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63 Cards in this Set
- Front
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BF is a 42 year old man with type 1 diabetes, hypertension, and chronic kidney disease who presents with the following:
Labs Na 135 meq/L Ca 10.2 mg/dl K 6.2 meq/L PO4 2.6 mg/dl ECG: peaked T waves; prolonged P-R interval; bradycardia Which of the following is the most appropriate first pharmacotherapeutic intervention for this patient? a. give intravenous furosemide 40 mg b. give intravenous Ca gluconate c. give oral sevelamer d. give oral sodium polystyrene suffocate |
b. give intravenous Ca gluconate
Please see objective b, slide #33. Patient has hyperkalemia with ECG changes and Ca gluconate should be given first to stabilize myocardial conduction even though his serum Ca is quite high. Intravenous furosemide and/or Kayexalate (selection d) can follow. Oral sevelamer would be useful for this patients hyperphosphatemia but its use should not precede administration of intravenous Ca. |
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BF is a 42 year old man with type 1 diabetes, hypertension, and chronic kidney disease who presents with the following:
Labs Na 135 meq/L Ca 10.2 mg/dl K 6.2 meq/L PO4 2.6 mg/dl ECG: peaked T waves; prolonged P-R interval; bradycardia Which of the following most closely approximates the appropriate administration of sodium polystyrene sulfonate to this patient? a. 15 Gm po q 4 hr x 3 doses b. 45 Gm po x 1 dose only c. 60 Gm po q 4 hr x 3 doses d. 180 Gm po q 4 hr x 1 dose only |
c. c. 60 Gm po q 4 hr x 3 doses
Please see objective 2, slide 34, and section entitled Hypokalemia in Chapter 54 of required reading: Enough Kayexalate must be given to capture at least 100 meq of K to lower this patient’s serum K to < 5.0 meq/L. Additionally, the oral dose of Kayexalate must be given in increments. Selections a, b, and d are incorrect as a consequence. |
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DH is a 73 year old man with diabetes, chronic kidney disease, osteoarthritis, and hypertension hospitalized with a urinary tract infection. His current medications include Metformin, Ibuprofen, and Lisinopril.
Which of the following most closely describes the number of risk factors this patient has for development of acute renal failure? a. three b. four c. five d. six |
d. six
Please see objective 1, slides 5 and 7, and sections entitled Epidemiology and Etiology of Chapter 45 of required reading. Risk factors in this patient are age > 60, diabetes, pre-existing renal disease, infection, hospitalization, and use of nephrotoxins (i.e. metformin, ibuprofen, and possibly lisinopril). |
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DH is a 73 year old man with diabetes, chronic kidney disease, osteoarthritis, and hypertension hospitalized with a urinary tract infection. His current medications include Metformin, Ibuprofen, and Lisinopril.
During this hospitalization it became necessary for the patient to undergo an elective cardiac catheterization. Since he will be receiving contrast media as part of this catheterization, which of the following would be LEAST useful for prevention of contrast media induced acute renal failure? a. discontinue all nephrotoxins prior to catheterization b. intravenous furosemide 40 mg twice daily the day before, day of, and day after the catheterization c. Sodium acetylcysteine 600 mg by mouth twice daily the day before and day of catheterization d. Intravenous normal saline the day before and day of catheterization |
b. intravenous furosemide 40 mg twice daily the day before, day of, and day after the catheterization
Please see objective 4, slides 20 and 21, and section entitled Pharmacologic Therapies of Prevention and Treatment of Acute Renal Failure in Chapter 45 of required reading. A diuretic is most likely to cause acute renal failure. Selections a, c, and d are reasonable strategies for prevention of acute renal failure. |
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DH is a 73 year old man with diabetes, chronic kidney disease, osteoarthritis, and hypertension hospitalized with a urinary tract infection. His current medications include Metformin, Ibuprofen, and Lisinopril.
In spite of your best efforts, DH develops acute renal failure following the catheterization. Which of the following is the best management strategy for this patient now? a. intravenous furosemide especially if patient is hypovolemic b. fluid restriction if hypovolemic c. hemodialysis d. combined use of metolazone and furosemide if patient is hypovolemic |
c. hemodialysis
Please see objective 5, slides 24 and 25, and section entitled Management of Established Acute Renal Failure in Chapter 45 of required reading. Furosemide, alone or together with metolazone, would be reasonable if the patient were hypervolemic. Their use otherwise would likely exacerbate the acute renal failure. Similarly, fluid restriction would do the same and would be appropriate, once again, if the patient were hypervolemic. |
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(refer to CASE A)
Which of the following most closely characterize the clinical stage of this patient’s renal function? a. patient has normal renal function b. stage 5 c. stage 3 d. stage 1 |
b. stage 5
In this patient CLcr =(140 – 52)(72) / (72) = 14.6 ml/min. This level of renal (dys)function is consistent with level 5. |
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(Refer to CASE A)
Which of the following conditions present in this patient are most likely to result in exacerbation of this patient’s renal dysfunction? a. diabetes, hypertension b. obesity, hyperlipidemia c. low income, ethnic minority d. tobacco use, hyperlipidemia |
a. diabetes, hypertension
Please see objective #3, slide 11 of Chronic Renal Failure presentation. Selection c lists susceptibility factors which are useful for characterizing risk if both were true of this patient. Selections b and d are all either initiation factors or progression factors but this patient is not obese and there was no mention of tobacco use in this case description. |
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(Refer to CASE A)
Which of the following would be most useful for determining whether or not this patient’s anemia is microcytic? a. serum folic acid concentration b. serum Fe concentration c. transferring saturation d. serum vitamin B12 concentration |
c. transferring saturation
Please see objectives 3 thru 6, slides 43 thru 47 and 50, and section entitled Anemia of Chronic Kidney Disease (in Treatment: Chronic Kidney Disease) in Chapter 47 of required reading. Since microcytic anemia is most likely related to a deficiency of Fe, only selection c provides the necessary information to determine whether or not this patient’s anemia is microcytic. |
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(Refer to CASE A)
Which of the following signs/symptoms would, if present in this patient, be consistent with renal osteodystrophy? a. chest pain, shortness of breath b. bone pain, myopathy c. pulmonary fibrosis, pulmonary hypertension d. all of the above |
d. all of the above
Please see objective 4, slide 29 of Chronic Renal Failure presentation, and section entitled Secondary Hyperparathyroidism and Renal Osteodystrophy (in Pathophysiology) of Chapter 47 of required reading. |
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(Refer to CASE A)
Which of the following would be most useful for initial management of this patient’s renal osteodystrophy? a. Calcium carbonate b. Lanthanum carbonate c. Magnesium/Aluminum hydroxide gel d. Cinacalcet |
b. Lanthanum carbonate
Please see objectives 5 and 6, slide 32, and section in Chapter 47 of required reading under “Treatment: Chronic Kidney Disease” entitled Secondary Hyperparathyroidism and Renal Osteodystrophy. Since this patient is already hypercalcemic and hypermagnesemic, selections a and c are incorrect. Selection d would be useful for reducing PTH concentrations later on. |
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(Refer to CASE A)
Which of the following is most correct about this patient’s systemic acidosis? a. there is no evidence that this patient has acidosis b. this is beneficial since it protects against renal osteodystrophy c. this is detrimental since it exacerbates renal osteodystrophy d. it is beneficial in that it increases Vit D synthesis |
c. this is detrimental since it exacerbates renal osteodystrophy
Please see objectives 3 and 4, slides 26 of Chronic Renal Failure presentation, and section in Chapter 47 of required reading entitled Chronic Metabolic Acidosis in Treatment in Chronic Kidney Disease. Selection a is incorrect since the patient’s bicarbonate level is below normal and consistent with acidosis. Selection b and d are both incorrect since acidosis is associated with the opposite phenomena. |
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(Refer to Case B)
Ms. LPG’s physician wishes to initiate corrective therapy for the hypokalemia. His goal of therapy is a serum K+ of 4.0 meq/L. Which of the following would be the best management strategy for this patient at this time? a. Give 150 meq KCl intravenously over 1 - 2 minutes b. Give 150 meq K Phosphate intravenously over 1 - 2 minutes c. Give 10 meq of KCl (mixed in 0.9% NaCl solution) intravenously hourly for 15 hrs d. Give 10 meq of KCl (mixed in 5% Dextrose solution) intravenously hourly for 15 hrs |
c. Give 10 meq of KCl (mixed in 0.9% NaCl solution) intravenously hourly
for 15 hrs Please see objective #2. Selection “a” and “b” are both incorrect due to the rapidity of administration. Parenteral K+ (whether as chloride or phosphate) is always administered slowly (see slides 22 and page 971 of text). Selection d is incorrect since dextrose administration will likely drive administered K+ intracellularly and delay correction of the problem. |
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(Refer to Case B)
Which of the following is the most likely cause of this patient’s hypercalcemia? a. Use of a diuretic such as furosemide, a loop diuretic b. Use of a diuretic such as hydrochlorothiazide (or HCTZ), a thiazide diuretic c. Inadequate Vit D intake d. This patient does not have hypercalcemia. |
b. Use of a diuretic such as hydrochlorothiazide (or HCTZ), a thiazide
diuretic Please see objective #1. Use of furosemide is associated with hypocalcemia (selection “a” incorrect; see slide #30 and pages 953 and 956 of text). Inadequate vitamin D intake would likewise be associated with hypocalcemia (selection “c” incorrect; see slide #29 and page 956 of text. Finally, selection “d” is incorrect even though the reported Ca++ for this patient is within normal limits. By virtue of this patient’s hypoalbuminemia, this patient’s functional Ca++ is above normal limits (10.5 mg/dl + 0.8 [4 – 2.5] = 11.7 mg/dl). |
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(Refer to Case B)
Shortly after administration of the correct dose of K+, a repeat serum K+ concentration is found to be 3.0 meq/L. Which of the following is most likely to be associated with resolution of this continuing hypokalemia? a. Give more K+ b. Change administration of KCl to K Phosphate c. Change administration of K Phosphate to KCl d. Initiate Mg replacement therapy. |
d. Initiate Mg replacement therapy.Please see objective #2. Selection “a” is incorrect since the correct dose was
already administered (see first sentence in question). Selections “b” and “c” are incorrect as the salt of K is not relevant to this problem. The problem (see slide #19 and page 970 of text) is this patient is hypromagnesemia and, until Mg is replenished or provided, serum K+ will not rise |
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(Refer to Case B)
Which of the following is most correct regarding this patient’s hypophosphatemia? a. a reasonable therapy for this problem would be a bisphosphonate although response would be delayed b. a reasonable therapy for this problem would be intravenous K Phosphate c. a reasonable therapy for this problem would be sevelamer. d. a reasonable cause of this problem in this patient is renal insufficiency |
b. a reasonable therapy for this problem would be intravenous K Phosphate
especially since this patient is also hypokalemic, although administration must be slow. Please see objective #2. Selection “a” is incorrect as it is a reasonable therapy for hypercalcemia (see slide #37 and page 954of text) and has no role in the therapy of hypophosphatemia. Selection “c” is incorrect as this product is used for treatment of hyperphosphatemia (see slide #51 and page 961 of text). Selection “d” is incorrect since this patient’s renal function is now within normal limits following her transplantation. Renal insufficiency is more often associated with hyperphosphatemia. |
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(Refer to Case B)
Ms. LPG’s physician now elects to initiate replenishment of this patient’s depleted Mg++. Which of the following would be LEAST beneficial to this patient at this time? a. Immediate administration of intravenous Ca gluconate b. Mg Oxide tablets 600 mg po bid c. MgS04 1.0 Gm intravenously d. MgS04 1.0 Gm intramuscularly |
a. Immediate administration of intravenous Ca gluconate
Please see objective #1. Such use of parental Ca++ would be appropriate for hypermagnesemia (and hyperkalemia for that matter) but not for this patient. Selection “b” is incorrect even though the dose is low (see slide #42) and selection “d” is incorrect even though such administration would be quite uncomfortable. In both instances, there is at least some benefit to the patient. Selection “c” represents the preferred administration strategy for parenteral Mg. |
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KM is a 64 year old man (5 ft 10 in; 73 kg) admitted to the hospital for an elective
cardiac catheterization (with contrast media). His past medical history includes arthritis (degenerative joint disease), diabetes, and heart failure and his list of medications includes ibuprofen (Motrin), a non-steroidal anti-inflammatory agent, metformin (Glucophage), furosemide (Lasix), a K-wasting diuretic, and insulin. His admission labs include the following: Na 142 meq/L, K 5.3 meq/L, Cl 110 meq/L, CO2 24 meq/L, BUN 20 mg/dl, Cr 2.0 mg/dl. The day after his cardiac catheterization, he is found to be in acute renal failure. Which of the following would have most likely prevented this occurrence of acute renal failure? a. discontinue ibuprofen, metformin, and furosemide b. low – dose dopamine, furosemide, and fluid restriction the day before the c. catheterization d. administer normal saline and N-acetylcysteine the day after the catheterization e. contrast media does not adversely affect renal function; no prophylactic measures are necessary |
a. discontinue ibuprofen, metformin, and furosemide
please see objective 5. Selection “b” is incorrect since two of these (furosemide and fluid restriction) actually increase the likelihood of ARF. Low dose dopamine has not been shown to work. Selection “c” is incorrect since both of these legitimate strategies need to be administered at least the day before the catheterization and not the day after as the selection describes. Selection “d” is incorrect. See pages 789-790 of text for details. |
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KM is a 64 year old man (5 ft 10 in; 73 kg) admitted to the hospital for an elective
cardiac catheterization (with contrast media). His past medical history includes arthritis (degenerative joint disease), diabetes, and heart failure and his list of medications includes ibuprofen (Motrin), a non-steroidal anti-inflammatory agent, metformin (Glucophage), furosemide (Lasix), a K-wasting diuretic, and insulin. His admission labs include the following: Na 142 meq/L, K 5.3 meq/L, Cl 110 meq/L, CO2 24 meq/L, BUN 20 mg/dl, Cr 2.0 mg/dl. The day after his cardiac catheterization, he is found to be in acute renal failure. Which of the following is the most correct characterization of this patient’s acute renal failure? a. post renal obstruction acute renal failure b. post renal azotemia acute renal failure c. either functional or intrinsic acute renal failure d. pre-renal azotemia acute renal failure |
c. either functional or intrinsic acute renal failure
See slide 11 and text pages 782-785 (Table 42-2, page 783 as well). Selection “a” does not fit the clinical circumstances of this case. Selection “b”, to my knowledge, does not exist but also does not fit the clinical circumstances. Selection “d” represents a laboratory abnormality and may precede frank acute renal failure. |
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KM is a 64 year old man (5 ft 10 in; 73 kg) admitted to the hospital for an elective
cardiac catheterization (with contrast media). His past medical history includes arthritis (degenerative joint disease), diabetes, and heart failure and his list of medications includes ibuprofen (Motrin), a non-steroidal anti-inflammatory agent, metformin (Glucophage), furosemide (Lasix), a K-wasting diuretic, and insulin. His admission labs include the following: Na 142 meq/L, K 5.3 meq/L, Cl 110 meq/L, CO2 24 meq/L, BUN 20 mg/dl, Cr 2.0 mg/dl. The day after his cardiac catheterization, he is found to be in acute renal failure. Which of the following represents the best strategy for managing this patient’s acute renal failure? a. fluid restriction if hypovolemic b. increase doses of all current medications c. aggressive use of furosemide especially if patient is anuric or oliguric d. fluid restriction if anuric or oliguric |
d. fluid restriction if anuric or oliguric
Failure to restrict fluid intake in the presence of oliguria or anuria would rapidly lead to profound peripheral and central edema (including pulmonary and CNS). Selection “b” is incorrect since three of the medications the patient is taking (i.e. furosemide, metformin, and ibuprofen) are nephrotoxic and should be discontinued until the patient recovers. Similarly, selection “c” is incorrect as well. Selection “a” is incorrect since fluid restriction in such a clinical setting would exacerbate the acute renal failure. If the patient were hypovolemic, then fluid administration would be appropriate. Please see pages 790-793 of text for further details. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following most appropriately characterizes this patient’s stage of renal dysfunction? a. Stage 1 b. Stage 2 c. Stage 3 d. Patient has normal renal function for his age. |
c. Stage 3
IBW = 50 + 2.3 (12) = 50 + 27.6 = 77.6 kg % IBW = (84.1 kg – 77.6 kg)/ 77.6kg = 109% Use TBW CLCr = [(140 – 64) (84.1)] / [(2.5)(72)] = 6391.6/180 = 36 ml/min |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following represents most appropriate therapy for this patient’s metabolic acidosis? a. patient should preferably be treated with either Shohl’s solution (citric acid/Na citrate) or Bicitra (citric acid/Na citrate) b. patient should preferably be treated with Polycitra (citric acid/Na citrate/K citrate). c. patient should preferably be treated with NaHCO3. d. patient does not yet have metabolic acidosis; no therapy is necessary yet. |
d. patient does not yet have metabolic acidosis; no therapy is necessary yet.
please see objectives 6 and 7. Patient may actually be mildly alkalotic. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following would be most preferable for initial management of this patient’s anemia? a. since this patient probably has a macrocytic anemia, begin therapy with Folic Acid. b. since this patient probably has a macrocytic anemia, begin therapy with vitamin B12. c. begin therapy with erythropoietin or darbepoietin. d. since this patient has no symptoms typically associated with anemia, no therapy for anemia is appropriate at this time. |
c. begin therapy with erythropoietin or darbepoietin
Selections “a” and “b” are both incorrect since this patient does not have a macrocytic anemia by virtue of an MCV that is within normal limits. Selection “d” is incorrect since absence of symptoms is not the primary determinant of initiating therapy (see slide #19). |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following describes the most appropriate use of Fe to mange this patient’s anemia? a. begin therapy with oral FeS04 given 2 to 3 times daily b. since this patient’s serum Fe concentration is within normal limits, Fe therapy should be withheld at this time. c. since Transferrin saturation and serum Ferritin are both within normal limits, Fe therapy should be withheld at this time. d. do not administer Fe until resistance to other therapies has been eliminated. |
a. begin therapy with oral FeS04 given 2 to 3 times daily
Selection “b” is incorrect since serum Fe concentration is an unreliable measure of total body iron stores. Selection “c” is incorrect even though these values are within normal limits. Please note that both Transferrin sat’n and Ferritin are low normal. It is quite likely that initiation of EPO or darbepoeitin (see previous question) will use up Fe stores and response to these agents would be limited as a result. Selection “d” is incorrect since Fe stores should ideally be optimized before initiation of EPO or darbepoeitin (see slide #19). |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following most correctly describes the goal of therapy for management of this patient’s anemia? a. minimal to no symptoms of anemia; MCV > 100 mm3 b. minimal to no symptoms of anemia; Hgb 11 Gm/dl; Hct 33% c. minimal to no symptoms of anemia; serum Fe 80 – 180 mcg/dl d. minimal to no symptoms of anemia; Hgb 15 Gm/dl; Hct 42% |
b. minimal to no symptoms of anemia; Hgb 11 Gm/dl; Hct 33%
please see objective 7and slide 17. Serum Fe concentration is still an unreliable measure of anemia. Ferritin and transferring saturation are not the monitoring parameters upon which this decision is made. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following would be most appropriate initial therapy for treatment of this patient’s renal osteodystrophy? a. since this patient’s serum Ca is within normal limits, he probably does not have renal osteodystrophy yet. b. Al/Mg hydroxide suspension (Maalox, Mylanta, others), an antacid c. Ca CO3 (Tums, others) d. Sevelamer (Renagel) |
d. Sevelamer (Renagel)
Although the patient’s observed Ca is within normal limits, the corrected Ca (i.e. 11.8 mg/dl) is not. Also, the Ca – phosphate product is > 55 (i.e. 65) which strongly suggests that this patient does have renal osteodystrophy which renders selection “a” incorrect. Selection “c” is incorrect by virtue of this patient’s corrected hypercalcemia. Selection “b” is incorrect since use of Mg salts is patients with chronic kidney disease may lead to hypermagnesemia and/or aluminum toxicity. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following represent the best initial therapy for management of this patient’s hypertension? a. a calcium channel blocker such as verapamil (Calan) or diltiazem (Cardizem). a. a beta blocker such as metoprolol (Lopressor). c. an ACE inhibitor such as ramipril (Altace) or lisinopril (Zestril) d. hypertension is a benign condition in this patient and does not need to be treated. |
c. an ACE inhibitor such as ramipril (Altace) or lisinopril (Zestril)
please see objective 6. Selection “a” represents a reasonable antihypertensive strategy but not for initial therapy. Selection “b” is incorrect since this patient has asthma. Please see slides 23 and 24. I would hope that an explanation of selection “d” would not be necessary. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following best describes appropriate use of anti-hypertensive medication(s) for this patient? a. a K – sparing diuretic, such as spironolactone (Aldactone), is clearly more beneficial than a K- wasting diuretic such as furosemide (Lasix). b. use of a beta blocker, such as metoprolol (Lopressor), is a reasonable choice even though it may exacerbate renal dysfunction. c. use of a beta blocker, such as metoprolol (Lopressor), is clearly contraindicated since it may exacerbate renal dysfunction. d. an angiotensin receptor blocker, such as candesartan (Atacand), is clearly more beneficial than an ACE inhibitor such as ramipril (Altace). |
b. use of a beta blocker, such as metoprolol (Lopressor), is a reasonable
choice even though it may exacerbate renal dysfunction. Use of an ARB is appropriate in the patient who is intolerant to an ACE inhibitor but it is not yet preferred over an ACE inhibitor. Consequently, selection “d” is incorrect. Selection “a” is incorrect since a K – sparing diuretic in this patient may exacerbate his hyperkalemia. Selection “c” is incorrect since the benefits of beta-blockade for exceed this largely theoretical risk. |
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Which one of the following statements regarding the effect(s) of chronic kidney
disease on protein binding and drug distribution is/are TRUE? a. The binding of acidic drugs (e.g., phenytoin) is typically increased and the volume of distribution is decreased in patients with CKD. b. The binding of acidic drugs (e.g., phenytoin) is typically decreased and the volume of distribution is increased in patients with CKD. c. The binding of basic drugs (e.g., quinidine) is typically increased and the volume of distribution is decreased in patients with CKD. d. The binding of basic drugs (e.g., quinidine) is typically decreased and the volume of distribution is increased in patients with CKD. e. A and C f. A and D g. B and C h. B and D |
g. B and C
The binding of acidic drugs is typically decreased in patients with chronic kidney disease while binding for basic drugs is typically increased. This has the opposite effect on the volume of distribution with the VD being larger for acidic drugs and smaller for basic drugs |
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There are now a number of examples of drugs predominately metabolized that
require dosage adjustment in patients with chronic kidney disease (CKD) because of reduced non-renal clearance. Which of the following drugs metabolized by a CYP enzyme would you MOST expect to have decreased clearance (due to decreased enzyme activity) in patients with CKD? a. Chlorzoxazone (predominately metabolized by CYP2E1) b. Omeprazole (predominately metabolized by CYP2C19) c. Ranolazine (predominately metabolized by CYP3A4) d. The clearance of all of these drugs would be decreased in CKD. e. CKD will not affect the clearance of any of these drugs. |
c. Ranolazine (predominately metabolized by CYP3A4)
Answer C is correct because metabolism by CYP2C9 and CYP3A4 has been shown to be decreased in patients with CKD (slide 33). CYP2E1 (chlorzoxazone was used as the example in class; see lecture slide 37) and CYP2C19 (slide 33) are not affected by CKD. |
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Based on only the drug characteristic specified, which of the following statements
would you predict to be TRUE regarding the expected amount of drug removed by conventional hemodialysis (i.e., hemodialysis using a cuprophane or cellulose membrane)? (Note: MW = molecular weight; VD = volume of distribution). The amount of drug removed by hemodialysis would be GREATER for: a. foscarnet (MW = 94) than for erythromycin (MW 733.9). b. ceftriaxone (fraction unbound = 0.10) than for cefazolin (fraction unbound = 0.50) c. amitriptyline (VD = 10 L/kg) than trimethoprim (VD = 1.6 L/kg). d. All of the above are true. e. A and B f. A and C g. B and C |
a. foscarnet (MW = 94) than for erythromycin (MW 733.9).
All else being equal, drugs with a smaller MW (especially less than 500) will be removed to a greater extent by hemodialysis than drugs with a larger MW (especially > 500). Answer B is wrong because drugs that have higher protein binding (i.e., having a lower fraction unbound) will not be cleared by dialysis as well as a drug with lower protein binding (i.e., having a higher fraction unbound). Answer C is wrong because drugs with a large VD (i.e., > 2 L/kg) are not cleared by dialysis as well as drugs with a smaller VD. Answers D through G are not correct based on the previous answers. |
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KM is a 64 year old man (5 ft 10 in; 73 kg) admitted to the hospital for an elective cardiac catheterization. His past medical history includes arthritis (degenerative joint disease), diabetes, and heart failure and his list of medications includes ibuprofen (Motrin), a non-steroidal antiinflammatory agent, metformin (Glucophage), furosemide (Lasix), a K-wasting diuretic, and insulin. His admission labs include the following: Na 142 meq/L, K 5.3 meq/L, Cl 110 meq/L, CO2 24 meq/L, BUN 20 mg/dl, Cr 2.0 mg/dl.
Based only on this information, appropriately categorize this patient’s renal dysfunction. a. Stage 1 normal; CLCr > 90 ml/min b. Stage 2 mild; CLCr 60-89 ml/min c. Stage 3 moderate; CLCr 30-59 ml/min d. Stage 4 severe; CLCr 15-39 ml/min |
c. Stage 3 moderate; CLCr 30-59 ml/min
(Chronic Renal Failure). IBW = 50 + 2.3 (10) = 73 kg CLcr = [(140 – 64) (73)] / [(2.0)(72)] = 38.5 ml/min |
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KM is a 64 year old man (5 ft 10 in; 73 kg) admitted to the hospital for an elective cardiac
catheterization. His past medical history includes arthritis (degenerative joint disease), diabetes, and heart failure and his list of medications includes ibuprofen (Motrin), a non-steroidal antiinflammatory agent, metformin (Glucophage), furosemide (Lasix), a K-wasting diuretic, and insulin. His admission labs include the following: Na 142 meq/L, K 5.3 meq/L, Cl 110 meq/L, CO2 24 meq/L, BUN 20 mg/dl, Cr 2.0 mg/dl. Since KM will be receiving contrast media prior to the cardiac catheterization, which of the following would be most appropriate for preventing contrast media – induced acute renal dysfunction? a. all medications should be continued without interruption for maximal renal protection b. administer normal saline and N-acetylcysteine the day before and the day of the catheterization c. low – dose dopamine, Lasix (furosemide), a diuretic, and fluid restriction the day before the catheterization d. contrast media does not adversely affect renal function; no prophylactic measures are necessary |
b. administer normal saline and N-acetylcysteine the day before and the day of the
catheterization Selection “a” is incorrect since at least three of the medications KM is taking may cause or exacerbate acute renal failure. Those medications are ibuprofen, metformin, and Lasix. Selection “c” and “d” are both incorrect. See pages 789-790 of text for details. |
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KM is a 64 year old man (5 ft 10 in; 73 kg) admitted to the hospital for an elective cardiac
catheterization. His past medical history includes arthritis (degenerative joint disease), diabetes, and heart failure and his list of medications includes ibuprofen (Motrin), a non-steroidal antiinflammatory agent, metformin (Glucophage), furosemide (Lasix), a K-wasting diuretic, and insulin. His admission labs include the following: Na 142 meq/L, K 5.3 meq/L, Cl 110 meq/L, CO2 24 meq/L, BUN 20 mg/dl, Cr 2.0 mg/dl. In spite of appropriate prophylaxis, KM develops acute renal failure 24 hours after the cardiac catheterization. Which of the following is the most likely etiology in this patient? a. pre-renal azotemia b. functional acute renal failure c. intrinsic acute renal failure d. post renal obstruction |
c. intrinsic acute renal failure
See slide 11 and text pages 782-785 (Table 42-2, page 783 as well). |
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(Refer to Case C)
PL’s physician wishes to treat his metabolic acidosis with NaHCO3. Which of the following most correctly characterizes this therapeutic strategy. a. good idea; NaHCO3 effectively and efficiently lowers serum pH b. good idea; patient is hypo-natremic c. bad idea; patient is hyper-natremic d. bad idea; patient has elevated blood pressure |
d. bad idea; patient has elevated blood pressure
Patient’s Na concentration is WNL so selections b and c are both incorrect. Selection a is incorrect since NaHCO3 raises serum pH. |
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(refer to Case C)
PL’s physician wants to administer folic acid for management of his macrocytic anemia. Which of the following describes most appropriate use of folic acid in this patient? a. good idea; patient has macrocytic anemia b. bad idea; patient does not have macrocytic anemia c. good idea but must administer with vitamin B12 d. bad idea; vitamin B12 is the drug of choice for macrocytic anemia |
b. bad idea; patient does not have macrocytic anemia
Since this patient’s MCV is < 100 mm3, he does not have macrocytic anemia. |
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(Refer to Case C)
Which of the following most closely characterizes the therapeutic goal for managing this patient’s anemia? a. Hgb 16 Gm/dl, Hct 48% b. Hgb 10 Gm/dl, Hct 30% c. Transferrin saturation < 15% d. MCV > 100mm3 |
b. Hgb 10 Gm/dl, Hct 30%
Please see slide 27 and page 826 of text for additional details. |
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(refer to Case C)
Which of the following would be most appropriate initial therapy for this patient’s hyperphosphatemia? a. aluminum hydroxide gel b. calcitriol c. calcium carbonate d. calcium citrate |
a. aluminum hydroxide gel
Since this patient’s corrected Ca concentration indicates that he is actually hypercalcemic, either Ca salt would be inappropriate. For the same reason calcitriol would likewise not be useful. Since the patient’s serum phosphate is > 7.0 mg/dl, the drastic measure of using Al becomes the best of these available choices. |
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(refer to Case C)
Which of the following most correctly describes role of cinacelet in the management of this patient’s hyperphosphatemia? a. it binds phosphate in the GI tract b. it enhances renal phosphate excretion c. it enhances sensitivity of the parathyroid gland to phosphate d. it enhances sensitivity of the parathyroid gland to Ca |
d. it enhances sensitivity of the parathyroid gland to Ca
Please refer to page 840 of text for details of this agent. |
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(refer to Case C)
Which of the following represents the best initial therapy of this patient’s hypertension? a. a calcium channel blocker such as verapamil or diltiazem b. a thiazide diuretic such as HCTZ c. an ACE inhibitor such as ramipril or lisinopril d. hypertension is a benign condition and need not be treated |
a. a calcium channel blocker such as verapamil or diltiazem
Thiazide diuretics are not effective in patients with a creatinine clearance < 30 ml/min and this patient’s approximately 9 ml/min. An ACE inhibitor would potentially exacerbate this patient’s severe hyperkalemia. I hope that an explanation of selection d is unnecessary. Please see slides 32 and 36 |
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(refer to Case C)
Which of the following most correctly characterizes this patient’s blood pressure goal? a. < 140/90 mm Hg b. < 130/80 mm Hg c. < 125/75 mm Hg d. > 140/90 mm Hg |
b. < 130/80 mm Hg
Even though this patient’s albumin is quite low, there is no mention of proteinuria. Consequently, his blood pressure goal is < 130/80. |
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(refer to Case C)
PL’s physician is forced to treat the hyperkalemia with kayexalate since all hemodialysis machines have been recalled. Which of the following describes most appropriate use of this agent in this patient to reduce K to 4.9 meq/L? a. 15 Gm po x 1 only b. 50 Gm po x 1 only c. 50 Gm po qid d. 200 Gm po x 1 |
c. 50 Gm po qid
(please see objectives 5 and 6 of CRF and objective 2 of electrolytes). See slide 26 of Electrolytes and pages 970 and 974-975 of text. Patient has an excess of approximately 200 meq of K+. Since 1.0 Gm of kayexalate exchanges 1.0 meq of Na+ for 1 meq of K+, a total dose of 200 Gm of kayexalate is needed preferably in divided doses. |
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Twenty four hours following a renal ultrasound (with intravenous contrast media),
LML’s (60 years old; 6’0”; 190 lbs) urine output has declined to 300 ml/24 hrs. Also the following labs are noted: Na 142 meq/L, K 4.0 meq/L, CO2 27 meq/L, Cl 105 meq/L, BUN 25 ng/dl, Cr 1.0 mg/dl. Based on this information, appropriately stage this patient’s renal dysfunction. a. 1 b. 2 c. 3 d. 4 |
b. 2
Patient’s calculated creatinine clearance is 86 ml/min (IBW = 50+2.3 [12] = 77.6 kg; CLcr = [140-60] [78]/[1.0x72] = 86 ml/min) which is consistent with stage 2 or selection “b”. |
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Twenty four hours following a renal ultrasound (with intravenous contrast media),
LML’s (60 years old; 6’0”; 190 lbs) urine output has declined to 300 ml/24 hrs. Also the following labs are noted: Na 142 meq/L, K 4.0 meq/L, CO2 27 meq/L, Cl 105 meq/L, BUN 25 ng/dl, Cr 1.0 mg/dl. LML is felt to have oliguric pre – renal azotemia. Which of the following would have most likely prevented its occurrence? a. N-acetylcysteine administered the day before and the day of the ultrasound b. Furosemide (Lasix®) and fluid restriction the day before the ultrasound c. ibuprofen (Motrin®) administered the day before and the day of the ultrasound d. contrast media does not adversely affect renal function; no preventative measures are necessary |
a. N-acetylcysteine administered the day before and the day of the
ultrasound Selections “b” and “c” would actually increase the likelihood of this problem. Selection “d” is incorrect. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 52 mg/dl, Cr 5.0 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 125 μm3, Alb 2.7 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 100 mcg/dl, TIBC 300 μg/dl, Transferrin sat’n 40%, Ferritin 200 mg/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following would be preferred for initial management of this patient’s macrocytic anemia? a. begin therapy with Folic Acid only b. begin therapy with Vitamin B12 only c. begin therapy with erythropoietin and/or Fe d. begin therapy with both Folic Acid and Vitamin B12 |
d. begin therapy with both Folic Acid and Vitamin B12
Selection “a” and “b” are incorrect since supplementation of folate in a patient with a B12 deficiency will alleviate the macrocytic anemia but will not prevent the neurologic complications of a B12 deficiency. Selection “c” will not appropriately manage a macrocytic anemia |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 52 mg/dl, Cr 5.0 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 125 μm3, Alb 2.7 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 100 mcg/dl, TIBC 300 μg/dl, Transferrin sat’n 40%, Ferritin 200 mg/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following describes most appropriate use of Fe to manage this patient’s anemia? a. since this patient’s serum Fe concentration is within normal limits, Fe therapy should be withheld at this time. b. begin therapy with oral FeS04 given 2 to 3 times daily. c. do not administer Fe until resistance to other therapies has been eliminated. d. since Transferrin sat’n and serum Ferritin are both within normal limits, Fe therapy should be withheld at this time. |
d. since Transferrin sat’n and serum Ferritin are both within normal limits,
Fe therapy should be withheld at this time. Selection “a” is incorrect since serum Fe concentration is an unreliable measure of total body iron stores. Selection “c” is incorrect since “resistance” is not an issue for this patient. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 52 mg/dl, Cr 5.0 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 125 μm3, Alb 2.7 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 100 mcg/dl, TIBC 300 μg/dl, Transferrin sat’n 40%, Ferritin 200 mg/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. What is the goal of therapy for management of this patient’s anemia? a. minimal to no symptoms of anemia; MCV < 100 mm3. b. minimal to no symptoms of anemia; Hgb 15 Gm/dl; Hct 42% c. minimal to no symptoms of anemia; Hgb 11 Gm/dl; Hct 33% d. minimal to no symptoms of anemia; normal Ferritin and Transferrin sat’n |
c. minimal to no symptoms of anemia; Hgb 11 Gm/dl; Hct 33%
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 52 mg/dl, Cr 5.0 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 125 μm3, Alb 2.7 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 100 mcg/dl, TIBC 300 μg/dl, Transferrin sat’n 40%, Ferritin 200 mg/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. FJ’s physician asks you for a dose recommendation for Aludrox® (aluminium hydroxide gel) for management of the patient’s renal osteodystrophy. Which of the following is the most appropriate reply? a. 15-30 ml po qid b. Aludrox® is an inappropriate drug for this patient c. since the patient’s serum Ca is within normal limits, he probably doesn’t need treatment for renal osteodystrophy d. since this patient’s serum K is only slightly above normal, he probably doesn’t need treatment for renal osteodystrophy |
b. Aludrox® is an inappropriate drug for this patient
While selection “a” is a reasonable dose for Aludrox®, its use in this patient is associated with an increased risk of Al-associated encephalopathy. Selection “c” is incorrect since it fails to account for this patient’s hypoalbuminemia and hyperphosphatemia. Selection “d” is incorrect since K is not part of the pathogenesis of renal osteodystrophy. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 52 mg/dl, Cr 5.0 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 125 μm3, Alb 2.7 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 100 mcg/dl, TIBC 300 μg/dl, Transferrin sat’n 40%, Ferritin 200 mg/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following represents the best initial therapy for management of this patient’s hypertension? a. a diuretic such as hydrochlorothiazide (Esidrix®, others) or triamterene (Dyrenium®) b. a diuretic such as furosemide (Lasix®) or bumetanide (Bumex®) c. ARB such as losartan (Cozaar®) or candesartan (Atacand®) d. hypertension is a benign condition in this patient and does not need to be treated. |
c. ARB such as losartan (Cozaar®) or candesartan (Atacand®)
Selection “a” is incorrect since HCTZ is not effective in patient with a creatinine clearance < 30 ml/min. Neither is triamterene but it is also a K-sparing diuretic would exacerbate this patient’s hyperkalemia. Selection “b” is incorrect since addition of these agents follows failure of ARB therapy. I hope that an explanation of “d” is not necessary. |
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Based on only the drug characteristic specified, which of the following statements
would you predict to be TRUE regarding the expected amount of drug removed by conventional hemodialysis (i.e., hemodialysis using a cuprophane membrane)? (Note: MW = molecular weight; VD – volume of distribution). The amount of drug removed by hemodialysis would be greater for: a. erythromycin (MW 733.9) than for foscarnet (MW = 94). b. cefazolin (fraction unbound = 0.50) than for ceftriaxone (fraction unbound = 0.10). c. amitriptyline (VD = 10 L/kg) than trimethoprim (VD = 1.6 L/kg). d. All of the above are true. e. None of the above are true. |
b. cefazolin (fraction unbound = 0.50) than for ceftriaxone (fraction unbound =
0.10). all else being equal, drugs with higher protein binding (i.e., having a lower fraction unbound) will not be cleared by dialysis as well as a drug with lower protein binding (i.e., having a higher fraction unbound). Answer a is not correct as dialysis clearance using a cuprophane membrane decreases significantly above a MW of 500 and is even more substantially reduced for MW > 1000. Answers c is not correct because drugs with a large VD (i.e., > 2 L/kg) are not cleared by dialysis as well as drugs with a smaller VD. Answers d and e and not correct based on the previous answers. |
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Tozer Approach to Dosage Individualization
Q = 1 - [fe × (1-KF)] Q = dosage adjustment factor fe = fraction eliminated unchanged in urine KF =CLcrf/CLcrN (CLcrN = 120 mL/min) Subscripts "N" and "f" refer to patients with normal renal function and renal failure, respectively. Equations for Adjustments: Tf = TN / Q; Df = DN x Q A 52 year old, 58 kg woman who has a creatinine clearance of 42 ml/min is to receive valacyclovir for prophylaxis against cytomegalovirus (CMV) infection after renal transplantation. Valacyclovir is predominantly (75 percent) eliminated renally unchanged. Based on this information, select the most appropriate dosing interval for this patient with impaired renal function. Assume the normal dosing interval (TN) is every 6 hours and that the maximum dosing interval is 24 hours. Select the dosing interval closest to what you calculate. a. 6 hours b. 8 hours c. 12 hours d. 18 hours e. 24 hours |
c. 12 hours
Calculated as Q = 1-[0.75 × (1 – (42 / 120))] = 0.513 and Tf = TN / Q = 6 / 0.513 = 11.7 hours (closest interval is therefore 12 hours). |
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Which one of the following statements is TRUE?
a. In general, the volume of distribution of basic drugs is increased in patients with chronic kidney disease. b. Total drug concentrations can be used reliably to monitor therapy and make dose modifications in patients with chronic kidney disease. c. The clearance of vancomycin by hemodialysis when using synthetic high-flux hemodialysis filters (e.g., polyacrylonitrile, polymethylmethacrylate, etc.) is less than the clearance observed with conventional (e.g., cuprophane) filters. d. Peritoneal dialysis is generally more effective in removing drug substances than hemodialysis due to the prolonged dialysate dwell times. e. None of the above; all of the statements are false |
e. None of the above; all of the statements are false.
Answer a is not correct because in general, basic drugs have a smaller volume of distribution (see lecture slide 14). Answer b is not correct because the relationship between total and free drug concentrations can be altered in patient with renal kidney disease, which can make total concentrations unreliable in this patient population (see lecture slides 17 and 23). Answer c is not correct because vancomycin clearance is much higher with synthetic high-flux filters than with cuprophane filters. Finally, answer d is not correct because peritoneal dialysis is generally less effective than hemodialysis in removing substances. |
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It is now recognized that chronic kidney disease (CKD) can affect hepatic drug
metabolism by decreasing the activity of drug-metabolizing enzymes, such as cytochrome P450 (CYP) enzymes. Which of the following drugs metabolized by a CYP enzyme would you LEAST expect to have decreased clearance (due to decreased enzyme activity) in patients with CKD? a. Chlorzoxazone (metabolized by CYP2E1) b. Warfarin (metabolized by CYP2C9) c. Erythromycin (metabolized by CYP3A4) d. The clearance of all of these drugs would be decreased in CKD. e. CKD will not affect the clearance of any of these drugs. |
a. Chlorzoxazone (metabolized by CYP2E1)
Answer A is correct because CYP2E1 is not affected by CKD (chlorzoxazone was used as the example in class; see lecture slide 31). Answers b and c are not correct since metabolism by CYP2C9 and CYP3A4 has been shown to be decreased in patients with CKD (slide 31). Answers D and E are not correct based on A-C. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following represents most appropriate therapy for this patient’s metabolic acidosis? a. patient should preferably be treated with either Shohl’s solution (citric acid/Na citrate) or Bicitra (citric acid/Na citrate) b. patient should preferably be treated with Polycitra (citric acid/Na citrate/K citrate). c. patient should preferably be treated with NaHCO3. d. patient does not yet have metabolic acidosis; no therapy is necessary yet. |
a. patient should preferably be treated with either Shohl’s solution (citric
acid/Na citrate) or Bicitra (citric acid/Na citrate) Selection “b” is incorrect due to the K content of this product and the patient already has mild hyperkalemia. Selection “c” is incorrect since the patient has HTN and the Na content of NaHCO3 would likely exacerbate this patient’s already elevated blood pressure. Selection “d” is incorrect by definition of metabolic acidosis (see slide 10). |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following would be preferred for initial management of this patient’s anemia? a. since this patient probably has a macrocytic anemia, begin therapy with Folic Acid. b. since this patient probably has a macrocytic anemia, begin therapy with vitamin B12. c. begin therapy with erythropoietin or darbepoietin. d. since this patient has no symptoms typically associated with anemia, no therapy for anemia is appropriate at this time. |
c. begin therapy with erythropoietin or darbepoietin.
Selections “a” and “b” are both incorrect since this patient does not have a macrocytic anemia by virtue of an MCV that is within normal limits. Selection “d” is incorrect since absence of symptoms is not the primary determinant of initiating therapy (see slide #19). |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. What is the goal of therapy for management of this patient’s anemia? a. minimal to no symptoms of anemia; MCV > 100 mm3. b. minimal to no symptoms of anemia; Hgb 15 Gm/dl; Hct 42% c. minimal to no symptoms of anemia; Hgb 11 Gm/dl; Hct 33% d. minimal to no symptoms of anemia; normal Ferritin and Transferrin sat’n |
c. minimal to no symptoms of anemia; Hgb 11 Gm/dl; Hct 33%
please see objective 7 and see slide 17. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following describes most appropriate use of Fe to manage this patient’s anemia? a. since this patient’s serum Fe concentration is within normal limits, Fe therapy should be withheld at this time. b. begin therapy with oral FeS04 given 2 to 3 times daily. c. do not administer Fe until resistance to other therapies has been eliminated. d. since Transferrin sat’n and serum Ferritin are both within normal limits, Fe therapy should be withheld at this time. |
b. begin therapy with oral FeS04 given 2 to 3 times daily
Selection “a” is incorrect since serum Fe concentration is an unreliable measure of total body iron stores. Selection “d” is incorrect even though these values are within normal limits. Please note that both Transferrin sat’n and Ferritin are low normal. It is quite likely that initiation of EPO or darbepoeitin will use up Fe stores and response to these agents would be limited as a result. Selection “c” is incorrect since Fe stores should ideally be optimized before initiation of EPO or darbepoeitin ( see slide #19). |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following would be most appropriate initial therapy for treatment of this patient’s renal osteodystrophy? a. Sevelamer (Renagel) b. Ca CO3 (Tums, others) c. Al/Mg hydroxide suspension (Maalox, Mylanta, others), an antacid d. since this patient’s serum Ca is within normal limits, he probably does not have renal osteodystrophy yet. |
a. Sevelamer (Renagel)
Although the patient’s observed Ca is within normal limits, the corrected Ca (i.e. 11.5 mg/dl) is not. Also, the Ca – phosphate product is > 55 (i.e. 64) which strongly suggests that this patient does have renal osteodystrophy which renders selection “d” incorrect. Selection “b” is incorrect by virtue of this patient’s corrected hypercalcemia. Selection “c” is incorrect since use of Mg salts is patients with chronic kidney disease may lead to hypermagnesemia and/or aluminum toxicity. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following correctly characterizes use of vitamin D for management of this patient’s renal osteodystrophy. a. its use should be withheld until phosphate concentration has been normalized. b. begin vitamin D capsules daily immediately. c. begin calcitriol (Rocaltrol) immediately. d. Vitamin D must be used together with Ca CO3 in this patient. |
a. its use should be withheld until phosphate concentration has been
normalized. Both “b” and “c” are incorrect since phosphate must be reduced first. Vitamin D, or more correctly, calcitriol will also raise phosphate levels and the present hyperphosphatemia must be normalized before beginning such therapy. Selection “b” is also incorrect since the patient will likely be unable to produce the 1, 25 dihydroxy derivative of vitamin D as a consequence of his chronic kidney disease. Selection “d” is incorrect also because vitamin D will likely be inactive but also because this patient is already hypercalcemic and will likely not benefit from exogenous Ca at the present time. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following represent the best initial therapy for management of this patient’s hypertension? a. a calcium channel blocker such as verapamil (Calan) or diltiazem (Cardizem). b. a beta blocker such as nadolol (Corgard) or atenolol (Tenormin). c. an ACE inhibitor such as ramipril (Altace) or lisinopril (Zestril) d. hypertension is a benign condition in this patient and does not need to be treated. |
c. an ACE inhibitor such as ramipril (Altace) or lisinopril (Zestril)
Selection “a” represents a reasonable antihypertensive strategy but not for initial therapy. Please see slides 23 and 24. I would hope that an explanation of selection “d” would not be necessary. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease,
hypertension, and diabetes. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 18 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.7Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Which of the following describes appropriate use of anti-hypertensive medication(s) for this patient? a. an angiotensin receptor blocker, such as candesartan (Atacand), is clearly preferred over an ACE inhibitor such as ramipril (Altace). b. a K – sparing diuretic, such as spironolactone (Aldactone), is clearly preferred over a K- wasting diuretic such as furosemide (Lasix). c. use of a beta blocker, such as metoprolol (Lopressor), may be a reasonable choice even though it may exacerbate renal dysfunction. d. use of a beta blocker, such as metoprolol (Lopressor), is clearly contraindicated since it may exacerbate renal dysfunction. |
c. use of a beta blocker, such as metoprolol (Lopressor), may be a
reasonable choice even though it may exacerbate renal dysfunction. Use of an ARB is appropriate in the patient who is intolerant to an ACE inhibitor but it is not yet preferred over an ACE inhibitor. Consequently, selection “a” is incorrect. Selection “b” is incorrect since a K – sparing diuretic in this patient may exacerbate his hyperkalemia. Selection “d” is incorrect since the benefits of beta-blockade for exceed this largely theoretical risk. |
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Hemodialysis
B.L. is a 72 year old, 65kg man. He presents to his primary care physician with complaints of weakness, lack of energy, and productive cough with yellow sputum. The treatment selected is oral ciprofloxacin. The usual dose of ciprofloxacin is 500 mg BID for patients with normal renal function, approximately 60% of ciprofloxacin is eliminated renally unchanged and this patient’s creatinine clearance is 35 ml/min. Based on this information, calculate the dosage adjustment factor (Q) that could be used to adjust the treatment regimen for B.L. a. 0.283 b. 0.425 c. 0.575 d. 0.710 e. 0.825 |
c. 0.575
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Hemodialysis
Which of the following drugs is LEAST likely to be removed by conventional hemodialysis (i.e., hemodialysis using a celluose membrane)? a. Foscarnet (MW = 94; Vd = 0.7 l/kg; Fraction bound = 0.17) b. Cefazolin (MW = 454; Vd = 0.2 l/kg; Fraction bound = 0.50) c. Ceftriaxone (MW = 450; Vd = 0.2 l/kg; Fraction bound = 0.90) d. Inulin (MW = 5200; Vd = 0.05 l/kg; Fraction bound = 0.00) |
d. Inulin (MW = 5200; Vd = 0.05 l/kg; Fraction bound = 0.00)
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It is now recognized that chronic kidney disease (CKD) can affect hepatic drug
metabolism by decreasing the activity of drug-metabolizing enzymes, such as cytochrome P450 (CYP) enzymes. Which of the following drugs metabolized by a CYP enzyme would you MOST expect to have decreased clearance (due to decreased enzyme activity) in patients with CKD? a. Caffeine (metabolized by CYP1A2) b. Warfarin (metabolized by CYP2C9) c. Midazolam (metabolized by CYP3A4) d. The clearance of all of these drugs would be decreased in CKD. e. CKD will not affect the clearance of any of these drugs. |
b. Warfarin (metabolized by CYP2C9)
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