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66.

NEPHROLOGY BOARD REVIEW QUESTIONS

Bradley M. Denker

QUESTION 1. A 50-year-old white male with a history of essential hypertension suffered two transient ischemic attacks without permanent neurological sequelae within the last 12 months. He is treated with lisinopril, 20 mg, and hydrochlorothiazide, 25 mg daily; office blood pressures (BP) are 140/85 mm Hg. A 24-hour ambulatory blood pressure monitor is obtained. Which of the following statements about 24-hour blood pressure monitoring is NOT TRUE?

    A. Cardiovascular risk correlates better with elevated blood pressure on ambulatory monitoring than with office blood pressures.

    B. Patients normally exhibit a nocturnal dip in blood pressure of at least 10%.

    C. Higher ambulatory blood pressure monitoring strongly correlates with progressive renal disease and the development of end-stage kidney failure.

    D. Dipping of nocturnal blood pressure correlates with the day–night difference in heart rate.

    E. Ambulatory blood pressure monitoring can be used to distinguish true hypertension from “white coat” hypertension.

QUESTION 2. A 55-year-old African-American male comes to the emergency room complaining of 2 days of blurred vision, headaches, and nausea. He has a history of hypertension but ran out of his medications about 2 weeks ago. He is awake and alert. Blood pressure is 220/120 mm Hg with no orthostatic changes. Funduscopic examination shows bilateral hemorrhages and blurred optic disk margins. The remainder of the physical examination was notable only for an S4 gallop and the absence of edema. Laboratory studies revealed a creatinine of 2.5 mg/dL (was 1.2 6 months prior) and normal electrolytes. Which of the following therapies is most appropriate for initial management?

    A. Sublingual nifedipine in the emergency room while awaiting an ICU bed

    B. Intravenous enalaprilat

    C. Intravenous nitroglycerin

    D. Intravenous esmolol

    E. Sodium nitroprusside

QUESTION 3. A 44-year-old white male with obesity (body mass index 32 kg/m²), type II diabetes with hemoglobin A1c (HbA1c) 8.4% on oral agents is found to have urinary microalbumin/creatinine of 112 µg/g and is seen in your office for follow-up. His office blood pressure is 160/100 mm Hg, but he is convinced that these elevations are secondary to white coat hypertension. You ask him to obtain a home blood pressure cuff and confirm its accuracy. He returns with home blood pressure readings ranging from 135/85 to 160/90 mm Hg. In addition to lifestyle changes, which of the following antihypertensive strategies is recommended as initial therapy?

    A. Hydrochlorothiazide 25 mg daily

    B. Hydrochlorothiazide 50 mg daily with the addition of a beta blocker within 2 weeks

    C. Lisinopril 10 mg daily and then titrate up to 40 mg to maximize BP effects

    D. Lisinopril 10 mg daily plus hydrochlorothiazide 25 mg and titrate to maximize BP effects

    E. Calcium channel blocker plus hydrochlorothiazide 25 mg

QUESTION 4. A 60-year-old black female is seen for the first time in many years. The family history is strongly positive for type 2 diabetes, and she is found to have a serum creatinine of 3.1 mg/dL, 1.5 g of protein/24 hours, and HbA1c of 8%. A renal ultrasound shows 11cm kidneys with echogenic cortex. Which of the following statements about the use of an angiotensin-converting enzyme (ACE) inhibitor in this patient is true?

    A. Since her renal failure is advanced, there is no benefit in delaying progression of her chronic kidney disease.

    B. Evaluate serum creatinine and serum potassium 1 month after initiating therapy.

    C. Evaluate serum creatinine and potassium 1–2 weeks after starting therapy and discontinue the drug if creatinine increases by 10% over baseline.

    D. Evaluate serum creatinine and potassium 1–2 weeks after starting therapy, and discontinue the drug if creatinine increases by 10% over baseline or serum potassium is 5.0 mEq/L.

    E. Evaluate serum creatinine and potassium 1–2 weeks after starting therapy, and discontinue the drug if creatinine increases by >30% over baseline or hyperkalemia (>5.4 mEq/L) develops despite dietary counseling and the use of loop diuretics.

QUESTION 5. A 27-year-old man with AIDS is hospitalized with a cough, fever, and a pulmonary infiltrate on chest x-ray (CXR). Therapy is initiated with trimethoprim-sulfamethoxazole. On admission, the serum creatinine is 1.6 mg/dL, and blood urea nitrogen (BUN) is 21 mg/dL; on reexamination 3 days later, the serum creatinine is 2.2 mg/dL and BUN is 23 mg/dL. Results of urinalysis both on admission and 3 days later are normal. Urine output on day 3 is 1350 mL. The most likely cause of the increased creatinine is:

    A. AIDS glomerulopathy

    B. Trimethoprim-mediated decrease in creatinine secretion

    C. Intratubular obstruction secondary to sulfonamide

    D. Acute interstitial nephritis (AIN) caused by trimethoprim-sulfamethoxazole therapy

    E. Acute tubular necrosis secondary to sepsis

QUESTION 6. A previously healthy 42-year-old man becomes ill with fever (temperature 38ºC), malaise, myalgias, and a sore throat. The next day, he describes gross hematuria and right flank pain. Urinalysis shows protein 3+ and RBC casts. His BUN is 42 mg/dL, and serum creatinine is 1.8 mg/dL. Electrolytes are within normal limits. Serological testing reveals normal complements, a normal IgA level, a 1:40 antinuclear antibodies (ANA) anti-DNA ab level of 0, and negative antistreptolysin O (ASLO), and antineutrophil cytoplasmic antibody (ANCA) titers. His anti-glomerular basement membrane (GBM) titers are also negative. Which of the following is the most likely diagnosis?:

    A. World Health Organization (WHO) class IV lupus nephritis

    B. IgA nephropathy

    C. Rapidly progressive glomerulonephritis secondary to granulomatosis with polyangiitis (Wegener granulomatosis)

    D. Goodpasture syndrome

    E. Poststreptococcal glomerulonephritis

QUESTION 7. All of the following statements regarding torsemide are true, EXCEPT:

    A. It has a bioavailability higher than that of furosemide.

    B. Like furosemide, torsemide is a loop diuretic.

    C. It has a shorter half-life than furosemide.

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