Os 214 Renal 2nd Exam (a)

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5. The ff is TRUE regarding patients with mild lower urinary tract symptoms by IPSS A. they have scores of less than 10 points B. they will require drug treatment C. they are not at risk of developing prostate adenoCA D. they should be advised to undergo annual DRE Mild LUTS is IPSS grade <7-8. these people require supportive management. Malignant transformation is always possible in NPH.

6. 32/M complains of bloody urine. On cytoscopy, a papillary growth is seen arising from the urinary bladder wall. The biopsy will reveal. A. Transitional cell CA B. Squamous cell CA C. rhabdomyosarcoma D. adenosarcoma Trans urologic emergencies. The most common histology for bladder cancer in adults is transitional cell CA.

13. In male catheterization, foley catheter should be inserted up to A. urine flows out of catheter B. midway C. up to the hub D. 25cm Trans urologic emergencies. In females, 5cm

14. A patient with renal colic will NOT LIKELY A. be restless B. present with urinary urgency and frequency C. complain of nausea and vomiting D. lie still because of severe pain In renal colic, the patients are restless due to severe pain

28. Potter's syndrome is due to anomaly in a. kidney ascent b. kidney induction c. ureteral budding d. --Potter’s syndrome is caused by absence of renal induction

30. A mutation in CAKUT gene X hinders the interaction between ureteric bud and metanephric blastema. Abnormalities in this induction lead to a. dysplastic kidney b. prune belly syndrome c. horseshoe kdney d. renal agenesis Trans CAKUT. No renal induction results in renal agenesis.

36. What suggests a secondary hypertension? a. onset at 40 years old b. family history c. unresponsive to medications in a previously stable hypertension d. --secondary hypertension is more common in the young. A strong history of hypertension in the family suggests essential hypertension

38. In a hypertensive crisis, the ff should be prioritized A. lower BP with IV drugs B. relief of dyspnea with IV drugs C. maintain patency of airways D. control tachycardia (I’m not sure but I think it’s A. According to the trans on HPN in children and adolescents, severe symptomatic HPN should be treated with IV antihypertensive drugs.)

39. In primary aldosteronism, the plasma renin activity (PRA) is A. suppressed B. enhanced C. not affected

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D. any of the above Typical example of primary aldosteronism is an aldosteronesecreting tumor. Renin is suppressed due to negative feedback

41. The gene in VUR is A. nephrin B. uroplakin III C. podocin D. nephrocalcin Trans CAKUT

43. In a 7yo boy presenting with UTI, the best diagnostic imaging modality is A. KUB-UTZ B. retrograde pyelography C. KUB-IVP D. VCUG Trans Interactive Session on UTI. For patients >5 y.o., the modalities used are UTZ and DMSA.

56. Which of the following can cause pseudohyponatremia A. hyperglycemia B. hypergammaglobulinemia C. hypertriglyceridemia D. AOTA Harrison’s p.255t: pseudohyponatremia can be caused by hyperglycemia, hyperproteinemia, and hyperlipidemia

58. Which is NOT TRUE regarding hypernatremia? A. All patients with hypernatremia are hyperosmolar B. It is always associated with dehydration C. it is not seen in normal adults with access to water D. NOTA Sorry, I don’t know the answer but this might help: Trans Fluid & Electrolyte Disturbances, Hypernatremia always represents hyperosmolality [water loss or sodium retention]. It is never seen in an alert adult with access to water unless there’s an abnormal thirst mechanism.

59. In the treatment of hyperkalemia, the following causes increased K+ entry into the cells: A. diuretics B. calcium gluconate C. β2 adrenergic agonists D. cation exchange resins Fluid & Electrolyte Disturbances, Trans last page & Harrison’s. Diuretics increase K+ excretion. Calcium gluconate decreases membrane excitability. Cation exchange resins are the K+:Na+ exchange and K+:Ca++ exchange. When administered parenterally or in nebulized form, β 2-adrenergic agonists promote cellular uptake of K+.

60. In patients with RTA, the anion gap is normal due to: A. hyperchloremia B. hypernatremia C. hyperkalemia D. hypercalcemia Normal anion gap a.k.a. hyperchloremic anion gap

61. Which of the following can cause hyperkalemia in a patient with CRF A. spironolactone B. diuretic C. calcium channel blocker D. α blockers Spironolactone is the diuretic of choice for CRF since it is metabolized in the liver. It spares potassium causing hyperkalemia.

62. LM 43/F with type 2 DM was referred for control of BP. BP=170/100, PR=85/min, (-)edema. Which if the following tests will you order to determine the level of desirable BP for LM? A. CBC

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B. serum potassium C. 24hr creatinine clearance D. 24hr urinary albumin (I’m not sure of this…)

(For 63-64) CE 23/F came in for nausea and vomiting. She was diagnosed with Chronic GN since 2 years ago and is on ARB. BP=140/90, PR=64/min, Wt=50 kg, (+) mild edema, Hgb=120 g/L, serum creatinine=1.8 mg/dL, serum K=4.0 mEq/L. 63. Which of the following is an appropriate management? A. tranfuse blood and observe B. Dialyze and transfuse C. Look for causes of nausea and vomiting and treat D. Give steroid and dialyze (Sorry I don’t know.…)

64 How will you treat CE’s hemoglobin A. transfusion B. iron tablets C. give erythropoietin D. NOTA (Again I’m don’t know… sorry. Based on the trans on chronic renal failure, give erythropoietin if Hgb is 10 g/dl, and transfuse if <10 g/dl. Normal Hgb for females is 12-16 g/dl.)

65. The following diseases can present with normal sized kidneys in ESRD EXCEPT A. chronic GN B. polycystic kidney disease C. Amyloidosis D. DM 66. 54/M with ESRD due to diabetic nephropathy undergoes hemodialysis 3x/week, has computed Kt/V of 1.4 during his last hemodialysis session. He continues to work as a businessman and even plays gold between dialysis days, and complains of no particular symptoms on extensive review A. you would tell the patient that he is being adequately dialyzed B. you would advise the patient that he will need to increase his hemodialysis to daily C. you would consider continuing thrice weekly dialysis but increase the session lengths to 5 hours per session D. you would advise the patient that he no longer needs to continue hemodialysis K/DOQI hemodialysis guideline 4: Kt/V should be at least 1.2

67. Dialysis is able to partially compensate for which of the following native function of the intact kidney A. gluconeogenesis B. increasing erythropoietic activity C. increasing 1α-hydroxylase activity D. excreting metabolic wastes 68. A stable hemodialysis patient’s last session yielded a computed Kt/V of 0.9 (you are confident that the Kt/V computation was properly done). He is on thrice a week hemodialysis. You would: A. lengthen the dialysis session B. use a lower blood flow rate during the session C. shift to a dialyzer with a lower KoA D. tell the patient that he is being adequately dialyzed lowering BFR would lower blood water clearance. Lowering KoA would lower the amt of substance that can pass through the membrane. The pt is not adequately dialyzed Kt/V should be at least 1.2

69. Which of the following complications is expected more in peritoneal dialysis compared to hemodialysis

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A. accumulation of advanced glycation end products B. higher risk of Hepa C infection C. hypocomplementemia D. dialysis dysequilibrium In PD, glucose is used to attract more water into the dialysate. These glucose are turned into AGEPs. All the rest are complications of HD (both short and long-term)

70. Which is not an indication for acute dialysis? A. intractable hyperkalemia B. intractable metabolic acidosis C. severe hyponatremia D. pulmonary edema Trans on Dialysis.

71. In which of the following conditions would immunosuppressive medications be most likely needed in the graft recipient A. transferring a kidney from one site to another in the same individual B. a kidney donated from an identical twin C. a kidney from a fraternal twin sharing placental circulation while in utero D. a kidney donated from an older sister Trans transplantation immuno and therapeutics; the more identical, the less crossmatching, less rejection

72. What is the likelihood that 2 siblings will have identical HLA A. 1% B. 25% C. 50% D. 99% Trans transplantation immuno and therapeutics. Mendelian transmission.

73. What is the primary role of tissue crossmatching in clinical transplantation A. to identify HLA match between donor and recipient B. to detect recipient preformed antibodies against the donor graft C. to detect NK cells from the donor that may harm the recipient D. to identify if the donor kidney hitologically matches in size with the donor kidney D. 99% Trans transplantation immuno and therapeutics. Tissue crossmatching primary role: detect preformed antibodies anti-HLA

74. Which cell is usually involved in the first signal immune response to rejection with the antigen presenting cell A. B lymphocytes B. Helper T-cells C. natural killer cells D. CD8 T-cells Trans transplantation immuno and therapeutics.

75. Which of the following drugs used in transplantation is a calcineurin inhibitor? A. cyclcosporine B. basiliximab C. azathioprine D. prednisone Trans transplantation immuno and therapeutics. The other calcineurin inhibitor is tacrolimus

76. In which of the following conditions will hematuria be most commonly found A. MCD nephrotic syndrome B. myoglobinuria C. kidney stone

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D. diabetic nephropathy 77. Which condition is commonly associated with low C3 A. poststreptoccocal GN B. hypertensive nephropathy C. IgA nephropathy D. thin basement membrane PSGN and MPGN both have activation of complement pathways in their pathogenesis thus there is consumption of complement components

78. Which is more commonly associated with glomerular hematuria than non-glomerular hematuria A. high urine specific gravity B. proteinuria C. clots in the urine D. intact RBCs in the urine Harrisons. Blood clot is almost never indicative of glomerular bleeding; rather it suggests a postrenal source in the urinary collecting system. The RBCs of glomerular origin are often dysmorphic. Hematuria with dysmorphic RBCs, RBC casts, and protein excretion >500mg/d is virtually diagnostic of glomerulonephritis.

79. Which condition is commonly associated with upper respiratory occurring together with nephritis A. diabetic nephropathy B. IgA nephropathy C. post-strep nephritis D. Hepa B associated nephritis Trans on hematuria: The clinical course of IgA nephropathy is synpharyngitic. Emedicine article on Acute Post-strep GN: IgA nephropathy usually presents as an episode of gross hematuria occurring during the early stages of a respiratory illness. Post-strep GN, there’s a latent period between the streptococcal infection and the development of clinical GN.

80. Which of the ff urine culture results is NOT diagnostic of a UTI A. 105 colonies of Klebsiella pneumoniae via a clean catch midstream urine sample B. 102 colonies of Acinetobacter via suprapubic aspirate C. 104 colonies of Proteus via midstream urine sample in a symptomatic child D. 105 colonies of Escherichia coli via a catheterized specimen Midstream catch should yield ≥105 CFU

81. By clinical history, the symptom LEAST LIKELY to be associated with acute uncomplicated cystitis is A. dysuria B. vaginal discharge C. back pain D. hematuria E. urinary frequency (Sorry, I don’t know the answer... Trans Interactive Session on UTI. The classic presentation of Acute Uncomplicated Cystitis (AUC) is dysuria, urinary frequency, and urgency. Also, in the case, there was only suprapubic tenderness with no hematuria, vaginal discharge, and CVA tenderness.)

82. The recommended duration of antibiotic treatment for acute cystitis in otherwise healthy women is A. 1 day B. 3 days C. 7days D. 10 days E. 14 days

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A. amoxicillin B. ceftriaxone C. cefixime D. levofloxacin E. cefuroxime Trans Interactive session on UTI. Amoxicillin is not recommended due to high incidence of resistance in the country.

84. Which is an unlikely cause of UTI A. Enterococcus faecalis B. Proteus mirabilis C. Staphylococcus epidermidis D. Staphylococcus aureus Harrison’s. A, B, D are all associated with UTI. Staph saprophyticus is the other Staph species associated with UTI

85. 35/F executive secretary, consults for a one day history of high grade fever and chills associated with nausea, vomiting, and hypogastric discomfort. Past history is unremarkable. Vital signs: BP=110/60, HR=88/min, RR=16/min, temp=37.9°C. (-)crackles, (+)R CVA tenderness. What is the diagnosis? A. acute uncomplicated cystitis B. acute uncomplicated pyelonephritis C. acute complicated pyelonephritis D. chronic pyelonephritis Trans Interactive session on UTI. Acute uncomplicated pyelonephritis is seen in otherwise healthy females without clinical or historical evidence of structural or functional urologic abnormalities. Classic syndrome of chills, fever, flank pain, CVA tenderness, nausea, and vomiting.

86. 25/F hospitalized for treatment of Staph aureus abscess of her left thigh. The wound is incised and drained and she receives antibiotic therapy. She is improving and discharged home a week later, but the next day she develops a fever. On PE, her temperature is 38.1°C and there is a diffuse erythematous skin rash of her trunk and extremities, a urinalysis show sp gr 1.020, pH 6.5, 1+blood, 1+protein, no glucose, and no ketones. There are 10-20WBCs/hpf and 1-5 RBCs/hpf, and a few eosinophils are noted on urine microscopic examination. Which is the most likely diagnosis A. acute tubular necrosis B. analgesic abuse nephropathy C. drug-induced interstitial nephritis D. post-infectious GN Trans on Renal Patho. Diffuse erythematous skin rash probably suggests an allergic reaction to the antibiotics that was given. Eosinophils were also present which is characteristic of drug-induced interstitial nephritis.

87. 10/F brought to the physician because of increasing lethargy and passing dark-coloured urine for the past week. She has a sore throat 2 weeks prior. On PE, she is afebrile with BP 140/90. Labs showed serum creatinine=2.8mg/dL, BUN=24mg/dL. Urinalysis shows dysmorphic RBCs. A renal biopsy is performed and on microscopic exam glomerular hypercellularity with neutrophils present. EM shows subepithelial humps. Which of the following lab findings is most likely to be present in this girl A. antibody to double stranded DNA B. anti-GBM antibody C. positive C3 nephritogenic factor D. elevated ASO titer

Trans Interactive session on UTI

Trans on Renal Patho. This patient has acute nephritic syndrome and the prototype is acute post-streptococcal GN (sore throat 2 weeks prior, hematuria, glomerular hypercellularity with neutrophils, subepithelial humps), which would result in elevated ASO titer.

83. The ff antibiotics are recommended empiric treatment of acute uncomplicated pyelonephritis in the Philippine setting EXCEPT

88. 50/M noted passing darker urine for the past week. On PE, no abnormal findings. Urinalysis showed pH=5.5, sp gr 1.013, 2+blood, no protein, no glucose.

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Urine cytology showed atypical uroepithelial cells. A urologist performs a cytoscopy and a fungating mass is noted. He has 60 pack year history of smoking cigarettes. Which of the following is the most likely diagnosis A. adenoCA of prostate B. acute insterstitial nephritis C. bladder CA D. renal cell CA Atypical uroepithelial cells tell us that it’s either urinary tract in origin. Smoking is a risk factor for bladder CA

89. 30/F has severe skin problems associated with severe hypertension and acute renal failure. Renal biopsy shows numerous glomerular crescents. Which if the ff abnormalities will most likely be seen in arterioles in the biopsy A. fibrinoid necrosis B. thickening of the muscle layer C. hyaline deposition D. fibrointimal thickening Trans on Renal Patho. Fibrinoid necrosis of arteries is seen in malignant hypertension.

90. 52/M previously healthy has experienced episodes of discomfort with urination for 3 mos. PE is normal. Lab studies include a urinalysis that reveal no glucose, no protein, and 1+blood. Microscopic urine exam shows numerous RBCs, a few WBCs, no casts. Urine culture is negative. Plain film radiograph of the pelvis shows a rounded, radiopaque lesion in the region of the bladder. Which of the ff lab test finding is most likely to be present in this man A. proteinuria B. elevated serum transaminases C. hypercalciuria D. RBC casts in urine A and D are definitely wrong, because urinalysis revealed no protein and there were no casts. Hypercalciuria may lead to stone formation, so C might be the answer… but I’m not sure of this.

91. 5/M has UTI. You want to evaluate for pyelonephritis. What is the BEST can to recommend A. DTPA renal scan B. DMSA renal scan C. LASIX renal scan D. CAPTOPRIL scan E. MAG3 renal scan Trans Diagnostic Imaging Trans of Block B. DMSA renal scan is used to for cortical imaging to detect small focal lesions, acute pyelonephritis or cortical scars .

92. A renal transplant patient needs to have his renal graft evaluated, how would you position the camera A. anterior B. posterior C. right lateral D. left lateral E. posterior oblique Kidneys in renal transplant patients are located within the peritoneum not retroperitoneum.

93. What exam will you request for if you are looking for an adrenal pheochromocytoma in a young hypertensive adult? A. KUB-IVP B. ultrasound C. CT scan D. renal angiogram Trans Genito-Urinary Imaging.

94. What is the usual imaging finding in acute pyelonephritis?

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A. enlargement of the kidneys B. normal findings C. renal mass D. pelveocaliectasia 95. In which of the ff cases would an IVP be the BEST imaging modality A. polycystic kidney disease B. nephrolithiasis C. renal cell CA D. hydronephrosis 96. Drug X is eliminated by the kidneys. It is filtered but not reabsorbed. If the patient is also receiving 40mg of furosemide a day leading to an increase in daily urine output of 50% above baseline, how will you adjust the dose of Drug X A. increase drug X by 25% B. increase drug X by 50% C. increase drug X by 75% D. there is no need to adjust the dose (For 97-100) Drug Y is 30% hepatic metabolism and 70% renal excretion. Moreover, renal excretion is primarily due to filtration with negligible secretion and reabsorption. The GFR is decreased to 60% of normal for Mr Juan dela Cruz and there is no change in secretion and reabsorption. Hepatic metabolism is not affected. 97. What is the ratio of renal to hepatic clearance for Mr Juan dela Cruz A. 0.9 B. 0.8 C. 0.7 D. 0.6 98. What is the total systemic clearance of Mr Juan dela Cruz in comparison with the normal A. 90% of normal B. 81% of normal C. 72% of normal D. 60% of normal Renal CL=GFR1=0.7,since GFR2=0.6GFR1 GFR2=0.42 -----> total CL=renal + hepatic=0.42+0.3=0.72

99. Assuming the same volume of distribution, what is the half life of Drug Y for Mr dela Cruz A. 111% of normal B. 123% of normal C. 138% of normal D. 167% of normal T1/2=(ln2)Vd/CL ----> Vd= T1/2(CL)/ln2 Since Vd is constant, T1/2a(CLa)/ln2= T1/2b(0.72CLa)/ln2 Manipulate constants -----> T1/2b=T1/2a/0.72 Therefore, T1/2b=1.38 T1/2a, where T1/2a is normal half-life

100. If you want to maintain the same drug exposure (AUC), how would you adjust the dose (hint: remember the relationship of dose, AUC, and clearance) A. decrease the dose in direct proportion to total systemic clearance (e.g. If CL is 80% of normal, dose is 80% of normal) B. increase the dose by the reciprocal of the total systemic clearance (e.g. if CL is 80% of normal, dose is 125% of normal) C. decrease the dose to the square of % total systemic clearance (e.g. if CL is 80% of normal, dose is 64% of normal)

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D. increase the dose by the square of the reciprocal of % total systemic clearance (e.g. if CL is 80% of normal, dose is 156% of normal) II. Matching type A. Acute nephritis B. Nephrotic syndrome C. Acute renal failure D. Chronic renal failure E. Tubule defects 101. Aling Nene, 50yo fish vendor, brought to the ER for a 5 day history of vomiting and diarrhea. She had no urine output for the past 12 hrs. BP 70/50, HR 120/min, RR 28/min. urine shows RBCs with muddy brown casts. Serum Na 125meq/L, K 2.5meq/L, Cl 90. ABG shows pH 7.10, HCO3 15mmol/L, BUN 25mg/dL, serum creatinine 5mg/dL (C) clue: acute oliguria/anuria 102. MD, 40yo hypertensive male, complains of nausea and vomiting. His BP is 160/100. He is pale with scratch marks over his extremities and trunk. UTZ show bilaterally small kidneys. Serum creatinine 1000μmol/L (D) clue: pallor & bilaterally small kidneys 103. Manang, 60/F, is referred for pedal edema. She has also been complaining of tingling sensations of her hands and feet and easy fatigability, exertional dyspnea, and orthopnea over the past year. PE shows macroglossia and hepatomegaly. 24hr urine shows 7gms protein. Serum creatinine 1mg/dL (B) clue: proteinuria >3.5 g & edema

A. Obstruction B. Inflammation/Erosion C. Neurogenic Bladder D. Nephrolithiasis 104. Delilah, 22/F, consults for painful urination, frequency, and urgency after coming from her honeymoon. Urine shows many RBCs and WBCs. (B) this is a case of UTI secondary to you know what

105. Lolo, 70/M, is admitted to the ER with anuria. Past history reveals nocturia, frequency, and terminal dribbling over the past several months. On PE a hypogastric mass is palpated. On rectal exam, the prostate is enlarged. Plain KUB revealed no localizing signs. (A) BPH or prostate CA Column A 106. cervical CA with bilateral pelvocaliectasia, creat 5mg% 107. CHF, BUN 40mg%, creat 1.5mg% 108. septic shock, FENa 2 109. liver cirrhosis, urine Na 5meq/L Column B A. pre-renal azotemia B. intrarenal azotemia C. post-renal azotemia 114. Chronic liver disease A. furosemide B. acetazolamide C. Spironolactone A is metabolized in the kidneys, thus can be given to those with liver problems. (??) B is for glaucoma.

Hi to those who would benefit from this. The group tried their best to answer this samplex TRUTHfully.

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Sorry kung mejo kulang, mejo marami ang di nakapass/nakalimot na kopyahin yung assigned sa kanila. Nevertheless, sana malaking tulong na po ito. Hi sa lahat ng friends namin.