First Aid for the USMLE Step 1 2011 EXPRESS workbook

page 165

Renal
Questions
ANATOMY
1.

Why is the left kidney harvested for transplantation rather than the right? (p. 458) _____________
______________________________________________________________________________

2.

Ureters pass __________ (over/under) the uterine artery and the ductus deferens. (p. 458)

PHYSIOLOGY
3.

Extracellular fluid consists of __________ (high/low) sodium chloride and __________ (high/low)
potassium, whereas intracellular fluid consists of __________ (high/low) sodium chloride and
__________ (high/low) potassium. (p. 459)

4.

What is the 60-40-20 rule of total body weight? (p. 459) __________________________________
______________________________________________________________________________

5.

The fenestrated capillary endothelium of the glomerular filtration barrier is responsible for the
filtration of plasma by which characteristic: size or charge? (p. 459) _________________________

6.

The fused basement membrane of the glomerulus containing heparan sulfate is responsible for the
filtration of plasma molecules by which characteristic, size or charge? (p. 459) ________________

7.

The epithelial layer of the glomerular filtration barrier is formed by which cells? (p. 459) _________
______________________________________________________________________________

8.

What is the formula for calculating the clearance of substance X, the volume of plasma from which
the substance is cleared completely per unit of time? (p. 459) _____________________________

9.

If renal clearance is greater than the glomerular filtration rate (GFR) of substance X, then there is a
net tubular __________ (reabsorption/secretion) of substance X. (p. 459)

10.

Creatinine clearance slightly __________ (overestimates/underestimates) the GFR rate because

creatinine is __________ (secreted/reabsorbed) by the renal tubules. (p. 459)

11.

What is the formula for estimating renal blood flow if renal plasma flow is known? (p. 459) ______
______________________________________________________________________________

12.

What are the effects of prostaglandins on the glomerulus? (p. 460) ________________________
______________________________________________________________________________

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13.

First Aid for the USMLE Step 1 2011 EXPRESS workbook

What are the effects of angiotensin II on the glomerulus? (p. 460) __________________________
______________________________________________________________________________

14.

Decreased plasma protein concentration causes __________ (decrease/increase/no change) in

renal plasma flow and __________ (decrease/increase/no change) in GFR, which in turn results in
__________ (decrease/increase/no change) in the filtration fraction. (p. 460)

15.

Constriction of the afferent arteriole causes __________ (decrease/increase/no change) in renal

plasma flow and __________ (decrease/increase/no change) in GFR, which in turn results in
__________ (decrease/increase/no change) in the filtration fraction. (p. 460)

16.

What is the formula for excretion rate? (p. 460) _________________________________________

17.

In the nephron, glucose at normal plasma concentrations is reabsorbed in which structure? And by
which transporter? (p. 460) ________________________________________________________

18.

At what plasma glucose concentration is the transport mechanism of the proximal tubule
completely saturated, leading to glucose spilling into the urine? (p. 460) _____________________

19.

How and where are amino acids reabsorbed in the kidney? (p. 460) ________________________
______________________________________________________________________________

20.

What substance is secreted into the lumen of the early proximal convoluted tubule and acts as a
buffer for hydrogen ions? (p. 461) ___________________________________________________

21.

Which two ions are actively reabsorbed in the thick ascending loop of Henle? (p. 461) _________
______________________________________________________________________________

22.

Which three ions are indirectly reabsorbed in the thick ascending loop of Henle? (p. 461) ________
______________________________________________________________________________

23.

Which hormone controls the reabsorption of calcium in the early distal convoluted tubule? (p. 461)
______________________________________________________________________________

24.

On which segment of the nephron does the hormone aldosterone act? (p. 461) _______________

25.

ADHs effect at V2 receptors results in what action? (p. 461) _______________________________

26.

The ratio of solute concentration in the tubular fluid versus plasma (TF/P) can indicate the level of
secretion or reabsorption of that solute along the proximal renal tubule. If the TF/P ratio of that
solute is less than that of inulin, there is net __________ (reabsorption/secretion) along the
proximal tubule. (p. 462)

27.

Along the length of the proximal tubule, does the relative concentration of chloride increase,
decrease, or stay the same? (p. 462) _________________________________________________

28.

Which five actions of angiotensin II serve to increase intravascular volume and blood pressure? (p.
462) __________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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29.

What is the site of action of angiotensin-converting enzyme? (p. 462) _______________________

30.

When blood pressure falls, the kidneys release which proteolytic enzyme? (p. 462) ____________

31.

ADH primarily regulates __________ (osmolarity/blood volume), whereas aldosterone primarily

regulates __________ (osmolarity/blood volume). However, in __________ (low/high) volume
states, both ADH and aldosterone act to protect __________ (osmolarity/blood volume). (p. 462)

32.

What are the effects of aldosterone secretion? (p. 462) __________________________________

______________________________________________________________________________
______________________________________________________________________________

33.

Atrial natriuretic peptide __________ (decreases/increases) renin secretion and __________

(decreases/increases) the GFR. (p. 462)

34.

Which cells produce renin in the kidney? (p. 463) _______________________________________

35.

Which hormone is released by the endothelial cells of renal peritubular capillaries in response to
hypoxia? (p. 463) ________________________________________________________________

36.

Which enzyme from the kidney is activated by PTH, and what is the function of that enzyme? (p.
463) __________________________________________________________________________

37.

In the chart below, checkmark the effect that each condition has on the potassium shift. (p. 464)
+

Effect

Shifts K Into Cell

Hypokalemia

Shifts K Out of Cell

Hyperkalemia

Acidosis
Alkalosis
-Adrenergic agonists
-Adrenergic antagonists
Cell lysis
Digitalis
Hyperosmolarity
Hypo-osmolarity
Insulin
Insulin deficiency
38.

By which mechanism does digitalis cause hyperkalemia? (p. 464) __________________________

39.

What is the primary electrolyte disturbance in metabolic acidosis? (p. 465) ___________________

40.

What is the compensatory respiratory response to metabolic acidosis, and does PCO2 increase or
decrease? (p. 465) _______________________________________________________________

41.

What are the ten causes of increased anion gap metabolic acidosis? (p. 465) ________________
______________________________________________________________________________
______________________________________________________________________________

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PATHOLOGY
42.

What four clinical findings are associated with nephritic syndrome? (p. 467) __________________
______________________________________________________________________________

43.

Match the nephritic syndrome with its characteristic finding on light microscopy. (p. 467)
_____ A. Acute poststreptococcal glomerulonephritis
_____ B. Alports syndrome
_____ C. Diffuse proliferative glomerulonephritis
_____ D. IgA glomerulopathy
_____ E. Rapidly progressive glomerulonephritis

44.

1.
2.
3.
4.
5.

Crescent-shaped scars
Immune complexes in mesangium
Lumps and bumps
Split basement membrane
Wire looping of capillaries

A 10-year-old boy presents with swollen ankles and periorbital edema, which were beginning to
resolve without intervention. Electron microscopy of a kidney biopsy specimen shows subepithelial
immune complex humps. Which form of nephritic syndrome does he most likely have? (p. 467) ___
______________________________________________________________________________

45.

Wegener's granulomatosis is __________ (c-ANCA/p-ANCA) positive, whereas microscopic

polyarteritis is __________ (c-ANCA/p-ANCA) positive. (p. 467)

46.

For which systemic disease is diffuse proliferative glomerulonephritis the most common cause of
death? (p. 467) __________________________________________________________________

47.

What four clinical findings are associated with nephrotic syndrome? (p. 468) __________________
______________________________________________________________________________

48.

Match the nephrotic syndrome with its characteristic findings. (p. 468)
_____ A. Amyloidosis
_____ B. Diabetic glomerulonephropathy
_____ C. Focal segmental glomerulosclerosis
_____ D. Membranous glomerulonephritis
_____ E. Membranoproliferative glomerulonephritis
_____ F. Minimal change disease

1.
2.
3.
4.
5.
6.

Associated with chronic disease

Foot process effacement on EM
Hyalinosis on LM
Kimmelstiel-Wilson lesion on LM
Spike-and-dome appearance on EM
Tram-track appearance on EM

49.

What is the most common glomerular disease seen in patients with HIV? (p. 468) ______________

50.

In diabetic glomerulonephropathy, what causes mesangial expansion? (p. 468) _______________

______________________________________________________________________________

51.

Kidney stones are most commonly composed of what element? (p. 469) _____________________

52.

Both antifreeze and vitamin C abuse can result in the formation of which type of crystals? (p. 469) _
______________________________________________________________________________

53.

An 80-year-old man with leukemia presents with hematuria and right-sided flank pain. Which type
of kidney stone is he most likely to have? And how would this stone appear on x-ray? (p. 469)
______________________________________________________________________________

54.

Name the four components of the WAGR complex. (p. 469) _______________________________
______________________________________________________________________________
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55.

Match the renal pathology with its characteristic findings. (pp. 469-472)
_____ A. Acute pyelonephritis
_____ B. Acute tubular necrosis
_____ C. Bladder cancer
_____ D. Chronic pyelonephritis
_____ E. Diffuse cortical necrosis
_____ F. Drug-induced interstitial nephritis
_____ G. Renal cell carcinoma
_____ H. Renal papillary necrosis
_____ I. Transitional cell carcinoma
_____ J. Wilms tumor

56.

page 169

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Associated with aniline dye exposure

Associated with diabetes
Associated with obstetric catastrophe
Associated with vHL syndrome
Muddy brown casts in urine
Nephroblastoma
Painless hematuria
Pyuria and azotemia
Thyroidization of kidney
WBC casts in urine

What are three causes of acute tubular necrosis? (p. 470) ________________________________
______________________________________________________________________________

57.

Which three general types of renal dysfunction can lead to acute renal failure? (p. 471) _________
______________________________________________________________________________

58.

True or False: Unilateral postrenal outflow obstruction can lead to acute renal failure. (p. 471) ____

59.

A patient's urine osmolarity is <350 mOsm/L, urine sodium level is >40 mEq/L, fractional excretion
of sodium is >4%, and BUN/creatinine ratio is >15:1. Is the etiology of the acute renal failure most
likely to be prerenal, renal, or postrenal? (p. 471) _______________________________________

60.

A patients urine osmolarity is >500 mOsm/L, urine sodium level is <10 mEq/L, fractional excretion
of sodium is <1%, and BUN/creatinine ratio is >20:1. Is the etiology of the acute renal failure most
likely to be prerenal, renal, or postrenal? (p. 471) _______________________________________

61.

What are the eight consequences of renal failure? (p. 471) ________________________________
______________________________________________________________________________

62.

Which type of mutation causes autosomal-dominant polycystic kidney disease (formerly adult
polycystic kidney disease)? (p. 472) _________________________________________________

63.

What are the two major causes of death associated with autosomal-dominant polycystic kidney
disease? (p. 472) ________________________________________________________________

64.

What are the complications of autosomal-recessive polycystic kidney disease in utero and after the
neonatal period? (p. 472) __________________________________________________________

PHARMACOLOGY
65.

What is the mechanism of action of acetazolamide? (p. 474) ______________________________

______________________________________________________________________________

66.

What is the mechanism of action of furosemide? (p. 474) _________________________________

67.

Which loop diuretic is used for diuresis of patients who are allergic to sulfa drugs? (p. 474) ______
______________________________________________________________________________

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68.

First Aid for the USMLE Step 1 2011 EXPRESS workbook

What are the effects of hydrochlorothiazide toxicity? (p. 474) _____________________________

______________________________________________________________________________

69.

What is the mechanism of action of spironolactone? (p. 475) ______________________________

______________________________________________________________________________

70.

What is the mechanism by which ACE inhibitors can cause angioedema? (p. 475) _____________
______________________________________________________________________________

71.

What are three clinical uses of ACE inhibitors? (p. 475) __________________________________
______________________________________________________________________________

Answers
ANATOMY
1.

Because the left kidney has a longer renal vein.

2.

Under. (Remember: "water [ureters] under the bridge [artery and ductus deferens]")

PHYSIOLOGY
3.

High; low; low; high. (Remember: HIKIN': HIgh K Intracellular.)

4.

60% of total body weight is made up of total body water, 40% is made up of intracellular fluid, and
20% is made up of extracellular fluid.

5.

Size.

6.

Net charge.

7.

Podocyte foot processes.

8.

Renal clearance of X = the urine concentration of X times the urine flow rate, divided by the plasma
concentration of X (Cx = Ux V/Px).

9.

Secretion.

10.

Overestimates; secreted. (The plasma concentration of creatinine is slightly lower than it would be
from filtration alone.)

11.

Renal blood flow = renal plasma flow divided by (1 - the hematocrit), or RBF = RPF/(1 - Hct). In a
normal individual, renal blood flow will be approximately double the renal plasma flow.

12.

Prostaglandins cause dilation of the afferent arteriole and an increase in the GFR.

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page 171

13.

Angiotensin II causes constriction of the efferent arteriole and an increase in the GFR.

14.

No change; increase; increase.

15.

Decrease; decrease; no change.

16.

Excretion rate = V Ux; where V is the urine flow rate and Ux is the urine concentration of X.

17.

Glucose is reabsorbed in the proximal tubule by sodium/glucose co-transport.

18.

350 mg/dL.

19.

Amino acids are filtered and then reabsorbed from the urine at the level of the proximal tubule by
three distinct sodium-dependent transporters, each with competitive inhibition.

20.

Ammonia.

21.

Sodium, potassium, and chloride.

22.

Magnesium and calcium.

23.

PTH.

24.

Collecting tubule.

25.

Insertion of aquaporin water channels on the luminal side of the collecting tubules, resulting in
increased water reabsorption.

26.

Reabsorption.

27.

Increase. (Chloride is reabsorbed distally in the nephron.)

28.

Vasoconstriction; stimulation of sodium resorption in the proximal tubule; release of aldosterone

from the adrenal cortex; release of ADH from the posterior pituitary; and simulation of thirst via the
hypothalamus.

29.

Lungs.

30.

Renin.

31.

Osmolarity; blood volume; low; blood volume.

32.

Aldosterone secretion from the adrenal cortex increases sodium channel and sodium/potassium
pump insertion in principal cells and enhances potassium and hydrogen excretion by upregulating
potassium channels in the principal cells and hydrogen ion channels in the intercalated cells. These
actions create a favorable gradient for sodium and water reabsorption.

33.

Decreases; increases.

34.

Juxtaglomerular cells.

35.

Erythropoietin.

36.

1-Hydroxylase, which converts 25-OH vitamin D to 1,25(OH)2 vitamin D.

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37.
+

Shifts K Into Cell

Hypokalemia

Effect

Shifts K Out of Cell

Hyperkalemia

Acidosis
Alkalosis

-Adrenergic agonists

-Adrenergic antagonists

Cell lysis

Digitalis

Hyperosmolarity

Hypo-osmolarity

Insulin

Insulin deficiency
+

38.

Digitalis blocks the Na /K /APTase pump from pumping K into the cell in exchange for Na , thus
+
leaving the K outside the cell.

39.

Decreased serum bicarbonate.

40.

Hyperventilation, which causes PCO2 to decrease.

41.

Methanol (formic acid), Uremia, Diabetic ketoacidosis, Paraldehyde or Phenformin, Iron tables or
Isoniazid, Lactic acidosis, Ethylene glycol (oxalic acid), and Salicylates. (Remember: MUDPILES.)

PATHOLOGY
42.

Azotemia, oliguria, hypertension, and proteinuria <3.5 g/day.

43.

A-3, B-4, C-5, D-2, E-1.

44.

Acute poststreptococcal glomerulonephritis.

45.

c-ANCA; p-ANCA.

46.

Systemic lupus erythematosus.

47.

Massive proteinuria (>3.5 g/day), edema, fatty casts, and hyperlipidemia.

48.

A-1, B-4, C-3, D-5, E-6, F-2.

49.

Focal segmental glomerular sclerosis.

50.

Nonenzymatic glycosylation of the efferent arterioles, leading to an increased GFR and thus
mesangial expansion.

51.

Calcium in the form of calcium oxalate, calcium phosphate, or both.

52.

Oxalate crystals.

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53.

Because of the patients leukemia (a disease with high cell turnover), he is at risk for developing
uric acid stones due to hyperuricemia, which are radiolucent and do not appear on x-ray studies.

54.

WAGR complex = Wilms' tumor, Aniridia, Genitourinary malformation, and mental-motor

Retardation.

55.

A-10, B-5, C-7, D-9, E-3, F-8, G-4, H-2, I-1, J-6.

56.

Renal ischemia, crush injury, and toxins.

57.

Prerenal (e.g., hypotension and reduced renal blood flow), intrinsic renal (e.g., tubular necrosis),
and postrenal (outflow obstruction).

58.

False; bilateral (not unilateral) postrenal outflow obstruction leads to acute renal failure.

59.

Postrenal.

60.

Prerenal.

61.

Na /H2O retention, hyperkalemia, metabolic acidosis, uremia, anemia, renal osteodystrophy,

dyslipidemia, and retarded grown and development in children.

62.

An autosomal dominant mutation in the APKD1 or APKD2 gene.

63.

Death usually results from complications of chronic kidney disease or hypertension (due to
increased renin production).

64.

Renal failure in utero, from autosomal recessive polycystic kidney disease, can lead to Potters
syndrome (see page 132). After the neonatal period, potential complications include hypertension,
portal hypertension, and progressive renal insufficiency.

PHARMACOLOGY
65.

Acetazolamide acts as a carbonic anhydrase inhibitor, causing self-limited sodium bicarbonate

diuresis and a reduction in total-body bicarbonate stores.

66.

Furosemide inhibits the Na /K /Cl cotransport system in the thick ascending limb of the loop of
Henle, thereby abolishing the hypertonicity of the medulla and preventing the concentration of
urine.

67.

Ethacrynic acid.

68.

Glucose (hyperGlycemia), lipids (hyperLipidemia), uric acid (hyperUricemia), and calcium

(hyperCalcemia). (Remember: HyperGLUC.)

69.

Spironolactone competitively antagonizes the aldosterone receptor in the cortical collecting tubule.

70.

ACE inhibitors prevent the inactivation of bradykinin, a potent vasodilator. Increased bradykinin
levels can lead to angioedema in susceptible individuals.

71.

To treat hypertension, to treat congestive heart failure, and to slow the progression of diabetic renal
disease.

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Notes
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