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RENAL PATHOPHYSIOLOGYRENAL PHARMACOLOGY

RENAL PATHOLOGY

FINAL EXAMINATION

December 13, 2005

__________________________ Student's name

INSTRUCTIONS

This examinati n is ! m" sed # mu$ti"$e !h i!e %uesti ns& (ite ) u( name n* th the %uesti n * +$et and the ans,e( sheet& The ans,e(s a(e t *e ,(itten n theans,e( sheet "(e#e(a*$) in "en!i$- sin!e it is easie( t !han.e ) u( ans,e(& F ( ea!hmu$ti"$e !h i!e %uesti n there is only one correct response - s ,(ite n$) ne $ette(

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as an ans,e(& At the end # the test- the ans,e( sheet sh u$d *e sta"$ed t the%uesti n * +$et and the) * th must *e handed in&

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NORMAL LABORATORY VALUES

Test Normal Range

Blood, Serum or Plasma

blood glucose 67-109 mg/dlScr

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Renal Pathophysiology Questions:

1. :5#c5 o t5e ollo=#ng #s least l#'el% to be #ltered reel% t5roug5 t5e glomerulus>a2 glucose

b2 am#no ac#ds

c2 5# ur#c ac#dd2 ammon#ae2 sod#um

". Renal sod#um 5andl#ng can be a ected b% c5anges #n?a2 card#ac out ut

b2 #nterst#t#al ;olumec2 4d2 sod#um concentrat#one2 total bod% otass#um content

T + $ $:@N8 T:$ A!+ST@$NS R+ +R T$ T + N+ T 34S+4 67-%ear-old man #s adm#tted to t5e #ntens#;e care un#t =#t5 a e;er o 10) , tac5%card#c and5% otens#;e =#t5 a blood ressure o &0/*0. e #s tac5% ne#c =#t5 a res #rator% rate o )". 3 R re;eals a le t lo=er lobe neumon#a. e becomes obtunded and re u#res #ntubat#on. e #s ;er%ag#tated and cont#nues to breat5e =#t5 RR o )" abo;e t5e ;ent#lator res #rator% rate sett#ng o1". e #s #mmed#atel% g#;en #soton#c sal#ne or ;olume resusc#tat#on.

e rema#ns ebr#le or t5e ne t da% =#t5 a ea' tem erature o 10 , ers#stent tac5% nea and5% otens#;e re u#r#ng ressor su ort, des #te aggress#;e ;olume re let#on =#t5 7 l#ters o 0.9Csal#ne #soton#c2 o;er t5e ast cou le o da%s.

aborator% data on t5e second da%? Na 1*9 m+ / , *. m+ / , 3l 116 m+ / , 3$ ) 1"m+ / , B!N "& mg/dl, 3reat 1.) mg/dl.

!r#nal%s#s? s ec# #c gra;#t% 1.01 / / no cells or casts.

). % ernatrem#a occurs because?

a2 4 #s st#mulated because o 5% otens#on. b2 total bod% sod#um content 5as #ncreased.c2 aldosterone roduct#on #ncreases sod#um retent#ond2 large #nsens#ble losses o =ater occurse2 metabol#c ac#dos#s romotes sod#um retent#on

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*. 4n 4B8 #s obta#ned =#t5 o 7."9, 3$" " , $" 60 mm g2. :5#c5 o t5e ollo=#nge lanat#ons best e la#ns 5o= 5%s#olog#cal range 7."0-7.702 #s ma#nta#ned>

a2 #ntracellular s5# t o #n e c5ange or b2 3$ ) #s recla#med r#mar#l% #n t5e ascend#ng loo o 5enlec2 c5lor#de #s an #m ortant e tracellular bu er

d2 3$ " #s lo=ered t5roug5 #ncreased res #rat#onse2 3$ ) #s not #ltered t5roug5 t5e glomerulus due to decl#ne #n 8 R

. 8lomerular #ltrat#on rate 8 R2 can be est#mated us#ng ur#nar% clearance o a substance.:5#c5 o t5e ollo=#ng #s true>

a2 B!N #s t5e best endogenous mar'er o 8 R because =5en 8 R alls t5e B!N r#ses to agreater degree t5an creat#n#ne

b2 t5e gold standard measure or 8 R #s creat#n#ne clearance.c2 #nul#n #s an endogenous substance sugar2, =5#c5 #s usuall% used to measure 8 R.d2 5# ur#c ac#d #s a small os#t#;el% c5arged molecule, =5#c5 #s reel% #ltered =#t5out

reabsor t#on or secret#on.

e2 serum creat#n#ne e onent#all% r#ses =#t5 decl#ne #n 8 R.6. 4ll o t5e ollo=#ng at#ents resent to t5e emergenc% room =#t5 nausea, general mala#se, andare ound to 5a;e an ele;ated creat#n#ne o 6.4 mg/dl. :5#c5 o t5e ollo=#ng at#ents 5as t5e

oorest rognos#s or reco;er% to normal renal unct#on>a2 76-%ear-old man =#t5 recentl% d#agnosed rostate cancer com la#ns o d# #cult%

ma#nta#n#ng ur#ne stream o;er t5e last " =ee's. e notes some decl#ne #n ur#ne ;olumeo;er t5e last ) da%s and #s ound to 5a;e a ost-;o#d res#dual ur#ne ;olume o )00 ml.

b2 * -%ear-old emale com la#ns o lu-l#'e s%m toms and subse uent 5emo t%s#s o;er t5elast ) =ee's. !r#ne sed#ment s5o=s red blood cell casts and man% d%smor 5#c a ear#ngred blood cells.

c2 )"-%ear-old =oman =#t5 d# #cult to control 5% ertens#on =as started on an 43+ #n5#b#tor l#s#no r#l2 and d#uret#c urosem#de2 a mont5 ago. $n e am, blood ressure #n t5e s#tt#ng

os#t#on #s 1 */9&, =5#c5 does not c5ange =#t5 stand#ng. S5e 5as an abdom#nal bru#t.d2 6-%ear-old male =#t5 osteoart5r#t#s o t5e 'nees 5as been ta'#ng #bu ro en &00 mg t#d

or t5e last ) =ee's. !r#ne sed#ment re;eals =5#te blood cells and =5#te blood cell casts.e2 7*-%ear-old =oman 5as 5% otens#on, e;er and con us#on. !r#ne and blood cultures bot5

gro= +. 3ol#. $;er t5e ne t "* 5ours s5e becomes anur#c.

7. 4 7-%ear-old =oman resents =#t5 nausea and ;om#t#ng or t5e last da%s. er med#cal5#stor% #ncludes d#abetes mell#tus and 5% ertens#on.

Ded#cat#ons? Deto rolol " mg b#d, l#s#no r#l 10 mg da#l% and #nsul#n.

P5%s#cal + am? T 9&.7 , BP 1"0/60 s#tt#ng and 90/*0 stand#ng, R 1"0, RR 1". No EF , 5eartand lungs unremar'able, d# usel% tender abdomen =#t5 5% oact#;e bo=el sounds and no lo=ere trem#t% edema.

S5e #s ound to 5a;e an ele;ated creat#n#ne o ".0 mg/dl.

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:5#c5 o t5e ollo=#ng laborator% #nd#ngs #s most cons#stent =#t5 5er resentat#on>a2 B!N 1"

b2 ur#ne 7c2 ur#ne s ec# #c gra;#t% 1.0)0

d2 ur#ne Na 6 m+ / , ur#ne creat & mg/dl, serum Na 1*0 m+ /e2 serum Na 160

&. 4 &-%ear-old male =#t5 ben#gn rostat#c 5% ertro 5% de;elo s acute renal a#lure =#t5 aB!N 0, creat#n#ne o ).* mg/dl. Renal ultrasound re;eals 5%drone 5ros#s. e #s #mmed#atel%sent to t5e emergenc% room or ole% cat5eter lacement, a ter =5#c5 l#ters o ur#ne dra#ns #ntot5e collect#on bag. @n " da%s, %ou =#ll most l#'el% see?

a2 ur#ne sed#ment =#t5 mudd% bro=n casts b2 ur#ne s ec# #c gra;#t% o 1.001c2 5% onatrem#a

d2 metabol#c al'alos#se2 5% er'alem#a

9. 4 &-%ear-old =oman =#t5 5% ertens#on, 34 , 3$P resents =#t5 s5ortness o breat5. $ne am, BP #s 1 0/90, s5e 5as =orsen#ng lo=er e trem#t% edema and lung e am re;eals crac'lesand decreased breat5 sounds #n r#g5t lo=er lobe reg#on. S5e #s ound to 5a;e d# use al;eolaro ac#t#es, ;ascular congest#on and a r#g5t lo=er lobe #n #ltrate on c5est -ra%. or t5#s s5e #sg#;en urosem#de and started on amo #c#ll#n. er current med#cat#ons also #nclude meto rolol,l#s#no r#l and albuterol.

ur#ng 5er ollo=-u ;#s#t " =ee's later, s5e com la#ns o e;er, ras5, ers#stent mala#se andat#gue. T 100.1 , BP #s 1)&/&6 s#tt#ng and stand#ng. + am re;eals resolut#on o crac'les and

#m ro;ement o edema. # use #ne er%t5ematous ras5 on trun' and abdomen.aborator% data re;eal a :B3 o 10.6, 5emoglob#n 11, 5ematocr#t )), latelet ")&, Na 1)6,

*.&, 3l 10", 3$) "0, B!N "1, creat ).". # st#c' ur#nal%s#s re;eals s ec# #c gra;#t% 1.010, , trace rote#n, 1( leu'oc%te.

er ele;ated B!N and creat#n#ne can be best e la#ned b%?a2 acute ;olume de let#on result#ng #n 5% o er us#on to t5e '#dne% rom o;erl% aggress#;e

d#ures#s b2 5% otens#on rom se s#s =#t5 resultant 4TNc2 ur#nar% tract #n ect#on #n;ol;#ng t5e '#dne%s %elone 5r#t#s2d2 ne 5roto #c#t% rom t5e l#s#no r#l caus#ng 4TNe2 tubular #n lammat#on rom ant#b#ot#c #nduced acute #nterst#t#al ne 5r#t#s

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10. T5e e;olut#on o acute tubular necros#s #s best descr#bed b%Ga2 once necros#s o t5e tubules occurs, local ;asoconstr#ct#on allo=s or s5unt#ng o lasma

lo= a=a% rom t5e #nHured ne 5ron. b2 t5e renal corte #s most rone to #sc5em#c #nHur% due to t5e 5a#r #n loo structure o t5e

;asa recta.

c2 re er us#on Hust a ter an #sc5em#c e;ent #s t5e t#me dur#ng =5#c5 most o t5e tubular5eal#ng occurs.d2 5% o er us#on o t5e '#dne% #n t5e sett#ng o ;olume de let#on #s not cons#dered a cause

o acute tubular necros#s.e2 to #c #nHur% o t5e tubule #s m#n#m#Ied #n t5e collect#ng duct =5ere 4 #s turned o to

urt5er d#lute t5e ur#ne.

11. :5#c5 o t5e ollo=#ng can med#ate a reduct#on #n lasma lo= across t5e glomerular barr#er>a2 rostagland#ns

b2 ang#otens#n ##c2 aldosterone

d2 macula densae2 ren#n

T + $ $:@N8 T:$ A!+ST@$NS R+ +R T$ T + N+ T 34S+

4 *"-%ear-old obese =oman 5as d#abetes mell#tus, ret#no at5% and neuro at5%. S5e re orts t5ats5e #s eel#ng =ell =#t5out an% ur#nar% s%m toms #nclud#ng ol%ur#a, d%sur#a or noctur#a. $ne am, BP #s 1*6/&&, R &&. Do#st mucous membranesG no EF G eart and lung e ams areunremar'able. o=er e trem#t#es =#t5 trace edema. e t 5eel =#t5 s5allo= ulcer.

aborator% data? B!N "0 mg/dl, creat 1." mg/dl, album#n ).& g/dl.!r#nal%s#s b% d# st#c' re;eals s ec# #c gra;#t% 1.0"0, , glucose 1(, rote#n negat#;e,leu'oc%te negat#;e, blood negat#;e

1". :5at are %our recommendat#ons to 5er =#t5 regard to 5er r#s' o de;elo #ng c5ron#c '#dne%d#sease>

a2 @ s5e controls 5er d#abetes mell#tus ade uatel%, s5e =#ll not de;elo c5ron#c '#dne%d#sease

b2 S5e =#ll not de;elo c5ron#c '#dne% d#sease as t5ere #s no e;#dence or #t at resentc2 er blood ressure #s o t#mall% controlled, =5#c5 =#ll 5el re;ent rogress#on o '#dne%

d#seased2 T5e absence o ne 5rot#c s%ndrome suggests t5ere #s no glomerular at5olog%e2 4 "*-5our ur#ne rote#n s5ould be assessed.

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1). 4ssum#ng s5e 5as d#abet#c ne 5ro at5%, %ou =ould recommend t5e ollo=#ng?a2 43+ #n5#b#tors or 4ng#otens#n rece tor bloc'ers s5ould be a;o#ded as t5e% =#ll cause

acute renal a#lure b2 blood ressure s5ould be ma#nta#ned at a lo=er goal o 1)0/&0c2 cont#nue current management o d#abetes mell#tus =5#c5 a ears to be ade uatel%

controlled as e;#denced b% t5e m#n#mal glucosur#ad2 greater lu#d #nta'e s5ould be encouraged g#;en 5er 5#g5 ur#ne s ec# #c gra;#t% suggest#ng;olume de let#on.

e2 e erc#se s5ould be a;o#ded as t5#s can #ncrease rote#nur#a =5#c5 5as been s5o=n toe acerbate c5ron#c '#dne% d#sease

1*. Bone d#sease renal osteod%stro 5%2 as a result o c5ron#c '#dne% d#sease occurs becauseGa2 5% er arat5%ro#d#sm romotes calc#ur#a

b2 renal osteod%stro 5% occurs to due to oor #ltrat#on o 5os 5orusc2 oor con;ers#on o c5olesterol to " -$ ;#tam#n d2 decl#ne #n 8 R results #n 5% ercalcem#a =#t5 resultant Jmetastat#cK calc# #cat#on #n

t#ssuese2 act#;ated ;#tam#n st#mulates PT

1 . 4 "1-%ear-old #s an#c emale 5as 5ad an &-lb =e#g5t ga#n, at#gue, lo=-grade e;ers andac5% Ho#nts or a mont5. Blood ressure #s 1")/7" mm g, a ras5 #s resent on t5e ace, t5ere #sno Hugular ;enous d#stent#on, lungs are clear and legs 5a;e 1( edema.

ab tests s5o=?

B!N 10 mg/dSerum creat#n#ne 0.& mg/d4lbum#n ".) gm/dTotal c5olesterol " mg/d3),3* and 3 0 all lo=4N4 os#t#;e -1?)"0Blood culture negat#;e4N34 negat#;ea8BD ant#bod% negat#;e!r#nal%s#s clear, %ello=, S.8. 1.01), rote#n 00 mg/d , 1 RB3/5 "* 5our ur#ne rote#n ).6 gm

T5e most l#'el% d#agnos#s #s?

a2 m#crosco #c ol%arter#t#s b2 membranous orm o lu us ne 5r#t#sc2 rol# erat#;e orm o lu us ne 5r#t#sd2 #d#o at5#c crescent#c glomerulone 5r#t#se2 ocal segmental glomeruloscleros#s

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16. T5e abo;e at#ent e er#ences sudden leur#t#c c5est a#n, 5emo tes#s and s5ortness o breat5. Lou sus ect t5at s5e #s e er#enc#ng?

a2 ant#bod%-med#ated ulmonar% 5emorr5age

b2 ulmonar% embol#smc2 ulmonar% edemad2 ulmonar% ;ascul#t#se2 ractured r#b

17. 4 19-%ear-old man #s seen or a -da% e #sode o gross 5ematur#a occurr#ng dur#ng an u erres #rator% #n ect#on. 4 s#m#lar e #sode 5a ened one %ear earl#er. Blood ressure #s 1*6/97.T5e 5%s#cal e am#nat#on #s ot5er=#se normal. aborator% stud#es s5o=?

B!N 1* mg/dSerum creat#n#ne 1.) mg/d

4lbum#n *.1 gm/d3),3* and 3 0 normal4N4 negat#;e4S $ t#ter negat#;e4N34 negat#;ea8BD ant#bod% negat#;e!r#nal%s#s tea-colored, S.8. 1.019, rote#n 100 mg/d , RB3/man%, red cell

casts

4 renal b#o s% s5o=s #ncreased cellular#t% o t5e glomerul# and #mmuno luorescence s5o=s?

a2 mesang#al @gD de os#t#on b2 @g8 #mmune com le de os#t#onc2 negat#;e sta#n#ngd2 l#near ca #llar% sta#n#ng or @g8e2 mesang#al @g4 de os#t#on

1&. or t5e ast mont5 a *0-%ear-old man =#t5 c5ron#c d%s e s#a and 5eartburn 5as been ta'#ng sod#um b#carbonate d#ssol;ed #n =ater or rel#e . Serum electrol%tes s5o= Na 1*1 m+ / , ( ).0 m+ / , 3l - 10m+ / and 3$ ) - " m+ / . Serum otass#um #s lo= most l#'el% because?

a2 al'alos#s s5# ts otass#um #nto cells. b2 5#g5 sod#um #nta'e #n5#b#ts catec5olam#ne release.c2 5#g5 sod#um #nta'e #n5#b#ts t5e ren#n a #s.d2 b#carbonate #s a non-reabsorbable an#on.e2 otass#um ollo=s sod#um #n t5e ur#ne.

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THE OLLO!"N# T!O QUEST"ONS RE ER TO THE NE$T %ASE

Lou 5a;e a 6&-%ear-old d#abet#c =oman =#t5 c5ron#c renal a#lure and 5% ertens#on. T5e at#ent no= 5asmuscle =ea'ness o t5e lo=er e trem#t#es and cannot =al'. Ded#cat#ons #nclude a beta-bloc'er, an 43+#n5#b#tor, a t5#aI#de d#uret#c and a salt subst#tute. T5e blood ressure #s 1)0/7 mm g. T5e lo=er

e trem#t#es 5a;e reduced muscle strengt5. Serum creat#n#ne #s ".0 mg/d , Na(

1*1 m+ / , (

7.& m+ .3l - 10 m+ / and 3$ ) - 1& m+ / .

19. 4 maHor t5reat to t5#s at#ent #s?

a2 atal arr5%t5m#a b2 a ser#ous allc2 5% o;olem#c s5oc' d2 se;ere d#arr5eae2 res #rator% al'alos#s

"0. T5e 5% er'alem#a #s caused b% all o t5e ollo=#ng + 3+PT?a2 salt subst#tute

b2 lo= ren#n statec2 t5#aI#de d#uret#cd2 43+ #n5#b#tor e2 beta-bloc'er

"1. 9-%ear-old male resents to %our o #ce or e;aluat#on o 5#s t5#rd calc#um o alate '#dne%stone. Lou ad;#se #ncreased lu#d #nta'e ". -) er da%2 and lan a "* 5our ur#ne collect#on toe;aluate 5#s r#s' actors or urt5er stone ormat#on. :5#c5 o t5e ollo=#ng #s most l#'el% to bean add#t#onal d#etar% recommendat#on>

a2 lo= calc#um d#et b2 lo= o alate d#etc2 #ncreased sod#um #nta'ed2 5#g5 #ber d#ete2 5#g5 rote#n d#et

"". @ a at#ent resents to t5e emergenc% room =#t5 a 1 mm '#dne% stone #n t5e ro #mal uretercaus#ng com lete obstruct#on o one o t5e '#dne%s, t5e most a ro r#ate acute management=ould be?

a2 #ncrease lu#d #nta'e to M)l er da% to reduce r#s' o urt5er stone ormat#on b2 consult a urolog#st to arrange or stone remo;alc2 rescr#be a t5#aI#de d#uret#c to reduce ur#nar% calc#um e cret#ond2 start ant#b#ot#cs to guard aga#nst %elone 5r#t#se2 #n#t#ate a "* 5our ur#ne collect#on to #n;est#gate r#s' or stone ormat#on

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"). T5e 5%s#cal e am #nd#ng t5at most strongl% correlates =#t5 5% er;olem#a #s?

a2 lo=er e trem#t% edema b2 tac5%card#ac2 b#lateral rales on c5est e am

d2 mo#st mucous membranese2 decreased s'#n turgor

"*. :5#c5 o t5e ollo=#ng mec5an#sms d#rectl% en5ance reabsor t#on o sod#um #n t5e proximal ne 5ron>

a2 4 ant#d#uret#c 5ormone2 b2 aldosteronec2 decreased 8 R d2 #ncreased s%m at5et#c tonee2 countercurrent mec5an#sm

" . 4 " -%ear-old male resents =#t5 a -da% 5#stor% o nausea, ;om#t#ng and d#arr5ea. $n 5%s#cal e am#nat#on 5e 5as t5e ollo=#ng

Pulse? 110 BP 9*/ 6Reduced s'#n turgor, dr% mucous membranes

e also 5as t5e ollo=#ng labsSod#um? 1*1 me /35lor#de 10 me /B#carbonate "* me /B!N "9 mg/d3reat#n#ne 1.0 mg/d

emoglob#n 1 g/dematocr#t * C

T5e most a ro r#ate resusc#tat#on lu#d =ould be?

a2 0.9C Na3l 1 *me / sod#um, 1 *me / c5lor#de2 b2 8atorade 1&me / sod#um, )me / otass#um, "1me / c5lor#de2c2 red blood cell trans us#ond2 album#ne2 0.* C Na3l 77me / sod#um, 77me / c5lor#de2

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"6. 4 "1-%ear-old coca#ne user #s ound on t5e '#tc5en loor. T5e 5%s#cal e am#nat#on s5o=s alet5arg#c %oung man =#t5 a tem erature o 100.0 , a ulse rate o 110/m#n, and a blood

ressure o 17 /100 mm g. T5ere are mult# le ;en# uncture s#tes #n t5e s'#n o 5#s le t orearm.T5e oro 5ar%n #s clear. T5e 5eart #s regular #n r5%t5m and no murmur or rub a rec#ated. T5elungs are clear. T5e abdomen #s ben#gn. T5ere #s d# use tenderness to al at#on o;er buttoc's

and oster#or as ects o legs.

T5e laborator% stud#es are as ollo=s?emoglob#n 16 g/dleu'oc%te count 10,7 0 / l

B!N " mg/dl3reat#n#ne ).& mg/dlPotass#um *.9 me /3reat#ne 5os 5o'#nase 0,) 0 !/!r#ne?

.0

S ec# #c gra;#t% 1.01"Prote#n traceBlood *(!r#ne sed#ment?

+r%t5roc%tes 1-" er 5#g5 o=er #eldeu'oc%tes 1-) er 5#g5 o=er #eld

3asts numerous granular casts

:5at #s t5e most l#'el% cause o t5#s at#ent s renal d#sease>

a2 rerenal aIotem#a

b2 c5ron#c glomerulone 5r#t#sc2 @F ne 5ro at5%d2 r5abdom%ol%s#se2 acute #nterst#t#al ne 5r#t#s

"7. :5#c5 o t5e ollo=#ng casts ound u on m#crosco #c e am#nat#on o ur#ne sed#ment aremost suggest#;e o glomerulone 5r#t#s>

a2 red blood cell casts b2 =5#te blood cell castsc2 granular bro=n casts

d2 5%al#ne castse2 =a % casts

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"&. 4 76-%ear-old man =#t5 t% e " d#abetes, TN, 34 and c5ron#c '#dne% d#sease rom

d#abet#c ne 5ro at5%. #s '#dne% unct#on 5as been relat#;el% stable toda% =#t5 a creat#n#ne o".* mg/dl. !r#nar% rote#n #s 1.) g/da% #ncreased rom 0.6 g/da% * mont5s ago =5#le on#s#no r#l or t5e last ) %ears. Re;#e= o s%stems #s unc5anged =#t5 no c5est a#n, s5ortness o

breat5 or edema, e ce t or a recent all on t5e #ce =5#le =al'#ng result#ng #n lo=er bac' a#n or t5e last ) =ee's. Ded#cat#ons? #s#no r#l 43+ #n5#b#tor2, 4S4, Deto rolol beta-bloc'er2,@nsul#n, @bu ro en. Blood ressure #s 1 0/90, R 6&. ungs are clear, no lo=er e trem#t% edema.Lou #ncrease t5e l#s#no r#l rom "0 mg da#l% to *0 mg da#l% or t5e #ncreased rote#nur#a and5% ertens#on. ollo=-u laborator% data "=ee's later2 re;eal B!N 6* mg/dl, creat#n#ne ).*mg/dl and . m+ / . !r#nal%s#s =#t5 s ec# #c gra;#t% 1.010, . , "( rote#n, no blood,leu'oc%tes, glucose or 'etones.

T5e laborator% abnormal#t#es?a2 3ould be rom t5e a#n med#cat#ons, =5#c5 causes ;asoconstr#ct#on at t5e a erentarter#ole.

b2 4re unl#'el% rom #s#no r#l as 5e 5as been on t5e med#cat#on or man% %earsc2 4re rom 5#s =orsen#ng d#abet#c ne 5ro at5% and 5% oren#nem#c 5% oaldosteron#smd2 S5ould #m ro;e =#t5 #n#t#at#on o a d#uret#ce2 4rose rom ;olume de let#on #n t5e sett#ng o osmot#c d#ur#es#s

"9. Lou are #n t5e emergenc% room =5en an elderl% man #s broug5t to see %ou #n se;ere d#stress.e 5as recentl% tra;eled to #dne%stan, t5e remote countr% o 5#s or#g#n, and 5e =as rescr#bed

se;eral bottles o an un'no=n med#cat#on, =5#c5 5e too'. :5#le %ou are scrambl#ng to #nd a#dne%stan# translator, to determ#ne t5e #dent# #cat#on o 5#s med#cat#ons, %ou re;#e= 5#s

blood=or', =5#c5 s5o=s a Na( o 1"& m+ / , a ( o ). m+ / , an 3$)- o 1* m+ / , a3l- o 10* m+ / , and an arter#al o 7." , and a 3$" o "& mm g. :5#c5 o t5e ollo=#ngmed#cat#ons #s most l#'el% res ons#ble or 5#s #llness>

a2 as #r#n b2 m#l' o magnes#a a otent cat5art#c, caus#ng d#arr5ea2c2 5%droc5lorot5#aI#ded2 t5eo 5%ll#ne a bronc5od#lator2e2 # ecac causes ;om#t#ng2

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)0. 4 6-%ear-old g#rl #s broug5t to t5e emergenc% room a ter colla s#ngG on #n#t#al resentat#ons5e #s unres ons#;e. er arents are not a;a#lable and or t5e moment, no ot5er 5#stor% #sa;a#lable. S5e 5as a blood ressure o 7*/)0, a 5eart rate o 11&/m#nute, and 5er mucousmembranes are dr%, 5er lungs are clear, and 5#s abdomen #s so t and non tender. T5ere #s noedema. 4n arter#al blood gas s5o=s a o 7.16 and a 3$" o &0. T5e Na( #s 1*0 m+ / , t5e

( #s *.7 m+ / , t5e 3l- #s 10 m+ / , and t5e 3$)- #s "& m+ / . $ t5e ollo=#ng, =5#c5 #st5e most l#'el% cause o 5er ac#d-base d#sturbance>

a2 o;erdose o slee #ng #lls b2 se;ere ;om#t#ngc2 d#abet#c 'etoac#dos#sd2 d#arr5eae2 o;erdose o sal#c%lates

)1. 4 "0-%ear-old =oman comes to see %ou because s5e #s not eel#ng =ell. er med#cal 5#stor%#s unremar'able, s5e ta'es no med#cat#ons, and 5er e am#nat#on #s notable or a blood ressure o

1)&/&*, a 5eart rate o 100/m#nute, and clear lungs, a normal abdomen, and no edema. 4rter#al #s 7.)), Na( #s 1) m+ / , ( #s *.& m+ / , 3l- #s 9" m+ / , and 3$)- #s 1 m+ / . T5e 3$" #s "9 mm g. $ t5e ollo=#ng, =5#c5 #s t5e most l#'el% d#agnos#s>

a2 adrenal #nsu #c#enc% b2 earl% regnanc%c2 surre t#t#ous #nta'e o d#uret#csd2 renal a#luree2 ulmonar% embol#sm

)". 4 *9-%ear-old alco5ol#c man #s adm#tted to t5e 5os #tal =#t5 a t=o =ee' 5#stor% o noa et#te and cont#nuous ;om#t#ng. #s b#carbonate le;el #s *0 m+ / and t5e #s 7. " o t5e

ollo=#ng, t5e maHor mec5an#sm or de;elo ment o t5e abnormal b#carbonate le;el #s

a2 #ncreased res #rator% e cret#on o 3$" b2 #ncreased ren#n e ect on t5e medullar collect#ng tubulec2 #ncreased 3$)- reabsor t#on #n t5e ro #mal tubuled2 decreased aldosterone e ect on t5e ro #mal and d#stal tubulese2 #ncreased 3$)- #ltrat#on #n t5e glomerulus

THE NE$T T!O QUEST"ONS RE ER TO THE OLLO!"N# %ASE&

4 7" %ear old =oman 5as se;ere congest#;e 5eart a#lure rom #sc5em#c 5eart d#sease. S5e #s on5%droc5lorot5#aI#de and urosem#de, t=o d#uret#cs. er e am s5o=s a blood ressure o 1"&/76,5eart rate o 90 t5at #s #rregularl% #rregular, b#lateral rales, an S) gallo , and asc#tes and )(

er# 5eral edema. 4 c5est ra% s5o=s leural e us#ons and ulmonar% ;ascular congest#on. er Na( #s 1"1 m+ / . er creat#n#ne le;el #s 1." mg/d . er B!N #s * mg/d . er ( #s ).7m+ / , t5e 3l- #s 7& m+ / , and t5e 3$)- #s )& mg/d . T5e #s 7. 1 and t5e 3$" #s *9mm g.

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)). T5e s#ngle most #m ortant e lanat#on or 5er 5% onatrem#a #s ?

a2 an #ncreased 4 e ect on t5e collect#ng duct b2 osmot#c d#ures#s and ur#ne sod#um loss

c2 a lo= sod#um d#et and decreased sod#um #nta'ed2 5#g5 le;el o aldosterone a ect#ng t5e cort#cal collect#ng ducte2 decreased #ltrat#on o sod#um and =ater #n t5e glomerulus

)*. :5at #s contr#but#ng to t5e abnormal >

a2 #ncreased aldosterone e ect on t5e cort#cal collect#ng duct b2 #ncreased ro #mal tubular reabsor t#on o sod#umc2 #ncreased ro #mal tubular reabsor t#on o 3$)-d2 #ncreased ( secret#on rom t5e #ntercalated cells o t5e cort#cal collect#ng ducte2 all o t5e abo;e

T + N+ T T:$ A!+ST@$NS R+ +R T$ T + $ $:@N8 34S+

4 )9 %ear old =oman 5as ocal and segmental glomeruloscleros#s, and 5er '#dne% unct#on 5as been stead#l% =orsen#ng. :5en %ou see 5er #n %our cl#n#c, s5e 5as a blood ressure o "00/&0,s5e #s ale and at#gued, and s5e 5as b#lateral rales, an S) gallo , and 1( edema. S5e 5ase cor#ated s'#n les#ons, rom e cess#;e #tc5#ng. er B!N #s 1"* mg/d , and t5e creat#n#ne #s17." mg/d . T5e Na( #s 1"0 m+ / , t5e ( #s 6.1 m+ / , t5e 3l- #s & m+ / , and t5e 3$)-#s 10 m+ / . er arter#al #s 7.16.

) . :5at #s t5e r#nc# al reason or 5er lo= serum Na( le;el>

a2 t5e serum Na( #s onl% alsel% lo= because o t5e ;er% 5#g5 B!N le;el b2 decreased glomerular #ltrat#on o =ater c2 #ncreased renal tubular secret#on o sod#umd2 decreased oral #nta'e o sod#ume2 #ncreased e ect o 4 on t5e cort#cal collect#ng tubule

)6. :5% #s 5er blood ressure ele;ated>

a2 s%c5olog#cal stress assoc#ated =#t5 5er #llness b2 #ncreased release o ren#n rom t5e Hu taglomerular a aratus o t5e '#dne%c2 decreased glomerular #ltrat#on o sod#umd2 d#rect e ect o B!N and creat#n#ne on ;ascular smoot5 musclee2 a card#ac arr5%t5m#a assoc#ated =#t5 a 5#g5 ( le;el.

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)7. 4 9-%ear-old =oman 5as breast cancer =#t5 metastases to t5e bra#n. S5e #s g#;en a d#agnos#s

o t5e s%ndrome o #na ro r#ate 4 secret#on. :5#c5 o t5e ollo=#ng laborator% tests =ould%ou e ect to see #n 5er cond#t#on>

a2 a ur#ne Na( o 7" m+ / b2 a ur#ne s ec# #c gra;#t% o 1.00"c2 a ur#ne osmolal#t% o m$sm/d2 a creat#n#ne le;el o ".) mg/de2 a serum sod#um le;el o 1*9 m+ /

)&. 4 "6-%ear-old male med#cal student ta'es a m#le Hog on a 5ot da% #n Eul%, and does not eator dr#n' dur#ng e erc#se. 4t t5e conclus#on o t5e run, 5e doesnOt eel =ell, and at a ;#s#t to t5e

#n #rmar%, 5#s blood ressure #s 100/70, 5eart rate #s 110, and 5e #s s=eat#ng, 5as clear lungs, andno edema. #s Na( #s 1*6 m+ / , ( #s ).9 m+ / , 3l- #s 11& m+ / , 3$)- #s "6 m+ / , andB!N #s ") mg/d , =#t5 a creat#n#ne o 1.0 mg/d . :5#c5 o t5e ollo=#ng statements #s l#'el% to

be correct>

a2 e 5as a modest #ncrease #n 5#s total bod% sod#um content b2 e robabl% 5as de;elo ed lact#c ac#dos#s.c2 e 5as a ;er% 5#g5 c#rculat#ng le;el o 4d2 #s 3l- le;el #s 5#g5 because o #ncreased ro #mal tubular reabsor t#one2 T5e 5#g5 serum Na( le;el 5as su ressed ren#n roduct#on.

)9. 4 71-%ear-old man =#t5 a negat#;e med#cal 5#stor% de;elo s e;er, nausea, ;om#t#ng, andd#arr5ea and 5as a ro ound decrease #n 5#s a et#te. e ;#s#ts 5#s 5%s#c#an =5o notes 5#stem erature to be 100 degrees, BP to be &"/60, 5eart rate to be 110/m#n, res #rator% rate #s"&/m#n, and 5e 5as decreased s'#n turgor, dr% mucous membranes, and clear lungs. T5e abdomen#s m#ldl% tender. abs s5o= a Na( o 1") m+ / , ( o ).* m+ / , 3l- o && m+ / , and

3$)- o "1 m+ / . T5e ur#ne s ec# #c gra;#t% #s 1.0)0, and t5e ur#ne osmolal#t% #s 10&0m$sm/'g "0. $ t5e ollo=#ng c5o#ces, =5at #s t5e r#nc# al reason t5at t5e serum sod#umle;el #s lo=>

a2 loss o sod#um rom t5e s'#n and res #rator% tract b2 #ncreased sod#um loss rom t5e '#dne%s due to osmot#c d#ures#sc2 s5# t o Na( #nto cellsd2 #ncreased tubular reabsor t#on o =ater e2 #ncreased aldosterone e ect

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*0. 4 )1-%ear-old man comes to see %ou or a 5%s#cal e am#nat#on. e 5as no 5#stor% o r#ormed#cal roblems, ta'es no med#cat#ons, does not smo'e c#garettes, 5as 1 - " alco5ol#c be;erages

er =ee', and 5as a negat#;e am#l% 5#stor% or 5% ertens#on or card#o;ascular d#sease. e Hogsor la%s s uas5 almost e;er% da%, and 5as a BD@ o "* o;er=e#g5t M " 2. e 5as t5ree blood

ressure read#ngs ta'en, =5#c5 are 1)&/7&, 1)"/&6, and 1"0/&&. #s 5%s#cal e am#nat#on #s

normal.:5#c5 o t5e ollo=#ng statements #s true>

a2 e 5as stage @ 5% ertens#on b2 #s ulse ressure #s bet=een 9 and 100 mm g.c2 e 5as a 5#g5er c5ance o de;elo #ng end stage renal d#sease and a m%ocard#al#n arct#on o;er 5#s l# et#me t5an someone =#t5 an a;erage blood ressure o 110/70.d2 e s5ould be =or'ed u or renal arter% stenos#s, 5% eraldosteron#sm, and a

5eoc5romoc%tomae2 e #s 5ealt5%, s5ould be reassured, and 5#s blood ressure needs no urt5er attent#on.

*1. 4 "-%ear-old man 5as a 5#stor% o sc5#Io 5ren#a and l#;es #n a grou 5omeG 5e #s on a;ar#et% o s%c5otro #c med#cat#ons. e de;elo s a sore t5roat and comes to t5e emergenc% room=5ere a 5%s#cal e am s5o=s a blood ressure o 1"&/&0, and no ob;#ous abnormal#t#es ot5ert5an 5ar%ng#t#s. abs s5o= a serum Na( o 1*7 m+ / , ( o ).9 m+ /l, 3l- o 11* m+ / ,and 3$)- o "* m+ / . T5e serum creat#n#ne #s 1.1 mg/d .T5e ur#ne anal%s#s s5o=s a s ec# #cgra;#t% o 1.001, and t5e ur#ne osmolal#t% #s 60 m$sm/ . :5at #s t5e most l#'el% e lanat#on or 5#s serum sod#um abnormal#t%>

a2 #ncreased #ngest#on o =ater due to 5#s s%c5#atr#c #llness b2 #ncreased reabsor t#on o =ater #n t5e medullar% collect#ng ductc2 #ncreased #nta'e o sod#um r#c5 oodsd2 #m a#red act#;#t% o 4 on renal tubular cellse2 decreased sod#um e cret#on b% t5e '#dne%

*". 4 *"-%ear-old 4 r#can 4mer#can man =#t5 a 5#stor% o 5% ertens#on =al's #nto %our o #cenot eel#ng =ell, =#t5 a 5eadac5e and blurred ;#s#on. $n e am, 5#s blood ressure #s ""0/1)6.:5#c5 o t5e ollo=#ng abnormal#t#es #s most l#'el% to be resent>

a2 ele;ated serum glucose le;el b2 rote#nur#a on ur#ne d# st#c' c2 ele;ated 5emoglob#n le;el abo;e 1 gm/d 2d2 #ncreased arter#al e2 ele;ated serum calc#um le;el

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Path Renal Questions

T5e glomerulus belo= 5as been subHected to an #mmuno luorescent sta#n or @g4.

*). $ t5e " 5otos belo= =5#c5 #s most l#'el% to re resent t5e corres ond#ng + sta#n oa glomerulus rom t5e same ne 5r#t#c at#ent, A or B> ' points

A B

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Datc5 4 and B, 5otos o small arter#es, =#t5 t5e ollo=#ng scenar#os?

A B

**. 4 comatose "7 %ear old 4 r#can-4mer#can man =#t5 a 5#stor% o a se;ere 5eadac5e reced#ng loss o consc#ousness. e 5as a st# nec' and t5e blood ressure #s " 0/1*0.

* . 4 69 %ear old man, =#t5 blood ressure o 160/9 . e #s on ant#5% ertens#;es.

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Note t5e l#g5t m#croscro #c 5oto belo=. +D s5o=ed d# use t5#c'en#ng o t5e basementmembrane =#t5 sube #t5el#al de os#ts. 4 s#l;er sta#n re;ealed #rregular s #'es rotrud#ng rom

t5e basement membrane. ' points

4. @d#o at5#c ra #dl% rogress#;e glomerulone 5r#t#sB. Dembranous glomerulo at5%

3. Post-stre tococcal glomerulone 5r#t#s

*6. :5#c5 #s t5e most l#'el% d#agnos#s, A, B, or %>

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T5#s gross renal 5oto m#g5t be rom a at#ent =#t5 s#c'le cell d#sease.

*7. $t5er cond#t#ons assoc#ated =#t5 t5e at5olog#cal ent#t% #llustrated #nclude all o t5eollo=#ng e()ept ? ' points

4. $bstruct#onB. #abetes mell#tus3. Renal arter% embol#sm

. 4nalges#c ne 5ro at5%

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4 at#ent =#t5 bacter#al endocard#t#s #s be#ng treated =#t5 @F met5#c#ll#n. e de;elo s renala#lure.

*&. Based on t5e b#o s% s5o=n abo;e, 5e #s g#;en a d#agnos#s o ? ' points4. 4cute tubular necros#sB. rug-#nduced #nterst#t#al ne 5r#t#s3. Post-#n ect#ous glomerulone 5r#t#s

. +nd stage '#dne% d#sease

*9. 4 %oung =oman de;elo s acute renal a#lure and a m#croang#o at5#c 5emol%t#c anem#a=#t5 t5romboc%to en#a. T5ere #s a 5#stor% o d#arr5ea and #ngest#on o rare 5amburger. S5e 5as5ad sl#g5t con us#on and restlessness but no se#Iures or loss o consc#ousness. :5#c5 #s t5e mostl#'el% d#agnos#s, A, B, or %>

4. 4dult 5emol%t#c-urem#c s%ndromeB. T5rombot#c t5romboc%to en#c ur ura3. 4cute tubular necros#s

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0. T5e gross a earance o t5#s d#agrammat#c '#dne% #s most cons#stent =#t5?' points

4. 35ron#c glomerulone 5r#t#sB. Renal #n arcts3. 35ron#c %elone 5r#t#s

. Renal arter% stenos#s+. S#c'le cell d#sease

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A B

:5#c5 o t5e abo;e renal tumors, A or B , #s assoc#ated =#t5 t5e eatures belo=>

1.4 c5#ld5ood tumor a blastoma2 QQQQQQQ

".R#s' actors #nclude tobacco smo'#ng, obes#t%, and estrogen use QQQQQQQ

).4n adult resent#ng =#t5 metastases and 5% ercalcem#a QQQQQQQ

*.:48R, delet#on 16 1) :T1 QQQQQQQ

. #stolog#call% tr# 5as#c QQQQQQQ

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Datc5 t5e adult structure =#t5 #ts embr%olog#cal recursor use eac5 onl% once2

4. D ller#an aramesone 5r#c2 duct

B. Desone 5r#c =ol #an2 duct3. 3oelom#c e #t5el#um. !rogen#tal s#nus

+. Detane 5r#c mesoderm

6.Per#toneal mesot5el#um QQQQQQQ

7. allo #an tubes QQQQQQQ

&.Prostate gland QQQQQQQ

9.Renal el;#s QQQQQQQ

60.8lomerulus QQQQQQQ

61.:5#c5 o t5e ollo=#ng de;elo mental de ects #s least l#'el% to be assoc#ated =#t5 t5e

ol#go5%dramn#os se uence>

4. B#lateral renal agenes#sB. Trac5eoeso 5ageal #stula3. 4utosomal recess#;e ol%c%st#c '#dne% d#sease

. 3%st#c-d%s last#c '#dne%s+. Prune bell% s%ndrome

6".4 %oung re;#ousl% 5ealt5% man #s 5% o;olem#c or t5ree 5ours a ter su er#ng se;eretrauma =#t5 blood loss. $ne com l#cat#on =5#c5 de;elo s #s a)ute tu*ula+ ne)+osis . :5#c5 ot5e ollo=#ng #s least l#'el% to be an add#t#onal com l#cat#on>

4. Subendocard#al m%ocard#al #n arct#onB. Transmural m%ocard#al #n arct#on3. 3entrolobular 5e at#c necros#s

. # use al;eolar damage 4R S2+. 3erebral 5% o #a

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True A2 or B2 alse?

6). !rot5el#al carc#noma o t5e bladder #s muc5 more common t5an s uamous cellcarc#noma o t5e bladder, #s more re uent #n males t5an #n emales, and 5as an assoc#at#on =#t5tobacco smo'#ng.

6*. T5e Hu taglomerular a aratus cons#sts o t5e glomerular cells #n t5e e erent arter#oleand t5e macula densa #n t5e adHacent ro #mal con;oluted tubule.

6 . @n us#ng t5e term J ocal segmental glomeruloscleros#sK, JsegmentalK re ers to a segmento t5e '#dne% and J ocalK re ers to a ocal o#nt #n t5e glomerulus

66. @n cons#der#ng mec5an#sms o glomerular #nHur%, an e am le o #nHur% due to reduct#on#n 8BD ol%an#on #s t5e ne 5rot#c s%ndrome assoc#ated =#t5 m#n#mal c5ange d#sease.

67. @n crescent#c glomerulone 5r#t#s t5e crescent #s ormed b% mesang#al cells and matr# .

26