1. The patient is a 64-year-old white woman (height 73 inches, weight 90 kg) who presents to
the clinic with abdominal pain and dizziness. She reports that she did not eat or drink for 24
hours because she has a history of gastroenteritis. On exam, the blood pressure reading
while sitting is 120/85 mmHg and drops to 90/60 mmHg when standing. Her heart rate is 95
beats/min. The laboratory tests reveal sodium (Na) is 140 mEq/L, potassium is 4 mEq/L,
chloride (Cl) is 105 mEq/L, blood urea nitrogen is 42 mg/dL, serum creatinine is 1.3 mg/dL,
and glucose is 190 mg/dL. What is the best action for this patient?
1. Administer trimethoprim/sulfamethazine double strength orally for 3 days.
2. Administer furosemide 40 mg intravenously.
3. Administer Insulin lispro 5 units subcutaneously.
4. Administer fluid bolus (500 mL of NaCl solution).
4. Administer fluid bolus (500 mL of NaCl solution)
Rationale: The patient presents with acute kidney injury (AKI) symptoms, and the initial
treatment of AKI is identifying and reversing the insult to the kidney if possible. This patient
has prerenal azotemia caused by hypotension and increased heart rate. Adding sulfa
antibiotics would not have any benefits for this patient because she does not have any signs
for urinary tract infections (answer 1). Administering diuretics such as furosemide (answer 2)
could worsen her volume depletion and probably further impair her kidney function.
,Although the glucose level is elevated, adding insulin units is unnecessary at this time
(answer 3). Fluid management is critical to managing AKI; therefore administration of a fluid
bolus with normal saline would be the best choice for this patient.
,2. A 63-year-old Asian man has diabetes, hypertension, and estimated glomerular filtration
rate of 40 mL/min/1.73 m2. He takes simvastatin 40 mg daily, ramipril 10 mg daily, and
metformin 1000 mg twice daily. Laboratory values reveal hemoglobin is 12 mg/dL,
parathyroid hormone is 200 pg/mL, sodium is 135 mEq/L, potassium is 3.9 mEq/L, calcium is
8.9 mEq/dL, albumin is 3.5 g/dL, phosphorus is 5.9 mg/dL, and 25-hydroxyvitamin D is 50
ng/mL. Which therapy is the best to prevent chronic kidney disease-mineral and bone
disorders?
1. Cinacalcet.
2. Ergocalciferol.
3. Calcium carbonate.
4. Calcitriol.
3. Calcium carbonate.
Rationale: There are many factors that can contribute to the development of chronic kidney
disease-mineral and bone disorders such as hypocalcemia, hyperparathyroidism,
hyperphosphatemia, decrease of vitamin D, and decreased production of 1.25-
dihydroxyvitamin D. The patient's laboratory values reveal hyperparathyroidism, which may
be related to an increasing phosphorus concentration. The first approach is to administer a
phosphate binder. Knowing the corrected calcium concentration is necessary for this
patient. The [measured Ca + (0.8) (4 − serum albumin) = 8.9 + (0.8) (4 − 3.5) = 8.9 + 0.4 = 9.3
, mEq/dL]; therefore this patient has hypocalcemia. Cinacalcet (answer 1) is reserved for
patients with hyperparathyroidism despite the normalization of phosphate in patients with
hypercalcemia. Ergocalciferol (answer 2) is unnecessary for this patient because his 25-
hydroxyvitamin D concentration is greater than 30 ng/mL. Calcium carbonate (answer 3) is
the best phosphate binder for this case because the patient has hypocalcemia, and it is
acceptable with a corrected serum calcium concentration. An active vitamin D medication
such as calcitriol (answer 4) could be added if the parathyroid concentration remains
elevated, despite normalization of serum phosphate.
the clinic with abdominal pain and dizziness. She reports that she did not eat or drink for 24
hours because she has a history of gastroenteritis. On exam, the blood pressure reading
while sitting is 120/85 mmHg and drops to 90/60 mmHg when standing. Her heart rate is 95
beats/min. The laboratory tests reveal sodium (Na) is 140 mEq/L, potassium is 4 mEq/L,
chloride (Cl) is 105 mEq/L, blood urea nitrogen is 42 mg/dL, serum creatinine is 1.3 mg/dL,
and glucose is 190 mg/dL. What is the best action for this patient?
1. Administer trimethoprim/sulfamethazine double strength orally for 3 days.
2. Administer furosemide 40 mg intravenously.
3. Administer Insulin lispro 5 units subcutaneously.
4. Administer fluid bolus (500 mL of NaCl solution).
4. Administer fluid bolus (500 mL of NaCl solution)
Rationale: The patient presents with acute kidney injury (AKI) symptoms, and the initial
treatment of AKI is identifying and reversing the insult to the kidney if possible. This patient
has prerenal azotemia caused by hypotension and increased heart rate. Adding sulfa
antibiotics would not have any benefits for this patient because she does not have any signs
for urinary tract infections (answer 1). Administering diuretics such as furosemide (answer 2)
could worsen her volume depletion and probably further impair her kidney function.
,Although the glucose level is elevated, adding insulin units is unnecessary at this time
(answer 3). Fluid management is critical to managing AKI; therefore administration of a fluid
bolus with normal saline would be the best choice for this patient.
,2. A 63-year-old Asian man has diabetes, hypertension, and estimated glomerular filtration
rate of 40 mL/min/1.73 m2. He takes simvastatin 40 mg daily, ramipril 10 mg daily, and
metformin 1000 mg twice daily. Laboratory values reveal hemoglobin is 12 mg/dL,
parathyroid hormone is 200 pg/mL, sodium is 135 mEq/L, potassium is 3.9 mEq/L, calcium is
8.9 mEq/dL, albumin is 3.5 g/dL, phosphorus is 5.9 mg/dL, and 25-hydroxyvitamin D is 50
ng/mL. Which therapy is the best to prevent chronic kidney disease-mineral and bone
disorders?
1. Cinacalcet.
2. Ergocalciferol.
3. Calcium carbonate.
4. Calcitriol.
3. Calcium carbonate.
Rationale: There are many factors that can contribute to the development of chronic kidney
disease-mineral and bone disorders such as hypocalcemia, hyperparathyroidism,
hyperphosphatemia, decrease of vitamin D, and decreased production of 1.25-
dihydroxyvitamin D. The patient's laboratory values reveal hyperparathyroidism, which may
be related to an increasing phosphorus concentration. The first approach is to administer a
phosphate binder. Knowing the corrected calcium concentration is necessary for this
patient. The [measured Ca + (0.8) (4 − serum albumin) = 8.9 + (0.8) (4 − 3.5) = 8.9 + 0.4 = 9.3
, mEq/dL]; therefore this patient has hypocalcemia. Cinacalcet (answer 1) is reserved for
patients with hyperparathyroidism despite the normalization of phosphate in patients with
hypercalcemia. Ergocalciferol (answer 2) is unnecessary for this patient because his 25-
hydroxyvitamin D concentration is greater than 30 ng/mL. Calcium carbonate (answer 3) is
the best phosphate binder for this case because the patient has hypocalcemia, and it is
acceptable with a corrected serum calcium concentration. An active vitamin D medication
such as calcitriol (answer 4) could be added if the parathyroid concentration remains
elevated, despite normalization of serum phosphate.
