L (mmol/L), K 4.9 mEq/L (mmol/L), and glucose 345 mg/dL (19.1 mmol/L). Which of the following is most true regarding lactic acidosis? A. Has rarely been reported with linezolid therapy of more than 4 weeks duration B. Administration of propofol at a dose of 10 mcg/kg/min for one day increases a patient's risk for lactic acidosis C. Occurs when the serum lactate concentration exceeds 2 mEq/L (mmol/L) D. Nucleoside-analogue reverse transcriptase-induced lactic acidosis is caused by the inhibition of the enzyme RNA gamma alpha E. None of the above is TRUE

A

14. An 85-year-old patient who resides in a nursing home develops hypophosphatemia (serum phosphorus 1.7 mg/dL [0.55 mmol/L]) secondary to limited oral intake associated with advanced dementia. His other laboratory data include: serum potassium 3.4 mEq/L (mmol/L) and total corrected calcium 8.5 mg/dL (2.13 mmol/L). Which of the following is the best therapy to initiate in this patient? A. Neutra-Phos-K B. K-Phos Neutral C. Neutra-Phos D. Potassium phosphate IV

A

6. A 68-year-old man, KL (weight = 70 kg; height = 69 in. [175 cm]), with a long-standing history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is as follows: pH 7.30, PCO2 34 mm Hg (4.5 kPa), HCO3−15 mEq/L (mmol/L), and PO2 80 mm Hg (10.6 kPa), and his most recent serum labs demonstrate Na 135 mEq/L (mmol/L), K 5.4 mEq/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. KL is found to be hypertensive (BP 170/92 mm Hg) and the medical resident asks you if there is an antihypertensive that should be avoided in KL based on the underlying condition that is felt to be contributing to KL's current acid-base status. Which of the following agent should be avoided in KL at this time? A. Angiotensin-converting enzyme (ACE) inhibitor B. Clonidine C. Hydralazine D. Amlodipine E. Long-acting nifedipine

A

6. Which of the following could be considered for treatment of a 47-year-old female with primary hyperparathyroidism to reduce stone number and diameter? A. Cinacalcet B. Calcium restricted diet C. Lithotripsy D. Etelcalcitide

A

8. A critically ill adult male is asymptomatic with a serum calcium of 8.1 mg/dL (2.03 mmol/L). Ionized calcium and albumin have not been evaluated. What is the most appropriate recommendation regarding this patient's serum calcium concentration? A. Check an ionized calcium concentration B. Administer calcium chloride 1 g IV over 10 minutes C. Administer calcium gluconate 2 g IV over 2 hours D. Administer calcium gluconate 3 g IV over 3 hours

A

9. Which of the following agents would be preferred in a hemodialysis patient with ESRD, a PTH persistently above 700 pg/mL (ng/L; 75 pmol/L), and elevated calcium levels? A. Etelcalcetide B. Cholecalciferol C. Calcitriol D. Ergocalciferol E. Calcifediol

A

9. Which of the following statement is most true regarding RTA? A. Proximal RTA (type II) is caused by a defect in the proximal tubule that prevents bicarbonate from being reabsorbed. B. Distal RTA (type IV) can be caused by aldosterone resistance and often results in hypokalemia. C. Proximal RTA (type II) and distal RTA (type I) are associated with sodium wasting and hypokalemia. D. Renal tubular acidosis is usually associated with a high anion gap resulting from an increase in unmeasured anions. E. None of the above is TRUE.

A

History: CB is an 85 yo female presenting to the ED with a bothersome cough, sore throat, headache, and stuffy nose. As a precaution, the ED physician orders labs. CB takes no medications. Labs from the last 2 years show her sodium runs between 128-134mEq/L. Labs: • Na 130mEq/L • K 3.7 mEq/L • Cl 100 mEq/L • BUN 21 mg/dL • Mg 1.9 mEq/L • SCr 1.2 mg/dL Question 1: CB's labs show she has which electrolyte abnormality? A. Hyponatremia B. Hypomagnesemia C. Hyperkalemia D. Hypernatremia

A

J.A. is a 38 yo female with ESRD receiving peritoneal dialysis. The most recent laboratory analysis reveals the following: Phosphorus 7.4mg/dL (2.5-4.5mg/dL), Calcium 9.0mg/dL (8.5-10.5mg/dL), albumin 2.5mg/dL, iPTH 542 pg/mL (10-60pg/mL), ABG: pH 7.33 (7.35-7.45), pCO2 - 34mm Hg (35-45mm Hg), HCO3 20mEq/L (22-35mEq/L), pO2-97mm Hg (80-100mm Hg). J.A. is prescribed a phosphate binder to treat hyperphoshatemia. She will also be prescribed a Vit D supplement to treat secondary hyperparathyroidism. Which Vit D supplement is the best choice for J.A.? A.paricalcitol (Zemplar) B.cinacalcet (Sensipar) C.calcitriol (Rocaltrol) D.ergocalciferol (Calciferol)

A

Pt HG was on mechanical ventilation in the ICU. He has been diagnosed with sepsis due to pneumonia and concern for bacteremia. His initial presentation involved acute shortness of breath, fever, tachycardia. pH=7.28 pCO2=52, pO2=72 HCO3=24.4 a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

A

Which of the following IV fluids is isotonic? A. Lactated ringers B. 3% sodium chloride solution C. D5W D. ½ NS

A

Which of the following statements is TRUE regarding cinacalcet (Sensipar)?I. Calcimimetic agentII. Leads to an increase in PTH without elevating calcium, phosphates, or CaxPIII. Interacts with cyp 3A4 medications A.I only B.I & III C.II & III D.I , II, & III

A

What is ascites and how is it treated?

A common complication of cirrhosis, ESRD, and right sided HF causing fluid buildup in the peritoneal cavity. Treatment: Spironolactone + Furosemide 100:40 ratio

History: CK is a 45 yo male with a history of alcoholism and liver cirrhosis who presents to the ED with increasing edema, a swollen abdomen, and significant weight gain. He reports feeling weaker than usual. CG takes no medications. Previous electrolytes are within normal limits. Labs: • Na 125mEq/L • K 3.5 mEq/L • Cl 100 mEq/L • BUN 17 mg/dL • Mg 1.9 mEq/L • SCr 0.98 mg/dL • Serum osmolality 265 mOsm/kg Question 1: CK's labs show he has which electrolyte abnormality? A. Hyponatremia B. Hypomagnesemia C. Hyperkalemia D. Hypernatremia Question 2: What type of hyponatremia does AG appear to have? A. Euvolemic hyponatremia B. Hypervolemic hyponatremia C. Hypovolemic hyponatremia Question 3: You are verifying CG's medication orders on admission to the medical unit. Which fluid order would you expect to see? A. Hypertonic saline 1-2 mL/kg/h B. NS 0.9% at 200-300 mL/h C. D5W or 0.45% NaCl D. No orders for fluid, initiate water and sodium restriction Question 4: In patients with chronic alcohol abuse, what other electrolyte imbalances would you expect to see? A. Hypomagnesemia B. Hypocalcemia C. Hypokalemia D. Hypophosphatemia E. All of the above

A, B, D, E

History: AG is a 65 yo male with a history of hypertension who presents to the ED complaining of fatigue, weakness, dizziness and nausea. His records show that his PCP started hydrochlorothiazide two weeks ago. Labs prior to starting HCTZ are all within normal limits. Labs: • Na 115mEq/L • K 3.7 mEq/L • Cl 100 mEq/L • BUN 15 mg/dL • Mg 2.1 mEq/L • SCr 1.0 mg/dL Vitals: • BP 85/60 mmHg • HR 105 bpm • T 98F Question 1: AG's labs show he has which electrolyte abnormality? A. Hyponatremia B. Hypomagnesemia C. Hyperkalemia D. Hypernatremia Question 2: What type of hyponatremia does AG appear to have? A. Euvolemic hyponatremia B. Hypervolemic hyponatremia C. Hypovolemic hyponatremia Question 3: The admitting resident wants to know how quickly the sodium needs to be raised over the next 24 hours. A. Raise serum sodium by no more than 18-20 mEq/L B. Raise serum sodium by no more than 16-20 mEq/L C. Raise serum sodium by no more than 12-16 mEq/L D. Raise serum sodium by no more than 8-12 mEq/L Question 4: The admitting resident also wants to know which fluid she should use to bring the sodium up. A. D5W B. NS C. Albumin 5% D. ½ NS Question 5: What are the risks associated with using hypertonic saline? A. Hypernatremia B. Osmotic demyelinating syndrome C. Hypovolemia D. IV site irritation (thrombophlebitis) E. All the above F. A, B, and D

A, C, D, B, F

How is loop diuretic resistance managed?

Addition of thiazide diuretics to block distal reabsorption and allow lower doses of loop diuretics to be administered.

When should mannitol be avoided in treating cerebral edema? How must it be administered?

Avoid in renal failure and active intracranial bleeding. Must be filtered during administration

1. A 31-year-old man, LG, was found to be unresponsive and apneic by an off-duty nurse a block away from the emergency department where she works. He was quickly brought to the emergency department where an arterial blood gas (ABG) sample revealed the following: pH 7.08, PCO2 80 mm Hg (10.6 kPa), and HCO3−23 mEq/L (mmol/L). His most recent serum labs demonstrated Na 130 mEq/L (mmol/L); Cl 111 mEq/L (mmol/L), and TCO2 23 mEq/L (mmol/L). His acid-base disturbance is: A. Respiratory acidosis with an elevated anion gap B. Respiratory acidosis with a normal anion gap C. Metabolic alkalosis D. Metabolic acidosis with a normal non-anion gap E. Metabolic acidosis with an elevated anion gap

B

13. Which of the following is most correct regarding administration of IV sodium bicarbonate to a patient with septic shock who has a high anion gap metabolic acidosis with an arterial pH of 7.29? A. Sodium bicarbonate use will reduce mortality. B. Sodium bicarbonate use may paradoxically reduce intracellular pH. C. Sodium bicarbonate use should be reserved for only those patients with an arterial pH less than or equal to 7.25. D. Sodium bicarbonate use will reduce the efficacy of norepinephrine. E. Sodium bicarbonate use will increase the risk for ventricular tachyarrhythmias.

B

14. Which of the following is a potential advantage of using ferric citrate as a phosphate-binding agent compared to other sevelamer carbonate? A. It is available in a powder formulation. B. It may increase iron indices. C. It is available as a chewable tablet. D. It can be given intravenously or orally. E. It does not cause stool discoloration.

B

15. Hemolysis related to hypophosphatemia is most likely caused by which of the following? A. Altered cardiac conduction B. Depletion of ATP stores C. Myocardial cell apoptosis D. All of the above

B

2. A 64 yr old female with severe alcoholism was found at home obtunded. Upon arriving to the hospital she was diagnosed with rhabdomyolysis and acute kidney injury. Laboratory data show serum calcium 8.3 mg/dL (2.08 mmol/L), serum albumin of 1.2 g/dL (12 g/L), and serum phosphorus 2.3 mg/dL (0.74 mmol/L). Which of the following electrolyte disorders is responsible for her conditions? A. Hypocalcemia B. Hypercalcemia C. Hyperphosphatemia D. Hypophosphatemia E. She does not have an electrolyte disorder

B

5. A 65-year-old female with asymptomatic hypercalcemia secondary to metastatic lung cancer presents with a serum calcium of 12.2 mg/dL (3.05 mmol/L). Her serum creatinine is 0.9 mg/dL(80 µmol/L) and estimated glomerular filtration rate >60 mL/min/1.73 m2. The decision is made to initiate therapy with an agent that inhibits bone resorption. Based on the efficacy and toxicity profile of the following agents, which would be the most appropriate to initiate in this patient? A. Prednisone B. Pamidronate C. Calcitonin D. Denosumab

B

7. A 67-year-old female with diabetic CKD, urinary albumin-to-creatinine ratio (uACR) of 55.4 mg/g (6.3 mg/mmol), a serum potassium of 4.5 mEq/L (mmol/L), and an eGFR of 38 mL/min/1.73 m2 is started on irbesartan 75 mg po once daily. The eGFR and serum potassium levels should be monitored at what time point after initiation of therapy? A. In ≤2 weeks B. Within 2 to 4 weeks C. Within 4 to 12 weeks D. In 6 months E. If the patient notices changes in urine output

B

8. According to KDIGO guidelines, what is the target blood pressure in a patient with kidney disease secondary to long-standing hypertension and an uACR = 423 mg/g (47.8 mg/mmol)? A. ≤125/75 mm Hg B. ≤130/80 mm Hg C. ≤135/85 mm Hg D. ≤140/90 mm Hg E. ≤150/90 mm Hg

B

A patient being treated for mild hypophosphatemia has a K of 6.0. Which of the following would not be an appropriate treatment option a. Neutra Phos b. Neutra Phos K c. K Phos Neutral

B

An alcoholic would be more likely to present with.. a. Hyperphosphatemia b. Hypophosphatemia

B

Question 3: Which of the following IV fluids is hypertonic? A. LR B. 7.5% sodium chloride solution C. ½ NS D. Albumin 25%

B

Question 5: True or False - Colloids are generally superior when compared to crystalloids for fluid resuscitation A. True B. False

B

What role does PTH play in maintenance of Ca and P homeostasis? a. decrease Ca, decrease P b. increase Ca, decrease P c. Increase Ca, increase P d. decrease Ca, increase P

B

Which of the following is not a cause of hypocalcemia? a. Excessive diuretic use b. Excessive sunlight exposure c. Chronic pancreatitis D. Gastric bypass

B

Which of the following supplements should be recommended for daily supplementation in a patient with stage 5 CKD requiring chronic hemodialysis? A.Multivitamin B.Vitamin B plus C, levocarnitine C.Vitamin A plus C and folic acid Folic acid only

B

JW is a 28 yo M who presents to the emergency department after a bike accident. He was riding his bike with friends after visiting multiple breweries and fell and hit his head on a dumpster. He is confused and anxious. He does not want his commanding officer to know about his accident. pH=7.46, pCO2=34 pO2=205, O2 Sat=99.5% a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis Is there compensation? a. Yes b. No

B, B

12. A patient with stage 3a CKD is to be started on oral iron for iron deficiency. This patient should be instructed to do which of the following? A. Avoid taking sucroferric oxyhydroxide within 2 hours of oral iron B. Take iron with meals to increase absorption in the GI tract C. Take at least 200 mg of elemental iron per day if tolerated D. Take an antacid with iron to minimize the risk of GI adverse effects E. Take oral iron with at least 8 ounces of water to prevent GI adverse effects

C

12. An adult female with chronic disease-related malnutrition who underwent surgery for esophageal cancer is initiated on enteral nutrition. Laboratory data prior to enteral nutrition included: serum phosphorus, 4 mg/dL (1.29 mmol/L); serum potassium, 4.1 mEq/L (mmol/L). Laboratory data 24 hours after initiation of enteral nutrition included: serum phosphorus, 0.8 mg/dL (0.26 mmol/L); serum potassium, 2.6 mEq/L (mmol/L). Which of the following best describes the pathogenesis of her hypophosphatemia? A. Decreased gastrointestinal absorption B. Decreased tubular reabsorption C. Increased internal redistribution D. Increased renal excretion

C

13. A patient with CKD 4 is noted to be iron deficient and is prescribed a full course of IV iron (1-1.5 g total). She will receive the total dose of IV iron divided over 2 clinic visits (today and one week later). Which regimen is most appropriate to administer at each visit? A. Ferumoxytol 510 mg IV push over 5 minutes B. Iron dextran 25-mg test dose followed by infusion of 500 mg over 30 minutes C. Ferric carboxymaltose 750 mg infused over 30 minutes D. Ferric gluconate 500 mg infused over 30 minutes E. Iron sucrose 1 g administered over 3 hours

C

13. An adult hospitalized male (93 kg, 6 ft 1 in. or 185 cm) has the following current laboratory data: magnesium, 2.1 mEq/L (1.05 mmol/L); phosphorus, 1.2 mg/dL (0.39 mmol/L); sodium, 136 mEq/L (mmol/L); potassium, 5.9 mEq/L (mmol/L); blood urea nitrogen, 10 mg/dL (3.6 mmol/L); serum creatinine, 0.9 mg/dL (80 µmol/L). What is the most appropriate electrolyte replacement at this time? A. K-Phos No. 2® 250-mg tablet by mouth every 6 hours B. Phos-NaK® 250-mg packet by mouth every 6 hours C. Sodium phosphate 45 mmol IV once D. Potassium phosphate 45 mmol IV once

C

14. Which of the following statements is most true regarding respiratory acidosis? A. Respiratory acidosis is common in patients who are wildly agitated in the emergency department. B. Respiratory acidosis is a primary increase in PCO2 resulting in a decreased arterial pH. C. The PCO2 is the primary stimulus to breathe in a patient with end-stage chronic obstructive pulmonary disease who is managed at home with oxygen therapy. D. Renal bicarbonate excretion is an expected response to respiratory acidosis. E. None of the above is TRUE.

C

15. According to KDIGO guidelines, statin therapy is recommended for primary prevention of cardiovascular events in which of the following patients? A. 60-year-old male with ESRD not previously on a statin B. 75-year-old female with ESRD and diabetes not previously on a statin C. 40-year-old male with CKD 3b with coronary artery disease D. 38-year-old female with CKD 2 and no cardiac risk factors E. Statins are recommended only for secondary prevention in patients with CKD

C

16. Which of the following treatments should be avoided in a patient with severe metabolic acidosis who has end-stage liver disease? A. Hemodialysis B. Sodium bicarbonate C. Tromethamine (THAM) D. Acetazolamide E. Ammonium chloride

C

2. A 31-year-old man, LG, was found to be unresponsive and apneic by an off-duty nurse a block away from the emergency department where she works. He was quickly brought to the emergency department where an arterial blood gas (ABG) sample revealed the following: pH 7.08, PCO2 80 mm Hg (10.6 kPa), and HCO3− 23 mEq/L (mmol/L). His most recent serum labs demonstrated Na 130 mEq/L (mmol/L); Cl 111 mEq/L (mmol/L), and TCO2 23 mEq/L (mmol/L). Which of the following is most true about extracellular buffering? A. The magnesium-potassium system plays an important initial role. B. The bicarbonate system is the most important because it is not dependent on the amount of bicarbonate that is filtered by the kidney. C. The phosphate buffer system plays a limited role given extracellular phosphate concentrations are low. D. The carbonic acid buffering system plays a minimal role given the low amount of CO2 produced by the body. E. The stomach plays an important role given its ability to alter the amount of gastric acid it produces.

C

2. A 51-year-old female with an eGFR of 37 mL/min/1.73 m2 and a urinary albumin-to-creatinine (uACR) ratio of 20.1 mg/g (2.3 mg/mmol) would be classified in which albuminuria and KDIGO category of CKD? A. 3a, A1 B. 3a, A2 C. 3b, A1 D. 3b, A2 E. 4, A1

C

3. A 44-year-old female with a history of CKD due to type 2 diabetes presents to your primary care clinic. Her most recent uACR is 113 mg/g (12.8 mg/mmol), her eGFR is 44 mL/min/1.73 m2, and blood pressure is 137/88 mm Hg. She is on chlorthalidone 12.5 mg po daily as her only antihypertensive drug. Which one of the following recommendations is most appropriate? A. No changes, blood pressure is at target B. Increase chlorthalidone to 25 mg po daily C. Start ramipril 2.5 mg po daily D. Start amlodipine 5 mg po daily E. Change chlorthalidone to hydrochlorothiazide 25 mg po daily

C

3. A 52-year-old female with stage 4 renal cell carcinoma presents to the emergency department with profound weakness, abdominal pain with nausea and vomiting, and profound dehydration. Laboratory analysis reveals: sodium 135 mEq/L (mmol/L), potassium 4.5 mEq/L (mmol/L), chloride 101 mEq/L(mmol/L), bicarbonate 24 mEq/L (mmol/L), serum creatinine 1.2 mg/dL (106 µmol/L), BUN 40 mg/dL (14.3 mmol/L), and serum calcium 14.2 mg/dL (3.55 mmol/L). What is the most likely cause of her hypercalcemia? A. Hypercalcemia B. Hyperphosphatemia C. Hypophosphatemia D. He does not have an electrolyte disorder

C

4. A 52-year-old female with stage 4 renal cell carcinoma presents to the emergency department with profound weakness, abdominal pain with nausea and vomiting, and profound dehydration. Laboratory analysis reveals: sodium 135 mEq/L (mmol/L), potassium 4.5 mEq/L (mmol/L), chloride 101 mEq/L(mmol/L), bicarbonate 24 mEq/L (mmol/L), serum creatinine 1.2 mg/dL (106 µmol/L), BUN 40 mg/dL (14.3 mmol/L), and serum calcium 14.2 mg/dL (3.55 mmol/L). Which of the following is the most appropriate initial therapy for this patient? A. Hemodialysis with a low-calcium bath B. High-dose IV loop diuretic C. Intravenous bisphosphonate D. Intravenous bisphosphonate E. Subcutaneous calcitonin

C

5. Hypertensive patients with CKD should limit dietary sodium to less than: A. 1 g/day B. 1.5 g/day C. 2 g/day D. 2.5 g/day E. 3 g/day

C

7. A 85-year-old patient has chronic kidney disease stage 3b (estimated GFR 40 mL/min/1.73 m2). Her present medications include ramipril 10 mg once daily, furosemide 80 mg BID, and metoprolol succinate 50 mg once daily. She is scheduled to have a colonoscopy and she is advised to purchase a sodium phosphate bowel preparation (Fleet Phospho-Soda). All but which of the following put her at increased risk for phosphate nephropathy or acute kidney injury? A. Chronic kidney disease B. Ramipril therapy C. Metoprolol therapy D. Diuretic therapy

C

8. Which of the following human immunodeficiency virus (HIV) medications has been most associated with lactic acidosis? A. Rilpivirine B. Efavirenz C. Stavudine D. Elvitegravir E. Delavirdine

C

9. An adult female presents with asymptomatic hypocalcemia secondary to vitamin D deficiency. She has no kidney or hepatic impairment. Which of the following is the most appropriate therapy to initiate at this time? A. Calcitriol B. Doxercalciferol C. Ergocalciferol D. Paricalcitol

C

A patient presents to your clinic with symptoms including confusion, hypertension, short QT interval, constipation and polydipsia. What electrolyte abnormality does this likely represent? a. Hyperphosphatemia b. Hypophosphatemia c. Hypercalcemia d. Hypocalcemia

C

Generally speaking, which of the following factors ENHANCE the removal of medications during dialysis?I. Low VdII. High protein bindingIII. Low molecular weight A.I only B.II only C.I & III D.II, & III

C

Question 2: The ED resident calls you and asks you to send 3% sodium chloride to the ED STAT for CB's hyponatremia. You are reviewing the chart and see that CK has chronic hyponatremia and that she is asymptomatic. What do you do? A. Send the 3% sodium chloride STAT B. Recommend LR STAT instead C. Recommend no acute treatment for hyponatremia

C

Question 2: Which of the following IV fluids is hypotonic? A. Normal saline B. 3% sodium chloride solution C. D5W D. Albumin 5%

C

Question 4: Which of the following fluids is NOT a colloid? A. FFP B. Albumin 5% C. ½ NS D. Hetastarch 6%

C

Which of the following formulations can be taken without food? a. Tums b. Caltrate c. Citracal d. Oscal

C

Which of the following iron preparations requires a test dose because of the high association with anaphylactic reactions? A.Sodium ferric gluconate B.Iron sucrose C.Iron Dextran D.Iron Polysaccharide

C

Which of the following is not an appropriate treatment for hyperphosphatemia? a. Dialysis b. Ferric citrate 2 mg TID c. Denosumab 120 mg every 4 weeks d. Calcium acetate 1334 mg TID with meals

C

Pt KB is a 38 yo M who presents with severe headache and he is breathing very quickly. He is also complaining of severe abdominal pain. His ABG shows pH of 7.32, HCO3- 20 mEq/L, pCO2 35 mmHg. Upon questions, he reports that he consumed antifreeze with his friends a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis Normal or High Anion Gap? a. High b. Normal

C, A

Pt HK presents with severe diarrhea. She states that she was diagnosed with COVID19 about a week ago and has barely left the bathroom since. She is unable to eat anything and feels very fatigued and confused. a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis Normal or High Anion Gap? a. High b. Normal

C, B

RG's nurse calls you and asks you to verify the patient's STAT potassium order. She also wants to know how quickly she can run the potassium chloride into the patient's IV. RG's electrolyte orders and documented IV lines are below. The patient is on continuous cardiac monitoring on the telemetry unit. Orders: • Potassium chloride 40mEq in 500mL of NS • Magnesium sulfate 2g in 100mL of sterile water Lines: • PICC line (peripherally inserted central catheter) • Peripheral line Question 1: Based on the policy, can the potassium chloride be administered peripherally? If so, how fast can it be administered in a peripheral line? A. The potassium cannot be administered in a peripheral line B. The potassium can be administered in a peripheral line over 1 hour C. The potassium can be administered in a peripheral line over 2 hours D. The potassium can be administered in a peripheral line only if it is run slowly over 24 hours Question 2: Based on the policy, can the potassium chloride be administered centrally? If so, how fast can it be administered in a central line? A. The potassium cannot be administered in a central line B. The potassium can be administered in a peripheral line over 1 hour C. The potassium can be administered in a peripheral line over 2 hours D. The potassium can be administered in a peripheral line only if it is run slowly over 24 hours Question 3: If the physician placed an order for a 2 liter per day fluid restriction and asked you to reduce volumes in the patient's IVs, which of the following would be an appropriate concentration of potassium that could be administered to RG? A. Potassium chloride 10mEq/100mL B. Potassium chloride 40mEq/250mL C. Potassium chloride 20mEq as an IV push D. The potassium cannot be concentrated further You call RG's nurse to tell her how fast she is able to run the potassium. She is now wondering if she can run the potassium and the magnesium into the same line or if she will need to hang them separately. Question 4: What do you tell the nurse about running the potassium and magnesium into the same line? A. The potassium and magnesium must be administered into different lines B. The potassium and magnesium can be administered in the same line

C, C, B, B

History: RG is a 75yo female presenting to the ED with weakness, fatigue, and muscle cramping in her legs. She recently had worsening leg edema and has doubled her furosemide dose for the last 3 days at the direction of her PCP. EKG: • QTc prolongation concerning for Torsades Labs: • Na 135mEq/L • K 2.2 mEq/L • Cl 100 mEq/L • BUN 31 mg/dL • SCr 1.5 mg/dL Question 1: What electrolyte abnormality does this patient have? A. Hypomagnesemia B. Hyponatremia C. Hypokalemia D. Hyperkalemia Question 2: Considering the patient's EKG changes and potassium level, which replacement strategy would be most appropriate for acute treatment? A. Potassium chloride 40mEq PO BID x 3 days B. Potassium chloride 20mEq PO x 1 dose C. Potassium chloride 40mEq IV x 1 dose D. Potassium chloride 10mEq IV x 2 doses Question 3: The following day, if RG's potassium is not within normal limits despite IV potassium replacement and discontinuation of furosemide. What other lab test would you order? A. Liver function tests B. Magnesium C. Phosphate Question 4: Which electrolyte imbalances is RG experiencing now? A. Hypernatremia B. Hypokalemia C. Hypermagnesemia D. Hypomagnesemia E. RG's electrolytes are normal F. B and D Question 5: Which electrolyte replacement strategy would be appropriate for this patient's hypomagnesemia? A. Magnesium sulfate 2g IV x 1 dose B. Magnesium citrate 300mL x 1 dose C. Magnesium oxide 400mg daily D. No treatment, this will resolve when hypokalemia resolves

C, C, B, F, A

History: BT is an 85 year old male found patient down in bathroom at home. 3 day history of nausea, vomiting and lethargy. Records show BT has renal impairment and started lisinopril 40mg daily 3 weeks ago. All electrolytes on lab draw from 6 weeks ago are normal. EKG: • Peaked T waves and shortening of QT interval. Labs: • Na 137mEq/L • K 8 mEq/L • Cl 107 mEq/L • BUN 30 mg/dL • Mg 2.0 mEq/L • SCr 1.6 mg/dL Question 1: BT's labs show he has which electrolyte abnormality? A. Hypernatremia B. Hypomagnesemia C. Hyperkalemia D. Hypokalemia Question 2: The ED physician would like to start treatment for BT's hyperkalemia. Which treatment would you recommend to be given first? A. Insulin B. IV dextrose C. Magnesium sulfate D. Calcium gluconate Question 3: Giving calcium gluconate will start to lower the serum potassium immediately. A. True B. False Question 4: The ED physician would like to start treatment for BT's hyperkalemia. Which treatment would you recommend to be given second? A. Insulin B. IV dextrose C. Magnesium sulfate D. Calcium gluconate Question 5: The purpose of giving IV dextrose and insulin is to... A. Prevent seizures B. Shift potassium to the extracellular space C. Lower the patient's blood glucose D. Shift potassium to the intracellular space

C, D, B, B, B

What can polycystic ovarian syndrome cause and how is it treated?

Causes excess of androgens and other hormonal imbalances. Treatment: Spironolactone with oral contraceptives

How do you treat hypercalcemia in primary hyperparathyroidism or those with secondary hyperparathyroidism due to renal failure?

Cinacalcet (Sensipar) 30mg BID

Colloid or Crystalloid?- 5% Albumin

Colloid

Colloid or Crystalloid?- Dextran

Colloid

Colloid or Crystalloid?- Packed Red blood cells (PRBC)

Colloid

Colloid or Crystalloid?-Hetastarch 6%

Colloid

Colloid or Crystalloid?- 0.9% NaCl (NS)

Crystalloid

Colloid or Crystalloid?- 5% Dextrose 0.45% NaCl

Crystalloid

Colloid or Crystalloid?- Dextrose 5% (D5W)

Crystalloid

Colloid or Crystalloid?- Lactated Ringers

Crystalloid

__________are intravenous fluids that can contain water, dextrose, Na+, Cl-, and other electrolytes.

Crystalloids

1. Risk factors for the development of CKD include which of the following: A. Family history of CKD and diabetes B. Obesity and hypertension C. Low birth weight and low education level D. A and B E. All of the above

D

11. An adult female with stage 4 chronic kidney disease is treated for iron deficiency anemia with ferric carboxymaltose 750-mg IV. She reports significant myalgias and weakness one week after the infusion. Which of the following electrolyte disorders is the most likely the cause of her symptoms? A. Hypercalcemia B. Hypocalcemia C. Hyperphosphatemia D. Hypophosphatemia

D

4. A 68-year-old man, KL (weight = 70 kg; height = 69 in. [175 cm]), with a long-standing history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is as follows: pH 7.30, PCO2 34 mm Hg (4.5 kPa), HCO3− 15 mEq/L (mmol/L), and PO2 80 mm Hg (10.6 kPa), and his most recent serum labs demonstrate Na 135 mEq/L (mmol/L), K 5.4 mEq/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. His acid-base disturbance is: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis (with a normal anion gap) E. Metabolic acidosis (with an elevated anion gap)

D

4. Patients with CKD and an eGFR<60 mL/min/1.73 m2 who have severe vomiting, diarrhea, or are dehydrated should be instructed to hold which of the following medications? A. Enalapril B. Metformin C. Furosemide D. Spironolactone E. All of the above

D

5. A 68-year-old man, KL (weight = 70 kg; height = 69 in. [175 cm]), with a long-standing history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is as follows: pH 7.30, PCO2 34 mm Hg (4.5 kPa), HCO3− 15 mEq/L (mmol/L), and PO2 80 mm Hg (10.6 kPa), and his most recent serum labs demonstrate Na 135 mEq/L (mmol/L), K 5.4 mEg/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. Which of the following conditions best explains his current acid-base status? A. Diabetic ketoacidosis B. Septic shock C. Proximal (type II) renal tubular acidosis (RTA) D. Distal (type IV) RTA E. Type I RTA

D

6. According to KDIGO guidelines, what is the blood pressure target in a patient with CKD and a urinary albumin-to-creatinine u(ACR) of 22 mg/g (2.5 mg/mmol)? A. ≤125/75 mm Hg B. ≤130/80 mm Hg C. ≤135/85 mm Hg D. ≤140/90 mm Hg E. ≤150/90 mm Hg

D

7. A 68-year-old man, KL (weight = 70 kg; height = 69 in. [175 cm]), with a long-standing history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is as follows: pH 7.30, PCO2 34 mm Hg (4.5 kPa), HCO3− 15 mEq/L (mmol/L), and PO2 80 mm Hg (10.6 kPa), and his most recent serum labs demonstrate Na 135 mEq/L (mmol/L), K 5.4 mEq/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. A decision is made to administer IV sodium bicarbonate to KL. What is the most appropriate sodium bicarbonate loading dose to administer? A. 1,026 mEq/L (mmol/L) B. 833 mEq/L (mmol/L) C. 595 mEq/L (mmol/L) D. 315 mEq/L (mmol/L) E. 168 mEq/L (mmol/L)

D

J.A. is a 38 yo female with ESRD receiving peritoneal dialysis. The most recent laboratory analysis reveals the following: Phosphorus 7.4mg/dL (2.5-4.5mg/dL), Calcium 9.0mg/dL (8.5-10.5mg/dL), albumin 2.5mg/dL, iPTH 542 pg/mL (10-60pg/mL), ABG: pH 7.33 (7.35-7.45), pCO2 - 34mm Hg (35-45mm Hg), HCO3 20mEq/L (22-35mEq/L), pO2-97mm Hg (80-100mm Hg). In addition to dietary restriction, which one of the following agents is best for initial management of J.A.'s hyperphosphatemia? A.Calcium carbonate (Tums) B.Aluminum hydroxide (Alu-Cap) C.Calcium Acetate (PhosLo) D.Sevelamer carbonate (Renvela)

D

TW is a 41 yo male on hemodialysis (HD) started on an epoetin dose of 3,500 units IV three times weekly 4 weeks ago. The Hgb at the time of dosing was 9.5g/dL . The current Hgb is 11.3 g/dL. Iron indices reveal the following: ferritin 225ng/mL (30-400ng/L), Tsat 35% (15-50%). Which of the following options is most appropriate for NT? A.Oral Ferrous sulfate 325mg B.1 gm sodium ferric gluconate divided over eight hemodialysis sessions C.Increase epoetin alfa dose by 25% and recheck Hgb in 1-2 weeks D.With hold epoetin alfa therapy until hemoglobin decreases to 10g/dL

D

What agent is preferred in refractory hypercalcemia in a patient with severe renal dysfunction? a. Pamidronate b. Calcitonin c. Zoledronic acid d. Denosumab

D

Which formulation of Vitamin D supplementation does not require activation? a. Cholecalciferol b. ergocalciferol c. Calcifidiol d. Calcitriol

D

Pt FR presents with complaints of GERD. He reports that he has been taking handfuls of tums multiple times a day to control his stomach aches. Upon questioning, he is confused and appears to be breathing slowly. pH=7.50 pCO2=53 mmHg, HCO3-=41.3 mmol/L a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis Compensation? a. Yes b. No

D, A

Match the following crystalloid intravenous solutions with the correct statement: Equivalent to "Free Water"

D5W

Match the following crystalloid intravenous solutions with the correct statement: Metabolized to water and carbon dioxide

D5W

10. A 31-year-old man presents with lethargy, weakness, labored respiration, and confusion. He has had diabetes for 15 years, and has been suffering from the "intestinal flu" for a day or so, for which he has been avoiding food to help prevent further vomiting and "make his stomach ache go away." Since he stopped eating, he thought that it would be a good idea to stop taking his insulin. When seen in the emergency department his urine dipped positive for both glucose and ketones and his breath had a strange sweet, fruity smell. The following arterial blood gas data was obtained: pH 7.27, PCO2 23 mm Hg (3.1 kPa), and HCO3− 10 mEq/L (mmol/L). His most recent serum chemistries are as follows: Na 132 mEq/L (mmol/L), Cl 83 mEq/L (mmol/L), K 4.9 mEq/L (mmol/L), and glucose 345 mg/dL (19.1 mmol/L). His acid-base disturbance is: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis (normal anion gap) E. Metabolic acidosis (elevated anion gap)

E

10. A patient with ESRD on hemodialysis (HD) has had a PTH of 500 pg/mL (ng/L; 54 pmol/L) for the past 3 months, a phosphorus of 7.4 mg/dL (2.39 mmol/L), a calcium of 9.8 mg/dL (2.45 mmol/L), and an albumin of 3 g/dL (30 g/L). She currently receives calcitriol 1 mcg IV three times weekly with HD, calcium acetate 1,334 mg three times daily with meals, and ergocalciferol 50,000 IU once weekly. Which of the following is most appropriate to control her CKD-MBD? A. Discontinue the calcium acetate and begin a 2-month course of aluminum hydroxide with meals B. Increase the calcium acetate to 2,001 mg with meals C. Increase the calcitriol dose to 1.5 mcg IV three times weekly D. Change the calcium acetate to calcium carbonate E. Discontinue the calcium acetate and begin lanthanum carbonate

E

11. A 31-year-old man presents with lethargy, weakness, labored respiration, and confusion. He has had diabetes for 15 years, and has been suffering from the "intestinal flu" for a day or so, for which he has been avoiding food to help prevent further vomiting and "make his stomach ache go away." Since he stopped eating, he thought that it would be a good idea to stop taking his insulin. When seen in the emergency department his urine dipped positive for both glucose and ketones and his breath had a strange sweet, fruity smell. The following arterial blood gas data was obtained: pH 7.27, PCO2 23 mm Hg (3.1 kPa), and HCO3− 10 mEq/L (mmol/L). His most recent serum chemistries are as follows: Na 132 mEq/L (mmol/L), Cl 83 mEq/L (mmol/L), K 4.9 mEq/L (mmol/L), and glucose 345 mg/dL (19.1 mmol/L). Which of the following statements is true regarding the expected compensation for his acid-base disturbance? A. Compensation will occur within days by the renal excretion of bicarbonate. B. Compensation will occur within days by renal reabsorption of bicarbonate. C. Compensation will occur within hours by increasing the respiratory rate. D. Compensation will occur within hours by decreasing the respiratory rate. E. None of the above is TRUE.

E

15. Which of the following therapies would be most likely administered to a patient with a sodium chloride-resistant metabolic alkalosis? A. Acetazolamide B. Arginine monohydrochloride C. Ammonium chloride D. IV hydrochloric acid E. Spironolactone

E

3. A 31-year-old man, LG, was found to be unresponsive and apneic by an off-duty nurse a block away from the emergency department where she works. He was quickly brought to the emergency department where an arterial blood gas (ABG) sample revealed the following: pH 7.08, PCO2 80 mm Hg (10.6 kPa), and HCO3− 23 mEq/L (mmol/L). His most recent serum labs demonstrated Na 130 mEq/L (mmol/L); Cl 111 mEq/L (mmol/L), and TCO2 23 mEq/L (mmol/L). Following the administration of naloxone 10 mg IV × 1 to LG, which of the following statements is most true regarding the expected compensation for his acid-base disturbance? A. Compensation will occur over the next 2 hours by the renal accumulation of bicarbonate. B. Compensation will occur over the next 24 hours as his respiratory rate decreases. C. Compensation will occur over the next 24 hours as his respiratory rate increases. D. Compensation will occur over the next 2 hours by the renal elimination of bicarbonate. E. Compensation will occur over the next 2 hours as his respiratory rate increases.

E

Alkalosis shifts K from _______ to ________

EC, IC

Beta Agonist shifts K from _______ to ________

EC, IC

Insulin shifts K from _______ to ________

EC, IC

Describe the pathophysiology of primary hyperaldosteronism and how it is treated.

Elevated aldosterone leads to retention of Na and fluid causing a reduction in renin due to increased blood volume, ultimately increasing BP. Treatment: Spironolactone Eplerenone Surgery (adrenalectomy)

Describe the pathophysiology of acute mountain sickness and how it is treated.

High altitude leads to less O2, blood vessel constriction, and fluid leakage into the lungs causing pulmonary edema. Treatment: Acetazolamide

Acidosis shifts K from _______ to ________

IC, EC

Beta Antagonist shifts K from _______ to ________

IC, EC

How is hypocalcemia treated in the case of Hypoparathyroidism?

IV & oral calcium or oral vitamin D.

What are inactive/active forms of Vitamin D supplementation?

Inactive: Ergocalciferol Cholecalciferol Calcifidiol Active: Doxercalciferol Calcitriol

What is glaucoma and how is it treated?

Increase in intraocular pressure causing visual field loss due to alterations of the optic disk. Treatment: Carbonic anhydrase inhibitors Systemic: Acetazolamide methazolamide Topical: Dorzolamide, brinzolamide

In treating a patient with hypercalcemia with hydration and furosemide, what labs should you monitor?

K, Mg, Na, Cl

This is a crystalloid that contains mostly Na+ and Cl-, but also lactate, K+, and Ca++

Lactated Ringers

Match the following crystalloid intravenous solutions with the correct statement: Considered a more "physiologic" source of Cl-

Lactated Ringers (LR)

Match the following crystalloid intravenous solutions with the correct statement: Historically preferred for fluid resuscitation in surgery/trauma patients

Lactated Ringers (LR)

Match the following crystalloid intravenous solutions with the correct statement: Metabolized to bicarbonate and can theoretically be useful for metabolic acidosis

Lactated Ringers (LR)

How do you treat mild-severe hypophosphatemia?

Mild to Moderate: Skim milk Neutra-phos/K K Phos neutral Fleet Phosphosoda Severe: IV phosphorus

How are NaCl, Ca2+, Mg2+ reabsorbed through the thick ascending limb?

NaCl: Na+K+2Cl- symporter channel. Ca/Mg: Passive diffusion through paracellular tight junctions

Chief Complaint "I feel tired, nauseated, and constipated." HPI Jane Lopez is a 42-year-old woman who presents to the outpatient dialysis center for her routine HD treatment. She has ESRD secondary to hypertension and has been on HD for 4 years. She has a failed AV fistula and graft and is currently dialyzed via central venous catheter. She has an upcoming appointment with the vascular surgeon to reevaluate her HD access. She also frequently leaves HD 30-60 minutes early against medical advice. PMH ESRD secondary to HTN Anuria HTN Anemia Secondary hyperparathyroidism H/O gestational diabetes 12 years ago GERD PSH Cesarean section 12 years ago Tubal ligation 10 years ago AV fistula creation 5 years ago (failed) AV graft creation 3 years ago (failed) FH Father died of MI at age 60. Mother deceased due to breast cancer. No siblings. Has a 12-year-old son in good health. SH Married, lives with husband and a 12-year-old son. Occasional social alcohol use. Smokes 1/2 ppd (decreased from one ppd × 10 years). Denies caffeine consumption. ROS Complains of feeling tired and weak over the past several weeks. Reports some swelling in feet and lower legs. Also reports constipation, nausea, and heartburn. Meds Furosemide 80 mg PO daily Metoprolol tartrate 50 mg PO BID Lisinopril 20 mg PO daily Calcium acetate 667 mg three caps PO TID with meals Nephro-Vite PO daily Omeprazole 20 mg PO daily Ferrous sulfate 325 mg PO TID Docusate 100 mg PO daily PRN Calcium carbonate PO PRN heartburn Epoetin alfa 10,000 units IV three times weekly with dialysis (dose stable for 3 months) Iron sucrose 50 mg IV once weekly at dialysis Calcitriol 0.5 mcg PO three times weekly with dialysis All NKDA Physical Examination Gen The patient is a WDWN Hispanic woman in NAD who appears her stated age. VS BP 175/88 mm Hg (predialysis); 149/89 mm Hg (postdialysis) Wt 195 lb (88.6 kg) predialysis; 177 lb (84.0 kg) postdialysis P 91 bpm, RR 16, T 36.5°C; Ht 5′4″ (163 cm) Skin Dry, scaly arms and legs HEENT PEERLA, EOMI, TMs intact Neck/Lymph Nodes Supple, no adenopathy, no thyromegaly Lungs/Thorax Clear, breath sounds normal CV RRR, no murmurs, no bruits Abd Soft, NT/ND Genit/Rect Deferred Ext Mild bilateral lower extremity edema Neuro Labs Favorite Table | Download (.pdf) | Print Na 143 mEq/L Hgb 9.3 g/dL AST 21 IU/L Alb 3.0 g/dL K 4.3 mEq/L Hct 27.5% ALT 4 IU/L Ca 9.7 mg/dL Cl 95 mEq/L CO2 26 mEq/L RBC 2.84 × 106/mm3 LDH 139 IU/L Alk phos 175 IU/L Phos 6.7 mg/dL iPTH 855 pg/mL BUN 59 mg/dL MCV 81.8 m3 T. bili 0.3 mg/dL T. sat 12% SCr 8.9 mg/dL Glu 88 mg/dL MCHC 32.4 g/dL WBC 5.7 × 103/mm3 Ferritin 99 ng/mL Mrs Lopez's nephrologist provided the following dialysis prescription: Dialyze 3.5 hours per session, three times per week (T, Th, Sat, morning shift) Estimated dry weight: 83.5 kg Dialyzer: F180 (high flux) Blood flow rate: 400 mL/min Dialysate flow rate: 800 mL/min Dialysate: Bicarbonate Na 145 mEq/L, K 2.0 mEq/L, Ca 2.5 mEq/L, HCO3 35 mEq/L Heparin: 5000 unit IV bolus, and then 1000 units/hr until 1 hour before termination

Objective information: eGFR=5 mL/min Hgb -9.3g/dL (>12 g/dL) Low iron indices: ferritin 99ng/mL (30-400ng/L), Tsat 12% (15-50%) Albumin: 3.0 g/dL (3.4-5.4 g/dL) Ca2+: 9.7 mg/dL (8.5-10.5 mg/dL) Corrected: 10.5 mg/dL P: 7.4 mg/dL (2.5-4.5 mg/dL) iPTH: 855 pg/mL (10-60 pg/mL) Elevated BP Subjective: Tired, nauseated, anuric, requiring HD, taking ESA, taking phosphate binder, taking Vit D supplement Additional information: Previous laboratory values to identify trends: Hgb, Ferritin/Tsat, Ca, Albumin, nondialysis day blood pressure, medication adherence. Assess the severity: G5 kidney failure GFR<15 mL/min/1.73 m2 Problem list 1) Uncontrolled HTN despite 3 BP medications: inappropriate medication (furosemide) 2) CKD-associated anemia with need to optimize iron replacement: Low, Hgb, RBC, MCV, and MCHC. Symptomatic-feeling tired and week. Oral Fe generally not effective for HD patients. Weekly IV Fe sucrose maintenance dose is low. 3) CKD-MBD- hypercalcemia, hyperparathyroidism, hyperphosphatemia: Possibly exacerbated by calcium acetate, calcium carbonate, and calcitriol. 4) Constipation, possible secondary to adverse effect of oral calcium and iron therapies. Fluid restrictions may be contributing as well. 5) GERD with inadequate control Pharmacotherapy in this case: 1) HTN: reduce CV morbidity/mortality. BP<130/80, Pre-dialysis <150/85; Post-dialysis >110/70 2) CKD associated Anemia: Reduce signs and symptoms, reduce need for blood transfusions, reduce complications: LVH/hospitalization. ESA Goal Hgb: 11g/dL. Iron therapy- correct iron deficiencies, lowest ESA dose. 3) CKD-MBD: prevent renal osteodystrophy and metastatic calcification. Improve iPTH and Phos without causing hypercalcemia. What non drug therapies might be useful? 1) CKD associated anemia: Blood transfusion (not in this case) 2) CKD-MBD: Hyperphosphatemia-dietary restrictions. Hypercalcemia: low calcium dialysate (2.5 mEq/L) and dietary restrictions. Hyperparathyroidism: parathyroidectomy is an option (not in this case) Developing Care Plan: 1) HTN: D/C furosemide-(not effective in anuric pts.), increase metoprolol & or lisinopril dose, or adjust HD schedule (to reduce intradialytic fluid gains) 2) Anemia: D/C oral iron- not effective in HD pts., parenteral iron-replacement is needed (1000 mg over 10 sessions) 3) CKD-MBD: Change to a non-calcium phosphate binder, Parenteral iron-replacement is needed (1000 mg over 10 sessions), change to Vit D analog &/or calcimimetic. Create Pt. Centered Plan 1) Initiate sodium and fluid restrictions: 1-2 g of Na per day. 1 liter or water per day. Complete prescribed HD sessions. D/C furosemide. D/C metoprolol tartrate. Start metoprolol succinate 100 mg QHS. Continue lisinopril 20 mg Qam. Check BP once daily at home in between HD sessions. 2) Start repletion dose of iron sucrose 100 mg as slow IV injection over 2-5 minutes at each HD session x 10 doses (total dose = 1000 mg). Monitor Hgb and iron indices 2 x per month. 3) D/C calcium acetate, initiate sevelamer carbonate 800 mg 3 tabs TID with meals. D/C calcitriol, initiate Zemplar 10 mcg IV per HD session, consider cinacalcet in no improvements in iPTH goal. Monitor phos, Ca2+, iPTH weekly. 4) D/C calcium acetate and ferrous sulfate. Encourage her to use docusate daily. 5) Stress adherence to omeprazole, consider increasing omeprazole to 20 mg BID, and encourage her to use docusate daily.

How do you treat cerebral edema? What requirement is necessary for this treatment to have an effect?

Osmotic diuretics: Mannitol, urea, glycerol Requires an intact BBB

Describe the pathophysiology of refeeding syndrome. What does it ultimately cause?

Phosphate stores are depleted during malnutrition. Nutritional replenishment causes an influx of glucose causing release of insulin. This increases the need for phosphate which is pulled intracellularly leading to hypophosphatemia.

How do you treat Symptomatic Hypercalciuma with life-threatening EKG changes, tetany, or pancreatitis for severe renal insufficiency and functioning kidneys?

Renal insufficiency: Hemodialysis (low calcium bath) Calcitonin Glucocorticoid Functioning kidneys: Saline rehydration Loop diuretic Hemodialysis Calcitonin Glucocorticoid Gallium nitrate

How do you treat Asymptomatic Hypercalcemia with Serum Calcium >12mg/dL and those with non-life-threatening symptoms?

Saline rehydration Loop diuretic Calcitonin Glucocorticoid IV bisphosphonate Mithramycin

What is the normal range of Serum Ca levels? ionized Ca? What is the corrected calcium equation in mg/dL?

Serum: 8.5-10mg/dL Ionized Ca >4.4 mg/dL Corrected Sca=Measured Ca+(0.8*[4g/dL-measured albumin (g/dL)])

How do you treat severe or asymptomatic hyperphosphatemia?

Severe: Dialysis Asymptomatic: Phosphate binders Ca salts Aluminum salts (Amphogel, Alu-Cap, Dilume)

This is a cation-exchange resin used for the treatment of mild to moderate hyperkalemia.

Sodium polystyrene

Which of the following is the primary goal of IV fluid resuscitation? a.Restore intravascular volume and prevent organ hypoperfusion b.Restore oncotic pressure and prevent tissue perfusion c.Restore metabolic imbalance and prevent congestive heart failure

a

Which of the following is true regarding sodium polystyrene sulfonate (Kayexalate)? (select all that apply) a.Available in oral dosage forms b.Can be administered rectally as a retention enema c.Should be mixed with water, 10% dextrose, and sorbitol for rectal administration d.Has a rapid onset

a,b

Which of the following general statements are TRUE? (select all that apply) a.Colloids may be considered after fluid resuscitation with a crystalloid has failed to achieve hemodynamic goals b.Colloids are fewer potential adverse effects than crystalloids c.Colloids are associated with higher costs d.Colloids have been shown to be superior to crystalloids for IV fluid resucitation e.There is no difference between crystalloids and colloids in the time to achieve fluid resuscitation.

a,c,e