Nephrology Self Assessment Program - Vol 18, No 2, May 2019 NephSAP Volume 18, Number 2, May 2019—Acute Kidney Injury and Critical Care Nephrology L 2. In addition to patients with acute leukemia, patients with which ONE of the following diagnoses is LEAST likely to receive inpatient palliative care services based on data from the ‘United States National Inpatient Sample Data? A. Acute respiratory distress syndrome B. Cardiogenic shock C. End-stage liver disease with cirrhosis D. AKT requiring dialysis The transfusion of longer-term stored packed red blood cells compared with fresher blood has been associated with which ONE of the following? ‘A. Increased risk of transfusion-related reactions B. No difference in mortality at 90 days C. Decreased number of RRT-free days within 28 days of transfusion D. Increased risk of AKI requiring RRT E, Decreased duration of mechanical ventilation A 79-year-old man with stage G4 CKD and recently diagnosed colon cancer is seen in consultation after admission to the intensive cate unit for septic shock. The patient has a mean arterial pressure of 62 mmHg on norepinephrine and dobutamine infusions. On physical exami- nation, he is cachectic, intubated, and sedated. ‘The lung fields are clear to auscultation. There is 1+ leg edema. The kidney function is at base- line, and serum electrolytes are normal. Urine output is 1.3 ml/kg per h after administration of 60 mg of intravenous furosemide. The intensiv- ist is interested in initiating enteral feeds as soon as possible, You begin a discussion of the relative merits of this intervention in light of the recent findings from the NUTRIREA-2 study. Based on data from the NUTRIREA-2 study, ‘enteral feeding is MORE likely to be associ- ated with which ONE of the following? ‘A. Decreased incidence of systemic bacteremia B. Increased incidence of gastrointestinal complications C. Decteased incidence of hypoglycemia m D. Increased incidence of 28-day mortality E, Decreased incidence of 28-day mortality 4. A 67-year-old woman with a history of stage G2 CKD secondary to diabetic nephropathy is eval- uated for AKI complicating septic shock. She recently underwent autologous stem cell trans- plantation for acute myelogenous leukemia. Her serum creatinine level has risen from 1.0 mg/dl to 4.9 mg/dl. She now has fever, hypotension, and suspected septic shock, Over the past 10 hours, the urine output has decreased to 0.2. mg/kg per h ‘A norepinephrine infusion increases the mean arte- rial pressure to 65 mmHg. You initiate continuous RRT. An angiotensin II infusion is initiated, and the ‘mean arterial pressure increases to 75 mmfg. Which ONE of the following is CORRECT about the impact of adding the angiotensin IT infusion? A. She is at decreased risk for inpatient mortality B. Her duration of RRT will be shorter C. Her Sequential Organ Failure Assessment (SOFA) score will increase D. Her duration of mechanical ventilation will be shorter 5. You are caring for a 71-year-old man with stage G3a CKD disease who has recently undergone a right hemicolectomy for colon cancer. Post- operatively, he artives in the intensive care unit receiving mechanical ventilatory support. He does not require vasopressor support. On physical examination, the blood pressure is 130/82 mmHg He is alert and follows commands, The heart and Jung examination results are untemarkable, and there is trace peripheral edema, His surgical and anesthesia teams initially plan a “restrictive” in- ‘ravenous fluid regimen designed to provide a net zex0 fluid balance, ‘Which ONE of the following is associated with this restrictive fluid strategy compared with a liberal fluid strategy? A. A decreased risk of surgical site infections B. An increased risk of AKI requiring RRTm2 C. An increased length of stay in the intensive care unit D. An increased risk of mortality at 1 year 6. A 63-year-old kidney transplant recipient is seen in consultation for stage 2 AKI complicating uurosepsis, She has received 4 L Ringer's lactate solution over the past 8 hours, She remains intubated and ventilated, and she requires support with norepinephrine and vasopressin. Laboratory studies show sodium 138 mEq/L, potassium 4.9 mEq(L, chloride 98 mEq/L, total CO; 18 mmoVL., BUN 36 mg/dl, and creatinine 2.6 mg/dl (increased from her most recent values, which averaged 1.1 mg/dl). An arterial blood gas shows pH 7.17 and PaCO; 20 mmHg. In the setting of acidosis, AKI, and shock, you recommend an infusion of 4.2% sodium bicarbonate titrated to achieve an arterial pH of 7.30. In this setting, administration of bicarbonate as specified will be associated with which ONE, of the following outcomes? A. Incteased risk of mortality B. Increased risk of hypercalcemia C. Decteased risk of progressive AKI requir- ing dialysis D, Decreased risk of intensive care unit-associated delirium, E, Fewer vasopressor-fice days 7. You are admitting a 65-year-old kidney trans- plant recipient with presumed urosepsis. The patient is confused, disoriented, and hypotensive, with a blood pressure of 90/55 mmHg. The temperature is 39.1°C, The oxygen saturation is 88% on ambient air. The oxygen saturation in- ‘creases to 93% alter initiation of oxygen at 4 L/min by nasal cannula. Laboratory studies show serum sodium 132 mEq/L, potassium 3.6 mEq/L, chloride 95 mE¢/L, total CO, 18 mmol/L, BUN 18 mg/dl, ‘creatinine 1.4 mg/dl (increased from 1.1 mg/dl 3 months ago), leukocyte count 15,200/1, hemo- globin 6.8 gidl, and platelet count 126,000/j1 Which ONE of the following is the MOST important step in mitigating this patient’s morbidity and mortality in the setting of impending septic shock? ‘A. Administration of a bolus of 30 ml/kg 0.9% normal saline solution Nephrology Self Assessment Program - Vol 18, No 2, May 2019 B. Administration of vasopressots to achieve a mean arterial pressure of 70 mmHg C. Administration of a combination of fluids and vasopressors to achieve a target central venous saturation of 70% D. Early administration of appropriate antibiotics 8. You are meeting with your hospital's chief in- formation officer and her team. They have several questions for you regarding the ability of the electronic medical records to improve the care of patients with AKI and also of those at risk for AKI Although electronic alerts that are not linked to care bundles or action items have not universally led to improved outcomes, subse~ quent analyses have demonstrated there are still subgroups of patients who may derive a clinical benefit from electronic AKI alerts Which ONE of the following individuals is MOST likely to benefit from electronic alerts in the medical record that identify AKI? A. A 35-year-old woman with serum creati- nine that has increased from 0.7 mg/dl to 2.4 mg/dl over 1 day B. A 76-year-old woman with serum creati- nine that has increased from 0.7 mg/dl to 1.0 mg/dl over 3 days C. A 68-year-old woman with serum creati- nine that has increased from 0.7 mg/dl to 2.4 mg/dl over 1 day D. A 66-year-old man with serum creatinine that has increased from 0.7 mg/dl to 2.4 mg/al over 3 days 9. The chief quality officer at your institution asks for your advice about clinical decision support systems and decision-making algorithms devel- oped for AKI Based on the existing literature, implementing such electronic medical record support will result in which ONE of the following im- provements in care for patients with and at risk for AKI? A. A reduction in nephrotoxin exposure and events requiring RRT, but no change in hospital mortality B. A reduction in RRT events, inpatient mor tality, and radiocontrast exposureNephrology SelAssessment Program - Vol 18, No 2, May 2019 10. Mu. 12. C. No change in nephrotoxin exposure or RRT events, but a reduction in inpatient mortality D. Uniform reductions in nephrotoxin expo- sure and inpatient mortality, but no change in RRT events E. A reduction in nephrotoxin exposure, but no change in RRT events and inpatient mortality Several weeks after joining a new practice, you note that you are often consulted late into the course of AKI. You discuss the relative merits of implementing an alert system that activates prompt recommending nephrology consultation atthe time of a clinically significant increase in the serum creatinine level or a decrease in urine output ‘Which ONE of the following outcomes has ‘been demonstrated to result from im- plementation of nephrology consultation prompted by an AKI alert system? A. Fewer cases of severe AKI, but no differ- ence in early nephrology consultation or renal recovery B. Fewer cases of severe AKI and increased carly nephrology consultation, but no change in renal recovery C. Fewer cases of severe AKI, a higher in- idence of renal recovery, and increased early nephrology consultation D. No change in the rate of severe AKI, increased early nephrology consultation, and a higher incidence of renal recovery Implementing a Kidney Disease Improving Global Outcomes—hased care bundle for post operative patients with urinary tissue inhibitor of metalloproteinase 2*IGF binding protein factor 7 levels >0.3 [(ng/ml)'/1000] MOST consistently leads to which ONE of the follow- ing patient outcomes? ‘A. Shorter length of mechanical ventilation B. Decreased rate of stage 2 and 3 AKI C. Decreased requirement for RRT D, Reduced inpatient mortality E, Decreased urine output A 28-year-old woman with ESRD receives a de- ceased donor kidney transplant. She is given a 100-mg dose of intravenous furosemide after successful anastomosis of the renal vessels. Two ns hours after furosemide administration, the sub- sequent urine output is noted to be $2 ml ‘This patient’s urine output in response to in- travenous furosemide (furosemide stress test) BEST predicts which ONE of the following ‘outcomes? A. Acute renal allograft rejection B. L-year mortality C. Delayed graft function after renal transplantation D. L-year graft. survival after renal transplantation 13. Which ONE of the following patients has the LOWEST risk of AKI? A. A 56-year-old man with fulminant hepatic failure due to acetaminophen toxicity re- quiring emergent liver transplantation and ahigh modified Model for End-stage Liver Disease score of 32 B. A 62-year-old man with a stage G3a:Al CKD (eGFR 46 ml/min per 1.73 m2) scheduled for elective coronary artery by- pass surgery with a GFR that increases by 42 ml/min per 1.73 m? after a protein load of 1.2 g/kg body weight C. A 38-year-old woman with Child-Pugh class C cisthosis, baseline serum creatinine of 1.3 mg/dl, receiving a 4 week course of ceftazidime and gentamicin for gram neg- ative bacteremia D. A 70-year-old woman with stage G4 CKD. (eGFR 28 ml/min per 1.73 m®), chronic systolic heart failure, with cardiogenic shock because of acute ischemic papillary muscle rupture now requiring an intra- aortic balloon pump and emergency mitral valve replacement 14. A 28-year-old man in your hospital’s neuro- intensive care unit has just been declated brain dead after a motoreycle accident that was associ- ‘ated with significant head trauma, His family and physicians are interested in determining whether he is a viable candidate for kidney donation Although you do not have any baseline informa- tion about his kidney function, his serum creat- {nine level has risen from 1.2 mg/dl to 1.41.6 m/l over the past 2 weeks.m4 15. 16. ‘Which ONE of the following biomarkers is ‘MOST likely to predict renal tubular injury on biopsy beyond that predicted by the serum tinine level? A. Urine kidney injury molecule-1 B. Urine neutrophil gelatinase-associated lipocalcin C. Urine liver-fatty acid binding protein D. Urine interleukin-18 A 65-year-old woman with class It New York Heart Association (NYHA) heart failure, hyper tension, and type 2 diabetes mellitus is under- going an evaluation for aortic valve replacement. Her baseline serum creatinine level is 2.1 mg/dl and the urine albumin-to-creatinine ratio is 536 mg/g. An echocardiogram shows a normal ejection fraction and moderate left ventricular hypertrophy. Based on the available data, which ONE of the following statements is MOST accurate re~ garding her risk of postoperative AKI? ‘A. Heer baseline serum creatinine is not a risk factor for postoperative AKI B. The transcatheter approach for aortic valve replacement may be associated with a lower risk of AKI compared with a surgical approach C. Albuminuria, but not serum creatinine, predicts the risk of postoperative AKI D. Left ventricular dysfunction, but not NYHA heart failure class, is associated with AKI risk A 70-year-old man with stage G3b:A3 CKD, diabetes mellitus, and hypertension is seen in consultation before coronary angiography. There is no history of congestive heart failure, and the physical examination is normal except for signs of diabetic retinopathy and neuropathy. An echo- cardiogram shows normal left ventricular func~ tion. You ate asked to recommend the best prophylactic regimen to prevent AKI. His GFR is 43 ml/min per 1.73 m2. The urine albumin-to- creatinine ratio is 978 mg/g. Which ONE of the following recom- mendations is MOST consistent with the findings of the Prevention of Serious Adverse Events Following Angiography (PRESERVE) trial? Nephrology Self Assessment Program - Vol 18, No 2, May 2019 A. Neacetyleysteine should be administered 2 days before radiocontrast exposure to reduce the risk of dialysis-requiring AKI in this high-risk patient B. Intravenous isotonic bicarbonate infusion is superior to isotonic saline solution in this patient, who does not have congestive heart failure C. Neither Neacetyleysteine compared with placebo nor isotonic bicarbonate therapy compared with saline solution is more likely to reduce the risk of dialysis-requiring AKI after radiocontrast exposure D. He should receive both isotonic bicarbon- ate and N-acetyleysteine for prophylaxis because he is at extremely high risk for contrast-induced nephropathy 17. A 60-year-old man with diabetes mellitus, hyper- tension, and chronic obstructive pulmonary dis- case is admitted to the hospital with pneumonia, Blood cultures grow Pseudomonas aeruginosa Over the next 48 hours, he experiences acute respiratory distress syndrome, hypotension te- quiring hemodynamic support with vasopressors, and oliguric stage 3 AKI It is determined that continuous RRT is the best dialysis option. Which ONE of the following statements most accurately reflects current evidence regarding the MOST appropriate modality of dialysis for this patient? A. Continuous venovenous hemodiafiltration is superior to other modalities of sotute removal in gram-negative sepsis B.A polymyxin B adsorptive modality is indicated and has been shown to improve 28-day mortality in patients with endotoxic shock in randomized controlled trials C. Diffusive solute removal is superior to convective solute removal in this clinical setting with both continuous and intermit- tent therapies D. There is no significant difference in out comes between diffusive or convective modalities of CRRT 18. A 70-year-old man with stage G3b:A2 CKD, diabetes mellitus, and hypertension is seen in the office after a recent hospitalization for hip sur- gery. His hospital course was complicated byNephrology SelAssessment Program - Vol 18, No 2, May 2019 19, stage 1 AKI. His baseline serum creatinine level was 1.9 mg/dl. While he was hospitalized, the serum creatinine level peaked at 3.1 mg/dl and eventually fell to the current level of 2.1 mg/dl ‘Which ONE of the following is the MOST accurate statement regarding the impact of the AKI episode on his long-term cardiovascular prognosis? A. Ithas no impact on his subsequent risk of, cardiovascular events B. It increases his risk of incident congestive heart failure C. Itis not associated with subsequent cardiac events because he did not experience dialysis- requiting AKT D. It is not associated with cardiac events because the kidney function almost com- pletely recovered to baseline A 55-year-old man with diabetes mellitus is evaluated in consultation for AKI complicating a 25% total body surface area burn and septic shock. The BUN and serum creatinine have risen from 46 mg/dl and 1.5 mg/dl on admission to 100 mg/dl and 5.7 mg/dl, respectively. The urine output has fallen to <200 ml over the past 24 hours, The blood pressure is 108/60 mmHg on vasopressors, and the central venous pressure is 14 cm H,O. The intensivists caring for the patient ask you about high-dose continuous RRT. Which ONE of the following should you tell them about dialysis dose and modality based on evidence derived from randomized con- trolled trials? ‘A. Continuous RRT, if chosen, should be provided with effluent flow rate of at least 35 ml/kg per h B. Continuous RRT, if chosen, should be provided with effluent flow rate of at least 20 ml/kg per h . Continuous venovenous hemofiltration should be chosen over continuous venove~ nous hemodialysis because it offers a sur- vival advantage in this patient D, Randomized trials support high-volume effluent flow of 70 ml/kg per h in this clinical setting ns 20. A 72-year-old woman is seen in consultation for AKI complicating acute decompensated heart failure Which ONE of the following types of cardiac dysfunction is associated with the HIGHEST risk of mortality in this patient with AKI? A. Isolated severe right ventricular systolic dysfunction (right ventricular ejection frac~ tion of 25%) B. Diastolic dysfunction with normal left ventricular systolic function C. Mild biventricular systolic dysfunction (sight and left ventricular ejection fractions of 50%) D. Modest left ventricular systolic dysfunction, (left ventricular ejection fraction of 45%) 21. A 72-year-old man with pneumonia due to Staphylococcal aureus is seen in consultation for nonoliguric AKI. He has been treated with intravenous vancomycin, and trough levels have ranged between 15 and 20 mg/L. On physical examination, he appears frail and is in mild respiratory distress, The blood pressure is 130/ 80 mmHg, and the temperature is 38.1°C. There are crackles and bronchial breath sounds in the left lower lung zone. There is trace peripheral ‘edema, Over the past 3 days, the serum creatinine level has risen from 1,2 mg/dl to 2.4 mg/dl. The urinalysis shows 1+ protein, no blood, and 5 to 10 muddy brown casts per high-power field ‘Which ONE of the following should you in- dicate in your consultation? A. Trough levels of 15 to 20 mg/L. are not associated with nephrotoxicity B. Only peak vancomycin levels correlate with nephrotoxicity C. No change in vancomycin dosing is war- ranted because he does not have oliguria D. Vancomycin nephrotoxicity has been as- sociated with trough levels =15 mg/L, 22. You ate asked to see a 79-year-old woman with influenza A complicated by secondary bacterial pneumonia and sepsis for AKI. She has been receiving vancomycin and piperacillin-tazobactam since admission 5 days ago. The serum creati- nine has tisen from 0.6 mg/dl to 1.7 mg/dl, and the urine volume has decreased to 500 ml per 4. On physical examination, she is confused and bedridden. The blood pressure is 110/60 mmHg,6 23. the heart rate is 110/min, and the respiratory rate is 22/min. The lung examination reveals diffuse crackles in the lower lung zones bilaterally. The pulse is imegularly imegular. There is no cardiac murmur. There is 1++ pretibial edema. The urinal- ysis shows 1+ protein and many muddy brown casts, Vancomycin trough levels are 16 to 20 mg/L, Which ONE of the following statements is the MOST accurate regarding antibiotic-medi ated renal toxicity in this patient? ‘A. Vancomycin nephrotoxicity is unlikely because trough levels are not greater than 25 mg/L. B. Vancomycin/piperacillin-tazobactam nephrotoxicity is unlikely in the absence of leukocyte casts C. The combination of vancomycin and piper- acillin-tazobactam is associated with a higher risk of AKI than either antibiotic alone D. Urgent dialysis is indicated to reduce van- ‘comycin levels and prevent further toxicity ‘A 67-year-old man with type 2 diabetes mellitus and hypertension is admitted to the coronary intensive care unit with acute decompensated hheart failure. He is seen in consultation because of a rise in his serum creatinine from 1,0 mg/dl on admission to 1.3 mg/dl 3 days later, He has received intermittent boluses of intravenous furo- semide, with a net diuresis of 3 kg, which resulted in an improvement in his congestive symptoms. ‘The serum N-terminal pro-B-type natriuretic pep- tide (NT-proBNP) level declined 35% from the admission level, which was initially elevated threefold above the reference range. Which ONE of the following statements BEST characterizes the association between kidney and cardiac dysfunction in this patient? ‘A. The reduction in the NT-proBNP level of, >30% is associated with improved sur vival independent of the change in kidney function B. The benefits of lowering NT-proBNP with diuresis are negated by the risks of con- comitant worsening of kidney function C. Neither the degree of change in NT-proBNP level nor the percentage change in creati- nine is of prognostic significance in this patient Nephrology Self Assessment Program - Vol 18, No 2, May 2019 D. The weight reduction of 3 kg is the most important predictor of improved outcomes in this patient 24. A 76-year-old woman with chronic systolic heart failure is admitted with acute decompen- sated heart failure, Her home medication regi- men included bumetanide 1 mg once daily and lisinopril. She is initially treated with increased doses of bumetanide and lisinopril. The serum creatinine rises from 1.6 mg/dl on admission to 2.1 mg/dl and is associated with onset of transient oliguria, The doses of bumetanide and lisinopril are reduced, and the serum creat- inine subsequently falls to 1.6 mg/dl on the third hospital day, with resolution of oliguria. She is discharged on an increased dose of bumetanide (1 mg twice daily) and her usual dose of lisinopril. Which ONE of the following statements MOST accurately reflects her short-term prognosis? A. She is not ata risk for readmission because she experienced stage 2 but not stage 3 AKI B. Although she experienced transient azote- ‘mia that returned to baseline within 3 days, she still is at a higher risk for readmission than are patients without AKT C. Given that her kidney function almost completely recovered to baseline, she is no longer at increased risk for adverse ‘outcomes after discharge D. Transient oliguria is more important than rise of creatinine is predicting the risk of readmission 28. A 70-year-old woman with advanced CKD due to diabetic nephropathy is evaluated before initia- tion of dialysis. She required coronary artery bypass surgery 2 months ago, which was com- plicated by stage 2 AKI. While hospitalized, the serum creatinine level rose from 2.0 mg/dl to 4.0 mgidl. Although the creatinine at discharge had improved slightly to 3.5 mg/dl, she subsequently had progressive CKD. She now has subtle uremic symptoms and a mild degree of volume overload. On physical examination, she is in no distress ‘The blood pressure is 130/80 mmHg. There is 1+ leg edema. The remainder of the examinationNephrology SelAssessment Program - Vol 18, No 2, May 2019 26. 27. is unremarkable, Laboratory studies show serum. sodium 138 mEq/L, potassium 5.4 mEq/L, chloride 102 mEq/L, total CO; 19 mmol/L, BUN 92 mg/dl, creatinine 8.5 mg/dl, calcium 9.2 mg/dl, and phosphorus 5.9 mgidl. The hemoglobin is 10.2 g/dl, Plans are under way to start dialysis in the outpatient setting next week. She has an arteriovenous fistula that is ready for use. ‘Which ONE of the following statements ‘MOST accurately characterizes the prognostic importance of AKI before initiation of long- term dialysis? ‘A. Her history of AKI in the predialysis period does not affect her mortality B. The episode of AKT will not affect her survival on dialysis because she has an arteriovenous fistula C. Given her history of AKI before initiation of dialysis, she should initiate dialysis in a hospitalized setting D, Her pre-ESRD episode of AKT is associ- ated with a 30% greater risk of mortality at 1 year in comparison with patients without AKI before incident dialysis, A 65-year-old man with stage G3a CKD is seen in consultation before coronary artery bypass grafting surgery. Which ONE of the following should you tell his surgeon with regard to on-pump versus off-pump ‘cardiopulmonary bypass and his risk of AKI? A. Off-pump surgery in eligible patients is associated with a reduced risk of AKI during the first postoperative month B. Off-pump cardiac surgery is associated with long-term preservation of renal func= tion at 1 year C. On-pump surgery poses no additional risk than off-pump surgery when the time on pump is <90 minutes D. On-pump surgery is preferred because it provides greater renal blood flow during the surgery A 44-year-old man with metastatic melanoma is, refered for AKI He started combination therapy with nivolumab (an antibody-inhibiting programmed cell death protein 1 (PD-1]) and 28, nT ipilimumab (@ cytotoxic ‘T-lymphocyte-associ- ated protein 4 [CTLA-4] inhibitor) 2. months ago. Over the past 6 weeks, the serum creatinine evel has risen from 1.3 mgidl to 2.8 mg/dl ‘Serum complement levels are normal. A complete blood count shows leukocyte count 6500/1, hemoglobin 12.9 g/dl, and platelets 427,000/L ‘The absolute cosinophil count is elevated at 2300/l (reference range <400/I). The urinalysis shows 5 to 10 leukocytes per high-power field and occasional leukocyte casts. The urine pro- tein-to-creatinine ratio is 3204 mg/g, and the urine albumin-to-creatinine ratio is 2986 mg/g. Which ONE of the following lesions is the MOST likely to be found on kidney biopsy? A. Acute tubulointerstitial nephritis with podocyte injury B. Renal-limited thrombotic microangiopathy C. Immune complex-mediated glomerulone- phritis D. Minimal change glomerulopathy with acute tubular necrosis E, Secondary membranous nephropathy A 60-year-old man is admitted to neurosurgical intensive care unit alter experiencing a hemor- thagic stroke. A ventriculostomy drain is placed because of increased intracranial pressure His course is complicated by contrast-induced AKI, which progresses to oliguric AKI after ‘onset of pneumonia and sepsis. On physical examination, he is intubated and sedated. The blood pressure 110/50 mmHg. The chest exam- ination shows crackles and decreased breath sounds in the right midlung zone. There is 2+ Jeg edema. Laboratory studies show sodium 130 mEq/L, potassium 6.2 mEq/L, chloride 94 mEq\L, total CO, 16 mmol/L, BUN 82 mg/dl, ‘and creatinine 6.1 mgiAll (increased from 1.2 mg/dl 8 days ago). The leukocyte count is 14,700/jl, the hemoglobin is 9.2 gid, and the platelet count is 203,000/ Which ONE of the following is the BEST choice of RRT for this patient? . Intermittent hemodiafiltration Intermittent hemodialysis, Continuous RRT Sustained low-efficiency dialys poe8 29. A 75-year-old woman with metastatic melanoma with cutaneous and pulmonary involvement is admitted to the intensive care unit for manage- ment of symptomatic hyponatremia. She started treatment with ipilimumab 10 weeks ago and experienced bifrontal headache with progressive confusion over the past week. On physical ‘examination, she is lethargic. The blood pressure is 118/60 mmHg, and the heart rate is 96/min. There is no cutaneous or mucosal hyperpigmen- tation, The heart and lung examination results are unremarkable, and there is no peripheral edema or focal neurologic deficits. The deep tendon reflexes demonstrate a delayed relaxation phase. Laboratory studies show serum sodium 116 mEq/L, potassium 4.3 mEq/L, chloride 82 mEq/L, total CO, 24 mmoVL, BUN 18 mg/dl, creatinine 1.1 mg/dl, and osmolality 242 mOsm/kg. The urine osmolality is 426 mOsm/kg, and the urine sodium is 62 mEq/L. Magnetic resonance imaging of the brain with contrast material shows diffuse pituitary enlargement without focal mass lesions, Which ONE of the following is the MOST likely cause of the hyponatremia? A. Ipilimumab-related hypophysitis with sec- ‘ondary adrenal insufficiency B. Primary adrenal insufficiency because of ipilimumab-telated autoimmune adrenalitis Nephrology Self Assessment Program - Vol 18, No 2, May 2019 C. Metastatic melanoma invading the pitui- tary gland D. Primary polydipsia 30. A 70-year-old woman with stage G3b:A2 CKD due to diabetic nephropathy receives a diagnosis of metastatic renal cell carcinoma, She begins ‘treatment with sorafinib, a tyrosine kinase in- hibitor targeting the vascular endothelial growth factor receptor. Three weeks into therapy, she experiences edema, hypertension with a blood pressure of 180/100 mmHg, and increased pro- teinuria, Medications ate amlodipine, lisinopril, chlorthalidone, and rosuvastatin, Laboratory studies show that the serum creatinine level has risen from a baseline level of 1.6 mg/dl to 2.3 mg/dl A complete blood count with differential and serum complement levels are normal, The urinalysis shows fine granular casts and oval fat bodies. The urine albumin-to-creatinine ratio is 6400 mg/g, increased from 106 mg/g 1 month ago. Which ONE of the following is the MOST likely diagnosis? A. Focal and segmental glomerulosclerosis plus thrombotic microangiopathy B. Renal vein thrombos C. Progression of diabetic nephropathy D. Immune complex glomerulonephritis