Kuc Clinical Pharmacy Final Exam

1. P.E. is a 56-year-old man who comes to the clinic with a 3-day history of fever, chills, pleuritic chest pain, malaise, and cough productive of sputum. In the clinic, his temperature is 102.1ºF (38.9ºC) (all other vital signs are normal). His chest radiograph shows consolidation in the right lower lobe. His white blood cell count (WBC) is 14,400 cells/mm3, but all other laboratory values are normal. He is given a diagnosis of community-acquired pneumonia (CAP). He has not received any antibiotics in 5 years and has no chronic disease states. Which is the best empiric therapy for P.E.?

Doxycycline 100 mg orally twice daily.

Cefuroxime axetil 250 mg orally twice daily.

Levofloxacin 750 mg/day orally.

Trimethoprim/sulfamethoxazole double strength orally twice daily.

The best empiric therapy for P.E. is Doxycycline 100 mg orally twice daily because it covers the most common pathogens that cause community-acquired pneumonia (CAP), including Streptococcus pneumoniae and atypical organisms such as Mycoplasma pneumoniae and Chlamydophila pneumoniae. It is also effective against the causative agents of CAP in patients who have not received antibiotics in the past 3 months. Additionally, Doxycycline has good oral bioavailability and is well-tolerated, making it a suitable choice for outpatient treatment.

Explanation

The best empiric therapy for P.E. is Doxycycline 100 mg orally twice daily because it covers the most common pathogens that cause community-acquired pneumonia (CAP), including Streptococcus pneumoniae and atypical organisms such as Mycoplasma pneumoniae and Chlamydophila pneumoniae. It is also effective against the causative agents of CAP in patients who have not received antibiotics in the past 3 months. Additionally, Doxycycline has good oral bioavailability and is well-tolerated, making it a suitable choice for outpatient treatment.

2. A 71-year-old woman is brought to the ICU from a nursing home because of confusion, fever, and flank pain. On physical examination, her temperature is 38.5°C (101.3°F), blood pressure is 82/48 mm Hg, heart rate is 123 beats/min ute, and respiration rate is 30 breaths/minute. Dry mucous membranes, costo vertebral angle tenderness, poor skin turgor, and an absence of edema are noted on physical examination. The leukocyte count is 15,600/j..tL; urinalysis shows 50 to 100 leukocytes and many bacteria per high power field. The patient has an anion-gap metabolic acidosis and high lactic acid level. Antibiotic therapy is started. Which of the following is most likely to improve the survival of this patient?

Aggressive fluid resuscitation

25% albumin infusion

Hemodynamic monitoring with a pulmonary artery catheter

Maintaining hemoglobin above 12 g/dL

Maintaining Pco2 below 50 mm Hg

Aggressive fluid resuscitation is the most likely option to improve the survival of this patient. The patient's presentation suggests sepsis, as indicated by the fever, hypotension, tachycardia, and leukocytosis. The dry mucous membranes, poor skin turgor, and absence of edema further support the diagnosis of hypovolemia. Aggressive fluid resuscitation helps restore intravascular volume and improve tissue perfusion, which is crucial in sepsis management. This intervention can help stabilize the patient's hemodynamics and prevent further organ damage.

Explanation

Aggressive fluid resuscitation is the most likely option to improve the survival of this patient. The patient's presentation suggests sepsis, as indicated by the fever, hypotension, tachycardia, and leukocytosis. The dry mucous membranes, poor skin turgor, and absence of edema further support the diagnosis of hypovolemia. Aggressive fluid resuscitation helps restore intravascular volume and improve tissue perfusion, which is crucial in sepsis management. This intervention can help stabilize the patient's hemodynamics and prevent further organ damage.

3. A patient has received 12 L of crystalloids as fluid resuscitation during the first 10 hours after admission to the ICU for septic shock. The patient's blood pressure and urine output have increased with each fluidbolus administered, but the patient's inspired oxygen requirements have also substantially increased over the past 3 hours. The attending physician would like to give low-molecular-weight, low-molar-substitution hydroxyethyl starch (HES) instead of crystalloids for the patient in an attempt to limit extravascular fluid accumulation. According to the published literature, which one of the following is the best reason to discourage the use of HES in this patient?

It is associated with increased incidence of mortality.

It is associated with an increased need for renal replacement therapy.

It is associated with increased need for packed red blood cell transfusion.

It is associated with an increased cost compared to crystalloids.

The best reason to discourage the use of HES in this patient is because it is associated with an increased incidence of mortality. This means that using HES for fluid resuscitation could potentially increase the risk of death for the patient.

Explanation

The best reason to discourage the use of HES in this patient is because it is associated with an increased incidence of mortality. This means that using HES for fluid resuscitation could potentially increase the risk of death for the patient.

4. A 55-year-old man with stage 3 chronic kidney disease comes to the office for follow-up. Glomerular filtration rate, calculated using the Modification of Diet in Renal Disease (MDRD) Study equation, has been consistent at 39 mL/min/1.73 m2, and serum creatinine level has been steady at 1.9 mg/dL. Medical history includes long-standing hypertension and type 2 diabetes mellitus. Current medications include metformin 500 mg twice daily, celecoxib 200 mg daily, nifedipine 30 mg daily, and quinapril 10 mg daily. The patient appears well developed and well nourished. Temperature is 36.4°C (97.5°F), pulse rate is 76/min, respirations are 18/min, and blood pressure is 130/78 mmHg. On physical examination, no abnormalities are noted. Ultrasonography of the kidneys shows bilateral renal cortical atrophy. Discontinuation of which of the following medications in this patient's regimen is most appropriate?

Metformin and celecoxib

Nifedipine and celecoxib

Nifedipine and metformin

Nifedipine and quinapril

Quinapril and metformin

The most appropriate medication to discontinue in this patient's regimen is metformin and celecoxib. This is because both metformin and celecoxib can potentially contribute to renal impairment, which can worsen the patient's stage 3 chronic kidney disease. Discontinuing these medications can help preserve the remaining kidney function and prevent further damage. Nifedipine and quinapril are commonly used to manage hypertension, and discontinuing them may lead to uncontrolled blood pressure. Nifedipine and metformin, as well as quinapril and metformin, are not the most appropriate choices to discontinue based on the patient's medical history and current condition.

Explanation

The most appropriate medication to discontinue in this patient's regimen is metformin and celecoxib. This is because both metformin and celecoxib can potentially contribute to renal impairment, which can worsen the patient's stage 3 chronic kidney disease. Discontinuing these medications can help preserve the remaining kidney function and prevent further damage. Nifedipine and quinapril are commonly used to manage hypertension, and discontinuing them may lead to uncontrolled blood pressure. Nifedipine and metformin, as well as quinapril and metformin, are not the most appropriate choices to discontinue based on the patient's medical history and current condition.

5. B.Y. is an 85-year-old woman who is bedridden and lives in a nursing home. She is chronically catheterized, and her urinary catheter was last changed 3 weeks ago. Today, her urine is cloudy, and a urinalysis shows many bacteria. B.Y. is not noticing any symptoms. A urine culture is obtained. Which option is best for B.Y.?

No therapy because she is chronically catheterized and has no symptoms.

No antibiotic therapy, but the catheter should be changed.

Oral ciprofloxacin 500 mg twice daily for 7 days and a new catheter.

In this scenario, B.Y. is an 85-year-old woman who is bedridden and has a chronically catheterized urinary catheter. Although her urine is cloudy and a urinalysis shows many bacteria, she is not experiencing any symptoms. Asymptomatic bacteriuria is common in chronically catheterized patients and does not require treatment unless there are accompanying symptoms such as fever or discomfort. Therefore, the best option for B.Y. is to not administer any therapy because she is chronically catheterized and has no symptoms.

Explanation

In this scenario, B.Y. is an 85-year-old woman who is bedridden and has a chronically catheterized urinary catheter. Although her urine is cloudy and a urinalysis shows many bacteria, she is not experiencing any symptoms. Asymptomatic bacteriuria is common in chronically catheterized patients and does not require treatment unless there are accompanying symptoms such as fever or discomfort. Therefore, the best option for B.Y. is to not administer any therapy because she is chronically catheterized and has no symptoms.

6. Which of the following statements best describes the mechanism by which mannitol causes hyponatraemia?

Hypotonic hyponatraemia

Isotonic hyponatraemia

Reducing renal free water clearance

Hypertonic hyponatraemia

Eincreased urine sodium excretion

Mannitol causes hypertonic hyponatremia by drawing water from the intracellular space into the extracellular space. This leads to an increase in extracellular fluid volume and a dilution of sodium concentration. As a result, the overall sodium concentration in the body decreases, causing hypertonic hyponatremia.

Explanation

Mannitol causes hypertonic hyponatremia by drawing water from the intracellular space into the extracellular space. This leads to an increase in extracellular fluid volume and a dilution of sodium concentration. As a result, the overall sodium concentration in the body decreases, causing hypertonic hyponatremia.

7. A 22 year old female with type I DM, presents to the emergency department with a 1 day history of nausea, vomiting, polyuria, polydypsia and vague abdominal pain. Deep sighing breathing, orthostatic hypotension, and dry mucous membranes.Labs: Na 132 , K 6.0, Cl 93, HCO3- 11 glucose 720, BUN 38, Cr 2.6. UA: pH 5, SG 1.010, ketones positive, glucose positive . ABG: pH 7.27 HCO3- 10 PCO2 23What is the acid base disorder?

Metabolic acidosis with high anion gap, with non compensatory respiratory alkalosis

Normal anion gap metabolic acidosis with full compensation

Metabolic alkalosis mixed with respiratory acidosis

None of the above

The patient's presentation of nausea, vomiting, polyuria, polydipsia, and vague abdominal pain along with the laboratory findings of low bicarbonate (HCO3-) levels, high glucose, and positive ketones suggest diabetic ketoacidosis (DKA). DKA is a type of metabolic acidosis characterized by an increased anion gap. The low bicarbonate levels indicate a primary metabolic acidosis. The respiratory alkalosis is a compensatory response to the acidosis, as the body tries to increase ventilation to eliminate carbon dioxide and decrease the acidity. Therefore, the correct answer is metabolic acidosis with high anion gap, with non-compensatory respiratory alkalosis.

Explanation

The patient's presentation of nausea, vomiting, polyuria, polydipsia, and vague abdominal pain along with the laboratory findings of low bicarbonate (HCO3-) levels, high glucose, and positive ketones suggest diabetic ketoacidosis (DKA). DKA is a type of metabolic acidosis characterized by an increased anion gap. The low bicarbonate levels indicate a primary metabolic acidosis. The respiratory alkalosis is a compensatory response to the acidosis, as the body tries to increase ventilation to eliminate carbon dioxide and decrease the acidity. Therefore, the correct answer is metabolic acidosis with high anion gap, with non-compensatory respiratory alkalosis.

8. Stage 1 diabetic nephropathy is characterized by:

Progressive deterioration of GFR

Marked nephron loss in renal biopsy

Increased GFR due to hyperfiltration

All of the above

None of the above

Stage 1 diabetic nephropathy is characterized by increased GFR due to hyperfiltration. This means that the glomerular filtration rate (GFR), which is the rate at which blood is filtered by the kidneys, is higher than normal. This is caused by the kidneys working harder to compensate for the damage caused by diabetes. However, it is important to note that this increased GFR is not sustainable and eventually leads to progressive deterioration of kidney function in later stages of diabetic nephropathy.

Explanation

Stage 1 diabetic nephropathy is characterized by increased GFR due to hyperfiltration. This means that the glomerular filtration rate (GFR), which is the rate at which blood is filtered by the kidneys, is higher than normal. This is caused by the kidneys working harder to compensate for the damage caused by diabetes. However, it is important to note that this increased GFR is not sustainable and eventually leads to progressive deterioration of kidney function in later stages of diabetic nephropathy.

9. Regarding diabetic nephropathy and RAAS blockade ,which is true:

Combination between ACEIs and ARBs is better than one alone

Hypokalemia is a common problem with the use of RAAS blockers

All of the above are true

All of the above are wrong

ACEI or ARBs are effective in reducing proteinuria and are nephroprotectors in the early stages of diabetic nephropathy. This means that these medications can help decrease the amount of protein in the urine and protect the kidneys from damage in the early stages of diabetic kidney disease. The combination of ACEIs and ARBs has been shown to be more effective than using either medication alone. Hypokalemia, or low potassium levels, is a common problem that can occur with the use of RAAS blockers. Therefore, all of the statements mentioned in the question are true.

Explanation

ACEI or ARBs are effective in reducing proteinuria and are nephroprotectors in the early stages of diabetic nephropathy. This means that these medications can help decrease the amount of protein in the urine and protect the kidneys from damage in the early stages of diabetic kidney disease. The combination of ACEIs and ARBs has been shown to be more effective than using either medication alone. Hypokalemia, or low potassium levels, is a common problem that can occur with the use of RAAS blockers. Therefore, all of the statements mentioned in the question are true.

10. All of the following can cause hypokalemia because of transcellular shift except

Beta blockers

Insulin

Metabolic alkalosis

Periodic paralysis

Hypokalemia refers to low levels of potassium in the blood. Transcellular shift is a process in which potassium is shifted from the extracellular fluid into the cells. Beta blockers, insulin, and metabolic alkalosis can all cause hypokalemia due to transcellular shift. However, periodic paralysis is a condition characterized by episodes of muscle weakness or paralysis, often due to a genetic defect in ion channels. It does not cause transcellular shift of potassium and therefore does not lead to hypokalemia.

Explanation

Hypokalemia refers to low levels of potassium in the blood. Transcellular shift is a process in which potassium is shifted from the extracellular fluid into the cells. Beta blockers, insulin, and metabolic alkalosis can all cause hypokalemia due to transcellular shift. However, periodic paralysis is a condition characterized by episodes of muscle weakness or paralysis, often due to a genetic defect in ion channels. It does not cause transcellular shift of potassium and therefore does not lead to hypokalemia.

11. Antineutrophil cytoplasmic antibody (ANCA) is typically present in which systemic disease

Goodpasture’ s syndrome

Wegener’ s granulomatosis

Systemic lupus erythematosus

Thrombotic thrombocytopenic purpura

ANCA is typically present in Wegener's granulomatosis. Wegener's granulomatosis is a systemic autoimmune disease that primarily affects the respiratory tract and kidneys. ANCA is an autoantibody that targets neutrophils, causing inflammation and tissue damage. The presence of ANCA is a characteristic feature of Wegener's granulomatosis and is used as a diagnostic marker for the disease. Goodpasture's syndrome, systemic lupus erythematosus, and thrombotic thrombocytopenic purpura are not typically associated with the presence of ANCA.

Explanation

ANCA is typically present in Wegener's granulomatosis. Wegener's granulomatosis is a systemic autoimmune disease that primarily affects the respiratory tract and kidneys. ANCA is an autoantibody that targets neutrophils, causing inflammation and tissue damage. The presence of ANCA is a characteristic feature of Wegener's granulomatosis and is used as a diagnostic marker for the disease. Goodpasture's syndrome, systemic lupus erythematosus, and thrombotic thrombocytopenic purpura are not typically associated with the presence of ANCA.

12. In which one of the following situations is urine sodium excretion likely to be less than 20 mmol/day?

SIADH

Renal disease

Acute diarrhoea

Hyperglycaemia

Hypothyroidism

In acute diarrhea, there is excessive loss of fluids and electrolytes through the gastrointestinal tract. This can lead to dehydration and a decrease in urine sodium excretion. As a result, the body tries to conserve sodium by reducing its excretion in the urine, leading to urine sodium excretion being less than 20 mmol/day.

Explanation

In acute diarrhea, there is excessive loss of fluids and electrolytes through the gastrointestinal tract. This can lead to dehydration and a decrease in urine sodium excretion. As a result, the body tries to conserve sodium by reducing its excretion in the urine, leading to urine sodium excretion being less than 20 mmol/day.

13. Which of the following statements characterizes minimal change disease

It is associated with renal insufficiency despite treatment

It is associated with selective proteinuria

It is the most common cause of nephrotic syndrome in adults

It is diagnosed on light microscopy after kidney biopsy

Minimal change disease is a kidney disorder characterized by selective proteinuria, which means that only certain proteins are excreted in the urine. This condition is not associated with renal insufficiency despite treatment, as it typically responds well to corticosteroid therapy. It is also not the most common cause of nephrotic syndrome in adults, as it is more commonly seen in children. Diagnosis of minimal change disease is typically made through electron microscopy, not light microscopy. Therefore, the statement "It is associated with selective proteinuria" accurately characterizes minimal change disease.

Explanation

Minimal change disease is a kidney disorder characterized by selective proteinuria, which means that only certain proteins are excreted in the urine. This condition is not associated with renal insufficiency despite treatment, as it typically responds well to corticosteroid therapy. It is also not the most common cause of nephrotic syndrome in adults, as it is more commonly seen in children. Diagnosis of minimal change disease is typically made through electron microscopy, not light microscopy. Therefore, the statement "It is associated with selective proteinuria" accurately characterizes minimal change disease.

14. Which of the following is true regarding dopamine use in patients with established intrinsic acute renal failure?

Doses of more than 5 µg/kg per minute are associated with increased urine output.

Low-dose dopamine is associated with faster recovery of renal function

Low-dose dopamine is associated with increased creatinine clearance.

Dopamine use has not been shown to improve mortality rates in this population.

Studies have shown that dopamine use in patients with established intrinsic acute renal failure does not improve mortality rates. Dopamine is commonly used to increase urine output and improve renal function, but there is no evidence to support its effectiveness in reducing mortality in this population. Therefore, the correct answer is that dopamine use has not been shown to improve mortality rates in patients with established intrinsic acute renal failure.

Explanation

Studies have shown that dopamine use in patients with established intrinsic acute renal failure does not improve mortality rates. Dopamine is commonly used to increase urine output and improve renal function, but there is no evidence to support its effectiveness in reducing mortality in this population. Therefore, the correct answer is that dopamine use has not been shown to improve mortality rates in patients with established intrinsic acute renal failure.

15. A 56-year-old woman comes to the emergency department because she has had increasing swelling of the right ankle over the past two days, since she sustained an injury while playing outdoors with her grandchildren. She says she has been taking over-the-counter ibuprofen 400 to 800 mg every four to six hours to relieve the pain. Medical history includes mild hypertension, which is currently controlled with lisinopril. Results of laboratory studies show elevated levels ofserum creatinine and blood urea nitrogen. Acute renal failure induced by use of nonsteroidal anti-inflammatory drugs is suspected. If this suspected diagnosis is correct, which of the following additional abnormal laboratory results is most likely?

Decreased serum chloride level

Decreased serum potassium level

Decreased serum sodium level

Elevated serum potassium level

Elevated serum sodium level

The correct answer is elevated serum potassium level. Acute renal failure induced by nonsteroidal anti-inflammatory drugs can lead to decreased renal blood flow and impaired filtration of potassium, resulting in elevated serum potassium levels. This condition is known as hyperkalemia. The other options, including decreased serum chloride, sodium, and potassium levels, are not typically associated with acute renal failure induced by nonsteroidal anti-inflammatory drugs.

Explanation

The correct answer is elevated serum potassium level. Acute renal failure induced by nonsteroidal anti-inflammatory drugs can lead to decreased renal blood flow and impaired filtration of potassium, resulting in elevated serum potassium levels. This condition is known as hyperkalemia. The other options, including decreased serum chloride, sodium, and potassium levels, are not typically associated with acute renal failure induced by nonsteroidal anti-inflammatory drugs.

16. A 36-year-old woman with diabetic nephropathy comes to the office for follow-up. During the interview, the patient says she has had fatigue for the past month. Physical examination shows pallor and pale conjunctivae, a grade 2/6 systolic murmur that is heard best over the left lower sternal border, and bilateral mild, pitting edema of the lower extremities. Laboratory studiesshow hemoglobin level of 9.8 g/dL and estimated glomerular filtration rate, calculated using the Modification of Diet in Renal Disease (MDRD) Study equation,is 19 mL/min/1.73 m2.Therapy with an erythropoiesis-stimulating agent is initiated. Which of the following is the target hemoglobin level for this patient?

7-8 g/dL

9-10 g/dL

11-12 g/dL

13-14 g/dL

15-16 g/dL

The target hemoglobin level for this patient is 11-12 g/dL. This is because the patient has symptoms of anemia, such as fatigue and pallor, and a low hemoglobin level of 9.8 g/dL. The goal of therapy with an erythropoiesis-stimulating agent is to increase the hemoglobin level to a target range that is appropriate for the patient's condition. In this case, a target hemoglobin level of 11-12 g/dL is considered appropriate for a patient with diabetic nephropathy and an estimated glomerular filtration rate of 19 mL/min/1.73 m2. Higher target hemoglobin levels may increase the risk of cardiovascular events and mortality in patients with chronic kidney disease.

Explanation

The target hemoglobin level for this patient is 11-12 g/dL. This is because the patient has symptoms of anemia, such as fatigue and pallor, and a low hemoglobin level of 9.8 g/dL. The goal of therapy with an erythropoiesis-stimulating agent is to increase the hemoglobin level to a target range that is appropriate for the patient's condition. In this case, a target hemoglobin level of 11-12 g/dL is considered appropriate for a patient with diabetic nephropathy and an estimated glomerular filtration rate of 19 mL/min/1.73 m2. Higher target hemoglobin levels may increase the risk of cardiovascular events and mortality in patients with chronic kidney disease.

17. A 26-yr-old African-American woman received her first deceased-donor transplant at age 21. After initially functioning well, the transplant was lost in the third month because of repeated cell-mediated rejection. She developed high levels of preformed antibodies and had a positive cross-match to several potential deceased donors. Her ABO-compatible brother, a one-haplotype match, donated a kidney. Standard cytotoxic and FACS cross-matching were repeatedly negative. Transplant surgery was uneventful, and the graft initially functioned well. After 4 d of anti-thymocyte polyclonal antibody, she received standard doses of cyclosporine, MMF, and steroids. By day 7, the serum creatinine was 1.2 mg/dl. On day 8, her urine output decreased and the serum creatinine increased to 2.4 mg/dl. An ultrasound with color Doppler showed good flow without obstruction. Urinalysis revealed 1+ protein with no cellular elements. Her biopsy displayed evidence of tubular injury with occasional perivascular polymorphsWhich ONE of the following choices offers the most likely diagnosis for her allograft dysfunction?

Delayed posttransplantation acute tubular necrosis (ATN)

Early pyelonephritis

Antibody-mediated rejection

Subclinical acute cell-mediated rejection.

The most likely diagnosis for the patient's allograft dysfunction is antibody-mediated rejection. This is supported by the patient's history of high levels of preformed antibodies and positive cross-match to several potential deceased donors. Additionally, the patient's biopsy displaying evidence of tubular injury with occasional perivascular polymorphs is consistent with antibody-mediated rejection. The other options, delayed posttransplantation acute tubular necrosis (ATN), early pyelonephritis, and subclinical acute cell-mediated rejection, do not align with the patient's clinical presentation and history.

Explanation

The most likely diagnosis for the patient's allograft dysfunction is antibody-mediated rejection. This is supported by the patient's history of high levels of preformed antibodies and positive cross-match to several potential deceased donors. Additionally, the patient's biopsy displaying evidence of tubular injury with occasional perivascular polymorphs is consistent with antibody-mediated rejection. The other options, delayed posttransplantation acute tubular necrosis (ATN), early pyelonephritis, and subclinical acute cell-mediated rejection, do not align with the patient's clinical presentation and history.

18. In management of patients with acute hyperkalemia, which should be administered first?

Sodium bicarbonate

Magnesium

Calcium

Dextrose

Sodium chloride

Calcium should be administered first in the management of patients with acute hyperkalemia. Hyperkalemia is a condition characterized by high levels of potassium in the blood, which can lead to serious cardiac complications. Calcium helps stabilize the cardiac membranes and can quickly counteract the effects of hyperkalemia, preventing life-threatening arrhythmias. Administering calcium first buys time to address the underlying cause of hyperkalemia and allows for subsequent treatments, such as sodium bicarbonate or other interventions, to be more effective.

Explanation

Calcium should be administered first in the management of patients with acute hyperkalemia. Hyperkalemia is a condition characterized by high levels of potassium in the blood, which can lead to serious cardiac complications. Calcium helps stabilize the cardiac membranes and can quickly counteract the effects of hyperkalemia, preventing life-threatening arrhythmias. Administering calcium first buys time to address the underlying cause of hyperkalemia and allows for subsequent treatments, such as sodium bicarbonate or other interventions, to be more effective.

19. Which of the following is a secondary cause for focal segmental sclerosis

Hodgkin’ s disease

Colon cancer

HIV disease

Hepatitis C infection

HIV disease is a secondary cause for focal segmental sclerosis. Focal segmental sclerosis is a kidney disease characterized by scarring in the glomeruli, the tiny blood vessels in the kidneys. HIV can directly affect the kidneys and lead to damage and scarring. This can result in focal segmental sclerosis. Therefore, HIV disease is a secondary cause for this condition.

Explanation

HIV disease is a secondary cause for focal segmental sclerosis. Focal segmental sclerosis is a kidney disease characterized by scarring in the glomeruli, the tiny blood vessels in the kidneys. HIV can directly affect the kidneys and lead to damage and scarring. This can result in focal segmental sclerosis. Therefore, HIV disease is a secondary cause for this condition.

20. A 56-year-old woman presents to your clinic for follow-up visit after undergoing renal transplantation 3months ago. She has been experiencing increasing symptoms of shortness of breath and has had fevers of up to 101 F (38.3 C). You admit her to the hospital and initiate a work-up of her symptoms. Cytomegalovirus (CMV) serologies are positive, and you initiate treatment.Which of the following interventions could have decreased the likelihood of this patient developing her illness and could have decreased the severity of her illness?

Intravenous ganciclovir during pretransplant evaluation

Prophylactic valganciclovir at time of transplantation and for 12 weeksthereafter

Trimethoprim-sulfamethoxazole daily for 3 to 6 months

Amoxicillin-clavulanate, 875 mg p.o., b.i.d.

Giving prophylactic valganciclovir at the time of transplantation and for 12 weeks thereafter could have decreased the likelihood of the patient developing CMV infection and decreased the severity of her illness. CMV infection is a common complication after renal transplantation and can lead to significant morbidity and mortality. Prophylactic antiviral therapy with valganciclovir has been shown to reduce the risk of CMV infection and its associated complications in transplant recipients. Therefore, initiating prophylactic valganciclovir in this patient could have prevented or minimized the development of her symptoms and improved her overall outcome.

Explanation

Giving prophylactic valganciclovir at the time of transplantation and for 12 weeks thereafter could have decreased the likelihood of the patient developing CMV infection and decreased the severity of her illness. CMV infection is a common complication after renal transplantation and can lead to significant morbidity and mortality. Prophylactic antiviral therapy with valganciclovir has been shown to reduce the risk of CMV infection and its associated complications in transplant recipients. Therefore, initiating prophylactic valganciclovir in this patient could have prevented or minimized the development of her symptoms and improved her overall outcome.

21. A 61-year-old man with progressive hypertensive renal disease visits your office for a routine follow-up visit. You have followed this patient for many years. The patient reports that he has become progressively fatigued over the past few weeks, and his exercise tolerance is failing. He also reports that he has developed persistent, generalized itching. A 24-hour urine collection reveals that his creatinine clearance is stable at 15 ml/min. His blood urea nitrogen (BUN) level is 90 mg/dl, and his creatinine level is 8.5 mg/dl. A nephrologist recently referred the patient to a vascular surgeon for hemodialysis vascular access. He states that his nephrologist has advised that he initiate hemodialysis therapy as soon as his vascular access is placed and matured.Which of the following statements regarding end-stage renal disease (ESRD) and hemodialysis is false?

A. Infection is second only to cardiovascular disease as a cause of deaths in patients with ESRD

Most deaths caused by infection in patients with ESRD are the result of pneumonia

Of the devices for gaining circulatory access, indwelling catheters carry the most risk for infection

S. aureus and S. epidermidis are the most commonly identified agents in infections related to dialysis vascular access

Most deaths caused by infection in patients with ESRD are not the result of pneumonia. Other types of infections, such as bloodstream infections, access site infections, and urinary tract infections, are more common causes of infection-related deaths in patients with ESRD.

Explanation

Most deaths caused by infection in patients with ESRD are not the result of pneumonia. Other types of infections, such as bloodstream infections, access site infections, and urinary tract infections, are more common causes of infection-related deaths in patients with ESRD.

22. A 47-year-old man who recently received a renal transplant and was started on steroids, cyclosporine, and mycophenolate mofetil presents for routine follow-up. On physical examination, his blood pressure is noted to be 189/96 mm Hg.Which of the following statements regarding hypertension and renal transplantation is true?

Hypertension is a rare posttransplantation complication

Mycophenolate mofetil can cause vasoconstriction and worsen hypertension

Graft dysfunction causes worsening of hypotension

Cyclosporine commonly induces a volume-dependent form of hypertension

Cyclosporine commonly induces a volume-dependent form of hypertension in patients who have undergone renal transplantation. This means that the hypertension is caused by an increase in blood volume, which can lead to an increase in blood pressure. This is a common complication in patients who are taking cyclosporine as part of their immunosuppressive regimen after a renal transplant. It is important to monitor blood pressure regularly in these patients and manage hypertension appropriately to prevent further complications.

Explanation

Cyclosporine commonly induces a volume-dependent form of hypertension in patients who have undergone renal transplantation. This means that the hypertension is caused by an increase in blood volume, which can lead to an increase in blood pressure. This is a common complication in patients who are taking cyclosporine as part of their immunosuppressive regimen after a renal transplant. It is important to monitor blood pressure regularly in these patients and manage hypertension appropriately to prevent further complications.

23. A 28-year-old man presents to clinic with a complaint of hematuria of 1 day's duration. He was well until 3 days ago, when he developed a sore throat, low-grade fever, and malaise, which lasted for approximately 48 hours. He had a similar episode approximately 1 year ago. He denies having rash, joint pains, or dysuria. On examination, he appears well, and he is afebrile. His blood pressure is 118/62 mm Hg. Urine dipstick assay is significant for 2+ blood and trace protein. Microscopic examination of the urine reveals 10 to 15 red cells per high-powered field; dysmorphic red cells and occasional red cell casts are noted as well. Further testing reveals a normal antistreptolysin-O (ASO) titer and serum complement level.Which of the following statements regarding this patient's condition is false?

Findings on urinalysis identify the source of bleeding as glomerular in origin

Renal biopsy is likely to reveal mesangial deposition of immunoglobulin A (IgA) on immunofluorescence microscopy

Results of analysis of the urine sediment are consistent with a finding of hypercalciuria as a cause of the hematuria

The correct answer is that the results of analysis of the urine sediment are consistent with a finding of hypercalciuria as a cause of the hematuria. This statement is false because the presence of dysmorphic red cells and red cell casts in the urine sediment suggests glomerular pathology, not hypercalciuria. Hypercalciuria is a condition characterized by elevated levels of calcium in the urine and is not typically associated with dysmorphic red cells or red cell casts. The other statements are true and consistent with the patient's presentation of acute glomerulonephritis, likely due to IgA deposition.

Explanation

The correct answer is that the results of analysis of the urine sediment are consistent with a finding of hypercalciuria as a cause of the hematuria. This statement is false because the presence of dysmorphic red cells and red cell casts in the urine sediment suggests glomerular pathology, not hypercalciuria. Hypercalciuria is a condition characterized by elevated levels of calcium in the urine and is not typically associated with dysmorphic red cells or red cell casts. The other statements are true and consistent with the patient's presentation of acute glomerulonephritis, likely due to IgA deposition.

24. A 60-year-old man who presented with fatigue and bone pain is found to be anemic and thrombocytopenic. Examination reveals pale conjunctivae and thigh tenderness but no peripheral edema. Radiographs demonstrate osteolytic lesions in several thoracic vertebrae and the left femur. Serum chemistries reveal a creatinine level of 1.2 mg/dl, a calcium level of 9.5 mg/dl, a total protein level of 11 mg/dl, and an albumin level of 3.2 mg/dl. On bone marrow biopsy, there is replacement of normal marrow with sheets of plasma cells. Urinalysis is unremarkable, but a 24-hour urine study reveals proteinuria of 2.0 g/day.Which of the following statements regarding this patient's proteinuria is true?

The likely underlying pathology involves a structural abnormalityof the filtration barrier that results in loss of negatively charged Proteins

The proteinuria reflects an overproduction of normally filtered proteins, which overwhelms the reabsorptive capacity of the tubules

The patient's degree of proteinuria and spectrum of clinical findings is consistent with the nephrotic syndrome

The patient's presentation with fatigue, bone pain, anemia, and thrombocytopenia, along with the presence of osteolytic lesions and replacement of normal marrow with plasma cells on bone marrow biopsy, suggests multiple myeloma. In multiple myeloma, there is an overproduction of abnormal plasma cells that can lead to the overproduction of normally filtered proteins. This overwhelms the reabsorptive capacity of the tubules, resulting in proteinuria. The other options are not consistent with the patient's clinical findings and underlying pathology.

Explanation

The patient's presentation with fatigue, bone pain, anemia, and thrombocytopenia, along with the presence of osteolytic lesions and replacement of normal marrow with plasma cells on bone marrow biopsy, suggests multiple myeloma. In multiple myeloma, there is an overproduction of abnormal plasma cells that can lead to the overproduction of normally filtered proteins. This overwhelms the reabsorptive capacity of the tubules, resulting in proteinuria. The other options are not consistent with the patient's clinical findings and underlying pathology.