Ground_Truth_Answers.csv

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."