50/M with multiple physical injuries from a vehicular crash status post fasciotomy for lower extremity compartment syndrome presents with oliguria. Laboratories are as follows: Crea 3.9 mg/dL; K 5.9 mmol/L; Phos 7.5 mg/dL (2.5–4.8 mg/dL); Uric acid 11.51 mg/dL (2.5–7.2 mg/dL); iCa 0.8 mg/dL (1.16–1.31 mg/dL); ABG: pH 7.3 / pCO2 32 mmol/L / pO2 90 / HCO3 10 / SpO2 93%; Urinalysis: CHON 1+, Urobilinogen (-), Bilirubin (-), Blood (+++), RBC 1-2/HPF (0-3/HPF), WBC 1-2/HPF (0-3/HPF). What will be the best intravenous fluid?

66/M referred for massive proteinuria and elevated creatinine. Past medical history is notable for osteoarthritis and hypertension. He has frequent intake of NSAIDs and is on olmesartan. Laboratories are as follows: Serum BUN 20 mmol/L; Serum creatinine 2.7 mg/dL; Serum sodium 140 meq/L; Serum potassium 4.9 mmol/L; Urine sodium 40 meq/L; Urine creatinine 30 mmol/L; Urinalysis: CHON+4, CHO negative, blood negative, specific gravity 1.010, WBC 0-1, RBC 0-1. Which of the following will be part of your additional diagnostics?

60/F referred for elevated creatinine and edema. Patient has heart failure on bumetanide and sacubitril + valsartan. Laboratories are as follows: Serum BUN 15 mmol/L; Serum creatinine 1.7 mg/dL; Serum sodium 140 meq/L; Serum potassium 3.7 mmol/L; Urine sodium 40 meq/L; Urine creatinine 30 mmol/L; Urine BUN 10 mmol/L; Urinalysis: CHON trace, CHO negative, specific gravity 1.015. Which of the following will best determine if acute kidney injury is prerenal or acute tubular necrosis?

81/M post endovascular aortic repair (EVAR) of an infra-renal abdominal aortic aneurysm was referred for rising creatinine. Physical examination showed livedo reticularis of the lower extremities. Laboratory examinations showed elevated serum eosinophils and a FeNa of 1.8%. Which laboratory can help you know the cause of acute kidney injury?

25/M with known chronic liver disease develops worsening abdominal distension and tenderness, bipedal edema, and fever. Serum creatinine is elevated at 3 mg/dL (previously 1.2 mg/dL 1 month ago). He is maintained on spironolactone, furosemide, and carvedilol. What new medications will be included in your plan? I. Ceftriaxone II. Terlipressin III. Human albumin IV. Dopamine

Aminoglycosides are among the most nephrotoxic medications but are sometimes clinically warranted. What dosing strategy best prevents nephrotoxicity from aminoglycosides but ensures efficient antibiotic action?

81/M with infrarenal abdominal aortic aneurysm was referred for renal risk stratification for a CT aortogram. He is hypertensive and post-stroke one year ago. Serum creatinine ranges from 1.5–1.8 mg/dL. What is the best strategy to prevent contrast-associated AKI?

A 44-year-old diabetic and hypertensive American female was referred due to increasing creatinine. Laboratory studies show eGFR of 40 ml/min/1.73 m² by CKD EPI, and hemoglobin A1c of 7%. Physical examination shows weight 80 kg, height 1.6 m, pulse rate 64/min, blood pressure 130/96 mmHg, and no other abnormalities. What predisposes her for the progression of her CKD?

TR, a 50-year-old male, diagnosed case of CKD secondary to hypertension on HD two times a week has the following routine labs: total calcium = 12 mg/dL; albumin = 4 g/dL; phosphorus = 8 mg/dL; intact PTH = 800 pg/mL (NV: 10–65 pg/mL). What medications should the patient receive?

Renal osteodystrophy is best diagnosed with what test?

CKD patients have an increased risk of stroke due to multiple factors. All are associated with stroke through its blood pressure effect, except…

A 50-year-old CKD G3 patient suffered a transient ischemic attack 3 months ago. Which of the following will reduce recurrent stroke rates according to guidelines?

A 20-year-old female with severe azotemia from ESKD was initiated on hemodialysis. After 30 minutes, she had headache, nausea, and started to become agitated. What can you do to minimize her symptoms?

A 65-year-old college professor now suffers from memory loss and episodes of confusion especially after her regular hemodialysis sessions. What is the optimal therapy, if possible, for the management of CKD patients with cognitive impairment?

RL, 38-year-old male was referred due to 2+ proteinuria on his routine urinalysis. He reported bubbly urine for the past 3 months, on and off swelling of his lower extremities, and episodes of elevated blood pressure. What will be your target BP for him based on the KDIGO guidelines?

Which indicates chronic changes in the fundoscopic exam in a hypertensive patient?

Which clinical findings are better correlated with home blood pressure reading?

Which is true of ambulatory BP monitoring?

Which of the following would cause a false positive aldosterone–renin ratio (ARR)?

Which patient would you suspect renovascular hypertension?

What is considered an absolute contraindication to renal biopsy?

A 40-year-old male consulted for hematuria on annual physical examination. What is the next best step?

A 50-year-old female on pamidronate for osteoporosis presents with new-onset nephrotic syndrome. What is your expected kidney biopsy electron microscopy finding?

A 70-year-old male came in for anorexia. His urinalysis showed 4+ proteinuria with subsequent kidney biopsy EM showing electron-dense subepithelial deposits. What is the next step in management?

A 25-year-old male diagnosed with minimal change syndrome presented with 3+ proteinuria on home dipstick 2 weeks after last steroid dose. What medications can be started?

A 37-year-old female with bipedal edema and nephritic syndrome presented with the following kidney biopsy findings. Which test(s) will you be ordering on follow-up to document resolution? I. ANA II. C3 III. Creatinine IV. p-ANCA

A 32-year-old male presents with episodic hematuria usually during bouts of upper respiratory tract infection. A diagnosis of IgA nephropathy was made. His 24-hour urine protein is 1.5 g and eGFR is 46 after four months of optimized supportive care. What is the next best step?

What is an appropriate starting fluid to use for replacement in patients with post-obstructive diuresis?

What maneuver traditionally defines the functional effect of upper urinary tract dilatation by measuring the hydrostatic pressures in the renal pelvis and bladder?

Which test is performed during infusion of saline and contrast mixture into the renal pelvis via a catheter?

What is the most common cause of ureteral obstruction in younger men?

Which fluoroquinolone could precipitate in the tubular fluid, resulting in crystalluria with stone formation and urinary tract obstruction?

Which imaging test is helpful in diagnosing upper urinary tract obstruction and provides information on the differential renal function (DRF) of both kidneys while avoiding the risk of contrast agents?

Which is the natural inhibitor of stone formation that inhibits crystallization and increases the upper limit of metastability?

What is the most prevalent kidney stone, accounting for 70 to 80% of kidney stones?

What systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels in preeclampsia will make one start antihypertensives?

Beta-blockers have been used in pregnancy without known teratogenic or adverse effects to the fetus. Which beta-blocker can cause teratogenic effects?

A 30-year-old pregnant patient was admitted for abnormal uterine bleeding and decreased fetal movements at 32 weeks AOG by LMP. The assessment is placental abruption. An emergency C-section was performed with massive intraoperative blood transfusion. The patient presented post-op with progressing oliguria, weakness, edema, and new-onset hypertension. Which of the following findings is consistent with this form of AKI post-partum?

Match the type of hypertensive emergency with its recommended treatment (0.5 point sub question). For Aortic dissection, which treatment is recommended?

Match the type of hypertensive emergency with its recommended treatment (0.5 point sub question). For Eclampsia or preeclampsia, which treatment is recommended?

Match the type of hypertensive emergency with its recommended treatment (0.5 point sub question). For Heart failure (or pulmonary edema), which treatment is recommended?

Match the type of hypertensive emergency with its recommended treatment (0.5 point sub question). For Hypertensive encephalopathy, which treatment is recommended?

FD, 29/F at 34 weeks gestation develops hypertension, thrombocytopenia, microangiopathic hemolysis, and AKI (creatinine 2.1 mg/dL). ADAMTS13 activity is <5% (NV: 50%-150%). What is the best treatment?

JM, 18/M diagnosed acute lymphoblastic leukemia (ALL) has just started chemotherapy. Shortly after starting treatment, his serum creatinine rises from 0.8 mg/dL to 1.9 mg/dL, and his urine output decreases significantly. His lab results show hyperkalemia, hyperphosphatemia, and elevated uric acid. What is the most likely cause of his renal dysfunction?

Which of the following best explains the mechanism of cisplatin-induced nephrotoxicity?

A 59-year-old metastatic colon cancer patient receiving bevacizumab presents with new-onset hypertension and proteinuria. Which renal pathology is most commonly associated with bevacizumab use?

A 63-year-old man with a history of lung cancer develops new-onset nephrotic syndrome. A renal biopsy shows thickened capillary walls with subepithelial immune complex deposits. Which glomerular disease is most likely paraneoplastic in this setting?

Which of the following is the most effective strategy to minimize cisplatin nephrotoxicity?

A 40-year-old man with a large abdominal mass diagnosed with non-Hodgkin lymphoma starts chemotherapy. Within 48 hours, his uric acid level rises to 11 mg/dL and he develops oliguria. Which treatment is most appropriate to lower his uric acid level?

A 67-year-old man with acute decompensated heart failure presents with hyponatremia and volume overload. What is the expected urine sodium value?

A 34-year-old woman has severe anasarca from nephrotic syndrome secondary to minimal change disease. Despite oral furosemide 40 mg once a day, she remains anasarcous. What diuretic strategy can be done next?

Which is the best example of osmotic thirst?

A 36-year-old woman with bipolar disorder presents with weakness and headaches after recently starting lithium and clonazepam. Laboratories: serum creatinine 1.3 mg/dL; BUN 10 mmol/L (2.1–8.5 mmol/L); serum sodium 149 mmol/L; serum potassium 3.0 mmol/L; serum ionized calcium 1.3 mg/dL (1.16–1.31 mg/dL); urinalysis: pH 7.0, specific gravity 1.006, CHO (−), CHON (−), hyaline casts 2–3/HPF; ABG: pH 7.36, pCO2 44, pO2 89, HCO3 24, SpO2 96%. What is the most appropriate next step in management?

A 55-year-old man with non–small cell lung cancer is referred for hyponatremia. Laboratories: serum creatinine 1.0 mg/dL; serum BUN 8 mmol/L (2.1–8.5 mmol/L); serum sodium 120 mmol/L; serum ALT 250 U/L (4–36 U/L); plasma osmolality 270 mOsm/kg H2O (275–295 mOsm/kg H2O); urine osmolality 600 mOsm/kg H2O (500–850 mOsm/kg H2O); 24-hour urine studies: volume 1000 mL, sodium 10 mmol/L, creatinine 1.8 g. What is the next best step?

A patient presents with serum calcium of 11.8 mg/dL, inappropriately normal PTH, and urine calcium excretion less than 100 mg/day (normal value: 100–300 mg/24 hours). What is the most likely diagnosis?

A 70-year-old man with prostate cancer develops hypercalcemia and lytic bone lesions. Labs show suppressed PTH and low vitamin D levels. What explains his hypercalcemia?

A 60-year-old diabetic male with CKD Stage 4 was referred to you for hyperkalemia (5.8) by his primary care physician. Patient claims to be compliant with a low-potassium and low-protein diet. Medications include insulin glargine, aspirin, amlodipine, and ketoanalogues of amino acids all of which he takes religiously. Which laboratory parameter is characteristic of this cause of hyperkalemia?

Which is true regarding hemodialysis in hyperkalemia?

The urine anion gap (UAG) is a surrogate measure of ammonium excretion by the renal tubules. What happens to the UAG in cases of acidosis due to diarrhea?

What acid base disorder can occur in a patient with increased pancreatic or biliary drainage secretions?

What is the most common cause of acquired proximal RTA in adults?

35/M, person living with HIV admitted and currently on trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jiroveci pneumonia presents with the following laboratories: Crea 1.7 mg/dL; Na 138 mEq/L; K 6.8 mEq/L; ABG: pH 7.31, pCO2 30, pO2 65, HCO3 11.5. The management will include... I. Shifting TMP-SMX to atovaquone II. Increase intravenous hydration with plain saline III. Giving oral sodium bicarbonate IV. Shifting TMP-SMX to pentamidine

Indications for dialysis in ethylene glycol intoxication... I. HCO3 20 mEq/L II. Osmolal gap 15 mOsm/kg III. Arterial pH 7.29 IV. Renal tubular casts in the urine

What condition causing metabolic alkalosis will respond to chloride hydration?

What metabolic profile will salicylate intoxication present with?

23/M brought to the ER for suspected alcohol poisoning. Laboratory results are: Capillary blood glucose 60 mg/dL; Crea 2.3 mg/dL; Potassium 3.2 mEq/L; Albumin 2.5 g/dL; Phos 1.2 mg/dL; ABG: pH 7.2, pCO2 29 mmHg, pO2 89 mmHg, HCO3 9 mmol/L; Serum ketones (Nitroprusside method): negative to trace. What is the intravenous fluid of choice?

What type of renal tubular acidosis (RTA) is usually associated with nephrocalcinosis and recurrent nephrolithiasis?

Which of the following is true regarding living kidney donation and cancer?

Which of the following options includes the pathologic findings of acute T-cell-mediated rejection?

Which B-cell development stages is not targeted by rituximab (anti-CD20 antibody)?

Which one of the following co-stimulation molecules on antigen-presenting cells (APCs) has an inhibitory function on T cells?

Which of the following is true regarding the nephrectomy procedure?

Which of the following is true of the vascular complications of kidney transplantation?

Which of the following does not usually cause bone marrow suppression?

Which of the following is true regarding mycophenolate acid?

A post–kidney transplant patient with a calculated panel reactive antibody (cPRA) of 98.5% is about to be sent home. Which of the following medications, at an additional dose, must be administered to the patient in the hospital setting before discharge?

How frequent should tacrolimus drug levels be monitored in the early posttransplant period?

Which of the following may decrease the likelihood of delayed graft function (DGF)?

In acute transplant rejection, which category typically has timing of clinical onset greater than 5 days?

In acute transplant rejection, which category may present with timing of clinical onset greater than 0 days (i.e., can occur very early)?

For tubulitis/interstitial inflammation, which rejection category most characteristically shows this finding?

Regarding microvascular inflammation, which rejection category most characteristically shows this finding?

Peritubular capillaritis and/or glomerulitis are most consistent with which rejection pattern?

C4d staining of peritubular capillaries is most consistent with which scenario?

Donor-specific antibody in serum is most consistent with which scenario?

For therapy selection, which option is most appropriate for acute T-cell mediated rejection (TCMR)?

For therapy selection, which option is most appropriate for active antibody mediated rejection (ABMR)?

What can cause low arterial pressure alarms during hemodialysis (HD)? I. Kink in the arterial line II. Hypotension III. Access arterial outflow stenosis IV. Access venous outflow stenosis

Which is true of high flux dialyzers? I. Most effective with blood flow rates of up to 250 mL/min II. Greater clearance of vitamin B12 III. Greater clearance of beta-2 microglobulin IV. Higher ultrafiltration coefficient

Which of the following statements correctly describe the indications, advantages, and limitations of different extracorporeal blood purification techniques in critically ill patients?

A critically ill patient in the ICU is experiencing persistent hypotension despite initial fluid resuscitation. The medical team decides to reassess the fluid management strategy. Based on principles of fluid resuscitation and current guidelines, which step should be considered next to manage this patient effectively?

Critically ill patients often experience complex interactions between different organ systems. Which of the following statements accurately describe the relationship between liver failure, heart failure, and respiratory distress syndrome in the context of acute kidney injury (AKI)?

In the context of renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI), understanding the effects of therapy intensity is crucial. Which of the following statements accurately reflect findings related to RRT intensity?

Which is true regarding regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT)?

What kind of diagnostic tool can be used to assess the lung volume and inferior vena cava diameter in critically ill patients with acute kidney injury (AKI)?

What is the target effluent flow in critically ill patients with acute kidney injury receiving continuous renal replacement therapy (CRRT)?

A 45-year-old female in the ICU is post–percutaneous biliary drainage (PTBD) insertion for acute cholangitis due to an obstructing cholelithiasis. Latest serum creatinine is 2.9 mg/dL with urine output of 0.8 cc/kg/hour. Medications being given are meropenem and metronidazole. What is the most appropriate supportive therapeutic strategy?

What is the main rationale for alkali therapy in a predialysis chronic kidney disease patient with metabolic acidosis?

What is the recommended protein intake in patients with hypercatabolic acute kidney injury on continuous veno-veno hemodiafiltration (CVVH)?

A patient with acute kidney injury needs antibiotics for high-risk pneumonia (meropenem). Her GFR is 18 via Cockcroft and Gault equation. Urine output is 800 cc in 24 hours and the patient has clinical signs of volume overload. What is your recommendation regarding meropenem dosing?

Why is the volume of distribution of water-soluble drugs often increased in chronic kidney disease?

Which pharmacokinetic parameter is least likely to be altered in chronic kidney disease, affecting drug dosing?

Which is true regarding the pathophysiology of perioperative AKI?

Which surgical procedure generally produce the lowest risk for AKI?

Which is true regarding preoperative risk factors for postoperative AKI?

What are the components of the Cleveland Clinic Score (Thakar) for Acute Renal Failure Requiring Dialysis Postoperatively?

61/M with T2DM-IR and 2-vessel CAD for emergency CABG was referred for pre-operative renal risk stratification. Pre-operative creatinine is 1 mg/dL. What is the most appropriate post-operative monitoring strategy?

45/F post laparoscopic adrenalectomy for adrenal adenoma was referred for hypotension. A-line values ranged from 70-80/50-60 mmHg. Passive leg raise (PLR) test is positive. Which is the best strategy to address her hypotension?

A 45/M with CKD G3B A2 has a kidney failure risk equation (KFRE) score of 10% risk of kidney failure in the next 2 years (high-risk). What is your recommended daily protein intake?

Which is correct about sodium restriction in CKD patients?

45/M with CKD G3A A3 from diabetes (insulin-requiring, uncontrolled) has a KFRE score of 10% risk of kidney failure in the next 2 years (high-risk). Which is true?

A 70-year-old woman on thrice-weekly hemodialysis is prescribed digoxin for atrial fibrillation. What pharmacokinetic alteration is most relevant?

A 78-year-old man with CKD is being considered for dose adjustment of an antibiotic. The pharmacist notes that body weight is missing from the record. Which equation is most appropriate to estimate kidney function in this case?

A CKD patient is prescribed ciprofloxacin for UTI and takes it with phosphate binders and omeprazole. What is the expected drug interaction?

A 62-year-old with new rapidly progressive kidney dysfunction has hematuria with dysmorphic RBCs and red cell casts. Serology returns MPO-ANCA positive. There is no biopsy contraindication, and the center is experienced in AAV care. Which is the best next step? (MK, problem-solving, 0.6)

28/F, non-pregnant, admitted for SLE flare, to include active nephritis. She was previously admitted 3x in the past year for flare of nephritis for which MPPT and cyclophosphamide regimens were given. What regimen can you give during this admission? (GK, problem-solving, 0.5)

A 45/F with idiopathic IgA nephropathy (Oxford M1 E1 S1 T0 C0) presents for follow-up. Baseline 6 months ago: eGFR 62 ml/min/1.73 m2, UPCR 1.8 g/g, BP 146/92. She completed 6 months of optimized supportive care: strict sodium restriction, weight loss counseling, and maximally titrated ARB achieving home BP ~122/74. Current labs: eGFR 58 ml/min/1.73 m2 (CKD EPI), UPCR 1.1 g/g on two measurements 4 weeks apart. She has well-controlled hypothyroidism, no diabetes, BMI 31 kg/m2, and a history of healed peptic ulcer disease 1 year ago. Hepatitis B/C, HIV negative. She asks whether to begin additional immunosuppression. What is the most appropriate next step? (MK, problem-solving, 0.8)

A 58/M with CKD G5 due to type 2 diabetes on hemodialysis for 10 months is referred for kidney transplant evaluation. He has HF NYHA class II dyspnea, a 35 pack-year smoking history (quit 2 years ago), and a prior treated pulmonary tuberculosis infection 20 years ago. BMI 29. Vitals: BP 138/78, HR 82. Exam unremarkable. Recent tests: echocardiogram LVEF 42% with no significant valvular disease; CT chest last year for lung nodule surveillance shows a stable 5-mm incidental pulmonary nodule with no cavitary lesions; HBsAg negative, anti-HCV negative, HIV negative; interferon-gamma release assay (IGRA) positive, chest radiograph today is clear. Which is the best next step in his evaluation before listing? (MK, problem-solving, 0.6)

A 58/M on PD for 10 months presents with 3 days of new purulent drainage at the catheter exit site and mild tenderness. He denies fever or abdominal pain and continues to dialyze without issues. On exam, there is purulent discharge at the exit site without surrounding erythema; no fluctuance is palpable along the tunnel. Ultrasound of the catheter tunnel shows no fluid collection. A Gram stain and culture of the purulent discharge are obtained. He has a history of MRSA nasal colonization documented 6 months ago. He has not been on recent antibiotics. There is no peritonitis. According to the ISPD 2023 recommendations for catheter-related infections, which is the most appropriate initial management? (MK, problem-solving, 0.7)

You started dapagliflozin in your patient with CKD 3B A3 from diabetes. Her eGFR dropped from 40 to 30 mL/min per 1.73 m2 (CKD EPI) in a span of 6 weeks of use. There is no intercurrent illness between follow-up visits. What is the next best step? (MK, problem-solving, 0.8)

58/F CKD G3B A3 from diabetes has recurrent urinary tract infection. What medications can be given as continuous prophylaxis for 6–12 months? (MK, problem-solving, 0.6)

A 28/M presents on day 6 of fever, myalgias, and conjunctival suffusion after wading through floodwater 10 days ago. He is icteric and mildly dyspneic. Vitals: temperature 38.5 °C, HR 112, MAP 58 mmHg (SBP 86, DBP 50), SpO2 93% RA. Urine output over the last 12 hours is 120 mL. Labs: WBC 12.5×10⁹/L, platelets 78,000/μL, AST 64 U/L, ALT 58 U/L, total bilirubin 5.2 mg/dL, creatinine 4.6 mg/dL (baseline unknown), K 5.9 mEq/L, Na 132 mEq/L. UA: sterile pyuria, protein 2+, pigmented “tea-colored” urine. Chest X-ray: new bilateral patchy infiltrates. PT 18 s, aPTT 48 s. He is on norepinephrine at 0.08 μg/kg/min after fluid resuscitation. According to the 2019 leptospirosis renal guidelines, which of the following is the best next step in management? (MK, problem-solving, 0.8)

A 46/F with CKD G5D is listed for kidney transplant. She is HCV RNA–negative with prior treated HCV (sustained viral response 3 years ago). A kidney offer becomes available from an HCV RNA–positive deceased donor. The center has immediate access to directly active antiretrovirals (DAA). What is the next best evidence-based? (MK, problem-solving, 0.6)

A 70/M with type 2 diabetes and CKD stage G4 has persistent albuminuria despite being on losartan, linagliptin and empagliflozin. Sugars are not controlled. According to KDIGO guidelines, which of the following treatment can be added? (MK, problem-solving, 0.6)

A 50/F patient with stage 4 CKD has a serum 25-hydroxyvitamin D level of 15 ng/mL and a parathyroid hormone (PTH) level of 120 pg/mL. She has no history of hypercalcemia or vitamin D hypersensitivity and is currently not taking any vitamin D supplements. What is the appropriate approach to vitamin D supplementation for this patient? (MK, problem-solving, 0.7)