Pharm III Renal Practice Questions

A 62-year-old man with advanced prostate cancer is admitted to the emergency department with mental obtundation. An electrolyte panel shows a serum calcium of 16.5 (normal 8.5-10.5 mg/dL). Which of the following therapies would be most useful in the management of severe hypercalcemia? A- Acetazolamide plus saline infusion B- Furosemide plus saline infusion C- Hydrochlorothiazide plus saline infusion D- Mannitol plus saline infusion E- Spironolactone plus saline infusion

B-Furosemide plus saline infusion:Diuretic therapy of hypercalcemia requires a reduction in calcium reabsorption in the thick ascending limb, an effect of loop diuretics. However, a loop diuretic alone would reduce blood volume around the remaining calcium so that serum calcium would not decrease appropriately. Therefore, a saline infusion should accompany the loop diuretic.

A 55-year-old male with kidney stones has been placed on a diuretic to decrease calcium excretion. However, after a few weeks, he develops an attack of gout. Which diuretic was he taking? A. Furosemide. B. Hydrochlorothiazide. C. Spironolactone. D. Triamterene. E. Urea.

B. Hydrochlorothiazide is effective in increasing calcium reabsorption, thus decreasing the amount of calcium excreted, and decreasing the formation of kidney stones that contain calcium phosphate or calcium oxalate. However, hydrochlorothiazide can also inhibit the excretion of uric acid and cause its accumulation, leading to an attack of gout in some individuals. Furosemide increases the excretion of calcium, whereas the K+-sparing osmotic diuretics, spironolactone and triamterene, and urea do not have an effect.

Which of the following should be avoided in a patient with a history of severe anaphylactic reaction to sulfa medications? A. Amiloride. B. Hydrochlorothiazide. C. Mannitol. D. Spironolactone. E. Triamterene.

B. Hydrochlorothiazide, like many thiazide and thiazide-like diuretics, contains a sulfa moiety within its chemical structure. It is important to avoid use in those individuals with severe hypersensitivity to sulfa medications. It may be used with caution, however, in those with only minor reaction to sulfa medications.

A 60-year-old patient complains of paresthesias and occasional nausea associated with one of the drugs she is taking. She is found to have hyperchloremic metabolic acidosis. She is probably taking A- Acetazolamide for glaucoma B- Amiloride for edema associated with aldosteronism C- Furosemide for severe hypertension and heart failure D- Hydrochlorothiazide for hypertension E- Mannitol for cerebral edema

A- Acetazolamide for glaucoma: Paresthesias and gastrointestinal distress are common adverse effects of acetazolamide, especially when it is taken chronically, as in glaucoma. The observation that the patient has metabolic acidosis also suggests the use of a carbonic anhydrase inhibitor like acetazolamide.

A 70-year-old retired businessman with a history of chronic heart failure has been taking digoxin and furosemide. He is now admitted with a history of vomiting, acute decompensated heart failure, and metabolic derangements. He has marked peripheral edema and metabolic alkalosis (pH, 7.50; pCO2, 45; HCO3, 36; Na+, 140). Which of the following drugs is most appropriate for the treatment of his edema? A- Acetazolamide B- Digoxin C- Eplerenone D- Hydrochlorothiazide E- Tolvaptan

A- Acetazolamide: Although acetazolamide is rarely used in heart failure, carbonic anhydrase inhibitors are quite valuable in patients with edema and metabolic alkalosis. The high bicarbonate levels in these patients make them particularly susceptible to the action of carbonic anhydrase inhibitors. Digoxin is useful in chronic systolic failure but is not first-line therapy and may cause vomiting, with depletion of stomach acid and reduced serum chloride; increasing the digoxin dose might cause arrhythmias. Tolvaptan might be useful if the patient were hyponatremic. Hydrochlorothiazide and eplerenone are not adequate for first-line therapy of edema in acute heart failure.

A 50-year-old man has a history of frequent episodes of renal colic with calcium-containing renal stones. A careful workup indicates that he has a defect in proximal tubular calcium reabsorption, which results in high concentrations of calcium salts in the tubular urine. The most useful diuretic agent in the treatment of recurrent calcium stones is A- Chlorthalidone B- Diazoxide C- Ethacrynic acid D- Mannitol E- Spironolactone

A-Chlorthalidone: The thiazides are useful in the prevention of calcium stones because these drugs reduce tubular calcium concentration, probably by increasing passive proximal tubular and distal convoluted tubule reabsorption of calcium. In contrast, the loop agents (choice C) facilitate calcium excretion. Diazoxide is a thiazide-like vasodilator drug but has no diuretic action; in fact, it may cause sodium retention. It is used in hypertension and insulinoma

A 62-year-old woman is being treated for chronic congestive heart failure. She has been put on hydrochlorothiazide therapy. Her serum electrolyte levels are being monitored and show a persistent hypokalemia. What would be most appropriate to add to her therapeutic regimen? A- Acetazolamide B- Amiloride C- Furosemide D- Indapamide E- Mannitol

Amiloride

How is spironolactone beneficial in HF? A. Promotes potassium secretion. B. Agonizes aldosterone. C. Prevents cardiac hypertrophy. D. Decreases blood glucose.

C. Spironolactone antagonizes aldosterone, which in turn prevents salt/water retention, cardiac hypertrophy, and hypokalemia. Spironolactone has endocrine effects on hormones but not on glucose.

An elderly patient with a history of heart disease is brought to the emergency room with difficulty breathing. Examination reveals that she has pulmonary edema. Which treatment is indicated? A. Acetazolamide. B. Chlorthalidone. C. Furosemide. D. Hydrochlorothiazide. E. Spironolactone.

C. This is a potentially fatal situation. It is important to administer a diuretic that will reduce fluid accumulation in the lungs and, thus, improve oxygenation and heart function. The loop diuretics are most effective in removing large fluid volumes from the body and are the treatment of choice in this situation. In this situation, furosemide should be administered intravenously. The other choices are inappropriate.

Which of the following is an important effect of chronic therapy with loop diuretics? A- Decreased urinary excretion of calcium B- Elevation of blood pressure C- Elevation of pulmonary vascular pressure D- Metabolic alkalosis E- Teratogenic action in pregnancy

D-Metabolic alkalosis: Loop diuretics increase urinary calcium excretion and decrease blood pressure (in hypertension) and pulmonary vascular pressure (in congestive heart failure). They have no recognized teratogenic action. They cause metabolic alkalosis (Table 15-1). Loop diuretics also cause ototoxicity.

A male patient is placed on a new medication and notes that his breasts have become enlarged and tender to the touch. Which medication is he most likely taking? A. Chlorthalidone. B. Furosemide. C. Hydrochlorothiazide. D. Spironolactone. E. Triamterene.

D. An adverse drug reaction to spironolactone is gynecomastia due to its effects on androgens and progesterone in the body. Eplerenone may be a suitable alternative if the patient is in need of an aldosterone antagonist but has a history of gynecomastia.

A 33-year-old man presents with severe thirst and frequent urination; symptoms have been developing over the past month. He claims to consume more than 8 liters of fluids per day. Despite that, he is always thirsty. Fasting blood glucose is 90 mg/dL. On brain MRI, the hyperintensity of the posterior pituitary is absent. What drug is likely used to treat this patient? A- Triamterene B- Desmopressin C- Digoxin D- Verapamil E- Propranolol

Desmopressin

Which of the following diuretics would be most useful in the acute treatment of a comatose patient with traumatic brain injury and cerebral edema? A- Acetazolamide B- Amiloride C- Chlorthalidone D- Furosemide E- Mannitol

E-Mannitol: An osmotic agent is needed to remove water from the cells of the edematous brain and reduce intracranial pressure rapidly

A patient presents to the emergency department with an extreme headache. After a thorough workup, the attending physician concludes that the pain is due to increased intracranial pressure. Which diuretic would work best to reduce this pressure? A. Acetazolamide. B. Indapamide. C. Furosemide. D. Hydrochlorothiazide. E. Mannitol.

E. Osmotic diuretics, such as mannitol, are a mainstay of treatment for patients with increased intracranial pressure or acute renal failure due to shock, drug toxicities, and trauma.

Which diuretic has been shown to improve blood pressure in resistant hypertension or those already treated with three blood pressure medications including a thiazide or thiazide-like diuretic? A. Chlorthalidone. B. Indapamide. C. Furosemide. D. Mannitol. E. Spironolactone.

E. Resistant hypertension, defined by the use of three or more medications without reaching the blood pressure goal, often responds well to aldosterone antagonists. This effect can be seen in those with or without elevated aldosterone levels.

Which Is Contraindicated In A Patient With Hyperkalemia? A. Acetazolamide. B. Chlorthalidone. C. Chlorothiazide. D. Ethacrynic acid. E. Spironolactone.

E. Spironolactone acts in the collect- ing tubule to inhibit Na+ reabsorption and K+ excretion. It is extremely important that patients who are treated with any potassium-sparing diuretic be closely monitored for potassium levels. Exogenous potassium supplementation is usually discontinued when potassium-sparing diuretic therapy is instituted and spironolactone is contraindicated in patients with hyperkalemia. The other drugs promote the excretion of potassium.

An alcoholic male has developed hepatic cirrhosis. To control the ascites and edema, which should be prescribed? A. Acetazolamide. B. Chlorthalidone. C. Furosemide. D. Hydrochlorothiazide. E. Spironolactone.

E. Spironolactone is very effective in the treatment of hepatic edema. These patients are frequently resistant to the diuretic action of loop diuretics, although a combination with spironolactone may be beneficial. The other agents are not indicated.

Which of the following statements about furosemide is NOT true: A- Diuretic resistance can develop with chronic use B- Oral bioavailability varies widely from 10-100% in normal individuals C- CKD results in major alterations in both pharmacokinetics and pharmacodynamics D- A maximally effective dose in the setting of HF is less potent than a maximally effective dose in normal individuals

C- CKD results in major alterations in both pharmacokinetics and pharmacodynamics

Which of the following classes of diuretics DO NOT require access to the tubular lumen for effective action: A- Loop diuretics B- Thiazide-type diuretics C- Mineralocorticoid receptor antagonists D- Osmotic diuretics E- None of the above F- All of the above

C- mineralocorticoid receptor

A 70-year-old woman is admitted to the emergency department because of a "fainting spell" at home. She appears to have suffered no trauma from her fall, but her blood pressure is 120/60 when lying down and 60/20 when she sits up. Neurologic examination and an ECG are within normal limits when she is lying down. Questioning reveals that she has recently started taking "water pills" (diuretics) for a heart condition. Which of the following drugs is the most likely cause of her fainting spell? A- Acetazolamide B- Amiloride C- Furosemide D- Hydrochlorothiazide E- Spironolactone

C-Furosemide: The case history suggests that the syncope (fainting) is associated with diuretic use. Complications of diuretics that can result in syncope include both postural hypotension (which this patient exhibits) due to excessive reduction of blood volume and arrhythmias due to excessive potassium loss. Potassium wasting is more common with thiazides (because of their long duration of action), but these drugs rarely cause reduction of blood volume sufficient to result in orthostatic hypotension.

A 58-year-old woman with lung cancer has abnormally low serum osmolality and hyponatremia. A drug that increases the formation of dilute urine and is used to treat SIADH is A- Acetazolamide B- Amiloride C- Desmopressin D- Ethacrynic acid E- Furosemide F- Hydrochlorothiazide G- Mannitol H- Spironolactone I- Triamterene J- Tolvaptan

J- Tolvaptan: Retention of water with hyponatremia and inability to form dilute urine in the fully hydrated condition is characteristic of SIADH. Antagonists of ADH are needed to treat this condition

A 51-year-old woman who has been in a road traffic accident presents with multiple injuries. She has a urine output of 350 mL over the previous 24 hours. Her serum creatinine level has increased from 4.2 mg/dL to 4.8 mg/dL over the same period. Question: What class of drug could be used to convert this patient's oliguric renal failure to the non-oliguric type and to facilitate further management? A- Potassium-sparing diuretic B- Thiazide diuretic C- Carbonic anhydrase inhibitor D- Loop diuretic E- Osmotic diuretic

Loop diuretic

Of the following, which class of diuretics would be the most effective diuretic in patients with acute renal failure? A- Potassium sparing B- Thiazide C- Carbonic anhydrase inhibitors D- Loop diuretic E- Combination of potassium sparing diuretics and thiazides

Loop diuretic

Match the diuretic to the indication (best answer): a)Loop diuretic b)Thiazide-type diuretic c)Mineralocorticoid receptor antagonist d)Osmotic diuretic e)Carbonic anhydrase inhibitor 1.Hypercalciuria w/ urolithiasis 2.Acute mountain sickness 3.Acutely decompensated heart failure 4.Hyperaldosteronism 5.Head injury w/ acute intracranial pressure elevation

Loop diuretic→ Acutely decompensated heart failure Thiazide-type diuretic→ Hypercalciuria w/ urolithiasis Mineralocorticoid receptor antagonist → Hyperaldosteronism Osmotic diuretic→ Head injury w/ acute intracranial pressure elevation Carbonic anhydrase inhibitor → Acute mountain sickness

A 17-year-old female athlete presents with easy fatigability and weakness. She has been training daily and she has no significant medical history. Her pulse is 55/min, regular, BP 120/80 mm Hg. There are no remarkable findings on a physical examination. Lab reports show the following: Serum Na+ =140 mEq/L. Cl-86 mEq/L. K+ 2.3 mEq/L. HCO3- 34 mEq/L. pH =7.50 Urine Na+ 82 mEq/24 h. K+ 168 mEq/24 h. What is the most likely cause of her condition? A- Anxiety-induced hyperventilation B- Bulimic vomiting C- Misuse of diuretics D- Somatoform disorder E- Use of anabolic steroids

Misuse of diuretics

Where is the primary site of secretion of arginine vasopressin (AVP)? A- Thalamus B- Anterior pituitary C- Adrenal cortex D- Adrenal medulla E- Posterior pituitary (Neurohypophysis)

Posterior pituitary (Neurohypophysis)

A 65-year-old African American man presents in your office for a follow-up for hypertension. 3 months earlier, you prescribed furosemide. He checks his blood pressure daily and states that it is markedly lower since he has been on the medication, but it feels like his heart is skipping a beat once in a while. What deficiency is most likely? A- Sodium B- Potassium C- Vitamin C D- Thiamin E- Riboflavin

Potassium

Some diuretics antagonize the effects of aldosterone at the cortical collecting tubule and the late distal tubule. These drugs are most useful in the therapy of mineralocorticoid excess. Which of the following drugs causes direct pharmacological antagonism of mineralocorticoid receptors? A- Triamterene B- Spironolactone C- Furosemide D- Hydrochlorothiazide E- Amiloride

Spironolactone

A group of college students is planning a mountain climbing trip to the Andes. Which would be appropriate for them to take to prevent mountain sickness? A. A thiazide diuretic such as hydrochlorothiazide. B. An anticholinergic such as atropine. C. A carbonic anhydrase inhibitor such as acetazolamide. D. A loop diuretic such as furosemide. E. A β-blocker such as metoprolol.

C. Acetazolamide is used prophylactically for several days before an ascent above 10,000 feet. This treatment prevents the cerebral and pulmonary problems associated with the syndrome as well as other difficulties, such as nausea.

SC is a 75-year-old white male who has HF. He is seen in clinic today, reporting shortness of breath, increased pitting edema, and a 5-pound weight gain over the last 2 days. His current medication regimen includes losartan and metoprolol succinate. SC has no chest pain and is deemed stable for outpatient treatment. Which of the following is the best recommendation? A. Increase the dose of metoprolol succinate. B. Start hydrochlorothiazide. C. Start furosemide. D. Discontinue losartan.

C. As it is possible that SC is having a HF exacerbation, increasing the dose of the β-blocker is not indicated at this time. There is no reason to stop losartan, based on the information we have. Loop diuretics are preferred over thiazide diuretics when patients require diuresis immediately.

A 75-year-old woman with hypertension is being treated with a thiazide. Her blood pressure responds well and reads at 120/76 mm Hg. After several months on the medication, she complains of being tired and weak. An analysis of the blood indicates low values for which of the following? A. Calcium. B. Glucose. C. Potassium. D. Sodium. E. Uric acid.

C. Hypokalemia is a common adverse effect of the thiazides and causes fatigue and lethargy in the patient. Supplementation with potassium chloride or foods high in K+ corrects the problem. Alternatively, a potassium- sparing diuretic, such as spironolactone, may be added. Calcium, uric acid, and glucose are usually elevated by thiazide diuretics. Sodium loss would not weaken the patient

Which of the following drugs might potentiate the antidiuretic effect of desmopressin (DDAVP)? A- Ethyl alcohol B- Tricyclic antidepressant drugs C- Heparin D- Lithium carbonate E- Propranolol

Tricyclic antidepressant drugs