ITE Nephrology and Hypertension 4 — Questions and Answers
Question 1: A 55-year-old man presents with serum creatinine of 3.2 mg/dL, hemoglobin of 8.8 g/dL, and ferritin of 210 ng/mL with transferrin saturation of 18%. He is on erythropoiesis-stimulating agents. What is the most appropriate next step for his anemia management?
- Increase ESA dose
- Administer IV iron (Correct answer)
- Transfuse packed red blood cells
- Add vitamin B12 supplementation
Correct answer: Administer IV iron
Functional iron deficiency (low TSAT despite adequate ferritin) in CKD patients on ESA therapy should be corrected with IV iron to optimize erythropoiesis.
Question 2: A patient with end-stage renal disease on peritoneal dialysis develops cloudy peritoneal effluent. Peritoneal fluid cell count shows 350 WBC/µL with 85% neutrophils. What is the most likely organism?
- Staphylococcus aureus
- Staphylococcus epidermidis (Correct answer)
- Pseudomonas aeruginosa
- Candida albicans
Correct answer: Staphylococcus epidermidis
Coagulase-negative staphylococci (S. epidermidis) are the most common cause of peritoneal dialysis-associated peritonitis, typically from touch contamination.
Question 3: A 45-year-old woman with hypertension and no prior kidney disease presents with sudden onset severe headache, BP 220/130 mmHg, papilledema, and serum creatinine of 3.8 mg/dL (baseline 0.9 mg/dL). Peripheral blood smear shows schistocytes. What is the diagnosis?
- Thrombotic thrombocytopenic purpura
- Hypertensive emergency with thrombotic microangiopathy (Correct answer)
- Hemolytic uremic syndrome from Shiga toxin
- Atypical HUS from complement dysregulation
Correct answer: Hypertensive emergency with thrombotic microangiopathy
Severe hypertension causing end-organ damage including microangiopathic hemolytic anemia represents hypertensive emergency with secondary TMA, distinct from primary TMA syndromes.
Question 4: A 60-year-old man with gout and CKD stage 3 has serum uric acid of 9.8 mg/dL. He has had 3 gout flares in the past year. What is the target serum uric acid level for urate-lowering therapy in this patient?
- Below 7.0 mg/dL
- Below 6.0 mg/dL (Correct answer)
- Below 5.0 mg/dL
- Below 8.0 mg/dL
Correct answer: Below 6.0 mg/dL
ACR guidelines recommend a target serum uric acid below 6.0 mg/dL for patients on urate-lowering therapy, and below 5.0 mg/dL for those with tophi.
Question 5: A 50-year-old man is found to have BP of 150/95 mmHg on three separate occasions. He denies symptoms of sleep apnea but his wife confirms loud snoring and witnessed apneas. Which antihypertensive class has the most evidence for improving BP control in the setting of obstructive sleep apnea?
- Beta-blockers
- ACE inhibitors
- Aldosterone antagonists (Correct answer)
- Calcium channel blockers
Correct answer: Aldosterone antagonists
Aldosterone excess is disproportionately common in resistant hypertension with OSA; spironolactone reduces BP in this population beyond CPAP therapy alone.
Question 6: A 38-year-old woman with recurrent kidney stones has 24-hour urine showing calcium oxalate supersaturation, hypercalciuria (320 mg/day), normal serum calcium, low urine citrate, and normal urine uric acid. What is the first-line treatment?
- Potassium citrate alone
- Hydrochlorothiazide plus potassium citrate (Correct answer)
- Allopurinol
- Dietary calcium restriction
Correct answer: Hydrochlorothiazide plus potassium citrate
Idiopathic hypercalciuria with calcium oxalate nephrolithiasis is treated with thiazides to reduce urinary calcium plus potassium citrate to increase urinary citrate and correct hypokalemia.
Question 7: A 35-year-old man with sickle cell disease presents with gradual onset renal insufficiency, isosthenuria, hematuria, and inability to concentrate urine. Urinalysis shows no casts. What is the most likely renal complication?
- Renal papillary necrosis
- Sickle cell nephropathy with focal segmental glomerulosclerosis (Correct answer)
- Membranoproliferative glomerulonephritis
- Renal cortical necrosis
Correct answer: Sickle cell nephropathy with focal segmental glomerulosclerosis
Sickle cell nephropathy progresses from early tubular defects (hyposthenuria) to FSGS-pattern glomerular disease from hyperfiltration in surviving nephrons.
ITE Nephrology and Hypertension 4
A 55-year-old man presents with serum creatinine of 3.2 mg/dL, hemoglobin of 8.8 g/dL, and ferritin of 210 ng/mL with transferrin saturation of 18%.
He is on erythropoiesis-stimulating agents.
What is the most appropriate next step for his anemia management?