id,explanation 2464,Answer D: About 50% of people with hypertension are controlled 2465,Answer A: Increased long-term BP variability is associated with an increased risk of cardiovascular events despite adequate BP control on most visits 2466,Answer D: Low dietary potassium promotes hypertension by increasing the activity of the sodium-chloride cotransporter (on a high sodium diet) 2467,Answer D: Add amiloride 2468,Answer B: In 1 year 2469,Answer B: Obtain 24-hour ambulatory BP monitoring 2470,Answer D: Add spironolactone 2471,"Answer B: Home BP tele-monitoring supervised by a health care provider results in higher rates of BP control than usual care Home BP monitoring, with or without remote telemonitoring, is associated with better BP control; therefore, choice B is correct, and choice A is incorrect. The best results occur when a healthcare provider, such as a physician, clinical pharmacist, or nurse, pairs the monitoring with interventions. Protocols involving patient education for self-titration of therapy are also quite effective for individuals with hypertension regardless of comorbid conditions, but it is estimated that only about 20% of hypertensive patients may be suitable to this intervention (incorrect choices C and D). Financial incentives to physicians result in modest increases in rates of BP control in hypertensive patients (incorrect choice E)." 2472,Answer D: 110/75 mmHg 2473,Answer A: Droxidopa 2474,Answer D: Make no changes to the current regimen 2475,Answer D: Her BMI 2476,Answer C: Inappropriately low atrial natriuretic peptide levels 2477,"Answer D: Regular use of continuous positive airway pressure for at least 4 hours per night Patients with obesity have an increased incidence of both sleep apnea and resistant hypertension. A recent study has shown that the combination of weight loss with regular use of CPAP improves BP and can reverse abnormal dipping patterns. The effects of CPAP on BP are also more pronounced with use of CPAP for more than 4 hours per night; hence, choice D is correct. Use of nocturnal oxygen supplementation has not been shown to be effective to reduce BP (choice A is incorrect). Behavioral and self-help psychotherapy are not effective in lowering BP as assessed by ambulatory blood pressure monitoring (choice B is incorrect). A randomized, double-blind, sham-controlled trial and a meta-analysis of device-guided breathing by Landman and coworkers found no benefit of device-guided breathing in lowering BP; thus, choice C is incorrect." 2478,Answer D: Order a CT angiogram 2479,Answer D: Refer for adrenal vein sampling 2480,Answer C: A lateralization index of 6 2481,Answer D: Plasma metanephrines 2482,Answer C: Genetic testing 2483,Answer D: Maintenance of his systolic BP at <120 mmHg 2484,Answer C: Reversal of INR to <1.3 plus lowering of systolic BP <160 mmHg within 4 hours 2485,Answer D: The absence of nocturnal dipping 2486,Answer B: Underlying CKD 2488,"Answer D: Add amlodipine, targeting a systolic BP of <120 mmHg " 2489,"Answer C: The low BP target (120 mmHg) resulted in a 38% reduction in the risk of heart failure In SPRINT, a systolic BP target of <120 mmHg, compared to a target of 140 mmHg, resulted in lower risk of several cardiovascular endpoints as well as all-cause death. Specifically, the composite endpoint of myocardial infarction and other coronary syndromes, stroke, heart failure, or cardiovascular death was decreased by 25%. This was driven largely by less heart failure (38%) and cardiovascular deaths (22%). All cause death was also decreased by 27%. Other components of the endpoint were also improved, but did not reach statistical significance (stroke was decreased by 11%, P=0.50, and myocardial infarction was decreased by 17%, P=0.19; other coronary syndromes were identical between the two groups). All subgroups benefited from the lower target, including patients older than 75 years. The differences between the two groups were substantial (15/8 mmHg at 12 months) an dpersisted for the duration of the trial. The risk of AKI was increased by 71% in the low BP target group, but the absolute risk was 4.4% (vs. 2.6% in the standard group, P<0.001). " 2490,Answer C: Refer for percutaneous renal angioplasty 2491,Answer E: 25OHD replacement has no effect on BP in hypertensive patients with 25OHD deficiency 2492,"Answer C: Beetroot juice lowers ambulatory BP by about 8/5 mmHg compared with placebo Beetroot juice is a good source of nitrates, resulting in BP lowering through the provision of nitrates that result in vasodilatation, improved endothelial function, and lower BP (-7.7/5.2 mmHg on 24h ABPM). There is no known effect of beetroot juice on aldosterone. In the available clinical studies, the effect was sustained at least up to 4 weeks. Pulse wave reflections have not been studied with beetroot therapy, but pulse wave velocity tends to decrease, thus suggesting that wave reflection would also likely decrease. There are no reports of hypertension associated with beetroot juice." 2493,Answer B: Target the hemoglobin A1c to <7.0 % before conception 2494,Answer C: Increased AST and ALT 2495,Answer E: Make no changes to the current regimen 2496,Answer A: Induction of labor and delivery 2497,Answer D: Continue intravenous magnesium and transition to oral antihypertensive medications 2498,Answer A: Labetalol 2499,Answer C: Aspirin at 81 mg daily 2500,Answer C: It increases the risk of cardiovascular disease 2501,Answer B: She is at increased risk of urinary tract infection 2502,Answer D: Acute fatty liver of pregnancy (AFLP) 2503,Answer A: Transfuse platelets and packed red blood cells 2504,Answer B: Long-chain 3-hydroxyl CoA dehydrogenase 2505,Answer C: Observation with expectant medical management 2506,Answer D: Renal blood flow returns to pre-pregnancy levels 2507,Answer D: Preeclampsia 2508,Answer A: Intravenous normal saline plus furosemide 2509,Answer D: Hemodialysis totaling ≥36 h/wk 2510,Answer C: A low soluble fms-like tyrosine kinase-1 to placental growth factor ratio 2511,Answer C: Enalapril 2512,"Answer B: She should start aspirin 81 mg daily immediately after pregnancy is diagnosed Approximately one in three women who have received a kidney transplant develop preeclampsia during pregnancy. Therefore, prophylaxis with low-dose aspirin is appropriate. In addition, heightened antenatal surveillance should be offered, including fetal growth and Doppler monitoring starting at 28 weeks gestation. The majority of women with kidney transplants are delivered by caesarean section. However, the indications for surgical delivery are the standard obstetric maternal or fetal indications, and vaginal delivery is not contraindicated. Therefore, option A is incorrect. Mycophenolate mofetil should be changed to azathioprine at least 3 months prior to attempting to conceive, to ensure graft stability; hence, option C is incorrect. Risk factors for adverse graft outcomes include hypertension, pre-pregnancy serum creatinine levels >1.5 mg/dl, and black ethnicity. There is no evidence to support an increased incidence of graft rejection after delivery, therefore commencing prednisone postpartum (option D) is incorrect." 2513,Answer A: The probability of achieving pregnancy is reduced compared with spontaneous conception 2514,Answer B: Stop mycophenolate mofetil and start azathioprine 2515,Answer D: Anti-Ro and anti-La antibodies 2516,Answer C: Furosemide 2517,Answer B: Reduce the tacrolimus dose 2518,Answer B: Enzyme replacement therapy 2519,Answer D: It does not increase the risk for a small gestation baby 2520,Answer C: A reduction in the loading dose and maintenance dose 2521,"Answer C: Empiric therapy with predisone and azathioprine, followed by adjusted treatment after delivery based on kidney biopsy performed postpartum " 2522,Answer A: Her risk of progression to ESRD during or shortly postpartum is about 20% 2523,Answer D: IgA nephropathy 2524,Answer C: Measure or estimate 24-hour creatinine excretion rate 2525,Answer E: Rituximab 2526,Answer D: Stain prior kidney biopsy with Congo Red 2527,Answer E: No additional diagnostic studies are required 2528,Answer A: Oral angiotensin receptor blockers (ARBs)d 2529,Answer A: Oral glucocorticoids 2530,Answer B: Oral cyclosporine and low-dose steroids for ≥4 months 2531,Answer C: As in A plus widespread effacement of the podocyte foot processes by electron microscopy 2532,"Answer C: Hyperexpression of PLA2R antigen by immunohistochemical studies of pronasedigested, paraffin-preserved specimens " 2533,Answer E: Continued supportive care and observation 2534,Answer B: Pronase digestion of paraffin-embedded material and staining for monoclonal IgG (light and heavy chains) 2535,Answer A: Sarcoidosis causing secondary membranous nephropathy 2536,Answer B: Oral ACEIs or ARBs 2537,Answer D: Perform a laser dissection/mass spectrometry analysis of the biopsy specimen 2538,Answer E: Serum immunofixation and free light-chain assays 2539,Answer B: An underlying autoimmune disorder 2540,Answer B: Staining the kidney biopsy for hepatitis B surface antigen and core antigen 2541,Answer D: Sofosbuvir plus simeprevir plus rituximab 2542,"Answer C: IgA−dominant, infection−related GN " 2543,"Answer C: Kidney prognosis is likely to be good long term, but uncertainty exists; therefore, yearly follow-up is advisable " 2544,Answer A: A calcineurin inhibitor 2545,Answer C: Treat with cyclophosphamide and corticosteroids as outlined in choice B but reduce the doses by ≥20% 2546,Answer B: Either intravenous cyclophosphamide or intravenous rituximab 2547,Answer A: Rituximab > azathioprine > mycophenolate > extended cyclophosphamide 2548,"Answer A: Plasmapheresis, high−dose corticosteroids, and cyclophosphamide " 2549,Answer A: Provide supportive care and management for ESRD 2550,"Answer A: The long−term prognosis is favorable, because the proteinuria declined to <0.7 g/d after 1 year " 2551,Answer B: Add low−dose Euro lupus cyclophosphamide for 3 months to corticosteroids 2552,Answer B: A sustained remission for at least 24 months 2553,Answer E: Conduct a detailed evaluation of his diet 2554,Answer E: Adynamic bone disease 2555,"Answer B: All surgical approaches, such as partial, subtotal, or total parathyroidectomy with or without autotransplantation, are effective " 2556,Answer B: Begin cinacalcet therapy 2557,Answer D: Cinacalcet 2558,Answer D: Add teriparatide 2559,Answer A: The effect of phosphate binders does not increase linearly with dose 2560,Answer C: Lithium-related primary hyperparathyroidism 2561,Answer C: Elevated IgGκ monoclonal protein 2564,Answer D: Add sodium thiosulfate 2566,Answer A: Start bisphosphonate therapy 2567,Answer C: Identify the method of serum phosphate measurement 2568,"Answer D: 24,25-dihydroxy vitamin D level " 2569,Answer B: Weight-based dose of denosumab 2570,Answer C: Giant cell granuloma formation 2571,Answer A: Prolonged hypocalcemia 2572,Answer A: Hypercalcemia 2573,Answer C: Both hypomagnesemia and hypermagnesemia increase the risk of premature mortality in dialysis patients 2574,Answer A: Cinacalcet therapy 2575,Answer B: A 25-hydroxy vitamin D level 2576,Answer D: Acetazolamide 2577,Answer A: The release of phosphaturic factor from the liver 2578,Answer C: Point of care ultrasonography 2579,Answer C: Ketoconazole 2581,Answer C: The stone should be sent for chemical analysis 2582,Answer C: Silodosin 2583,Answer B: His peritonitis-free survival after switching back to PD is comparable with that of those who did not require transfer to hemodialysis after experiencing peritonitis 2585,Answer B: HHD would confer a lower risk of hospitalization compared to PD 2586,Answer A: Repeat the cell count after infusing 1 L of dialysate that dwells for 1-2 hours 2587,Answer B: It results in improved fluid balance 2588,Answer A: An increased risk of infectious complications 2589,Answer C: An increase in dialysate sodium to 140 mEq/L 2590,Answer D: An improvement in peak oxygen consumption 2591,Answer C: It will likely delay or obviate the need for future parathyroidectomy 2592,Answer B: He has about a 10% risk of persistent hyperparathyroidism 2593,Answer C: Improved relative mortality 2594,Answer A: Increased 6-month mortality 2595,Answer D: <4% weight gain 2596,Answer D: No additional management 2597,Answer C: They enhance flow-mediated brachial artery dilation 2598,Answer C: Gradual lowering of the target weight 2599,Answer D: Hand hygiene after removal of gloves and other personal protective equipment 2600,Answer C: Referral to nephrologists when patients are anticipated to require RRT at least 1 year in advance 2601,Answer D: An additional provider visit within the month following discharge 2602,Answer D: Her family history 2603,Answer C: Stabilization of systemic markers of inflammation 2604,Answer A: A dialysate calcium level of 2.0 mEq/L 2605,Answer D: Continue pravastatin at the current dose 2606,Answer B: Lack of interest 2607,Answer B: Transesophageal echocardiography 2608,Answer E: Multiple daily insulin injections 2609,Answer B: An oral charcoal adsorbent 2610,Answer C: Bisoprolol 2611,Answer D: Her insurance status 2612,Answer C: Warfarin with time in the therapeutic range >70% 2613,Answer D: Increase furosemide to 40 mg twice daily 2614,Answer D: Furosemide at 40 mg/d plus sodium chloride tablets at 1 g three times daily 2615,Answer B: 3% saline to increase SNa+ 4–6 mEq/L 2616,Answer C: Weight gain >3 kg after exercise 2617,"Answer C: Continue desmopressin, decreasing fluid intake in response to thirst only " 2618,Answer B: Desmopressin at 4 µg subcutaneously plus intravenous 5% dextrose in water (D5W) to achieve a serum sodium of 118–122 mEq/L 2619,Answer A: Discontinue metformin 2–3 days before CA 2620,Answer A: Discontinue furosemide and begin intravenous 0.9% saline at 125 ml/h 2621,Answer D: Decrease dietary sodium intake to 2–3 g/d 2622,Answer A: 4.0 L 2623,Answer A: Excessive water intake and retention 2624,Answer D: Observation of clinical status after correction of hypovolemia 2625,Answer A: Torsemide has increased bioavailability and a longer half-life 2626,Answer B: 1.8 L 2627,"Answer D: Respiratory acidosis, metabolic alkalosis, and metabolic acidosis " 2628,Answer C: Bartter syndrome 2629,Answer B: Start chlorthalidone 2630,Answer A: Hypomagnesemia 2631,Answer A: Decreased activity of 11β-hydroxysteroid dehydrogenase 2632,Answer A: The frequency of colonic necrosis is approximately 0.1% 2633,Answer B: Increased activity of the NCC in the distal convoluted tubule 2634,Answer C: Urine calcium-to-creatinine ratio 2635,Answer D: The early distal convoluted tubule 2636,Answer E: Proximal renal tubular acidosis 2637,Answer D: Incomplete distal renal tubular acidosis (type 1) 2638,Answer C: An 18-year-old woman with sensorineural hearing loss and goiter 2639,Answer B: Gentamicin 2640,Answer A: Ammonium chloride challenge test 2641,Answer C: Isotonic sodium bicarbonate infusion 2642,Answer D: Continue current regimen 2643,Answer A: His race 2644,Answer B: It is associated with increased waitlist mortality 2645,"Answer D: His risk of contracting HIV, hepatitis C virus (HCV), or hepatitis B virus from a PHS-IRD donor is <1% " 2646,Answer C: Her projected waiting time for a deceased donor kidney is likely to be <4 months Educational objective: Counsel a prior living donor about options for transplantation 2647,Answer A: Consent to receive an HCV-positive kidney may dramatically reduce his waiting time Educational objective: Counsel a patient with hepatitis C virus infection about treatment and the benefits and risks of consenting to a hepatitis C seropositive donor kidney 2648,Answer D: AKI in the donor kidney does not affect allograft function at 1 year Educational objective: Know the outcomes of transplanting donor kidneys with AKI 2649,Answer A: The presence of the donor-specific antibody increased her risk of DGF 2650,Answer C: Pregnancy after kidney donation is associated with an increased risk of gestational hypertension and preeclampsia 2651,Answer C: It is three to five times higher than non-donors in the general population 2652,Answer E: It is associated with an increased risk of acute rejection 2653,Answer D: Induction therapy associates with approximately 50% rejection risk reduction compared to no induction therapy 2654,Answer A: Dose reductions stemming from adverse effects are associated with an increased risk of rejection and graft failure Educational objective: Cite the benefits and risks of mycophenolate use after kidney transplantation 2655,Answer B: Blood transfusion may induce donor-specific antibody and an increased risk of rejection Educational objective: Know the risks and recommended methods of transfusion in transplant recipients 2656,Answer D: HLA antibody desensitization is associated with inferior patient and graft survival compared with HLA-compatible transplantation 2657,Answer E: Urine protein-to-creatinine and/or urine albumin-to-creatinine ratio 2658,Answer C: A biphosphonate 2659,Answer A: Subtotal parathyroidectomy 2660,Answer A: Transition MMF to azathioprine >6 weeks prior to attempts to conceive and plan to increase tacrolimus about 20%-25% during the second trimester to maintain therapeutic levels Educational objective: Manage immunosuppression prior to and during pregnancy 2661,Answer D: Lisinopril 2662,Answer C: His risk of DGF is higher than nonobese transplant recipients 2663,Answer A: Midodrine use 2664,Answer B: Use of thymoglobulin induction therapy 2665,Answer A: Development of de novo donor-specific antibodies 2666,Answer A: An additional 1-year waiting time (total waiting time = 2 years) on the basis of prior skin cancer history 2667,Answer D: Recurrent MN with progressive proteinuria typically responds to rituximab Educational objective: Know the outcomes of recurrent membranous nephropathy after transplantation 2668,Answer A: She is an eligible candidate for SPK transplantation 2669,Answer D: SPK transplant waiting time is substantially shorter than for deceased donor kidney transplant alone 2670,"Answer C: A 54-year-old man with HCV infection, type 2 diabetes mellitus, an eGFR of 35-40 ml/min/1.73m2, and proteinuria of 1g/day " 2671,Answer A: A lower incidence of CMV viremia 2672,Answer A: A lower incidence of acute rejection 2673,"Answer D: An increase in incident fistula rate, a decline in graft rate, and no change in catheter rate " 2674,Answer C: An improvement in serum albumin 2675,Answer E: The fact that she is female 2676,Answer E: The risk of death is lower with fistulas than with grafts 2677,Answer C: Placement of an early cannulation arteriovenous graft 2678,Answer C: Measurement of access flow and cardiac output 2679,Answer E: No additional intervention 2680,Answer B: Placement of tunneled central vein catheter closer to the initiation of dialysis Educational objective: Choice of appropriate hemodialysis access 2681,Answer B: Small-dose venography to assess peripheral and central veins 2682,Answer B: Its use will be associated with no clinically meaningful increase in arteriovenous graft patency 2683,"Answer B: Superior patency at 6, 12, and 24 months " 2684,Answer D: Continue to use the fistula with blood flows <450 ml/min 2685,Answer A: It is associated with an increased risk of unassisted fistula maturation failure in comparison with no stenosis 2686,Answer C: The optimal tests for identifying an inflow stenosis are access flows <650 ml/min or the combination of a positive physical examination plus access flows <650 ml/min 2687,Answer B: A reduced risk of subsequent fistula thrombosis 2688,Answer B: Patients undergoing fistula thrombectomy within 24 hours of diagnosis have higher patency rates at 3 months than do patients treated later 2689,Answer B: Advanced laparoscopic placement has lowest mechanical complication rate Education objective: Explain technical considerations of peritoneal dialysis catheter insertion 2690,Answer B: Patients starting PD 1 week after catheter placement had significantly higher leaks in comparison with patients who started after 4 weeks 2691,Answer A: Patient-targeted educational interventions increase the odds of receiving PD as the initial treatment modality 2692,Answer A: Ultrasonographic flow measurements and left arm arteriogram 2693,Answer B: A complication from use of the citrate lock solution 2694,Answer D: Exchange the tunneled catheter over a guidewire with balloon angioplasty to disrupt the fibrin sheath 2695,Answer B: Refer the patient immediately to the vascular surgeon for evaluation for impending rupture of the arteriovenous access 2696,Answer B: Her radiocephalic arteriovenous fistula is an excellent choice for vascular access for intensive HD 2697,"Answer B: Refer the patient for a low-dose contrast angiogram, including direct arteriogram Educational objective: Manage arteriovenous access inflow stenosis" 2698,"Answer C: In nonmaturing fistulas, accessory veins should be ligated if they divert >25 percent of the outflow" 2699,Answer C: Plan contrast venography of her central veins to evaluate for unsuspected central venous stenosis 2700,Answer C: A twofold increase in peak systolic flow velocity ratio 2701,Answer B: Hydronephrosis 2702,Answer D: A discontinuous thrill with only a systolic component at the juxta-anastomotic site 2733,Answer D: The fellow tells the patient that his kidney disease is caused by a mutation in the gene that encodes the alpha-5 chain of type IV collagen 2734,Answer A: Genetic analysis for hereditary forms of FSGS 2735,Answer A: The IgG in the kidney biopsy may be monoclonal 2736,"Answer B: The worsening kidney function may be due thrombotic microangiopathy from the sunitinib, and you would like to do a kidney biopsy for diagnosis before recommending any changes to the patient’s cancer therapy " 2737,Answer D: A kidney biopsy to verify your suspicion that this patient has staphylococcal-associated IgA GN 2738,Answer D: Cryoglobulinemia can occur with hepatitis C and hepatitis B 2739,Answer D: What was the magnitude and time course of the patient’s hematologic response to therapy 2740,Answer B: Serum immunofixation plus serum free light chains 2741,Answer C: Avoid nonsteroidal anti-inflammatory drugs and proton pump inhibitors 2742,"Answer C: You continue treatment for anti-GBM disease with plasmapheresis, steroids, and cyclophosphamide, and after the patient goes into remission you provide the patient with maintenance immunosuppression " 2743,Answer A: A combination of low-dose tacrolimus and low-dose mycophenolate mofetil (MMF) with prednisone 2744,Answer C: Talk to the patient about repeating a kidney biopsy to determine if her lupus nephritis is still active or if the proteinuria represents chronic disease and immunosuppression can be safely tapered 2745,Answer B: Add an antimalarial to the regimen 2746,Answer C: Dialysis vintage >5 years 2747,Answer D: Restart MMF and corticosteroids to treat a presumptive diagnosis of class V plus class III or IV lupus nephritis 2748,Answer C: Rituximab 2749,Answer C: ANCA became undetectable after induction therapy 2751,"Answer D: Because the patient did not have lung or upper respiratory vasculitis, her chances of disease relapse while she is using dialysis are lower " 2752,"Answer D: The patient had moderately severe MPO-ANCA-associated nephritis, received induction therapy with oral cyclophosphamide, and became ANCA negative when maintenance therapy was initiated " 2753,Answer A: His serum creatinine level at presentation is an independent predictor of dialysis dependency at one year 2754,Answer B: Begin enzyme replacement therapy now 2755,Answer C: COL4 (type IV chain of collagen) 2756,"Answer D: Antiviral therapy, rituximab or cyclophosphamide, plus plasmapheresis " 2757,Answer B: Entecavir 2758,Answer D: Cyclophosphamide plus corticosteroids 2759,Answer C: Conduct further hematological investigation to search for a B cell clone 2760,Answer C: Anti-B cell therapy with rituximab plus bendamustine 2761,Answer A: IgG4-related disease 2762,Answer C: Further evaluation should include testing for hepatitis C virus infection Educational objective: Counsel a patient with fibrillary glomerulonephritis 2763,Answer C: A QRS-T angle ≥75 on signal-averaged electrocardiogram 2764,Answer D: Elevated BMI is associated with improved survival in patients who have evidence of systemic inflammation 2765,Answer D: It is not inferior to cinacalcet in lowering PTH concentrations 2766,Answer A: The risk of SCD is the same in HD and PD 2767,Answer C: A drop in systolic pressure to <90 mmHg is associated with increased mortality risk Educational objective: Cite the significance of intradialytic hypotension in patients treated with hemodialysis 2768,Answer B: HDF provides superior β-2 microglobulin clearance 2769,Answer B: Moderate interstitial lung edema by lung ultrasonography is associated with increased risk of death 2770,Answer D: His diagnosis of acute myocardial infarction 2771,Answer A: AF is associated with an increased risk of ischemic stroke 2772,Answer A: Reduce apixiban to 2.5 mg twice daily 2773,Answer D: Ergocalciferol 2774,Answer D: A reduction in the progression of coronary artery calcification 2775,Answer A: Higher dialysate sodium concentration 2776,"Answer C: Elevated FGF23 levels in ESRD are associated with an increased risk of cardiovascular events, infections, and mortality " 2777,Answer A: The majority of patients on HD experience deterioration of cognitive function 2778,Answer D: Roxadustat is a possible future alternative agent for the treatment of his anemia 2779,Answer A: PIH is associated with higher all–cause hospitalization and mortality 2780,Answer C: Tenapanor caused a dose-dependent reduction in the serum phosphate concentration 2781,Answer A: Preoperative prophylactic antibiotics reduce the risk of early peritonitis Educational objective: Counsel a patient about early peritonitis complicating initiation of peritoneal dialysis 2782,Answer D: Recurrent and recent bacterial peritonitis 2783,Answer C: Centers with >29% of dialysis patients treated with PD 2784,Answer A: Abdominal wall complications can be reduced to <10% by initiating PD with low dwell volumes with gradual titration over the first month of therapy 2785,Answer A: Patients who have cirrhosis and ESRD who are treated with PD have a significantly lower mortality in comparison with HD patients who have cirrhosis and ESRD. 2786,Answer B: Active smoking/substance abuse 2787,Answer A: There is a U-shaped association between hemoglobin A1c levels and mortality Educational objective: Correctly characterize the epidemiology of mortality and glucose metabolism in ESRD 2788,"Answer D: Diabetic ESRD patients who receive probiotics containing lactobacillus were found to have decreased fasting serum glucose and serum insulin, along with increased insulin sensitivity " 2789,Answer A: Her fraction of total MGP that is carboxylated is more likely to be lower 2790,Answer A: Incremental HD is associated with a significantly slower decline in residual kidney function compared with conventional dialysis 2791,Answer A: Avoid skin trauma and subcutaneous injections 2792,Answer C: Maintenance IV iron is not associated with a greater likelihood of achieving hemoglobin between 10 and 12 g/dl 2793,Answer A: Cystoscopy and computed tomographic urogram if the cystoscopy is normal 2794,Answer B: Glomerular hypertrophy 2795,Answer D: Start empiric therapy with oral corticosteroids 2796,Answer A: Perform genetic testing for a podocytopathy 2797,Answer C: Anti-thrombospondin 7A staining of the renal biopsy specimen 2798,Answer E: Observe with renin-angiotensin inhibition therapy only 2799,Answer B: Combinations of rituximab with low-dose cyclophosphamide can achieve very high remission rates 2800,"Answer D: Treatment with high-dose steroids, cyclophosphamide, and plasmapheresis Educational objective: Choose the best treatment strategy for rapidly progressive crescentic IgA nephropathy " 2801,Answer E: Increased serum C3 and normal C4 levels 2802,"Answer B: A posttransplant regimen consisting of tacrolimus, MMF, and early corticosteroid withdrawal " 2803,Answer C: Serum free light chains and immunofixation 2804,Answer D: Stain biopsy specimen for DNAJB9 deposition 2805,Answer A: Presence of two APOL1 high-risk alleles 2806,Answer B: 6.6 per 100 patient years 2807,Answer: His age 2808,Answer B: Information on his birth weight will be of value in determining his prognosis Educational objective: Discern that low birth weight and low nephron endowment is an important risk factor for progression of focal and segmental glomerulosclerosis 2809,Answer A: Serum anti−PLA2R antibody negative and PLA2R1 antigen positive in glomeruli Educational objective: Know that the absence of anti-PLA2R antibody in the serum and positive histologic PLA2R antigen staining in membranous nephropathy with normal kidney function is a reliable indicator of remission at 6 months 2810,Answer C: Rituximab therapy would likely offer better prospects for long-term control of her disease 2811,Answer C: Magnitude of proteinuria 2812,Answer D: Normal with no abnormality seen 2813,Answer A: Lower mesangial proliferation grade 2814,Answer D: IgM and C3 deposition 2815,Answer C: Repeated immunofluorescence study of a pronase digested paraffin block section 2816,Answer B: Initiate treatment with rituximab 2817,Answer A: Increased C4d mesangial deposition 2818,Answer C: Serum free light chain assay 2819,Answer C: Staining of renal biopsy specimen for DNAJB9 2820,Answer B: Serum albumin <2.5 g/dl at the time of diagnosis prior to transplant 2821,Answer C: Rituximab 375 mg/m2 weekly for 4 doses 2822,Answer A: IgA nephropathy 2823,Answer D: AKI requiring dialysis 2824,Answer B: No difference in mortality at 90 days 2825,Answer B: Increased incidence of gastrointestinal complications 2826,Answer B: Her duration of RRT will be shorter 2827,Answer B: An increased risk of AKI requiring RRT 2828,Answer C: Decreased risk of progressive AKI requiring dialysis 2829,Answer D: Early adminstration of appropriate antibiotics 2830,Answer B: A 76-year-old woman with a serum creatinine that has increased from 0.7 mg/dl to 1.0 mg/dl over 3 days 2831,"Answer B: A reduction in RRT events, inpatient mortality, and radiocontrast exposure " 2832,"Answer C: Fewer cases of severe AKI, a higher incidence of renal recovery, and increased early nephrology consultation " 2833,Answer B: A decreased rate of stage 2 and 3 AKI 2834,Answer C: Delayed graft function after renal transplantation 2835,Answer B: A 62-year-old man with a stage G3a:A1 CKD (eGFR 46 ml/min per 1.73 m2) scheduled for elective coronary artery bypass surgery with a GFR that increases by 42 ml/min per 1.73 m2 after a protein load of 1.2 g/kg body weight 2836,Answer B: Urine neutrophil gelatinase-associated lipocalcin 2837,Answer B: The transcatheter approach for aortic valve replacement may be associated with a lower risk of AKI compared to a surgical approach 2838,Answer C: Neither N-acetylcysteine compared to placebo nor isotonic bicarbonate therapy compared to saline is more likely to reduce the risk of dialysis-requiring AKI after contrast exposure 2839,Answer D: There is no significant difference in outcomes between diffusive or convective modalities of CRRT 2840,Answer B: It increases his risk of incident congestive heart failure 2841,"Answer B: Continuous RRT, if chosen, should be provided with effluent flow rate of at least 20 ml/kg per h " 2842,Answer A: Isolated severe right ventricular systolic dysfunction (right ventricular ejection fraction of 25%) 2843,Answer D: Vancomycin nephrotoxicity has been associated with trough levels ≥15 mg/L 2844,Answer C: The combination of vancomycin and piperacillin-tazobactam is associated with a higher risk of AKI than either antibiotic alone 2845,Answer A: The reduction in the NT-proBNP level of >30% is associated with improved survival independent of the change in kidney function 2846,"Answer B: Although she experienced transient azotemia that returned to baseline within 3 days, she still is at a high risk for readmission than are patients without AKI " 2847,Answer D: Her pre-ESRD episode of AKI is associated with a 30% greater risk of mortality at 1 year in comparison with patients without AKI before incident dialysis 2848,Answer A: Off-pump surgery in eligible patients is associated with a reduced risk of AKI during the first postoperative month 2849,Answer A: Acute tubulointerstitial nephritis with podocyte injury 2850,Answer C: Continuous RRT 2851,Answer A: Ipilimumab-related hypophysitis with secondary adrenal insufficiency 2852,Answer A: Focal and segmental glomerulosclerosis plus thrombotic microangiopathy 2853,Answer D: The patient does not need to be isolated because he has developed immunity as the result of a prior hepatitis B infection 2854,Answer C: He has hepatitis C infection and has previously been infected with hepatitis B 2855,Answer C: Order a chest radiograph 2856,Answer D: Immediately transfer the patient to a hospital for both airborne and contact isolation Educational objective: Recognize disseminated herpes zoster and recommend appropriate infection-control precautions 2857,Answer C: After contact with a patient with a recent diagnosis of Clostridioides difficile-induced diarrhea 2858,"Answer C: Make alcohol-based hand rub readily available near dialysis stations, and observe hand hygiene opportunities monthly, providing staff with feedback regarding their performance Educational objective: Implement current recommendations for hand hygiene in hemodialysis clinics " 2859,"Answer B: Failure of personnel to change gloves and perform hand hygiene when moving between patients, between patients and potentially-contaminated surfaces, and between machines " 2860,Answer C: Avoid administration of medications from the same syringe to more than one patient Educational objective: Identify risk factors associated with safe injectable medication handling and administration in hemodialysis clinics 2861,Answer D: Reverse osmosis membrane 2862,Answer B: A blood leak due to a ruptured dialyzer membrane 2863,Answer D: Recent exposure to hepatitis B vaccine 2864,Answer C: Failure to perform proper hand hygiene between patient encounters 2865,Answer B: Use an alcohol-based chlorhexidine (>0.5%) solution for cleansing the exit site skin and scrub the hub with 70% alcohol 2866,Answer D: Double application of tuberculocidal disinfectant 2867,"Answer A: Develop action plans to improve infection control practices, explaining the rationale of each plan with provision of feedback on the plan’s impact " 2868,"Answer A: Medical directors are responsible for the oversight of all care-related activities, including the high BSI and CVC rates at that facility " 2869,Answer B: Gram-negative blood stream infections have been reported with hemodialyzer reuse Educational objective: Know the risks of hemodialyzer reuse 2870,"Answer D: Assess whether continuing dialysis is less detrimental than withholding treatment Educational objective: Appropriately respond to abnormal dialysate bacterial culture results The Centers for Medicare/Medicaid Services (CMS) End-Stage Renal Disease Interpretive Guidance does not indicate that hemodialysis treatment must be terminated when allowable water quality levels have been exceeded. The maximum allowable bacterial level is 200 colony forming units per ml. Dialyzers act as an efficient ultrafilter and bacteria, fungi, and viruses are excluded from crossing the dialyzer membrane. At an absorptive capacity and molecular weight cutoff of 25-30 kilodaltons, intact dialyzer membranes protect patients cross-over of viable bacteria from dialysate to blood. In addition, current dialysis machines often incorporate a secondary ultrafilter in the dialysate pathway that adds additional protection from bacterial exposure. The physician must assess the most appropriate action is optimal for each patient. Therefore, option D is correct. For example, a clinician may have to decide whether withholding dialysis on a patient requiring massive fluid removal or electrolyte control is more detrimental than continuing dialysis with a bacterial level above the maximum level. CMS regulation stipulates “The use of water outside of AAMI standards should be extremely rare. The medical director is ultimately responsible for this decision; short term exposure to contaminants is limited to one treatment, rather than not receiving dialysis may be the optimal choice.” Bacteria in dialysis water could result in the presence of endotoxin and endotoxin fragments. The possible continuous exposure to endotoxin and endotoxin fragments could result in pyrogenic reactions and other inflammatory responses. In the setting of dialyzer reuse (where dialyzers are rinsed and reprocessed using reverse osmosis processed water), bacterial contamination of the water distribution system has resulted in patient bloodstream infections. Prophylactic antibiotics would be ineffective in mitigating the inflammatory response as a result from improperly maintained water quality and would result in unnecessary antibiotic exposure (option A is incorrect). Blood cultures would not detect the presence of endotoxin or endotoxin fragments (option B is incorrect). Decreasing dialysis and blood flow or changing to a different hemodialysis machine would not avert exposure to endotoxin and endotoxin fragments (options C and E are incorrect). Bacterial contamination must be addressed by chemical disinfection of the water distribution system, following by retesting of bacterial colony counts and endotoxin levels. If the problem persists and/or continues despite multiple rounds of disinfection, more aggressive action may be needed to eliminate bacterial contamination or replace the contaminated water system." 2871,"Answer B: Obtain one set of blood cultures from the hemodialysis catheter and one set of blood cultures from the hemodialysis circuit, both before antibiotic administration " 2872,Answer C: Replace vancomycin with cefazolin to complete at least 4 weeks of antibiotics 2873,Answer A: Dialyze the patient at a station with as few adjacent stations as possible 2874,Answer D: Vancomycin is the most commonly prescribed intravenous antibiotic 2875,Answer C: Switch to the “rope ladder” for needle placement in the fistula 2876,Answer A: Infection surveillance and use of infection rate data to drive prevention 2877,Answer A: A tanker truck that has been repurposed from hauling vegetable oil for transporting water is an acceptable source of water for hemodialysis pretreatment systems 2878,Answer E: Lack of an effective culture of safety 2879,Answer C: Perform chemical disinfection 2880,"Answer A: Dialyze the patient at the far end of the room, and restrict the chair solely for that patient’s use " 2881,"Answer A: Use extra care in the terminal cleaning of the dialysis station, with special attention to the dialysis chair after the patient has completed the dialysis treatment " 2882,Answer A: Review the patient’s baseline vital signs 2951,D. Discontinuation of beverages containing artificial sweeteners 2952,"C. About 13% of African Americans carry two high-risk APOL1 variants, and the penetrance of associated CKD is <40% " 2953,"B. Disability-adjusted life years attributed to CKD have increased in the United States, while disability-adjusted life years for cardiovascular disease and cancer have decreased Educational objective: Realize that disability adjusted life years attributed to CKD within the United States increased about 52% between 2002 and 2016. " 2954,C. Even mild elevations in blood lead levels among adults have been associated with an increased risk of CKD 2955,D. More timely and effective implementation of CKD care has been shown to reduce adverse kidney disease outcomes in adults with diabetes 2956,A. A population-based approach to diabetes care based in the community and the primary clinical setting 2957,"B. Regardless of race, control of glucose levels and BP among adults with type 2 diabetes mellitus slows progression of CKD." 2958,Answer C: Incretin-based therapies are not associated with an increased risk of hypoglycemia or mortality among adults with non-dialysis-dependent CKD when compared with other glucose-lowering agents 2959,Answer D: The initial decline in eGFR will be accompanied by a slower rate of eGFR decline over time 2960,D. Marijuana use is not associated with CKD incidence or progression 2961,"A. Yes, cigarette smoking, cocaine, methamphetamine, and heroin use are all associated with an increased risk of kidney failure " 2962,D. A four-fold increase in the albumin-to-creatinine ratio may indicate higher risk of ESRD 2963,B. A 2-gram sodium-restricted diet 2964,C. The proton pump inhibitor should not be discontinued if the medication is required to treat his Barrett esophagus and there is no clinical evidence of harm 2965,A. An erythropoiesis-stimulating agent will not slow his CKD progression 2966,A. His lifetime risk of ESRD may be increased by more than four-fold because of his childhood history of kidney injury 2967,A. Tubulointerstitial nephritis with infiltrates predominantly of T lymphocytes Educational objective: Cite the pathologic findings of Mesoamerican nephropathy 2968,C. An SGLT-2 inhibitor 2969,B. The risk of genital infections is higher 2970,D. The risk of metformin-associated lactic acidosis is dependent on the stage of CKD 2971,C. It will lower his mortality risk 2972,B. Pantoprazole 2973,C. Increased left ventricular mass index 2974,B. It reduces the risk of incident CKD and ESRD 2975,A. Diet and exercise 2976,"D. Compared with oral iron therapy, the incidence of adverse events is similar with intravenous ferric carboxymaltose " 2977,C. Addition of mineralocorticoid receptor antagonist 2978,A. The current level of eGFR 2979,D. Coronary artery calcification in CKD is associated with an increased risk of adverse cardiovascular events 2980,B. Both higher UACR and lower eGFR are associated with abnormal white matter volume 2981,D: A Dietary Approaches to Stop Hypertension-style (DASH) diet that restricts red and processed meat 2982,D: Short-term data indicate a slower decline in eGFR compared with placebo Educational objective: Cite the current evidence regarding the outcomes of pentoxifylline therapy in diabetic kidney disease 5416,B. A reduced risk of cardiovascular death 5417,B. A lower mean GFR at baseline 5418,B. The calculated GFR is 30% lower using the Schwartz formula 5419,D. Increased intracellular potassium efflux that initiates programmed podocyte death Educational objective: Cite a possible pathophysiologic mechanism that may explain how high risk APOL1 variants contribute to progressive kidney disease 5420,B. Discontinue empaglifozin 5421,D. It will not impact the rate of CKD progression 5422,"C. He should not start urate-lowering therapy, because existing evidence does not support efficacy in delaying the need for RRT " 5423,A: Low potassium intake is associated with faster annual eGFR decline 5424,D. Furosemide 5425,B. Existing studies show no benefit 5426,A. It is freely filtered and then metabolized by the proximal tubule 5427,D. Discontinue esomeprazole and start ranitidine 5428,D. His HIV status 5429,B. APOL1 risk variants may be present in persons with African ancestry 5430,B. Her parental history of cardiovascular disease 5431,D. His LVH is associated with an increased risk of renal death 5432,A. Cardiac resynchronization therapy 5433,D. Apixaban 5434,D. His systolic BP 5435,A. His elevated high-sensitivity C-reactive protein 5436,B. Smoking cessation 5437,B. Bariatric surgery can reduce the risk of decline in eGFR and risk of ESRD Educational objective: Counsel a CKD patient about the relative benefits and risks of bariatric surgery 5439,B. Coronary artery bypass surgery 5440,D. His urinary sodium excretion is associated with an increased risk for cardiovascular events 5441,D. Grazoprevir and elbasvir 5442,B. They are associated with a higher risk of CKD progression 5443,B. Discontinue metformin 5444,D. Hepatorenal syndrome 5445,B. Improved mental status 5446,B. Midodrine plus octreotide or terlipressin alone 5447,D. Daily SCr measurements 5448,C. Urine volume <200 ml over 2 hours after 1.5 mg/kg of intravenous furosemide 5450,D. Intravenous isotonic crystalloid solution and/or albumin tailored to her hemodynamic status with addition of vasopressors if unresponsive to fluids/albumin Educational objective: Understand the role of goal directed therapy in the setting of sepsis. 5451,D. Intravenous isotonic crystalloid solution and/or albumin tailored to her hemodynamic status with addition of vasopressors if unresponsive to fluids/albumin 5452,D. Increased risk for acute lung injury 5453,B. Isotonic balanced electrolyte solution 5454,C. Increased risk of RRT 5455,C. Radiocontrast exposure 5456,A. Decreased rate of progression to stage 2 AKI 5457,A. Give a fluid bolus and reassess in 1 hour 5458,B. Her bilirubinuria 5459,A. Severe oliguria lasting over 3 hours 5460,D. Baseline CKD 5461,D. Nifedipine and clarithromycin 5462,D. Her risk of AKI is two-fold higher than if she were not treated with vancomycin Educational objective: Cite the risk of AKI associated with vancomycin exposure 5463,C. Abdominal injury 5464,B. Pravastatin 5465,B. Stage 2 AKI 5466,B. Continuous RRT (24h/d) 5467,A. She is likely to experience at least a transient improvement in kidney function Educational objective: Know the renal outcomes of VAD placement in heart transplant candidates with preexisting chronic kidney disease 5468,B. Advanced CKD prior to AKI attenuates the effect of AKI on the long-term risk of progressive CKD 5469,A. Norfloxacin or rifaximin 5470,B. Prednisone 0.5−1 mg/kg per day 5471,C. Kidney ultrasound 5472,A. Synthetic cannabinoids 5473,A. Carfilzomib 5475,B. 3% NaCl bolus IV (100 mL over 10 min up to ×3) 5476,E. Terminate the current treatment and re-lower the serum [Na+] with D5W and desmopressin 5477,A. Extracellular fluid volume replacement by normal saline infusion leading to increased free water 5479,A. Hypernatremia is iatrogenic and requires intravenous or oral free water supplementation 5480,"D. Assuming minimal ongoing free water losses, the infusion of 4 liters of free water would decrease the serum sodium concentration to approximately 154 mmol/L." 5481,B. Hypertonic saline infusion test and resultant copeptin release will accurately differentiate between central diabetes insipidus and primary polydipsia 5482,"B. Cerebral edema is unlikely to occur in this setting of acute hypernatremia, and rapid correction of serum Na to baseline should be undertaken" 5483,C. Begin continuous venovenous hemodiafiltration with standard sodium concentration dialysate and replacement fluid; at the same time continue hypertonic saline infusion to maintain permissive hypernatremia 5484,A. Early (“continuous”) vomiting 5485,D. Loss of potassium in the sweat glands from perspiration with extracellular fluid volume depletion and secondary hyperaldosteronism 5486,"D. Plasma K+ ↓, Plasma. HCO3- ↑, Urine pH ↑, Fractional excretion of [HCO3 —] 15%" 5487,B. Surreptitious diuretic use 5488,B. Mutation in SLC12A3 gene encoding NCC in the distal tubule 5489,C. Initiate patiromer to allow continued treatment with renin-angiotensin system inhibitors. 5493,B. The recent reduction in insulin dosing may be the precipitant for this clinical presentation. 5494,C. Concomitant use of antibiotics has been associated with increased risk of pyroglutamic acidosis from acetaminophen use. 5495,D. Alkali therapy has been shown to reduce urine ET-1 and aldosterone levels. 5496,1. Switching to a diet of alkali-producing fruits and vegetables may delay progression to hypobicarbonatemic acidosis 5497,"1. In patients with CKD stage III to V, treatment of metabolic acidosis has been associated with reduction in progression to ESKD." 5498,B. Surreptitious vomiting 5504,C. Implementation of hospital-wide clinical support system that alerts clinicians that the patient has AKI 5505,C. (Urinary tissue inhibitor of metalloproteinases-2) • (insulin-like growth factor-binding protein 7) (TIMP-2) • (IGFBP7) 5506,C. Proteinuria 5507,D. Creatinine and urine protein 3 months after discharge 5508,C. Mortality is increased in a graded fashion with worsening AKI 5509,C. is incorrect because isotonic fluid should be used for volume resuscitation. 5510,C. Give 0.9% sodium chloride before and after cardiac catheterization 5511,B. Implement the KDIGO AKI bundle with use of urinary (TIMP-2) • (IGFBP7) 5512,"C. At 30 days after hospital discharge, fewer than a third of the patients have not fully recovered kidney function and still present acute kidney disease" 5513,"E. In patients with cardiogenic shock, those with higher values of central venous pressure and lower values of mean arterial pressure are more prone to the development of AKI" 5514,A. The urinary test (TIMP-2) • (IGFBP7) can be applied in patients undergoing cardiopulmonary bypass as a screening tool to select those at high risk for AKI who might benefit 5515,"B. If decongestive goals are not met with the use of furosemide, the next pharmacologic step consists of adding a thiazide or thiazide-like agent such as metolazone or chlorthalidone" 5516,C. Untreated spontaneous bacterial peritonitis with septic shock 5517,C. Portal blood flow is reduced 5518,B. The proportion of renal tubular creatinine secretion is increased 5519,E. Liver transplantation 5520,C. Clone-directed therapy of the paraproteinemia 5521,D. Low-purine diet and allopurinol 5522,D. Close and frequent monitoring of clinical status and laboratory parameters in the ICU and initiate KRT if indication arises 5523,A. Continuous kidney replacement therapy (CKRT) (24 hours/day) 5524,A. Regional citrate anticoagulation (RCA) 5525,"C. If patient is given invasive ventilation, he is more likely to need KRT" 5526,D. Circuit clotting rate may be higher than 30% even when anticoagulation is started 5527,B. Nephrotic-range proteinuria can be secondary to COVID-19 in patients who have high-risk APOL-1 alleles 5528,A. AKI 5529,B. 25% to 35% 5530,D. Immunotherapy-related acute interstitial nephritis 5532,A. Membranous nephropathy secondary to kidney GVHD 5533,A. Pigmented granular casts 5535,C. No further evaluation or therapy is required 5536,B. Begin cinacalcet therapy 30 mg daily 5537,D. Add cinacalcet 5538,A. Addition of cinacalcet is appropriate based on this patient’s laboratory findings 5541,C. Both cinacalcet and parathyroidectomy decrease fibroblast growth factor-23 5542,A. FGF23 increases the production of inflammatory cytokines 5543,B. DEXA is predictive of fracture risk in adults with CKD Stage G3a-G5D 5544,C. The majority of such patients would be expected to achieve remission of hyperparathyroidism after 1 year on cinacalcet therapy 5545,A. A gain of function mutation in the calcium sensing receptor gene 5546,D. Her treatment with multiple insulin injections 5547,A. Primary hyperparathyroidism 5548,D. Measure an ionized calcium 5549,C. Monoclonal protein causing an artefactual increase in 25-hydroxyvitamin D 5550,A. Hypomagnesemia 5551,A. Zoledronic acid 5552,C. Ionized calcium 5553,A. Increased serum uric acid is a risk factor for stone formation in men without a previous history of stone formation 5554,C. Serum calcium 5555,A. 24-hour urine metabolic evaluation 5556,A. Hypophosphatemia 5557,D. Ferric carboxymaltose infusions 5558,C. Tumor–induced osteomalacia 5559,"E. Serum 1,25-dihydroxyvitamin D " 5560,"D. Increased 2,8-dihydroxyadenine excretion " 5561,D. Decreased gastrointestinal absorption 5562,B. Increased stone risk with vitamin C supplementation is seen only in men 5563,B. Observation on a twice-a-year schedule 5564,1. Increase the proportion of Black individuals meeting criteria for a diagnosis of CKD 5565,D. Lower eGFR and greater urinary albumin excretion predict ESKD and mortality among individuals with and without diabetes 5566,1. Urinary albumin excretion is a valid surrogate end point 5567,B. A meta-analysis of randomized trials confirmed the utility of a decrease in eGFR slope as a potential surrogate end point for clinical trials of interventions to prevent ESKD 5568,B. Dapagliflozin 10 mg/d 5569,C. Allopurinol lowers uric acid level but does not slow the rate of GFR decline 5570,D. Combining sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonist (GLP1RA) lowers the risk of cardiovascular and renal adverse events 5571,E. Increased intake of fruits and vegetables 5572,A. History of CKD 5573,C. Lower extremity amputation 5574,B. 35%–55% 5575,A. <10% 5576,B. CKD G3bA1 5577,B. Prevalence would decrease among White adults and increase among Black adults 5578,D. Incident CKD risk tool 5579,D. Fibrinoid necrosis 5580,B. Point-of-care ultrasonography (POCUS): inflammation 5581,B. TNFR1 5582,D. Congenital or cystic kidney disease 5583,A. COL4A 5584,"D. The presence of masked uncontrolled hypertension, identified by ambulatory BP monitoring (ABPM), is associated with higher risk of composite cardiovascular and renal outcomes compared with participants with controlled BP" 5585,"C. Compared with continuing renin-angiotensin system (RAS) inhibition, stopping this therapy is associated with a higher absolute risk of death and major adverse cardiovascular events in patients with CKD 4" 5586,"D. In DAPA-CKD, the renal benefits were consistent across the spectrum of eGFR, albuminuria, and the presence/absence of diabetes mellitus (DM)" 5587,D. Chlorthalidone dose may need to be reduced with the initiation of an SGLT2 inhibitor. 5588,"C. In randomized controlled studies, vadadustat and daprodustat were noninferior to darbepoetin in achieving a mean change in hemoglobin from baseline to end of study" 5589,B. Finerenone is associated with reduction in the urinary albumin-creatinine ratio from baseline in patients on maximal doses of RASi 5590,"D. Higher levels of activity, defined as exercise of at least 30 minutes a day, is associated with lower odds of CKD" 5591,D. Sodium Zirconium Cyclosilicate (ZS-9/SZC) also can help improve acidosis 5592,"A In a study of patients with CKD followed for >6months, treatment with veverimer was associated with improvements in objective measurements of physical function" 5593,"D. The new KDIGO 2021 guidelines (recommendation 1B) place greater importance on consistency with standardization of BP measurement methods, and on minimizing overtreatment or undertreatment of BP that may result from routine, nonstandardized, or “casual” office BP measurements (answer option [A] is incorrect). The proper checklist for standardized BP measurements is as noted in table below and includes a recommendation that patients empty their bladder before BP check (answer option [D] is correct). There are several points on the checklist that would add to the time and resources required in a usual clinic workflow to successfully implement standardized BP checks (answer option [C] is incorrect). These include a requirement that patients avoid caffeine, exercise, and smoking for 30 minutes before BP measurement, avoiding checking BPs while the patient is sitting or lying on the examination table, and the need for repeated measurements, separated by 1–2 minutes. " 5594,A. Perform a kidney allograft biopsy 5595,B. Assess for donor-specific antibodies 5596,D Assess for donor-derived cell-free DNA 5597,A. Assess for donor-specific antibodies 5598,A. Receiving dialysis at a for-profit dialysis unit is associated with lower rates of renal transplant referral 5599,A. Educational and support programs targeted at minority transplantation candidates and their families can increase the chance of receiving a live donor kidney 5600,"D. In an analysis comparing kidneys discarded in the US due to histological features with matched kidneys transplanted in France, the allograft survival rate was 80% at 5 years " 5601,C. Grade 1A chronic active T cell-mediated rejection 5602,A. The patient is at increased risk for death with a functioning graft 5603,"B. It would be helpful to first look at the matching at the DQ locus; if he is not matched at DQ, eplet matching may be of benefit " 5604,B. IL-6 inhibitors have been shown to improve long-term allograft survival in randomized controlled trials 5605,B. Uncontrolled hypertension with concern for pulmonary hypertension 5606,D. Patient will require a second transplant and should be listed and maintained on current immunosuppression while his potential living donor is evaluated 5607,B. His allograft dysfunction is most likely related to volume depletion and prerenal AKI 5608,D. She should complete a 24-hour ambulatory BP monitoring to decide whether or not she has hypertension 5609,"C. Discuss potential risks and benefits of genetic testing with him now, and proceed with genetic testing only if he agrees " 5610,C. Perform a 24-hour urine creatinine collection to further assess her GFR 5611,C. Counsel her on her higher relative risk for future ESKD after donation compared with normal weight candidates but low overall absolute risk 5612,"C. Perform a 24-hour urine stone profile, and if it is normal, accept for right donor nephrectomy" 5613,"D. Living kidney donors have an increased risk of cardiovascular death and ischemic heart disease compared with healthy, nondonor control individuals after the first decade of donation " 5614,"B. Acceptable donor, proceed with transplantation" 5615,B. Monoclonal antibodies 5616,C. Cause of kidney disease 5618,C. Poorly controlled hyperphosphatemia on dialysis 5619,E. He should be referred for transplant evaluation now 5620,D. Achievement and duration of complete remission 5621,C. Refer him for sleeve gastrectomy 5622,D. Accepting a kidney from hepatitis C–positive donor may help shorten the time to kidney transplantation 5623,E. Living donor kidney transplantation followed by a pancreas after kidney transplantation 5624,B. 25%–35% 5625,"B. According to the most recent US National Health and Nutrition Examination Survey (NHANES) data from 2017 to 2018, rates of hypertension control have decreased " 5627,A. Hypertension treatment and control rates improved for all racial and ethnic groups 5628,"D. Patients with high cognitive function showed benefit, whereas those with low function did not " 5629,"D. After 6 months of lifestyle therapy, drug treatment should be considered for patients with a history of premature birth or multiple cardiovascular risk factors " 5630,E. 2021 KDIGO hypertension guideline 5631,A. Increased vascular resistance via impaired angiogenesis 5632,C. Endocytosis of transient receptor potential vanilloid 5 (TRPV5) in the distal convoluted tubule 5633,B. Altered gut microbiota 5634,"B. High-salt diet promotes the development of Th17 cells, which upregulate renal sodium reabsorption " 5635,C. Continue current medications 5636,D. He should continue taking his medications as prescribed and ensure he is compliant 5637,"A. Physical activity and exercise training reduce obesity, and a 2%–3% reduction in weight will lower BP, but reductions of at least 5%–10% are desired within 6 months to yield improvements in the major CVD risk factors " 5638,A. Younger age 5639,"A. The most effective approach is to use TM based on telemonitoring of BP and tracking of additional vital and nonvital signs with data exchange between patients and a case manager through the web, emails, text messaging, or video consultation, integrated with education on lifestyle, risk factors, and proper use of antihypertensive medications " 5640,D. Use of home BP monitoring with transmission regularly for feedback to healthcare provider and adjustment of medications has been shown to significantly improve BP 5641,A. Switch to triple combination therapy to improve BP control and compliance 5642,B. Pseudoresistant hypertension 5643,D. Arrange for a 24-hour ambulatory BP monitor 5644,B. Order adrenal vein sampling 5645,D. Maintain current treatment 5646,A. Repeat plasma free metanephrines 5647,B. Thiazide diuretics are ineffective in patients with eGFR <30 ml/min per 1.73 m2 5648,D. Spironolactone 5649,B. Onset of hypertension after 20 weeks’ gestation 5650,A. Essential hypertension 5651,"A. Her risk of preeclampsia is high, primarily because of her prior history of preeclampsia and hypertension; type 2 DM and CKD also contribute to risk but to a lesser degree than hypertension and prior preeclampsia " 5652,B. Stop the losartan and start labetalol 5653,"B. The woman should understand that aspirin may not be effective for preeclampsia prevention in women with chronic hypertension, but if prescribed, it should be started before 16 weeks’ gestation " 5654,C. Presence of anti-nephrin antibody 5655,D. Send for genetic testing 5656,B. EXT1/EXT2 is seen more commonly in patients with underlying autoimmune diseases 5657,A. Initiate an SGLT2 inhibitor 5658,"D. In the MENTOR study, those treated with rituximab had higher rates of remission at 24-month follow up " 5659,D. Initiate an ACE-I 5660,"A. In patients with contraindication to glucocorticoids, calcineurin inhibitors would be an appropriate first line of therapy " 5662,"D. Glucocorticoids reduce the risk of progression of kidney disease but are associated with increased risk of adverse events. This risk is markedly attenuated, though still present at lower doses (0.4mg/kg per day) " 5663,C. The tool was updated to more accurately predict risk with variables obtained 1-2 years after biopsy 5664,"A. Although exceptions may occur, immunofluorescence microscopy generally shows both IgG and C3 deposits in post-infectious GN but not C3GN" 5665,D. C3GN in this patient is likely caused by an acquired autoantibody to components of the alternative complement pathway 5666,C. A high chronicity score 5667,D. GN is more common in microscopic polyangiitis than in GPA 5668,B. A reduced dose glucocorticoid regimen is equally effective as a standard dose regimen and associated with fewer infections in patients treated with cyclophosphamide 5669,D. Prolonged maintenance treatment with rituximab for up to 3 years is associated with a lower relapse rate and similar incidence of serious adverse events compared with maintenance treatment for 18 months 5670,C. Antibodies to laminin-521 are found more frequently in patients with lung hemorrhage 5671,B. Treatment with daily oral cyclophosphamide is preferred to pulse intravenous dosing 5672,B. The time from diagnosis of SLE to the development of lupus nephritis is shorter in Blacks and other minority groups 5673,"C. Belimumab, in addition to standard therapy, has demonstrated efficacy in the treatment of lupus nephritis and extrarenal manifestations of SLE" 5674,C. The mortality of stage 3 AKI in patients admitted to the intensive care unit with COVID-19 exceeds 50% 5675,B. COVID-19–associated collapsing glomerulopathy has been described in patients with high-risk APOL1 genotypes 5676,D. Treatment of HIV alone is unlikely to lead to full or partial remission of kidney disease 5677,E. Cessation of tenofovir disoproxil fumarate will lead to improvement in proteinuria 5678,"E. She should be treated with a pangenotypic DAA, and rituximab should not be used, at least initially and rituximab should not be used, at least initially " 5679,C. Exclude renal vein thrombosis with appropriate imaging r 5680,"E. Providing that institutional safeguards have been established and the patient’s HIV is controlled with antiretroviral therapy, he is a good candidate for transplantation " 5681,C. The need for intervention to halt excessive bleeding from a clinically indicated kidney biopsy occurs in three out of 1000 5682,B. Restart her angiotensin receptor blocker 5683,C. add semaglutide starting at a dose of 0.5 mg subcutaneously once weekly 5684,C. Recommend that she purchase a validated home BP monitor and provide her with guidance on appropriate measurement technique 5685,D. Recommend 24-hour ambulatory BP monitoring to confirm the presence of masked uncontrolled hypertension 5686,A. Recommend that he undergo 24-hour ambulatory BP monitoring 5687,"C. What medications or drugs, prescription or otherwise, are you using?" 5688,B. A urine dipstick registering ++ protein 5689,"C. Now that you have had a heart attack, your body is showing us that it is vulnerable to things like an elevated BP, and we really need to work hard to get this under control soon." 5690,D. He is at increased risk for a major adverse cardiovascular event or death. 5691,D. Evaluate her for primary aldosteronism 5692,B. Intensive BP control was associated with reduced risk of mild cognitive impairment at 5 years follow-up 5694,"A. As compared with monotherapy, initiation of combination antihypertensive therapy is associated with reduced mortality at 3-year follow-up" 5695,B. Intensive BP control in SPRINT was associated with a small but persistent decline in GFR compared with standard BP control 5696,C. He should be instructed on lifestyle modification with the decision on medication dependent on assessment of 10-year CVD event risk 5697,D. Spironolactone is the most appropriate next agent 5698,"D. Smartphone apps that provide reminder alerts, adherence reports, and peer support may improve medication adherence" 5699,D. Number of deaths and disability related to hypertension continued to rise while age-standardized rates declined between years 2007 and 2017. 5700,A. Patients with BP of ≥130/80 mmHg before the age of 40 years are at increased risk of cardiovascular disease 5701,D. Recommendation for antihypertensive medication will increase by only <2% of the adult US population 5702,A. Antihypertensives may be less effective in the presence of periodontitis 5703,B. Low BP in patients her age is linked to dementia if patients have a history of high BP 5704,D. Assure him that long working hours are associated with both masked hypertension and sustained hypertension 5705,B. Hypertension generally correlates with the prevalence of obesity and physical inactivity 5706,B. Observational data suggest that working >48 hours weekly is associated with increased risk of hypertension compared with working <35 hours weekly 5707,A. Renal tubular a-adrenergic receptors 5708,B. Decreased expression of the (pro)renin receptor 5709,A. Increased sodium delivery to the collecting duct epithelial sodium channel to stimulate potassium excretion 5710,E. Prior destruction of EVs from this patient will reduce acetylcholine-induced vasodilation 5711,D. Decreased activity of renal nerves 5712,C. Renal denervation may decrease hypertension and the severity of OSA 5713,B. Hypertension correlates better with the dietary sodium/potassium ratio than with sodium intake alone 5714,"A. When compared with corticosteroids as first-line therapy, treatment with tacrolimus is associated with similar rates of remission and relapse" 5715,"C. In secondary FSGS, glomerular hypertension causes podocyte injury, leading to podocyte detachment and loss" 5716,"C. In retrospective studies, up to 30% of adults with steroid resistant FSGS had a potentially causative genetic mutation identified" 5717,C. Thrombospondin type 1 domain containing 7A (THSD7A)-associated MN is associated with high rates of underlying malignancy 5718,"D. In the MENTOR study, those treated with rituximab had higher rates of remission at 24-month follow-up" 5719,D. C3 nephritic factors are seen in many patients with monoclonal gammopathy–associated C3 glomerulopathy 5720,B. Treatment with mycophenolate mofetil and steroids has been associated with improved rates of remission of C3G in observational studies 5721,A. Renal cortical necrosis can be an underappreciated presentation of pregnancy-associated TMA 5722,D. IgA nephropathy commonly recurs after renal transplantation 5723,"C. In the PEXIVAS trial, reduced corticosteroid dosing was associated with no difference in risk of ESKD, but with reduced rates of infectious complications" 5724,"A. In a clinical trial comparing it with maintenance therapy with azathioprine, rituximab was superior at maintaining remission of AAV" 5725,B. The time to from diagnosis of SLE to the development of lupus nephritis is shorter in African Americans and other minority groups 5726,B. Post hoc analyses suggest that patients who achieve full depletion of peripheral B cells may gain greater benefit from rituximab 5727,D. He is at risk for immune complex glomerulonephritis that may or may not be related to his HIV 5728,"D. She should be treated with a pangenotypic direct-acting antiviral (DAA) irrespective of her eGFR, and rituximab should not be used, at least initially " 5729,C. Arrange for CT venography to exclude renal vein thrombosis 5730,D. He would do better with transplantation and should be referred for evaluation 5731,"D. In addition to mild acute tubular necrosis (ATN) from the viral syndrome, she has diabetic nephropathy with histologic changes that preceded clinical evidence such as GFR decline or albuminuria " 5732,"C. The sodium glucose cotransporters increase sodium delivery to the macula densa, which decreases GFR " 5733,D. Increased cardiovascular mortality risk 5734,B. Continue the metformin and start an SGLT2 inhibitor 5735,A. Light chain proximal tubulopathy 5736,"D. DNAJB9 positive fibrillary glomerulonephritis is not an monoclonal gammopathy of renal significance (MGRS)-associated lesion, and therefore, no hematologic workup is recommended" 5737,C. Type I cryoglobulinemic glomerulonephritis 5738,C. Hold nivolumab and initiate glucocorticoids 5739,B. Collapsing FSGS 5740,B. Initiate denosumab 5741,D. Drug-Induced AAV 5742,C. X-linked recessive 5743,"C. GLA mutation, α-galactosidase A deficiency, lyso-GB3 accumulation " 5744,D. Tubular maximal reabsorption of phosphate/GFR in a second morning urine after an overnight fast. 5745,D. The expression of the sodium-driven phosphate transporter NaPi-IIb increases when dietary phosphate is low. 5746,"(C), Her phosphate concentration is maintained by intestinal absorption, internal shifts and renal excretion." 5747,A. Denosumab-induced hypocalcemia. 5748,B. Claudin. 5749,C. A loss of function mutation in the CLDN19 gene. 5750,"B. Measuring 1,25(OH)2 vitamin D. " 5751,D. High serum alkaline phosphatase. 5752,D. Treatment with lanthanum carbonate either alone or in combination with nicotinamide has little effect on serum PTH in patients with stage 4 CKD. 5753,A. Change calcium acetate to sevelamer carbonate. 5754,D. Phosphate increases PTH production by reducing binding of calcium to the calcium-sensing receptor. 5755,"B. Increased risk of fracture, increased risk of vascular events, increased risk of mortality. " 5756,"B. A 40-year-old man who had noticed pain in his thigh when he stands and had previously been treated with aluminum hydroxide for severe hyperphosphatemia. Radiographs of the hands show subperiosteal resorption. PTH is 290 ng/L, serum phosphate is 5.4 mg/dl. " 5757,C. The bone formation rate gradually decreases over approximately 6 months and then remains at a rate that is below normal. 5758,"D. Klotho inhibits Wnt signaling by blocking the frizzled receptor, and this reduces the number of osteoblasts. " 5759,A. A patient with high PTH and increased calcium and alkaline phosphatase. 5760,"A. Secondary calciprotein particles (CPP-II) form as kidney function declines and as result of decreases in expression of fetuin-A and γ-linolenic acid—rich protein, and induce osteoblast differentiation of vascular smooth muscle cells. " 5761,"(D), Abdominal aortic calcification has been associated with increased risk of cardiovascular events and increased mortality, which persists after transplantation. " 5762,C. Change magnesium to 2 mg/dl. 5763,C. Calcium-containing phosphate binder. 5764,C. Factors that increase the fracture risk of ESRD patients include age and CKD with mineral and bone disorder but not osteoporosis. 5765,D. She should be screened by DXA every 12 to 24 months. 5766,C. Teriparetide. 5767,B. Denosumab. 5768,D. The location of skin lesions influences prognosis. 5769,D. Add sevelamer. 5770,B. Physical inactivity. 5771,D. Renal ultrasonography. 5772,A. High calcium. 5773,"C. The risk conferred by bariatric surgery can be minimized by restricting dietary fat, increasing dietary calcium or taking a calcium supplement with meals and maintaining high urinary volume of >2.5 L/day. " 5774,"A. Continue dialysate [K] 2 mEq/L, reinforce dietary restriction, check for recirculation, add a potassium-binding resin on non-dialysis days " 5775,C. Decrease frequency of episodes of intradialytic hypotension 5776,C. Add a loop diuretic on non-dialysis days and continue to limit her ultrafiltration rate (UFR) during dialysis to <13 mL/kg per h 5777,"D. Follow her closely for uremic symptoms; when she decides to start HD, admit her for nonurgent placement of tunneled dialysis catheter and initiate HD in the hospital " 5778,D. Measure her creatinine clearance and discuss with her the possibility of starting dialysis 2 days per week 5779,D. Continue current APD regimen and reassess again later 5780,B. Straight double-cuff Tenchkoff catheter 5781,B. Review the causes of her episodes of peritonitis to reduce risk of recurrence 5782,C. Use low-glucose degradation product (GDP) and neutral pH biocompatible PD solution 5783,D. Add furosemide 250 mg daily 5784,C. More than 15% 5785,D. Switch to oral amoxicillin 5786,B. APD is associated with a lower risk of technique failure than CAPD. 5787,D. No differences have been found in rates of complications such as peritonitis and exit site infections when straight and coiled PD catheters have been compared 5788,B. Risk factors for fluid overload (as measured by BIS) in PD patients include hypoalbuminemia and diabetes 5789,B. Exposure to PD fluids containing high concentrations of glucose has been associated with faster loss of RRF 5790,"D., During the past decade, mortality rates for patients on PD declined more quickly than rates for HD patients " 5791,E. The patient has lactic acidosis as a result of the presence of lactate as a buffer in the dialysate 5792,A. Convert to nocturnal HD 7 hours five times per week at the same dialysate volume of 30 L 5793,C. He may not need to use phosphate binders with nocturnal HD 5794,"A. The approximate number of prevalent patients in the United States is PD 60,000 and HHD 10,000 " 5795,D. HHD has been associated with improved survival compared with PD in patients who have been on in-center HD for longer than 1 year 5796,A. Use of PD but not HHD increased during the COVID-19 pandemic 5797,A. The amount of medical and procedural supervision available to the patient 5798,"B. “Prognosis varies; however, most experience tells us that on average patients may live about 7 days without dialysis. This may be slightly more or less depending on other medical conditions that someone has, and how much residual renal function one has.” " 5799,B. Baclofen 5800,C. Number of hospitalizations in the past year 5801,"C. He is at increased risk of having technique failure with a home modality, such as PD " 5802,D. Those who pursue conservative management spend less time in hospital 5803,"B. In patients who are on HD, the frequency of dialysis after an admission for pulmonary edema affects the rates of readmission " 5804,B. Testing for anti-A antibody titers to assess suitability for non-A1 donor kidneys. 5805,A. Hospital admissions during the first year of waitlisting. 5806,C. He should be encouraged to consent for KDPI >85 kidneys because of the increased survival with high KDPI kidneys compared to remaining on the waitlist for a KDPI 35-85 kidney. 5807,B. It is likely that the PHS-IR kidney is of higher expected function/longevity than the next non-IR offer will be 5808,D. Transplantation of HCV Ab+/NAT+ kidneys followed by DAA therapy is cost-effective compared to continued waiting on dialysis and subsequent receipt of an HCV-negative deceased donor kidney 5809,C. Age >50 years 5810,A. Hypothermic machine perfusion (HMP) of the explanted kidney 5811,A. Reduced incidence of delayed graft function 5812,D. Lower C max but higher AUC. 5813,"D. Discontinue mycophenolate, start everolimus " 5814,B. Entrance into a paired exchange program 5815,D. Increased risk of uncensored graft loss 5816,D. Chronic active antibody-mediated rejection 5818,B. Clinical tolerance has been induced in zero antigen mismatched living donor recipients though it is only durable in about one-third of patients 5819,E. Recurrent disease is more likely to develop after living related donor transplantation compared with deceased donor kidney transplantation 5820,D. Pretransplant skin cancer increases the risk of post-transplant lymphoproliferative disorder 5821,A. Persistent high grade EBV viremia is a risk factor for cancer other than post-transplant lymphoproliferative disorder 5822,C. Use of two or more immunosuppressive agents 5823,A. It will increase her risk of rejection 5824,C. Most transplant programs submit transplant candidates to a rigorous cardiovascular evaluation though the evidence basis for this approach is lacking 5825,A. Statin therapy after transplantation is associated with improved survival post transplantation 5826,B. Omeprazole therapy 5827,C. Subtotal parathyroidectomy more effectively controls hypercalcemia when compared with cinacalcet 5828,D. Bisphosphonate therapy is associated with improvements in bone mineral densitometry scores after transplantation 5829,B. Hepatitis C treatment should be deferred until after transplantation of a hepatitis C+ graft in order to reduce waiting time 5830,A. HIV+ patients have a higher risk of graft loss than HIV- recipients 5831,B. It is associated with a lower risk of CMV after kidney transplantation compared with calcineurin inhibitor therapy 5832,A. Living donor kidney transplantation followed by a pancreas after kidney transplant will likely provide the best long-term renal outcomes 5833,B. He should be told that approximately 15% of transplants fail due to recurrent glomerular disease 5834,"C. Tenapanor blocks the Na+/H+-exchanger isoform 3 (NHE3), thereby reducing paracellular phosphate transport " 5835,B. Measure tubular maximal reabsorption of phosphate/glomerular filtration 5836,"A. In the general population, plasma phosphate levels at the upper end of the normal range have been associated with increased cardiovascular mortality " 5837,A. Increased intestinal absorption of calcium 5838,D. A loss-of-function mutation in the CLDN16 gene 5839,D. Hypocalciuria 5840,C. High alkaline phosphatase levels are a risk factor for calcimimetic-induced hypocalcemia 5841,B. Recipients of etelcalcetide who received the drug for a year experienced a decrease in PTH level of approximately 40% at 1 year 5842,B. Development of SHPT is associated with increased major cardiovascular events and death 5843,A. Tenapanor 5844,B. Intracellular phosphate concentrations are reduced by hemodialysis 5846,"D. Ideally, this patient should have a bone biopsy in order to identify the optimal therapy " 5847,"B. Try to obtain a bone biopsy, because hypercalcemic hyperparathyroidism in kidney-transplant recipients commonly does not represent high bone turnover but instead normal or low bone turnover " 5848,D. Schedule a bone biopsy before starting therapy 5849,"Correct Answer: A, The nephrologist should be worried about mineral and bone-related parameters, as CKD-MBD is associated with poor outcomes " 5850,C. Factors that increase fracture risk for ESKD patients include age and CKD-MBD and post-menopausal osteoporosis 5851,D. She should be screened by DXA as per general population screening guidelines 5852,C. Teriparetide 5853,D. Parathyroidectomy 5854,C. Hypocalcemia 5855,D. Warfarin 5856,A. Avoid hypercalcemia 5857,B. The 1-year survival rate is likely higher in this patient compared to dialysis-dependent patients with end-stage kidney disease who develop calciphylaxis 5858,A. Untreated pneumothorax 5859,A. Presence of circumferential calcium deposits in hypodermal vessels 5860,C. Start him with expulsive medical therapy (tamsulosin) and get a follow-up for him with a urologist over the next week to evaluate further therapy 5861,"B. Perform a complete metabolic assessment, including 24-hour urine for calcium, oxalate, citrate, uric acid, and electrolytes, to establish mechanisms for his hypercalciuria " 5862,D. A 24-hour urine collection for measuring stone risk factors is indicated to identify metabolic abnormalities that may need to be addressed 5863,A. 24-hour urine collection for measurement of stone risk factors and blood for genetic analyses 2463,"Answer D: You should inform him that his cardiovascular risk is increased and that you recommend that he start drug treatment Choice D is correct because isolated diastolic hypertension is associated with increased risk of cardiac events (choices A is incorrect) and requires treatment (incorrect option B). This risk is less than systo-diastolic or isolated systolic hypertension (option C is incorrect). If his office diastolic BP was in the 90-99 mmHg range, he would fall under the umbrella of “mild” hypertension, a subgroup with uncertain long-term benefits from treatment in the absence of diabetes. However, this definition applies to office BP; there are no data defining thresholds for treatment of “mild hypertension” based on home or 24-h ambulatory BP readings. " 5438,"C. She is at increased risk for preterm labor Educational objective: Provide appropriate pre-conception counseling and peripartum management of type 1 diabetes mellitus Piccoli et al. compared pregnancy outcomes of 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. Women with stage 1 CKD and a systemic disease (type 1 diabetes mellitus, systemic lupus erythematosus, or kidney transplantation) had an increased risk for preterm delivery. Hence, option C is correct. The authors found that mild decrements in eGFR in the “normal range” were found to be associated with adverse pregnancy outcomes, even in the absence of hypertension and proteinuria. Hence, option A is incorrect. Given the history of increased albuminuria, lisinopril should be continued until the time of conception; thus, option B is incorrect. Poor glycemic control adversely affects fetal outcomes, and has been associated with an increased risk for cardiac and neural tube defects. The American Diabetes Association recommends maintenance of HbA1c levels <7.0% prior to conception. Statins are considered FDA Category X, indicating that animal studies or human studies have demonstrated risk to the fetus. Therefore, option D is incorrect." 5817,"A. Plasmapheresis and intravenous immunoglobulin (IVIG) A systematic review and meta-analysis of 21 studies (10 randomized controlled trials), involving 751 participants was recently published. Plasmapheresis and intravenous immunoglobulin (IVIG) were used as standard-of-care in recent studies, despite only a trend to improvement in graft survival. Together with plasmapheresis and IVIG, rituximab did not add benefit, and there was insufficient data supporting the use of bortezomib. While heterogeneity in treatments, definition of antibody-mediated rejection (AMR), quality, and follow-up all limit firm conclusions regarding best treatment practices, plasmapheresis and IVIG remain the most evidence-based regimen for AMR. Therefore, option A is correct, and the other listed options are incorrect." 5693,"C. Treatment with thiazide diuretics has been associated with better BP control and reductions in cardiovascular outcomes, as compared with other first-line agents for management of hypertension. LEGEND-HTN used a big data approach to analyze administrative claims and electronic health record databases to identify patients initiating antihypertensive medications, and assess clinical outcomes. This study found that as compared with angiotensin-converting enzyme (ACE) inhibitors, dihydropyridine calcium channel blockers, and angiotensin receptor blockers, thiazide diuretics were associated with better BP control and reduced rates of cardiovascular events including hospitalization for heart failure, stroke and myocardial infarction (C). This study also found inferior outcomes in patients treated with nondihydropyridine calcium channel blockers (A) as a first-line agent. Chlorthalidone and hydrochlorthiazide had similar effects on rates of myocardial infarction, heart failure, and stroke, but treatment with chlorthalidone was associated with higher rates of hyponatremia, hypokalemia, and acute kidney injury (B). Wei et al. performed a meta-analysis of 46 clinical trials of treatment of hypertension. In contrast to LEGEND-HTN, this particular analysis showed that ACE inhibitors, dihydropyridine calcium channel blockers, and thiazide diuretics were similarly effective in reducing overall cardiovascular events. It also found that ACE inhibitors were most effective in reducing risk of myocardial infarction (D)." 5474,"B. Exercise-associated hyponatremia Exercise-associated hyponatremia (EAH) results from an acute fall in serum Na+ concentration ([Na+]) to <135 mmol/L that occurs during or up to 24 hours after prolonged exercise or endurance activity. EAH has a common pathogenesis of fluid intake more than required, which is usually coupled with non-osmotically and inappropriately elevated AVP concentrations. Symptomatic EAH can lead to death; therefore, appropriate treatment with hypertonic saline is essential to improve outcomes and prevent death caused by cerebral edema and brain herniation. A is incorrect because dehydration is defined by an increase, not decrease, in serum [Na+]. C, D and E are incorrect since heat illness, hypoxia and volume depletion are unlikely contributors to presentation based on her vital signs." 5478,"B. Decreased thirst in response to hypertonicity in the elderly. This patient was administered tolvaptan, a V2 receptor antagonist, for improving his chronic hyponatremia. His diet related QOL and appetite improved, because he did not have to either observe fluid restriction or take a large amount of urea, which has a bitter taste. In initiating tolvaptan, he was advised to drink enough water to satisfy his thirst whenever he felt thirsty to prevent hypernatremia, and he followed this advice. Older adults are less likely to feel thirst and have a narrower dynamic range of thirst than younger people. In other words, with respect to water deficiency in the body, thirst is slaked with relatively less hydration than in younger people. As a result, the amount of water consumed may be insufficient to compensate for water deficiency in the body. In clinical practice for the correction of hyponatremia, attention should be paid to this important aspect in the elderly. Answer A is incorrect as aquaresis would not cause hypernatremia in the setting of an intact thirst response. C and D are incorrect, since the text states that he had a good appetite and was instructed to drink ad libitum. E is not the best answer given rapidity of overcorrection of serum [Na+]. Article 2: Pathophysiology, Evaluation, and Treatment of Hypernatremia" 5490,"C. A mutation in the SCNA4 gene for the alpha subunit of the skeletal muscle cell sodium channel. Acute transient hyperkalemia suggests an abnormality of potassium distribution not excretion. His history of onset in early childhood and family history suggests a heritable condition. The most likely heritable condition resulting in transient hyperkalemia associated with periodic muscle weakness is hyperkalemic periodic paralysis, which is an autosomal dominant disorder caused by a point mutation in the SCNA4 gene for the alpha subunit of the skeletal muscle cell sodium channel. A, B and D are not correct. Loss of function mutations of ENaC and mutations of WNK, genes encoding Kelch-like 3 and Cullin 3, (which increase expression and/or activity of NCC) cause pseudohypoaldosteronism type 2 (also known as Gordon syndrome or familial hyperkalemic hyperkalemia) with chronic hyperkalemia and often hyperkalemic metabolic acidosis." 5491," B. A deep learning algorithm using an electrocardiogram is able to exclude hyperkalemia with acceptable accuracy A deep learning algorithm using electrocardiogram (ECG) is able to exclude hyperkalemia with acceptable accuracy. Artificial intelligence and deep learning models are being studied to detect ECG changes associated with hyperkalemia. In one study a deep learning model was trained to detect potassium >5.5 mEq/L using >1.5 million ECGs from 449,380 patients and tested in a validation cohort including 61,965 CKD patients. Using a high sensitivity operating point to maximize its utility as a screening tool, the negative predictive value was greater than 99%, which is as good or better than many other commonly used screening tools. A and C are incorrect. Potassium is measured from serum after the collected blood is allowed to clot, a process that releases potassium. As a result, serum potassium concentrations typically exceed plasma or whole blood measurements by 0.1-0.7 mM. Whole blood techniques measure potassium immediately after the sample is obtained, without further processing. D is incorrect. Although it is often argued that serum potassium is the most accurate measure, recent trials suggest that whole blood potassium may be a more accurate measure of the relevant physiological variable than serum potassium." 5492,"C. Sodium zirconium cyclosilicate also removes hydrogen ions and may increase serum bicarbonate Data from three placebo-controlled trials demonstrated a dose-dependent increase in mean serum bicarbonate of 0.3 to 1.5 mM within 48 h of treatment with sodium zirconium cyclosilicate. These changes were maintained over 29 days. With highest sodium zirconium cyclosilicate maintenance doses, the percentage of patients with serum bicarbonate <22 mM declined from 39% at baseline to 4.9% at 29 days. A is not correct. Zirconium cyclosilicate has been shown in randomized trials to reduce potassium in both dialysis and nondialysis CKD patients. B is not correct. The sodium load delivered with sodium zirconium cyclosilicate is substantial, and chronic use has been associated with edema in more than 10% of patients, especially in those patients with eGFR <30 ml/minute. D is not correct. Although zirconium cyclosilicate works quickly since it acts in both the small and the large intestines, it has not been shown to provide added benefit to standard therapy, including insulin and glucose, for acute severe hyperkalemia" 5501,". It was generated by metabolism of retained lactate to bicarbonate and should spontaneously correct The patient developed lactic acidosis due to septic shock. Because of concern about the severe metabolic acidosis, bicarbonate was administered, which returned pH toward normal, but with large amounts of circulating lactate. When the patient became hemodynamically stable, the liver metabolized the circulating lactate to bicarbonate generating a metabolic alkalosis. Because the patient’s hemodynamics are stable, he should correct the metabolic alkalosis as is evidenced by the urine pH of 8. C is not the best answer. Although significant volume contraction could prolong duration of alkalosis, restoration of stable hemodynamic parameters together with the urine pH of 8 suggest that he is volume replete, excreting bicarbonate and correcting the alkalosis. A and B are unlikely given that prior lab values and blood pressure have been normal. The answer is found in section on Clinical conditions that cause metabolic alkalosis, subsection on Exogenous alkali gain." 5502,"C. Primary hyperaldosteronism This patient presents with new onset of hypertension, which is noteworthy for the presence of a hypokalemic alkalosis in the absence of any diuretics or signs of volume depletion. The key part of the workup is the measurement of plasma renin and aldosterone. While renin and aldosterone levels need to be interpreted in the context of volume status, that is not the case when renin is low, and aldosterone is high. The only explanation for this is primary hyperaldosteronism. B is incorrect since renin levels would be high in renovascular disease. A is incorrect since patients with Gitelman Disease present with high renin and high aldosterone, and usually low or normal blood pressure. D is incorrect as these patients present with hypertension but with low renin and low aldosterone. The most common causes for primary hyperaldosteronism are adrenal adenoma and bilateral adrenal hyperplasia. Other possible causes are adrenal carcinoma and glucocorticoid suppressible hyperaldosteronism. The correct answer is found in sections on Clinical Conditions that cause metabolic alkalosis, subsections on Increased delivery of sodium, and increased distal transport activity" 5503,"B. Syndrome of apparent mineralocorticoid excess due to glycyrrhizic acid This patient presents with new onset of hypertension, which is noteworthy for the presence of a hypokalemic alkalosis in the absence of any diuretics or signs of volume depletion. Once again, the key part of the workup is the measurement of plasma renin and aldosterone. The low levels of renin and aldosterone point to an aldosterone-independent activation of distal nephron Na+, K+, and H+ transport. The most common cause of this is Cushing’s syndrome, but the patient has no evidence on physical examination and plasma cortisol is normal. Adrenogenital syndromes with elevation of nonaldosterone mineralocorticoids would also be possible but is unlikely to present at age 35 and in the absence of any findings. Thus, the most likely diagnosis is inhibition of 11-beta-HSD-2 which allows glucocorticoids to bind to and activate the mineralocorticoid receptor. This could be due to a genetic disorder or more commonly due to glycyrrhizic acid intake. Since certain brands of chewing tobacco contain glycyrrhizic acid, this is the most likely diagnosis. A and D are incorrect as surreptitious diuretic use and villous adenoma (latter resulting in diarrhea) would both present with high renin and high aldosterone levels: C is incorrect since primary hyperaldosteronism presents with low renin and high aldosterone levels." 5531,"C. Obtain cystatin C level, continue abemaciclib, and repeat laboratory studies in 1 week Abemaciclib has been associated with elevations in serum creatinine that usually occur with 28 days after starting the treatment and generally remain elevated but stable for the duration of therapy. Abemaciclib inhibits renal creatinine secretion, which leads to elevations in serum creatinine rather than a true kidney toxicity. Cystatin C is useful in this setting as an alternative measure of GFR that is not affected by creatinine secretion. Answer option (A) is incorrect. Bevacizumab nephrotoxicity manifests as new or worsening hypertension, proteinuria, and in some cases AKI and TMA. Answer option (B) is incorrect. Denosumab is associated with hypocalcemia and other electrolyte abnormalities but has not been shown to cause AKI. Answer option (D) is incorrect. Given that the rise in serum creatinine is probably related to the decreased renal secretion, abemaciclib can be continued with careful monitoring." 5617,"A. Her age is a risk factor for not mounting an antibody response Available results show a reduced SARS-CoV-2 IgG response (38%–54%) to two doses of mRNA vaccination in kidney transplant recipients compared to healthy individuals (100%) and dialysis patients (90%). Factors reported to be associated with lower responses in KTR are older age, worse renal function, and use of triple immunosuppressive medications including antimetabolites, especially higher doses of mycophenolate mofetil or mycophenolic acid (answer options [B] and [C] are incorrect). Anti-thymocyte globulin treatment effect probably does not last for 4 years. A study involving 101 solid organ transplant recipients reported a 40% antibody response after the 2nd dose of an mRNA vaccination, which was increased to only 68% after a 3rd dose (answer options [E] and [D] are incorrect). A double-blind, randomized, controlled trial of a third dose of mRNA-1273 vaccine (Moderna) in 120 kidney transplant recipients without previous history COVID-19 disease reported that the median percent virus neutralization was 71% in the mRNA-1273 group and 13% in the placebo group. Her age of 35 does not decrease her response to vaccination (answer option [A] is correct)." 5626,"B. Careful office measurement followed by out-of-office measurement if BP is elevated There are several important concepts to consider in making and confirming a diagnosis of hypertension. It is important to look for both white-coat or office hypertension and masked hypertension in addition to sustained hypertension to decide on the appropriate approach. The correct answer is to follow up an elevated office measurement with an out-of-office measurement, preferably by 24-hour ambulatory BP monitoring, but home measurements are also an option. Answer option A is incorrect because it is likely the repeated readings will also be elevated, and this would not discriminate between office hypertension and sustained hypertension. Answer option C is incorrect because it would not be cost effective to order ambulatory BP monitoring as a screening tool, even for patients with normal BP. This is complicated somewhat by the need to consider masked hypertension, where office measurements may not be elevated but out of office readings are elevated. The 2017 ACC/AHA BP guideline recommends considering ambulatory BP monitoring for patients with elevated BP, systolic BP 120–129 mm Hg, or diastolic BP <80 mm Hg or when there is evidence for target organ damage but BP in the" 5661,"A. Add dapagliflozin 10 mg/day Add dapagliflozin 10 mg /day. The Dapa-CKD trial, included 271 patients with IgA nephropathy, eGFR 25–75 ml/min per 1.73 m2 and albuminuria 200–5000 mg/g creatinine At 2.4 years the risk of 50% eGFR decline or ESKD or death from renal cause was lower in the dapagliflozin group versus placebo with no difference in benefit between diabetic and non-diabetic patients. Among 270 patients with IgA nephropathy, the risk of the composite endpoint was lower in the dapagliflozin group compared with placebo (4% versus 15%) (answer option A is correct). Although the previous teaching was that patients without significant proteinuria and stable eGFR were unlikely to progress, a retrospective study showed that among 145 patients with biopsy demonstrated IgA, almost 20% had significant progression of chronic kidney disease over 22 years (answer option B is incorrect). C and D are incorrect. The 2021 KDIGO guidelines suggests BP target <120 mm Hg systolic for all patients with glomerulonephritis (answer options C and D are incorrect). Even with conservative interpretation of consensus guidelines, this patient is treated to target on an optimal renoprotective agent. The addition of joint therapy with an ACE inhibitor and ARB is not recommended." 2580,"Answer D: Even correcting for diabetes, hypertension, and albuminuria, kidney stone formation is associated with an increased risk of cardiovascular events In a Cohort study of 3,195,452 people aged >18 years registered in the universal health care system in Alberta, Canada, between 1997 and 2009, a total of 25,532 (0.8%) participants had at least one kidney stone, and 91,465 (3%) individuals had at least one cardiovascular event during follow-up. Compared with people without kidney stones, and after adjustment for cardiovascular risk factors such as diabetes, hypertension, albuminuria, and other potential confounders, people who had at least one kidney stone had a higher risk of subsequent acute myocardial infarction, the need for coronary revascularization, and stroke (option D is correct). The magnitude of the excess risk associated with a kidney stone appeared more pronounced for younger people than for older people (option C) and for women than men. Having more than one kidney stone did not appear to increase the risk (option E)." 2584,"Answer C: Encapsulating peritoneal sclerosis The recent onset of abdominal pain, weight loss, and ultrafiltration failure should raise suspicion for encapsulating peritoneal sclerosis (EPS). This patient’s peritoneal equilibrium test shows an initial increase, and then a decrease in the dialysate to plasma ratios (D/P) of creatinine, as well as loss of sodium sieving characteristic of encapsulating peritoneal sclerosis. Figure 1 shows that the fall in the D/PNa+ ratio resulting from a decrease in the dialysate sodium concentration that is observed in normal sodium sieving is no longer apparent. Hence, option C is the best answer. Morelle and coworkers suggested that abnormal peritoneal transport heralds the development of EPS. In a cohort of 234 peritoneal dialysis (PD) patients at a single academic center in Europe over a 20-year period, a total of 7 patients developed EPS. As part of routine care, a modified 3.86% glucose PET was performed yearly. When compared with long-term PD patients who did not develop EPS, affected patients showed an early decline in ultrafiltration. In fact, the accompanying loss of sodium sieving was the most potent predictor for the development of EPS. In a careful pathologic analysis of peritoneal biopsies, patients with EPS were found to have excessive vascular proliferation and fibrotic changes when compared to uremic or long-term PD patients who did not develop EPS. Further microscopic imaging revealed that the quantity and density of collagen was increased in patients with EPS when compared to controls. Surprisingly, and despite the clinical hallmark of ultrafiltration failure, aquaporin-1 expression was similar in patients with EPS compared to unaffected controls on PD. This led the authors to hypothesize that specific changes in the peritoneal make up, specifically a diseased collagen matrix, causes the decrease in osmotic conductance leading to ultrafiltration failure in EPS (rather than vasculopathy or the lack of aquaporin- 1). The incidence of EPS is variable, but only a minority of patients develops EPS even after prolonged courses of peritoneal dialysis. Ultrafiltration failure due to a peritoneal dialysate leak (option A) or increased lymphatic absorption (option B) is characterized by stable D/P urea and creatinine ratios over time, unlike the results noted in this woman; therefore, options A and B are incorrect. Patients with ultrafiltration failure due to high membrane transport characteristics have increased D/Pcreatinine ratios that exceed 0.8 and D/Pglucose ratios that are <0.3; thus, option D is incorrect."