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Self-Assessment Questions

Nephrology

Glomerulonephritis: Review Questions

Sri G. Yarlagadda, MD, and Ursula C. Brewster, MD

Dr. Yarlagadda is a fellow, and Dr. Brewster is an assistant professor of medicine; both are at the Section of Nephrology, Yale University School of Medicine, New Haven, CT.



Choose the single best answer for each question.

1. A 35-year-old man with no past medical history presents to the emergency department (ED) with cough and shortness of breath that have been present for 1 week. He reports occasional blood-tinged sputum. He denies malaise, weight loss, fevers, or joint pain. Blood pressure is 140/80 mm Hg, heart rate is 80 bpm, and oxygen saturation is 97% on room air. Laboratory testing reveals a blood urea nitrogen (BUN) level of 48 mg/dL (normal, 11-23 mg/dL) and serum creatinine level of 3.5 mg/dL (normal, 0.6-1.2 mg/dL). Serum electrolytes are normal. Urinalysis reveals 1+ protein, moderate blood, 3 to 4 red blood cell casts, and 2 to 3 granular casts per high-power field. Chest radiograph shows infiltrates in both lungs. A spot urine protein/creatinine ratio is 0.6 g/mg. Enzyme-linked immunoassay for anti-glomerular basement membrane (GBM) antibodies is positive. A titer for antineutrophil cytoplasmic antibodies (ANCA) is undetectable. The patient undergoes a renal biopsy. Light microscopy reveals crescents in the glomeruli, and immunofluorescence reveals linear staining of IgG along the glomerular capillaries. What is the best management strategy for this patient?
  1. Dialysis
  2. Intravenous (IV) prednisolone
  3. Observation
  4. Plasma exchange, prednisone, and cyclophosphamide
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2. A 9-year-old boy presents to the ED with his mother with puffy eyes and scant urine. His general health has been good until 2 weeks ago when he developed a sore throat and swollen glands. An antibiotic was started at that time. He appears well except for facial swelling and edema in his feet. Blood pressure is 150/90 mm Hg. The remainder of the physical examination is normal. Laboratory testing reveals a serum creatinine level of 1.8 mg/dL, BUN of 35 mg/dL, albumin level of 3.2 g/dL (normal, 3.3-5.2 g/dL), serum complement C3 level of 80 mg/dL (normal, 100-233 mg/dL), serum complement C4 level of 25 mg/dL (normal, 14-18 mg/dL), anti-streptolysin O titer of 230 U (normal, < 200 U), and an antinuclear antibody titer of 1:20 (> 1:40 is abnormal). Urinalysis reveals 1+ protein, 10 to 20 red blood cells, 2 to 6 white blood cells, and occasional red blood cell casts. Urine protein is 2 g/24 hr. What is the next step in the management of this patient?

  1. Diuretics and antihypertensive medication
  2. IV prednisone
  3. Kidney biopsy
  4. Oral cyclophosphamide
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3. A 60-year-old man presents to the ED with a 6-week history of fatigue, myalgias, weight loss, and shortness of breath. Past medical history is significant for hypertension for 10 years. Urine output and blood pressure are normal. There is no skin rash, hepatomegaly, splenomegaly, or peripheral edema. Laboratory testing reveals a hemoglobin level of 10 g/dL (normal, 13-18 g/dL), BUN of 68 mg/dL, and serum creatinine level of 4.5 mg/dL. Serum electrolytes are normal. Serum creatinine 1 year ago was 0.9 mg/dL. Urinalysis shows 2+ protein, 15 to 20 red blood cells, 5 to 10 white blood cells, and a few erythrocyte casts and granular casts per high-power field. Complement levels are normal. Ultrasound of the kidneys reveals 11-cm kidneys bilaterally with no hydronephrosis. Chest radiograph reveals patchy infiltrates in both lungs suggestive of bilateral multilobar pneumonia. The patient received 2 L of normal saline with no improvement in serum creatinine. Results of testing for serum anti-GBM antibodies, ANCA, and antinuclear antibody, serum protein electrophoresis, and urine electrophoresis are pending. What is the next step in the management of this patient?

  1. Emergent renal biopsy
  2. Lung biopsy
  3. Nasal and sinus biopsies
  4. Wait for results of serologic testing and continue supportive therapy
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Questions 4 and 5 refer to the following case.

A 37-year-old man presents to the ED with painless swelling in both ankles and a 10-lb weight gain over the past 3 months. During a physical examination 1 year prior, 2+ protein was noted on dipstick urinalysis, but the patient denied further evaluation because he felt well. There is no family history of renal disease. Blood pressure is 120/80 mm Hg. Physical examination is notable for edema in his legs up to the mid thighs. Laboratory testing reveals a hemoglobin level of 14 g/dL, hematocrit of 42%, serum glucose level of 80 mg/dL, serum creatinine level of 1.1 mg/dL, BUN of 28 mg/dL, albumin level of 2.6 g/dL, serum total cholesterol level of 325 mg/dL (normal, < 200 mg/dL), and serum triglyceride level of 800 mg/dL (normal, < 160 mg/dL). Serum complement levels are within normal limits. Urinalysis demonstrates 4+ protein on dipstick. Urine microscopy reveals 0 to 2 erythrocytes, hyaline casts, oval fat bodies, and fatty casts. A spot protein/creatinine ratio is 6 g/mg. The patient undergoes a renal biopsy.

4. What is the most likely biopsy finding?
  1. Acute postinfectious glomerulonephritis
  2. Alport’s syndrome
  3. Crescentic glomerulonephritis
  4. Membranous nephropathy
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5. Renal biopsy results are as suspected. A careful inquiry into the use of nonsteroidal anti-inflammatory drugs and other drugs is negative. Serologic testing for hepatitis B and C is negative. An age-appropriate work-up for malignancy is negative. What is the next step in this patient’s management?

  1. Furosemide and an angiotensin-converting enzyme (ACE) inhibitor
  2. Monthly albumin infusions
  3. Oral prednisone
  4. Warfarin
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