NR575 AGACNP Certification Review Renal and Genitourinary with 100% correct answers + rationales 2026

1. The patient is a 64-year-old white woman (height 73 inches, weight 90 kg) who presents to the clinic with abdominal pain and dizziness. She reports that she did not eat or drink for 24 hours because she has a history of gastroenteritis. On exam, the blood pressure reading while sitting is 120/85 mmHg and drops to 90/60 mmHg when standing. Her heart rate is 95 beats/min. The laboratory tests reveal sodium (Na) is 140 mEq/L, potassium is 4 mEq/L, chloride (Cl) is 105 mEq/L, blood urea nitrogen is 42 mg/dL, serum creatinine is 1.3 mg/dL, and glucose is 190 mg/dL. What is the best action for this patient?

1. Administer trimethoprim/sulfamethazine double strength orally for 3 days.

2. Administer furosemide 40 mg intravenously.

3. Administer Insulin lispro 5 units subcutaneously.

4. Administer fluid bolus (500 mL of NaCl solution).

4. Administer fluid bolus (500 mL of NaCl solution)

Rationale: The patient presents with acute kidney injury (AKI) symptoms, and the initial treatment of AKI is identifying and reversing the insult to the kidney if possible. This patient has prerenal azotemia caused by hypotension and increased heart rate. Adding sulfa antibiotics would not have any benefits for this patient because she does not have any signs for urinary tract infections (answer 1). Administering diuretics such as furosemide (answer 2) could worsen her volume depletion and probably further impair her kidney function. Although the glucose level is elevated, adding insulin units is unnecessary at this time (answer 3). Fluid management is critical to managing AKI; therefore administration of a fluid bolus with normal saline would be the best choice for this patient.

2. A 63-year-old Asian man has diabetes, hypertension, and estimated glomerular filtration rate of 40 mL/min/1.73 m2. He takes simvastatin 40 mg daily, ramipril 10 mg daily, and metformin 1000 mg twice daily. Laboratory values reveal hemoglobin is 12 mg/dL, parathyroid hormone is 200 pg/mL, sodium is 135 mEq/L, potassium is 3.9 mEq/L, calcium is 8.9 mEq/dL, albumin is 3.5 g/dL, phosphorus is 5.9 mg/dL, and 25-hydroxyvitamin D is 50 ng/mL. Which therapy is the best to prevent chronic kidney disease-mineral and bone disorders?

1. Cinacalcet.

2. Ergocalciferol.

3. Calcium carbonate.

4. Calcitriol.

3. Calcium carbonate.

Rationale: There are many factors that can contribute to the development of chronic kidney disease-mineral and bone disorders such as hypocalcemia, hyperparathyroidism, hyperphosphatemia, decrease of vitamin D, and decreased production of 1.25-dihydroxyvitamin D. The patient's laboratory values reveal hyperparathyroidism, which may be related to an increasing phosphorus concentration. The first approach is to administer a phosphate binder. Knowing the corrected calcium concentration is necessary for this patient. The [measured Ca + (0.8) (4 − serum albumin) = 8.9 + (0.8) (4 − 3.5) = 8.9 + 0.4 = 9.3 mEq/dL]; therefore this patient has hypocalcemia. Cinacalcet (answer 1) is reserved for patients with hyperparathyroidism despite the normalization of phosphate in patients with hypercalcemia. Ergocalciferol (answer 2) is unnecessary for this patient because his 25-hydroxyvitamin D concentration is greater than 30 ng/mL. Calcium carbonate (answer 3) is the best phosphate binder for this case because the patient has hypocalcemia, and it is acceptable with a corrected serum calcium concentration. An active vitamin D medication such as calcitriol (answer 4) could be added if the parathyroid concentration remains elevated, despite normalization of serum phosphate.

3. The patient is a 35-year-old African American woman who is admitted to the hospital with a 2-day history of nausea, vomiting, abdominal cramps, dysuria, and flank pain. She is diagnosed with pyelonephritis and is prescribed a 5-day course of parenteral aminoglycosides. The patient develops acute tubular necrosis. Antibiotic therapy is adjusted based on culture and sensitivity results. Which set of laboratory data is consistent with this presentation?

1. Blood urea nitrogen (BUN)/serum creatinine ratio is 15:1, urinary sodium more than 40 mEq/L, fractional excretion of sodium (FENa) more than 2%, specific gravity is less than 1.015, and muddy casts are present.

2. BUN/serum creatinine ratio is 15:1, urinary sodium is greater than 40 mEq/L, FENa greater than 2%, specific gravity is less than 1.015, no casts visible.

3. BUN/serum creatinine ratio is greater than 20:1, urinary sodium is less than 20 mEq/L, FENa is les

1. Blood urea nitrogen (BUN)/serum creatinine ratio is 15:1, urinary sodium more than 40 mEq/L, fractional excretion of sodium (FENa) more than 2%, specific gravity is less than 1.015, and muddy casts are present.

Rationale: The patient develops acute tubular necrosis (ATN), so she has an intrinsic acute kidney injury (AKI). Aminoglycosides can cause direct damage to the tubules. In ATN, the blood urea nitrogen/serum creatinine ratio could be normal (between 10 and 15:1), but it is greater than 20:1, so it is reflecting hypovolemia, which is common in prerenal azotemia. Urinary sodium less than 20 mEq/L is a marker of hypovolemia. The fractional excretion of sodium (FENa) value could distinguish between prerenal and intrinsic AKI. A low FENa (less than 1%) in a patient with oliguria suggests that the tubular function is still intact, but a FENa greater than 2% refers to intrinsic AKI. The specific gravity is normal in intrinsic AKI and is elevated (greater than 1.018) in prerenal azotemia. Muddy casts are often present in intrinsic AKI because of the renal tubule cell damage. Therefore answers 2, 3, and 4 are incorrect.

4. A 53-year-old Asian man presents to the emergency department with an 8-hour history of strong chest pain, diaphoresis, and dyspnea. His medical history includes diabetes type 2, and he takes metformin 1000 mg twice daily. The nurse practitioner is concerned about a possible myocardial infarction and recommends coronary angiography. The patient develops acute tubular necrosis after the procedure. Which set of laboratory data is consistent with this presentation?

1. Blood urea nitrogen (BUN)/serum creatinine ratio is 20:1, urinary sodium is greater than 40 mEq/L, fractional excretion of sodium (FENa) is less than 1%, specific gravity is 1.018, and no visible casts.

2. BUN/serum creatinine ratio is 15:1, urinary sodium is greater than 40 mEq/L, FENa is greater than 2%, specific gravity is 1.010, and no visible casts.

3. BUN/serum creatinine ratio is 10:1, urinary sodium is greater than 40 mEq/L, FENa is greater than

4. BUN/serum creatinine ratio 20:1, urinary sodium is less than 20 mEq/L, FENa is less than 1%, specific gravity is 1.018, and muddy casts are present.

Rationale: The patient develops acute tubular necrosis (ATN); therefore, he has an intrinsic acute kidney injury. Coronary angiography can cause nephrotoxicity because of the use of intravenous contrast. Metformin should be stopped about 24 hours before the coronary angiography procedure because the iodinated contrast dye can increase the nephrotoxicity risk. Blood urea nitrogen/serum creatinine ratio could be normal (10 to 15:1) in ATN, but it becomes greater than 20:1 in prerenal azotemia. Urinary sodium greater than 40 mEq/L is an indication of ATN, but when it becomes less than 20 mEq/L, it reflects hypovolemia. A fraction excretion of sodium (FENa) less than 1% is an indication of intact tubular function, but a FENa greater than 2% refers to an intrinsic AKI. The specific gravity is normal in ATN, and it is greater than 1.018 in prerenal azotemia. The presence of casts is a strong marker for ATN. Therefore, answers 1, 2, and 3 are incorrect.

5. A 67-year-old Asian man has an estimated glomerular filtration rate of 40 mL/min/1.73 m2. His hemoglobin (Hgb) is 13.5 g/dL, with normal red blood cell indices without treatment. What is the recommended minimum frequency of Hgb monitoring for this patient?

1. Monthly.

2. Every 3 months.

3. Every 6 months.

4. Every 12 months.

4. Every 12 months

Rationale: This patient has stage 3 chronic kidney disease (CKD) because his estimated glomerular filtration rate is less than 60 mL/min/1.73 m2. His hemoglobin (Hgb) concentration is greater than 13 g/dL, so he does not have anemia. Hgb concentration should be monitored according to the CKD stage. Monthly monitoring is never recommended for a patient who does not have anemia (answer 1). Monitoring Hgb every 3 months should occur for patients with stage 5 CKD and receiving dialysis (answer 2). Monitoring of Hgb concentration is recommended every 6 months for patients with stages 4 and 5 CKD who have not received dialysis treatment (answer 3). Monitoring Hgb every 12 months should be recommended for patients with stage 3 CKD (answer 4).

6. The patient is a 59-year-old white woman who comes to the clinic for a follow-up. The patient's estimated glomerular filtration rate is 25 mL/min/1.73 m2. Her hemoglobin (Hgb) is 10.5 g/dL, and the nurse practitioner recommends iron tablets once daily. The patient does not receive dialysis treatment. What is the recommended minimum frequently of Hgb monitoring for this patient?

1. Not needed.

2. Four times every year.

3. Two times every year.

4. Every 12 months.

3. Two times every year.

Rationale: The patient has stage 4 chronic kidney disease (CKD) because her estimated glomerular filtration rate (eGFR) is less than 30 mL/min/1.73 m2 and greater than 15 mL/min/1.73 m2. Her hemoglobin (Hgb) is less than 13 g/dL; therefore she is diagnosed with anemia and the nurse practitioner recommends iron tablets. The patient has anemia and should monitor her Hgb according to her eGFR; therefore answer 1 is incorrect. Monitoring of hemoglobin concentration four times per year should be recommended for patients with stage 5 CKD who are receiving dialysis (answer 2). The Hgb should be monitored at least two times per year for patients with stage 4 CKD or stage 5 CKD and who do not receive dialysis treatment (answer 3). Monitoring hemoglobin concentration once yearly should be recommended for patients with stage 3 CKD (answer 4).

7. A 54-year-old patient with chronic kidney disease stage 4 (estimated glomerular filtration rate is 20 mL/min/1.73 m2) has received a diagnosis of gram-negative bacteremia. The nurse practitioner prescribes drug X for him, but there are no published reports on how to adjust the dose of drug X in a patient with impaired kidney function. The package of drug X shows that it has significant renal elimination with 30% excreted unchanged in the urine. The usual dose of drug X is 400 mg/day intravenously and is provided as 100 mg/mL in a 6-mL vial. Which is the best dosage of drug X for this patient?

1. 5.5 mg/mL.

2. 4.1 mg/mL.

3. 3.6 mg/mL.

4. 3 mg/mL.

4. 3 mg/mL.

Rationale: The fraction of drug excreted in the urine can determine the proper dose of a drug when specific dosing guidelines are not available. The Rowland-Tozer equation can determine the percentage of the usual dosage to give a patient with known kidney disease (Q), considering the ratio of the patient's renal function to normal.

If the usual dose of drug X is 400 mg/day, so the adjusted dose will be 300 mg/day (400 × 0.75) = 300. Thus the patient should receive 3 mL of the 100 mg/mL preparation (300 mg/100 mg/mL). Therefore answers 1, 2, and 3 are incorrect.

8. The patient is a 57-year-old white man who has a history of hypertension and currently takes ramipril 10 mg once daily. His estimated glomerular filtration rate is 35 mL/min/1.73 m2 and albumin/creatinine ratio is 25 mg/g. According to the Kidney Disease Improving: Global Outcomes guidelines, what is the patient's blood pressure goal?

1. 130/80 mmHg.

2. 140/90 mmHg.

3. 120/90 mmHg.

4. 140/70 mmHg.

3. 120/90 mmHg.

Rationale: The Kidney Disease: Improving Global Outcomes guidelines provide recommendations for blood pressure goals for patients with chronic kidney disease according to the severity of proteinuria. The patient's albumin/creatinine ration (ACR) is less than 30 mg/g; therefore he is considered to have normal to mildly elevated albuminuria. According to the guidelines, patients with albuminuria in this stage (1) should have a goal blood pressure less than 140/90 mmHg (answer 2 is correct). When the patient's ACR is greater than 30 mg/g, he is considered to have a moderate to severe elevated albuminuria, and according to the guidelines, the goal of the blood pressure should be less than 130/80 mmHg (answer 1 is incorrect). Answer 3 is incorrect because the systolic blood pressure is too low (less than 130 mmHg), and answer 4 is incorrect because the diastolic blood pressure is too low (less than 80 mmHg).

9. A 43-year-old woman presents to the clinic for follow-up. The patient's medical history is positive for diabetes type 2 and hypertension. On exam, her blood pressure is 145/88 mmHg, A1c is 7.5, albumin/creatinine ratio is 40 mg/g, and her estimated glomerular filtration rate is 45 mL/min/1.73 m2. According to the Kidney Disease Improving: Global Outcomes guidelines, what is the patient's blood pressure goal?

1. 130/80 mmHg.

2. 140/90 mmHg.

3. 150/90 mmHg.

4. 130/70 mmHg.

1. 130/80 mmHg.

Rationale: The Kidney Disease Improving Global Outcomes (KDIGO) guidelines provide recommendations for blood pressure goals for patients with chronic kidney disease. The patient's medical history includes diabetes type 2 and the albumin/creatinine ratio is greater than 30 mg/g; therefore she is considered to have a moderate to severe elevated albuminuria. According to the KDIGO guidelines, the goal blood pressure should be less than 130/80 mmHg (answer 1 is correct) for patients with chronic kidney disease (CKD) and moderate to severe elevated albuminuria. The goal blood pressure of less than 140/90 mmHg is preferred for patients with CKD and normal to mildly elevated albuminuria (answer 2) is incorrect. Answer 3 is incorrect because the systolic blood pressure goal is too high, and answer 4 is incorrect because the diastolic blood pressure is too low.

10. A 54-year-old Hispanic man (height 73 inches, weight 53 kg) with a history of severe Crohn disease presents to the emergency department. The patient complains of severe vomiting and bloody diarrhea; therefore he is malnourished, and he is not able to tolerate anything by mouth. His serum creatinine is 0.6 mg/dL, and his estimated kidney function is critical. What is the best method for assessing kidney function for this patient?

1. Iothalamate study.

2. 24-hour urine collection.

3. Cockcroft-Gault equation.

4. Modification of Diet in Renal Disease study equation.

2. 24-hour urine collection.

Rationale: This patient is significantly below his ideal body weight and has malnutrition. An iothalamate study (answer 1) will measure glomerular filtration rate (GFR), but it is not used clinically. A timed urine collection (answer 2) is best to assess the kidney function for this patient. However, the urine collection must be complete to ensure an accurate measurement of renal function. Cockcroft-Gault equation (answer 3) and Modification of Diet in Renal Disease study equation (answer 4) are incorrect because these equations would likely overestimate his renal function. Although these equations are the most appropriate for estimating kidney functions, it is better to use them on the intact kidney.

11. A 68-year-old woman presents to the hospital to evaluate her kidney function. Laboratory data show sodium 140 mEq/L, blood urea nitrogen 35 mg/dL, serum creatinine 1.8 mg/dL, urinary sodium 26 mEq/L, and urinary creatinine 15.3 mg/dL. What is the best estimation for the patient's fractional excretion of sodium?

1. 4.3%.

2. 1.2%.

3. 3.5%.

4. 2.1%.

4. 2.1%.

Rationale: Calculation of fractional excretion of sodium (FENa) is necessary for estimating acute kidney injury (AKI) and to differentiate between the prerenal azotemia and the intrinsic AKI. When FENa is calculated and the result is greater than 2%, the patient has an intrinsic AKI.

12. A 68-year-old African American man (height 68 inches, weight 49 kg) is admitted in a long-term care facility with a 3-year history of advanced Alzheimer disease. The patient has confusion and is aggressive toward the facility staff. He refuses to take any food or his medications. His laboratory test shows serum creatinine is 0.5 mg/dL. The patient has oliguria, weight loss, and is malnourished. Which is the best equation for assessing kidney function?

1. Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI).

2. Brater equation.

3. Jelliffe equation.

4. 24-hour urine collection.

4. 24-hour urine collection.

Rationale: The patient is malnourished and refuses food and medications; therefore he has oliguria. The chronic kidney disease epidemiology collaboration (CKD-EPI) equation is based on stable serum creatinine, so it is difficult to use where there is an unstable serum creatinine (answer 1). Brater (answer 2) and Jelliffe (answer 3) equations are probably more accurate than Cockcroft and CKD-EPI, but they have not been rigorously tested. If the patient is nonoliguric, creatinine clearance can be calculated according to a timed urine collection and by using the average of serum creatinine samples obtained before and after the urine collection (answer 4).

13. A 57-year-old Asian woman is admitted to the intensive care unit after having a myocardial infarction 5 days ago; her New York Heart Association is class III and left ventricular ejection fraction is 35%. She currently has pneumonia and hypotension for 3 days despite the adequate hydration. Before her admission, her serum creatinine was 1.0 mg/dL; yesterday, the blood urea nitrogen (BUN) and serum creatinine were 33 mg/dL and 2.9 mg/dL, respectively. Today, her BUN and serum creatinine are 42 mg/dL and 4 mg/dL, respectively. Her urine osmolality is 285 mOsm/kg, and her sodium urine is 45 mEq/L; there are tubular cellular casts in the urine. Which is the most likely renal diagnosis?

1. Prerenal azotemia.

2. Functional-mediate acute kidney injury (AKI).

3. Acute tubular necrosis.

4. Postrenal AKI.

3. Acute tubular necrosis.

Rationale: The patient has hypotension despite adequate hydration. The blood urea nitrogen and serum creatinine are between 10 and 15:1, urinary sodium is greater than 40 mEq/L, and there is low urinary osmolality and cellular casts. All these signs refer to intrinsic acute kidney injury (AKI); therefore answer 3 is correct. Prerenal azotemia (answer 1) is considered when the urinary sodium is less than 20 mEq/L, high urinary osmolality, absence of casts, and the blood urea nitrogen/serum creatinine ratio is greater than 20:1. Functional AKI would look similar to prerenal AKI on urinalysis with no presence of casts and low urinary sodium (answer 2). Postrenal AKI (answer 4) occurs when the patient has kidney stones or cancers.

14. A 53-year-old man presents to the clinic with a history of dysuria and a burning sensation while urinating. The patient is diagnosed with benign prostatic hypertrophy. He currently takes tamsulosin 0.8 mg daily, tadalafil 5 mg daily, and finasteride 5 mg daily. His laboratory tests show blood urea nitrogen is 18 mg/dL, serum creatinine is 1.5 mg/dL, urinary sodium is 43 mg/dL, serum sodium is 135 mEq/mL, urinary osmolality is 285 mOsm/kg, and fractional excretion of sodium is 2.5%. What is the most likely renal diagnosis?

1. Postrenal acute kidney injury (AKI).

2. Chronic kidney disease.

3. Functional-mediated AKI.

4. Intrinsic AKI.

1. Postrenal acute kidney injury (AKI).

Rationale: Bladder outlet obstruction is the most common cause of postrenal acute kidney injury (AKI) (answer 1). The patient suffers from benign prostatic hypertrophy because the laboratory tests reveal blood urea nitrogen (BUN)/creatinine ratio is between 10 and 15:1, urinary sodium is greater than 40 mEq/mL, there is a low urine osmolality, and fractional excretion of sodium is greater than 2%. Chronic kidney disease (answer 2) is kidney damage for more than 3 months, as defined by structural or functional abnormality of the kidney, with or without decreased glomerular filtration rate. Functional-mediated acute kidney injury (AKI) (answer 3) is determined when the serum BUN/creatinine ratio is greater than 20:1, urinary sodium is less than 20 mEq/mL, there is a high urine osmolality, and the fractional excretion of sodium is less than 1%. Intrinsic AKI (answer 4) would look similar to postrenal AKI on urinalysis. In addition, the cellular tubular casts are a marker of the intrinsic AKI.

15. A 45-year-old Hispanic woman comes to the hospital for follow-up. Her medical history is positive for hypertension and diabetes type 2. She currently takes lisinopril 20 mg daily and glipizide 5 mg twice daily. Her urinalysis shows blood urea nitrogen and serum creatinine are 40 mg/dL and 1.5 mg/dL, respectively; urinary sodium is 15 mEq/mL; and no casts are visible. What is the most likely renal diagnosis?

1. Postrenal acute kidney injury (AKI).

2. Intrinsic AKI.

3. Glomerular disease.

4. Functional AKI.

4. Functional AKI.

Rationale: The patient does not have any signs or symptoms of postrenal acute kidney injury (AKI). Postrenal AKI is related to presence of kidney stones, cancers, or benign prostatic hypertrophy for men (answer 1). The muddy brown granular casts, urinary sodium greater than 40 mEq/mL, and a blood urea nitrogen/serum creatinine ratio between 10 and 15:1 are markers for intrinsic AKI (answer 2). Glomerular disease (answer 3) occurs with or without a decrease in glomerular filtration rate (GFR), and proteinuria is the hallmark of glomerular disease. Lisinopril is an angiotensin-converting enzyme inhibitor that causes a vasodilatation of efferent arterioles and leads to a decrease in glomerular hydrostatic pressure and resultant decrease in GFR; this occurs in a functional AKI (answer 4).

16. A 35-year-old patient presents to the emergency department with a 10-day history of dysuria, abdominal pain, vomiting, and flank pain. He is diagnosed with pyelonephritis and is prescribed a 14-day course of trimethoprim/sulfamethazine tablet double strength. His medical history includes hypertension, osteoarthritis, and hypothyroidism. His medications are captopril 50 mg twice daily, acetaminophen 500 mg three times per day, and levothyroxine 105 mcg/day. Which drug can cause pseudonephrotoxicity?

1. Captopril.

2. Acetaminophen.

3. Levothyroxine.

4. Trimethoprim/sulfamethazine.

4. Trimethoprim/sulfamethazine.

Rationale: Captopril (answer 1) is an angiotensin-converting enzyme inhibitor (ACEi) that can cause vasodilatation of efferent arterioles and lead to decrease of glomerular hydrostatic pressure; thus an ACEi can cause functional acute kidney injury (AKI). Acetaminophen (answer 2) is metabolized by N-acetyl-p-benzoquinone, which is produced by liver. Levothyroxine (answer 3) has not been shown to have any nephrotoxicity symptoms. Trimethoprim/sulfamethazine (answer 4) could inhibit the tubular secretion of creatinine and leads to pseudonephrotoxicity.

17. A 67-year-old white man who has had chronic kidney disease stage 4 for 7 years is maintained on chronic hemodialysis. His medical history includes hypertension, myocardial infarction, and mild congestive heart failure. His medications are epoetin 10,000 units intravenously three times weekly at dialysis, renal multivitamins, valsartan 80 mg twice daily, bisoprolol 5 mg once daily, aspirin 75 mg once daily, calcium acetate and 1334 mg three times daily with meals. Laboratory values show hemoglobin 9 g/dL, intact parathyroid hormone 300 pg/mL, sodium 135 mEq/mL, potassium 4.5 mEq/mL, phosphorus 4.7 mg/dL, calcium 9 mg/dL, serum creatinine 7 mg/dL, and albumin 3.5 g/dL. His ferritin concentration is 95 ng/mL, and his transferrin saturation is 18%. Which approach is the best way to manage the patient's anemia?

1. Intravenous iron.

2. Increase epoetin dosage.

3. Oral iron.

4. Maintain current regimen.

1. Intravenous iron.

Rationale: The hemoglobin concentration of the patient is not at goal; it should be greater than 10 g/dL. Iron studies show that the patient is iron deficient because the ferritin concentration is less than 500 ng/mL and transferrin saturation is less than 30%. Intravenous iron (answer 1) is the most appropriate approach for patients with chronic kidney disease (CKD) who are receiving hemodialysis. Increasing the epoetin dosage (answer 2) would not increase red cell production with the absence of adequate iron. Oral iron (answer 3) is recommended for patients with nondialysis CKD. The patient is not at goal, which makes answer 4 incorrect.

18. The patient is a 43-year-old woman (height 65 inches, weight 75 kg) who is admitted to the hospital with a history of chronic kidney disease stage 3. The patient does not receive hemodialysis treatment. She has a medical history that includes diabetes type 2; she reports an allergy from sulfa-containing medication (hives). On exam, the laboratory tests show hemoglobin concentration is 9.5 g/dL, ferritin concentration is 150 ng/dL, transferrin saturation is 25%, calcium is 9.5 mg/dL, potassium is 3.3 mEq/mL, phosphorus is 5 mg/dL, intact parathyroid hormone is 250 pg/mL, and serum creatinine is 3.5 mg/dL. Which approach is the best way to manage the patient's anemia?

1. Adding epoetin 6500 units three times per week.

2. Administer intravenous iron.

3. The patient does not need medications.

4. Administer oral iron.

1. Adding epoetin 6500 units three times per week.

Rationale: The patient has anemia of chronic kidney disease (CKD). She suffers from CKD stage 3, and the hemoglobin concentration is lower than 10 g/mL; therefore adding epoetin doses would be recommended for this patient, according to Kidney Disease Improving Global Outcomes guidelines (answer 1). Administering intravenous iron (answer 2) would be appropriate for patients with CKD who are receiving dialysis treatment. In addition, iron should be added after administering epoetin doses if the iron stores are still insufficient. The patient is not at goal; therefore she needs to manage her anemia, which is related to the CKD (answer 3). Administering oral iron (answer 4) would be appropriate for patients with nondialysis CKD. Moreover, iron supplements should be added after administering epoetin dosages if the hemoglobin concentration is still low.

19. The patient is a Hispanic man who comes to the health care facility with his 76-year-old grandmother for follow-up. The grandmother's medical history is positive for Alzheimer's disease and chronic kidney disease stage 4. She has not received dialysis treatment. The grandson reports that she takes her medication regularly. She takes memantine 5 mg once daily, rivastigmine 6 mg twice daily, epoetin 6500 units three times per week, and renal multivitamins. Her laboratory values reveal hemoglobin concentration is 9.3 g/dL, ferritin concentration is 100 ng/dL, transferrin saturation is 24%, sodium (Na) is 145 mEq/mL, potassium is 5 mEq/mL, chloride is 108 mEq/mL, calcium is 9.5 mg/dL, albumin is 3.4 g/dL and serum creatinine is 3.5 mg/dL. Which approach is the best and most useful for this patient?

1. Adding intravenous iron.

2. Administering red blood cells.

3. Adding oral iron.

4. Increasing the epoetin dose to 10,

3. Adding oral iron.

Rationale: The patient presents with chronic kidney disease (CKD) stage 4 and she has not received dialysis. Her hemoglobin concentration (Hgb) is lower than 10 g/dL and she receives epoetin doses without any increase in the hemoglobin concentration. Adding intravenous iron (answer 1) is not recommended for patients with non-dialysis CKD. Administering red blood cells (answer 2) would not be preferred for this patient. The patient does not have coronary heart disease, which could prevent her from taking epoetin doses; however, epoetin administration reduces the need for red blood transfusion. Adding oral iron (answer 3) is the most preferred strategy for managing the patient's anemia with non-dialysis CKD because the ferritin concentration is less than 300 ng/mL and transferrin saturation is less than 30%, according to the KDIGO guidelines. Increasing epoetin dosage (answer 4) would not be beneficial because the iron stores are still deficient. Moreover, the epoetin would not increase the red blood cell production with the absence of adequate iron.

20. The patient is a 47-year-old Asian man (weight 66 kg) who is admitted to the intensive care unit after an acute myocardial infarction and pulmonary edema. He has a history of hypertension and he smoked tobacco 15 years ago. He currently takes lisinopril 20 mg/day, nicotine patch 14 mg/day applied every morning, and aspirin 75 mg/day. Before this admission, his serum creatinine was normal (baseline is 0.9 mg/dL). After 24 hours, his kidney function had declined (blood urea nitrogen is 25 and serum creatinine is 2.1 mg/dL), despite receiving 4 L of intravenous fluid. Urinalysis shows muddy brown casts and the urinary volume is decreased to 250 mL over the last 12 hours. What is the best assessment for kidney function for this patient?

1. Creatinine clearance (CrCl) using Cockcroft equation.

2. Estimated glomerular filtration rate using the Modification of Diet in Renal Disease study equation.

3. CrCl using the Brat

4. Collection of urine over 24 hours.

Rationale: The patient presents with acute kidney injury (AKI) stage 2 because of an increasing serum creatinine of 2 to 2.9 times greater than baseline and a urinary volume less than 0.5 mL/kg/hr for the last 12 hours; therefore the kidney function is unstable. The Cockcroft equation (answer 1) and the Modification of Diet in Renal Disease study equation (answer 2) are incorrect because they are preferred in patients with stable kidney functions. The Brater equation would be preferred over the other methods, but it overestimates the kidney functions because the patient is anuric (answer 3). A 24-hour urine collection (answer 4) would be recommended for patients with unstable serum creatinine and anuria.

21. The patient is a 47-year-old Asian man (weight 66 kg) who is admitted to the intensive care unit after an acute myocardial infarction and pulmonary edema. He has a history of hypertension and he has smoked 1 pack of cigarettes a day for the last 15 years. He currently takes lisinopril 20 mg/day, nicotine patch 14 mg/day applied every morning, and aspirin 75 mg/day. Before admission, his serum creatinine was normal (baseline is 0.9 mg/dL). After 24 hours, his kidney functions have declined (blood urea nitrogen is 25 and serum creatinine is 2.1 mg/dL), despite receiving 4 L of intravenous fluid. On urinalysis, muddy brown casts are present, and the urinary volume has decreased to 250 mL over the last 12 hours. What is the most likely cause of this patient's impaired kidney function?

1. Chronic kidney disease.

2. Acute tubular necrosis.

3. Postrenal acute kidney injury.

4. Prerenal azotemia.

2. Acute tubular necrosis.

Rationale: The patient presents with acute kidney injury (AKI) stage 2 caused by an increasing serum creatinine 2 to 2.9 times greater than baseline and a urinary volume less than 0.5 mL/kg/hr over the last 12 hours. Chronic kidney disease (CKD) (answer 1) is kidney damage for more than 3 months, as defined by structural and functional abnormality of the kidney with or without decreased of glomerular filtration rate, according to The National Kidney Foundation Kidney Disease Outcome Quality Initiative. The patient has muddy brown casts in his urine, and his blood urea nitrogen (BUN)/serum creatinine ratio is between 10 and 15:1; these are markers of acute tubular necrosis (answer 2). Postrenal AKI (answer 3) occurs in patients with benign prostatic hyperplasia, some kinds of cancers, and in the presence of nephrolithiasis. Prerenal azotemia occurs for patients with BUN/serum creatinine ratio greater than 20:1 and there is no presence of visible casts (answer 4).

22. The patient is a 47-year-old Asian man (weight 66 kg) who is admitted to the intensive care unit after an acute myocardial infarction and pulmonary edema. He has a history of hypertension and he has smoked 1 pack of cigarettes a day for the last 15 years. He currently takes lisinopril 20 mg/day, nicotine patch 14 mg/day applied every morning, and aspirin 75 mg/day. Before admission, his serum creatinine was normal (baseline is 0.9 mg/dL). After 24 hours, his kidney function has declined (blood urea nitrogen is 25 and serum creatinine is 2.1 mg/dL), despite receiving 4 L of intravenous fluid. On urinalysis, muddy brown casts are present, and the urinary volume has decreased to 250 mL over the last 12 hours. Which medication should be discontinued at this time because of its potential for adverse effects on kidney functions?

1. Keep the current medications.

2. Nicotine patch.

3. Lisinopril.

4. Aspirin.

3. Lisinopril.

Rationale: The strategy of managing acute kidney injury (AKI) is to remove any potentially nephrotoxic drugs, direct toxins, or medications that alter intrarenal hemodynamics; therefore staying at the current regimen (answer 1) is incorrect. Nicotine patches (answer 2) do not have an adverse effect on kidney function, so they should be continued. Lisinopril is an angiotensin-converting enzyme inhibitor, which is one of the most nephrotoxic drugs and could impact kidney function (answer 3). Although, nonsteroidal antiinflammatory drugs are a nephrotoxic drug that should be discontinued to manage AKI, using a low dose of aspirin is acceptable and could be used without adversely effecting kidney function (answer 4).

23. The patient is a 47-year-old Asian man (weight 66 kg) who is admitted to the intensive care unit after an acute myocardial infarction and pulmonary edema. He has a history of hypertension and he has smoked 1 pack of cigarettes a day for the last 15 years. He currently takes lisinopril 20 mg/day, nicotine patch 14 mg/day applied every morning, and aspirin 75 mg/day. Before admission, his serum creatinine was normal (baseline is 0.9 mg/dL). After 24 hours, his kidney function has declined (blood urea nitrogen is 25 and serum creatinine is 2.1 mg/dL), despite receiving 4 L of intravenous fluid. On urinalysis, muddy brown casts are present, and the urinary volume has decreased to 250 mL over the last 12 hours. Which intervention is best to manage the patient's presentation?

1. Furosemide.

2. Hydrochlorothiazide.

3. Water and sodium restriction.

4. Intravenous 0.9% sodium chloride.

1. Furosemide.

Rationale: The patient presents with intrinsic acute kidney injury (AKI), anuria, and pulmonary edema. Although loop diuretics such as furosemide have not been shown to improve clinical outcomes for patients with acute tubular necrosis (ATN), they may increase the urinary output, which will improve the fluid and electrolyte balance. Thus adding furosemide would be appropriate for this patient (answer 1). Thiazide diuretics (answer 2) are not appropriate for patients who have AKI or if the creatinine clearance is less than 30 mL/min/1.73 m2. Water and sodium restriction (answer 3) would be beneficial for management of this patient, but this restriction cannot be used if loop diuretics have failed. Administering intravenous 0.9% sodium chloride could worsen the case because the patient has hypervolemia.

24. The patient is a 66-year-old American African woman (height 73 inches, weight 85 kg) who is admitted to the intensive care unit with a severe community-acquired pneumonia. Her vital signs are body temperature 103.5°F, respiratory rate 35 breaths/min, blood pressure 85/60 mmHg, and serum creatinine 2 mg/dL (baseline is 0.8 mg/dL). She received ceftriaxone 1 g intravenously and moxifloxacin 750 mg orally. According to RIFLE (risk, injury, failure, loss of kidney function, and end-stage kidney disease) classification, which stage is represented in this patient?

1. Injury to kidney.

2. Failure of kidney.

3. Loss of kidney function.

4. End-stage kidney disease.

1. Injury to kidney.

Rationale: To stratifying acute kidney injury (AKI) you can use the RIFLE (risk, injury, failure, loss, and end-stage kidney disease) criteria. The patient presents with severe community-acquired pneumonia and has an increasing serum creatinine two times the baseline. According to RIFLE classification, increasing serum creatinine two times the baseline is classified as an injury to the kidney (answer 1). When the serum creatinine is increased more than 4 mg/dL or serum creatinine is increased to three times the baseline, it is classified as failure of the kidney (answer 2). Loss of kidney function occurs when there is a complete loss of kidney function for greater than 4 weeks (answer 3). End-stage kidney disease (answer 4) happens when there is a complete loss of kidney function for greater than 3 months.

25. A 56-year-old white woman is admitted to the intensive care unit for an angiography procedure. The patient has had severe chest pain, sweating, and shortness of breath for the past 3 hours. Her vital signs are blood temperature 150/90 mmHg, respiratory rate 30 breaths/min, heart rate 88 beats/min, and serum creatinine 4.3 mg/dL (baseline is 1.0 mg/dL). According the Acute Kidney Injury Network criteria, which stage is represented in this patient?

1. Stage 1.

2. Stage 2.

3. Stage 3.

4. Stage 4.

3. Stage 3.

Rationale: The patient presents with acute kidney injury. Acute Kidney Injury Network (AKIN) is a diagnostic criteria and requires one of the following with 48 hours: an absolute increase in serum creatinine greater than 0.3 mg/dL or 1.5 to 1.9 × baseline (stage 1) (answer 1 is incorrect), increase in serum creatinine 2-2.9 mg/dL × baseline (stage 2) (answer 2 is incorrect), or increase in serum creatinine greater than 3 × baseline, which means serum creatinine more is increased than 4 mg/dL (stage 3) (answer 3 is correct). AKIN criteria involve three stages only; therefore (answer 4) is incorrect.

26. A 32-year-old woman in her first trimester presents to the emergency department with her husband with severe vomiting and nausea. She denies alcohol abuse; she reports allergy from pets (rhinitis). On physical exam, her vital signs show blood pressure is 94/65 mmHg, heart rate is 90 beats/min, respiratory rate is35 breaths/min, blood urea nitrogen is 40 mg/dL, serum creatinine is 1.8 mL/dL, sodium is 129 mEq/mL,chloride is 108 mL/dL, potassium is 2.9 mEq/mL, and urinary sodium is 15 mEq/L. Which strategy is the best for management of this case?

1. Adding furosemide.

2. Intravenous 0.9% of sodium chloride.

3. Fluid restriction.

4. Oral hydration with water.

2. Intravenous 0.9% of sodium chloride.

Rationale: The patient presents with signs of volume depletion because of her pregnancy, which leads to acute kidney injury. From her values, the blood urea nitrogen (BUN)/serum creatinine ratio is greater than 20:1 and urinary sodium is lower than 20 mEq/L; therefore there are signs for prerenal azotemia. Adding loop diuretics (answer 1) could worsen the case. The best strategy for management of this patient is fluid resuscitation with intravenous 0.9% sodium chloride solution (answer 2). The patient does not have any signs of edema; therefore the fluid restriction would not beneficial (answer 3). The patient has severe vomiting and is intolerant of oral hydration with water (answer 4).

27. A 43-year-old man comes to the emergency department with severe pain in flank areas and back, dysuria, and vomiting. A computed tomography shows calcium stones in the urethra and the right kidney. The laboratory tests are obtained and reveal blood urea nitrogen is 25 ng/dL, serum creatinine is 2 mg/dL, urinary sodium is 50 mEq/L, and no casts are visible. The patient has postrenal acute kidney injury as a diagnosis. What is the best treatment for a patient with nephrolithiasis?

1. Furosemide.

2. Fluid restriction.

3. Increase fluid intake.

4. Spironolactone.

3. Increase fluid intake

Rationale: The patient presents with nephrolithiasis and signs of acute kidney injury (AKI). The blood urea nitrogen/serum creatinine ratio is 10 to 15:1 and urinary sodium is greater than 40 mEq/L. These are markers for postrenal AKI. Adding furosemide could lead to volume depletion and worsen the case (answer 1). Fluid restriction (answer 2) is not beneficial for this patient. For removing kidney stones, increasing hydration is the best strategy for management of this case (answer 3). Spironolactone (answer 4) would not be appropriate for this case because it is not preferred for patients with creatinine clearance less than 30 mL/min/1.73 m2.

28. A 63-year-old man is admitted to the intensive care unit with a 3-day history of fever, flank pain, and vomiting. The patient is diagnosed with a complicated pyelonephritis. His medical history includes liver alcoholic cirrhosis and mild encephalopathy. After 2 days of admission, his blood urea nitrogen (BUN) is 100 mg/dL and serum creatinine is 4 mg/dL. the nurse practitioner recommends renal replacement therapy. Which of the following is incorrect regarding indications for renal replacement therapy?

1. Blood urea nitrogen (BUN) is greater than 100 mg/dL.

2. Refractory metabolic acidosis.

3. Uremia and encephalopathy.

4. Life-threatening hypomagnesemia.

4. Life-threatening hypomagnesemia.

Rationale: Renal replacement therapy is indicated for acute kidney injury for the following reasons: blood urea nitrogen (BUN) is greater than 100 mg/dL (answer 1), treatment of refractory metabolic acidosis has failed with pharmacological treatment (answer 2), uremia and encephalopathy, and life-threatening electrolyte imbalance, such as hyperkalemia but not hypomagnesemia (answer 4 is incorrect).

29. A 57-year-old white woman presents to the hospital with intermittent chest pain. Her medical history includes hypertension, diabetes type 2, and chronic kidney disease (Kidney Disease Improving Global Outcomes stage 3). She currently takes captopril, hydrochlorothiazide, and metformin. Her laboratory values show serum creatinine 1.6 mg/dL, hemoglobin 13 g/dL, and hematocrit 39%. There is no evidence for edema. The patient is to undergo elective cardiac catheterization. Which medication should be interrupted before beginning cardiac catheterization?

1. Captopril.

2. Hydrochlorothiazide.

3. Metformin.

4. No medication should be stopped.

3. Metformin.

Rationale: The patient has chronic kidney disease history with an elevated serum creatinine. Metformin should be interrupted for two reasons. One reason is that metformin is historically contraindicated for patient with serum creatinine is greater than 1.5 mg/dL in men and 1.4 mg/dL in women because it would increase the risk of lactic acidosis. Metformin also should be interrupted if the patient is to undergo procedures using iodinated contrast dye in 24 hours because of the risk of nephrotoxicity. It should then reinitiated after 48 hours. Therefore answers 1, 2, and 4 are incorrect.

30. A 57-year-old white woman presents to the hospital with intermittent chest pain. Her medical history includes hypertension, diabetes type 2, and chronic kidney disease (Kidney Disease: Improving Global Outcomes stage 3). She currently takes captopril, hydrochlorothiazide, and metformin. Her laboratory values show serum creatinine 1.6 mg/dL, hemoglobin 13 g/dL, and hematocrit 39%. There is no evidence for edema. The patient is to undergo elective cardiac catheterization. Which approach is best for hydration?

1. Oral hydration with water.

2. 0.9% of sodium saline.

3. 0.45% of sodium saline.

4. 5% dextrose and 0.45% sodium saline.

2. 0.9% of sodium saline.

Rationale: The patient has chronic kidney (CKD) disease and is going to have elective cardiac catheterization. Intravenous contrast use could cause direct tubular toxicity and could decrease tubular flow rates. The patient has risk factors for nephrotoxicity such as preexisting CKD and diabetes type 2. Oral hydration with water (answer 1) would not be effective hydration for preventing contract induced nephrotoxicity. The intravenous 0.9% of saline solution is considered the most effective hydration for preventing contrast-induced nephrotoxicity (answer 2). Therefore answers 3 and 4 are incorrect.

31. A 57-year-old white woman presents to the hospital with intermittent chest pain. Her medical history includes hypertension, diabetes type 2, and chronic kidney disease (Kidney Disease: Improving Global Outcomes stage 3). She currently takes captopril, hydrochlorothiazide, and metformin. Her laboratory values show serum creatinine 1.6 mg/dL, hemoglobin 13 g/dL, and hematocrit 39%. There is no evidence for edema. The patient is to undergo elective cardiac catheterization. After the administration of contrast, what is the optimal time to reevaluate renal function to assess for the development of contrast-associated nephrotoxicity?

1. 24 hours.

2. 3 days.

3. 7 days.

4. 10 days.

1. 24 hours.

Rationale: The contrast could increase the serum creatinine and the blood urea nitrogen (BUN) within 24 hours and peak 2 to 5 days after the procedure. Monitoring of serum creatinine at 24 hours will help identify the development of contrast-associated nephrotoxicity; therefore (answer 1) is correct. Waiting for more than 48 hours would delay the detection of renal damage, so answers 2, 3, and 4 are incorrect.

32. A 52-year-old woman presents to an oncology facility to receive her chemotherapy course. She receives cisplatin. Her laboratory values include sodium 135 mEq/L, potassium 3 mEq/L, calcium 9 mg/mL, magnesium 1.7 mg/mL, and serum creatinine 1.8 mg/mL. Which of the following is incorrect for prevention of cisplatin-induced nephrotoxicity?

1. Use the smallest dosage possible.

2. Aggressive intravenous hydration within 24 hours.

3. Adding amifostine.

4. Increase frequency of administration.

4. Increase frequency of administration.

Rationale: The patient receives cisplatin and it could increase serum creatinine peaks 10 to 12 days after therapy starts and may continue to increase with subsequent cycles of therapy. There are many risk factors of toxicity, which should not be avoided, whereas cisplatin administration includes using the smallest dosage possible (answer 1 is correct), administering an aggressive intravenous hydration (answer 2 is correct), adding a cisplatin-chelation as amifostine (answer 3 is correct), and decreasing the frequency of administration (answer 4 is incorrect).

33. A 38-year-old woman, who has had a history of bipolar disease for 15 years presents to the clinic for follow-up. She has taken lithium for the last 11 years. Her laboratory values show serum creatinine is 1.9 mg/dL and blood urea nitrogen is 23 mg/dL; she is admitted to the intensive care unit to treat lithium toxicity symptoms. Which strategy is incorrect for prevention of lithium-induced chronic interstitial nephritis?

1. Maintaining a low lithium concentration.

2. Monitoring the kidney function closely.

3. Administration of furosemide.

4. Oral hydration is beneficent.

3. Administration of furosemide.

Rationale: Long-duration of lithium (more than 10 years) could lead to worsening kidney function, which is often asymptomatic. There are many strategies that should be taken to decrease the risk of lithium-induced chronic interstitial nephritis, which include maintaining the lowest lithium concentration (answer 1), monitoring the kidney function closely (answer 2), and avoiding dehydration (answer 4). Adding loop diuretics could worsen the case and leads to volume depletion; therefore it could increase the risk of nephrotoxicity (answer 3).

34. A 57-year-old Hispanic man presents to the health care facility with a history of hypertension, previous myocardial infarction, chronic kidney disease, and diabetes type 1. He denies any drug allergies or history of drug abuse, but he smokes cigarettes (2 packs per day). His medications include metoprolol succinate 100 mg daily, aspirin 81 mg, candesartan 16 mg/day, and insulin glargine 16 units before bed. His vital signs reveal blood pressure is 194/85 mmHg, heart rate is 65 beats/min, and respiratory rate is 25 breaths/min. His laboratory values show albumin/creatinine ratio is 450 mg/g, serum creatinine is 1.8 mg/dL, and estimated glomerular filtration rate is 40 mL/min/1.73 m2. According to his Kidney Disease Improving Global Outcomes (KDIGO) criteria, what is the best assessment for his kidney disease?

1. Stage 1.

2. Stage 2.

3. Stage 3.

4. Stage 4.

3. Stage 3.

Rationale: The patient's estimated glomerular filtration rate is 40 mL/min/1.73 m2; therefore according to the Kidney Disease Improving Global Outcomes stages, his chronic kidney disease would be classified as stage 3 (answer 3 is correct).

35. A 57-year-old Hispanic man presents to the health care facility with a history of hypertension, previous myocardial infarction, chronic kidney disease, and diabetes type 1. He denies any drug allergies or history of drug abuse, but he smokes cigarettes (2 packs per day). His medications include metoprolol succinate 100 mg daily, aspirin 81 mg, candesartan 16 mg/day, and insulin glargine 16 units before bed. His vital signs reveal blood pressure is 194/85 mmHg, heart rate is 65 beats/min, and respiratory rate is 25 breaths/min. His laboratory values show albumin/creatinine ratio is 450 mg/g, serum creatinine is 1.8 mg/dL, and estimated glomerular filtration rate is 40 mL/min/1.73 m2. According to Kidney Disease Outcomes Quality Initiative stages, what is the best assessment for his kidney disease?

1. Stage 1.

2. Stage 2.

3. Stage 3.

4. Stage 4.

3. Stage 3.

Rationale: According to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI), chronic kidney disease (CKD) is kidney damage for greater than 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR). The patient's estimated GFR (eGFR) is 40 mL/min/1.73 m2; therefore according to KDOQI stages, he is in stage 3 (eGFR is between 30 and 59 mL/min/1.73m2) (answer 3 is correct). A patient's GFR would be classified as stage 1 when the GFR is less than 90 mL/min/1.73 m2 (answer 1 is incorrect). A patient's GFR would be classified as stage 2 when the GFR is between 60 and 89 mL/min/1.73 m2 (answer 2 is incorrect). Also, a patient's GFR could be classified as stage 4 when the GFR is between 15 and 29 mL/min/1.73 m2 (answer 4 is incorrect).

36. A 57-year-old Hispanic man presents to the health care facility with a history of hypertension, previous myocardial infarction, chronic kidney disease, and diabetes type 1. He denies any drug allergies or history of drug abuse, but he smokes cigarettes (2 packs per day). His medications include metoprolol succinate 100 mg daily, aspirin 81 mg, candesartan 16 mg/day, and insulin glargine 16 units before bed. His vital signs reveal blood pressure is 194/85 mmHg, heart rate is 65 beats/min, and respiratory rate is 25 breaths/min. His laboratory values show albumin/creatinine ratio is 450 mg/g, serum creatinine is 1.8 mg/dL, and estimated glomerular filtration rate is 40 mL/min/1.73 m2. Using the Kidney Disease Improving Global Outcomes categorization, which assessment is best for this patient's albuminuria?

1. Category A1.

2. Category A2.

3. Category A3.

4. Nephrotic-range of proteinuria.

3. Category A3.

Rationale: The Kidney Disease Improving Global Outcomes guidelines provide guidance on categorization of albuminuria according to the albumin/creatinine ratio (ACR). Category A1 is an ACR less than 30 mg/g (answer 1 is incorrect). Category A2 is a moderate increase of albuminuria with an ACR of 30 to 300 mg/g (answer 2 is incorrect). Category A3 is a severe increase of albuminuria with an ACR greater than 300 mg/g (answer 3 is correct). Nephrotic-range proteinuria is a protein excretion exceeding 3000 mg/g (answer 4 is incorrect).

37. A 47-year-old Asian woman presents to the health care facility with a

history of hypertension, chronic kidney disease, and diabetes type 1. She denies any drug allergies or history of drug abuse. Her medications include metoprolol succinate 100 mg daily, aspirin 81 mg, and insulin glargine 16 units before bed. Her vital signs reveal A1c is 7.5%, blood pressure is 194/85 mmHg, heart rate is 65 beats/min, and respiratory rate is 25 breaths/min. Her laboratory values show albumin/creatinine ratio is 250 mg/g, serum creatinine is 1.8 mg/dL, and estimated glomerular filtration rate is 40 mL/min/1.73 m2. Which action is the best to limit the progression of her kidney disease?

1. Add ramipril.

2. Increase metoprolol succinate dosage.

3. Add amlodipine.

4. Add nifedipine.

1. Add ramipril.

Rationale: The patient presents with diabetic nephropathy because of her diabetes mellitus and the presence of moderate albuminuria. Progression could be accelerated by poor blood pressure control and poor blood glucose control. In patients with diabetic nephropathy, the A1c goal should be less than 7%, and the blood pressure goal should be less than 130/80 mmHg to limit the progression of the kidney disease. Adding angiotensin-converting enzyme inhibitors (ACEis) would reduce the mortality and chronic kidney disease progression, so (answer 1) is the best choice. Increasing the metoprolol succinate dosage could control the blood pressure, but it would not limit the kidney progression (answer 2). Adding nondihydropyridine calcium channel blockers might be initiated in patients who cannot tolerate ACEis or angiotensin receptor blockers (answer 3). Adding dihydropyridine as nifedipine (answer 4) is not recommended in diabetic nephropathy because of the conflicting literature on its efficacy.

38. A 43-year-old man comes to the health care facility for follow-up. His medical history includes hypertension, diabetes type 2, osteoarthritis, and chronic kidney disease. He currently takes atenolol 50 mg/day, acetaminophen 500 mg twice daily, and glipizide 5 mg daily. He does not smoke cigarettes and denies any drug abuse. Two months ago, his vital signs were blood pressure 143/93 mmHg, serum creatinine 1.8 mg/dL, A1c 7.3%, and albumin/creatinine ratio 400 mg/g. The nurse practitioner recommended the addition of enalapril. Today, his vital signs are blood pressure 135/85 mmHg, serum creatinine 2.1 mg/dL, and serum potassium 5.3 mEq/L. Which recommendation is the best for this patient?

1. Change enalapril to valsartan and monitor serum potassium, serum creatinine, and blood pressure in 2 weeks.

2. Change enalapril to diltiazem and monitor serum potassium, serum creatinine, and blood pressure in 2 weeks.

3. Add ch

3. Add chlorthalidone and monitor serum potassium, serum creatinine, and blood pressure in 2 weeks.

Rationale: This patient has diabetic nephropathy based on his laboratory values, which include elevation in blood pressure, serum creatinine, and albumin/creatinine ratio. The blood pressure goal for patients with diabetic nephropathy should be less than 130/80 mmHg. The increase is serum creatinine is less than 30%; therefore enalapril should be continued without change. That makes answers 1 and 2 incorrect. Adding chlorthalidone (answer 3) is the best choice to achieve the blood pressure goal and monitoring of serum creatinine and potassium are appropriate for this patient (answer 3). Increasing the beta-blockers would not be beneficial for limiting his kidney function prognosis (answer 4).

39. The patient is a 35-year-old African American woman with chronic kidney disease and hypertension history she comes to the clinic for checkup. Her vital sighs reveal blood pressure 128/75 mmHg, serum creatinine 3 mg/dL (baseline 1.9 mg/dL), and albumin/creatinine ratio 35 mg/g. Her medications are enalapril 10 mg twice daily and metolazone 5 mg daily. Which action is the best for this patient?

1. Stop enalapril.

2. Continue the current regimen.

3. Decrease enalapril dosage.

4. Increase metolazone dosage.

1. Stop enalapril.

Rationale: The patient has moderately increased albuminuria, chronic kidney disease, and elevation of the serum creatinine from the baseline. Hold angiotensin-converting enzyme inhibitors if serum potassium is greater than 5.6 mEq/L and serum creatinine is greater than 30% after the initiation; therefore (answer 1) would be the best action for this patient and answers 2 and 3 are incorrect. Metolazone is a thiazide diuretic that will not add any benefits if the dosage is increased for patients with elevated serum creatinine more than 30% (answer 4 is incorrect).

40. A 59-year-old man is admitted to the hospital with a history of chronic kidney disease (stage 3), gout, and previous myocardial infarction. His medications include aspirin 81 mg daily, allopurinol 50 mg daily, and carvedilol 12.5 mg twice daily. The nurse practitioner is concerned about his lipid concentration; his laboratory values show low-density cholesterol is 200 mg/dL and triglycerides are 300 mg/dL. Which medication benefits the patient the most?

1. Pravastatin 20 mg/day.

2. Niacin 1000 mg daily.

3. Ezetimibe.

4. Lifestyle modification only.

1. Pravastatin 20 mg/day.

Rationale: The patient has a history of chronic kidney disease (CKD), myocardial infarction (MI), and elevation of low-density cholesterol; therefore he needs lifestyle modification with a pharmacological treatment (answer 4 is incorrect). Adding statins is recommended for patients with CKD who are older than 50 years. In addition, pravastatin is safer than other statins for patients with kidney disease (answer 1). Niacin (answer 2) would be an acceptable regimen for treatment the hyperlipidemia, but it is contraindicated for patients with a history of gout. Using ezetimibe alone would not have the same benefits as using it with statins (answer 3).

41. The patient is a 57-year-old woman who is admitted to the hospital for dialysis treatment. She has a history of hypertension and osteoarthritis. She is being assessed for hemodialysis access. Which hemodialysis access is the best for this patient?

1. Arteriovenous fistula.

2. Arteriovenous graft.

3. Tenckhoff catheter.

4. Subclavian catheter.

1. Arteriovenous fistula.

Rationale: The best access for this patient is the arteriovenous fistula (answer 1) because it is natural and formed by the anastomosis of an artery and vein. In addition, it has the lowest incidence of infection and thrombosis, lower cost, and longest survival. Arteriovenous graft (answer 2) is the second choice, which is usually preferred for patients with vascular diseases. Tenckhoff catheter (answer 3) is a catheter for peritoneal dialysis. A subclavian catheter (answer 4) is commonly used if permanent access is unavailable, but it is not preferred because it has high infection and thrombosis rates, and low blood flow leads to inadequate analysis.

42. A 70-year-old man is undergoing long-term hemodialysis and has several episodes of hypotension during hemodialysis. After the nonpharmacological approach is optimized, which medication is best to manage his low blood flow?

1. Fludrocortisone.

2. Midodrine.

3. Sodium chloride tablets.

4. Levocarnitine.

2. Midodrine.

Rationale: Fludrocortisone (answer 1) is a synthetic mineralocorticoid that is used for hypertension in other situations. The best-studied agent is midodrine, an α1 agonist, 2.5 to 10 mg orally before dialysis. Sodium chloride tablets (answer 3) would not work acutely and should be avoided. Levocarnitine (answer 4) has been tried, but there are insufficient data for its benefits.

43. A 73-year-old Hispanic man comes to the clinic for his dialysis treatment. He has a 10-year history of cigarette smoking and a 5-year history of marijuana use. His medical history includes hypertension, previous myocardial infarction, and heart failure New York Heart Association class II. He has an episode of hypotension during his dialysis. Which choice is the incorrect approach and should be avoided?

1. Increase of ultrafiltration rate.

2. Decrease of ultrafiltration rate.

3. Administer saline boluses.

4. Trendelenburg position.

1. Increase of ultrafiltration rate.

Rationale: The patient has hypotension during his dialysis treatment. The hypotension should be prevented by midodrine before the dialysis. When hypotension occurs during a hemodialysis treatment, the nonpharmacological approaches should be tried such as decreasing the ultrafiltration rate (answer 2), administering saline boluses (answer 3), and Trendelenburg position (answer 4). Therefore increasing the ultrafiltration rate would be an incorrect answer (answer 1).

44. A 63-year-old woman comes to the health care facility with a history of chronic kidney disease and receives peritoneal dialysis. She has a fever and abdominal pain. She notes her abdominal dialysate has become cloudy. Her laboratory values of the dialysate reveal many white blood cells, primarily neutrophils. Gram stain and culture of the fluid are obtained. What is the best empiric therapy for this patient, according to the International Society for Peritoneal Dialysis guidelines?

1. Cefazolin and ceftazidime instilled intraperitoneally.

2. Vancomycin instilled intraperitoneally.

3. Clindamycin plus vancomycin intravenously.

4. Metronidazole plus gentamicin intravenously.

1. Cefazolin and ceftazidime instilled intraperitoneally.

Rationale: This patient presents with peritonitis, which is the most common cause peritoneal dialysis failure. The empiric treatment should cover the gram-positive and gram-negative bacteria. The intraperitoneal administration is preferred more than the intravenous administration. According to the International Society for Peritoneal Dialysis guidelines, the best empiric therapy is the intraperitoneal administration of a first-generation cephalosporin or vancomycin plus intraperitoneal administration of a third-generation of cephalosporin or aminoglycosides; therefore answer 1 is the best choice, and answer 2 is incorrect. In addition, cefazolin could provide activity against staphylococcus unless an area has a high rate of methicillin-resistant organisms. The third-generation cephalosporin or aminoglycosides has activity against Pseudomonas. In a patient with dialysis-related peritonitis, empiric anaerobic coverage is unnecessary, so answers 3 and 4 are inappropriate.

45. The patient is a 56-year-old Asian man who presents to the health care facility with chronic kidney disease receiving peritoneal dialysis. The patient read several websites about peritoneal dialysis complications, and he has concerns about it. Which complication of peritoneal dialysis would be incorrect?

1. Dialysis-related peritonitis.

2. Fluid overload.

3. Hyperglycemia.

4. Hypercalcemia.

3. Hyperglycemia.

Rationale: Peritoneal dialysis often is less preferred than hemodialysis because of its complications, which include the peritonitis (answer 1 is correct), fluid overload (answer 2 is correct), hypoglycemia (answer 3 is incorrect), and hypercalcemia or hypocalcemia (answer 4 is correct).

46. A 70-year-old white man receiving hemodialysis treatment who has had end-stage kidney disease for 7 years comes to the clinic. His hemodialysis access is an arteriovenous fistula. The patient's medical history includes hypertension, mild congestive heart failure, atrial fibrillation, and epilepsy. He takes aspirin 81 mg daily, metoprolol succinate 100 mg/day, ramipril 20 mg daily, epoetin alfa 10,000 units three times every week, calcium acetate 2 g three times daily after meals, and renal multivitamins daily. Laboratory values show hemoglobin is 10.5 g/dL, parathyroid hormone is 650 pg/mL, sodium is 143 mEq/L, potassium is 4.9 mEq/L, calcium is 9 mg/dL, serum creatinine is 7.5 mg/dL, albumin is 2.5 g/dL, phosphorus is 7.9 mg/dL, serum ferritin is 600 ng/mL, and transferrin saturation is 33%. His red blood cells and white blood cells are normal. The patient is afebrile. What is the most likely cause of this patie

4. Hyperparathyroidism.

Rationale: Infection and inflammation are the most common causes for epoetin resistance (answer 1), but the patient is afebrile and nothing in his presentation suggests an infection or inflammatory process. The patient does not have iron deficiency because his serum ferritin is greater than 500 ng/mL and transferrin saturation is greater than 30% (answer 2). Phenytoin (answer 3) has been associated with anemia in other patient population, but not in patients receiving hemodialysis treatment. The patient has hyperparathyroidism, which is one of the most common causes for epoetin resistance (answer 4).

47. A 70-year-old white man receiving hemodialysis treatment with end-stage kidney disease for 7 years comes to the clinic. His hemodialysis access is an arteriovenous fistula. The patient's medical history includes hypertension, mild congestive heart failure, atrial fibrillation, and epilepsy. He takes aspirin 81 mg daily, metoprolol succinate 100 mg/day, ramipril 20 mg daily, epoetin alfa 10,000 units three times every week, calcium acetate 2 g three times daily after meals, and renal multivitamins daily. Laboratory values show hemoglobin is 10.5 g/dL, parathyroid hormone is 650 pg/mL, sodium is 143 mEq/L, potassium (is 4.9 mEq/L, calcium is 9 mg/dL, serum creatinine is 7.5 mg/dL, albumin is 2.5 g/dL, phosphorus is 7.9 mg/dL, serum ferritin is 600 ng/mL, and iron saturation is 33%. His red blood cells and white blood cells are normal. The patient is afebrile. What is the best to manage this patient's hyperparathyro

2. Change calcium acetate to sevelamer and cinacalcet.

Rationale: The patient needs to treat his hyperparathyroidism, which places him at high risk of renal osteodystrophy and vascular calcification. Although his measured calcium is normal, the corrected calcium concentration is elevated, and he has a high phosphorus concentration. Therefore changing to calcium carbonate (answer 1) or increasing the calcium acetate dosage (answer 4) are incorrect. Changing calcium acetate to sevelamer is the best choice to avoid the increase in calcium concentration. In addition, adding cinacalcet will lower the intact parathyroid hormone (PTH) and potentially serum calcium (answer 2). Adding intravenous vitamin D analog can worsen hypercalcemia, and it has no impact on reducing the intact PTH (answer 3).

48. A 55-year-old man with chronic kidney disease and hypertension presents to the clinic for consultation. His medications are epoetin alfa 14,000 units three times every week, renal multivitamins daily, and ramipril 10 mg daily. Which of the following is NOT true regarding erythropoiesis-stimulating agents?

1. Erythropoiesis-stimulating agents (ESAs) are under the U.S. Food and Health Administration Risk Evaluation and Mitigation Strategies program.

2. ESA dosage should be decreased to 50% if hemoglobin increases to greater than 1 g/dL in 2 weeks.

3. ESA resistance is caused by iron deficiency, infection, hyperparathyroidism, and folate deficiency.

4. Monitor hemoglobin every 2 to 4 weeks.

2. ESA dosage should be decreased to 50% if hemoglobin increases to greater than 1 g/dL in 2 weeks.

Rationale: Patients who are receiving erythropoiesis-stimulating agents (ESAs) should be under the U.S. Food and Drug Administration Risk Evaluation and Mitigation Strategies program (answer 1). If the hemoglobin increase is greater than 1 g/dL in 2 weeks, ESAs should be decreased to 25% only (answer 2). There are many reasons contributing to ESA resistance such as iron deficiency, folate and vitamin B12 deficiency, infection and inflammation, hyperparathyroidism, vitamin C deficiency, and other factors (answer 3). Hemoglobin should be monitored every 2 to 4 weeks during initiation, and at least monthly in dialysis patients and at least 3 months in nondialysis patients with chronic kidney disease (answer 4).

49. A 73-year-old man with stage 5 chronic kidney disease who receives dialysis treatment presents to the health care facility for follow-up. The laboratory values show calcium 9.8 mg/dL, phosphorus 7 mg/dL, sodium 145 mEq/L, potassium 4.5 mEq/L, parathyroid hormone (PTH) 800 pg/dL, and 25-hydroxyvitamin D 10 ng/mL. What is the frequency of laboratory monitoring for this patient, according to the Kidney Disease Improving Global Outcomes guidelines?

1. No need for frequent laboratory monitoring for grade 5 chronic kidney disease.

2. Calcium every 6 to 12 months, phosphorus every 6 to 12 months, intact PTH, and 25-hydroxyvitamin D is in baseline.

3. Calcium every 3 to 6 months, phosphorus every 3 to 6 months, intact PTH every 6 to 12 months, and 25-hydroxyvitamin D is in baseline.

4. Calcium every 1 to 3 months, phosphorus every 1 to 3 months, intact PTH every 3 to 6 months, and 25-hydroxyvitamin D is in baseline.

4. Calcium every 1 to 3 months, phosphorus every 1 to 3 months, intact PTH every 3 to 6 months, and 25-hydroxyvitamin D is in baseline.

Rationale: According to the Kidney Disease Improving Global Outcomes guidelines, there is laboratory frequency monitoring in chronic kidney disease (CKD) stages 3 to 5, and this patient presents with CKD stage 5; therefore answer 1 is incorrect. At CKD stage 3 calcium should be monitored every 6 to 12 months, phosphorus every 6 to 12 months, intact parathyroid hormone (PTH) and 25-hydroxycitamin D are at baseline (answer 2). At CKD stage 4, calcium should be monitored every 3 to 6 months, phosphorus every 3 to 6 months, intact PTH every 6 to 12 months, and 25-hydroxyvitamin D is at baseline (answer 3). At CKD stage 5, calcium should be monitored every 1 to 3 months, phosphorus every 1 to 3 months, intact PTH every 3 to 6 months, and 25-hydroxyvitamin D is at baseline (answer 4).

50. The patient is a 37-year-old white man with stage 4 chronic kidney disease who presents to the health care facility for follow-up. He currently takes epoetin alfa 14,000 units three times every week, renal multivitamins, ergocalciferol, and cinacalcet. His laboratory tests show serum creatinine is 6.5 mg/dL, intact parathyroid hormone is 550 pg/mL, 25-hydroxyvitamin D is 15 ng/mL, and serum ferritin is 550 mg/dL. Which statement is incorrect about cinacalcet?

1. Cinacalcet has drug interaction with ketoconazole, which may increase cinacalcet concentration by up to twofold.

2. Cinacalcet inhibits CYP2D6.

3. Cinacalcet is safe for patients with seizure disorders.

4. Cinacalcet could cause hypocalcemia.

3. Cinacalcet is safe for patients with seizure disorders.

Rationale: Cinacalcet is a calcimimetic that attaches to the calcium receptor on the parathyroid gland and increases the sensitivity of receptors to serum calcium concentration, reducing parathyroid hormone (PTH). Cinacalcet is metabolized primarily by CYP3A4; thus ketoconazole (CYP3A4 inhibitor) could increase the cinacalcet concentration by up to twofold (answer 1). Cinacalcet could inhibit CYP2D6, inhibiting the metabolism of cytochrome CYP2D6 substrates such that dosage reduction in drugs with narrow therapeutic indices may be required (e.g., tricyclic antidepressants) (answer 2). Cinacalcet can be used cautiously in patients with seizure disorders (answer 3 is incorrect). Cinacalcet could cause hypocalcemia as an exacerbation (answer 4).

51. A 66-year-old Hispanic woman with end-stage kidney disease for 10 years is admitted to the health care facility for dialysis treatment. Her nurse practitioner prescribed for her etelcalcetide because of her elevated intact parathyroid hormone and calcium. According to the guidelines, which statement is false for the etelcalcetide medication?

1. The initial dose of etelcalcetide is 5 mg intravenously three times weekly after hemodialysis.

2. Use etelcalcetide with caution for patients with seizure disorders.

3. Etelcalcetide could cause QT prolongation and may worsen heart failure.

4. Discontinue cinacalcet for at least 14 days before initiation of etelcalcetide.

4. Discontinue cinacalcet for at least 14 days before initiation of etelcalcetide.

Rationale: Etelcalcetide is a synthetic peptide calcimimetic that activates the calcium-sensing receptor on the parathyroid gland, reducing parathyroid hormone (PTH). The initial dose is 5 mg intravenously three times weekly after hemodialysis, and the dosage could be titrated in 2.5- to 5-mg increments at intervals of at least every 4 weeks (answer 1). Etelcalcetide could be used with caution for patients with seizure disorders and may cause hypocalcemia (answer 2). Etelcalcetide has an adverse effect of QT prolongation, worsening heart failure, nausea, diarrhea, and hypocalcemia (answer 3). Cinacalcet should be discontinued for at least 7 days before initiation of etelcalcetide; thus, answer 4 is incorrect.

52. The patient is a 73-year-old woman with chronic kidney disease stage 3 who is admitted to the emergency department with a 3-day history of abdominal pain, vomiting, and flank pain. The laboratory evaluation reveals that there is an infection in her urinary tract; she is diagnosed with pyelonephritis. Which medication should not be adjusted for patients with decreased kidney function?

1. Metronidazole.

2. Meperidine.

3. Spironolactone.

4. Rosuvastatin.

1. Metronidazole.

Rationale: Almost all antibiotics require dosage adjustment exception ceftriaxone, metronidazole, clindamycin, nafcillin, and macrolides (answer 1). Meperidine should be avoided for patients with decreased kidney function because it may accumulate (answer 2). Potassium-sparing diuretics such as spironolactone should be avoided for patients with creatinine clearance less than 30 mL/min/1.73 m2 (answer 3). Almost all statins, particularly rosuvastatin, should be adjusted for patients with decreased kidney function (answer 4).