Distal tubule and collecting duct function US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Distal tubule and collecting duct function. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Distal tubule and collecting duct function US Medical PG Question 1: A 61-year-old male is given acetazolamide to treat open-angle glaucoma. Upon diuresis, his urine is found to be highly alkaline. Which of the following accounts for the alkaline nature of this patient’s urine?
- A. Inhibition of bicarbonate reabsorption in the proximal tubule (Correct Answer)
- B. Inhibition of bicarbonate reabsorption in beta-intercalated cells
- C. Inhibition of acid secretion in alpha-intercalated cells
- D. Inhibition of chloride reabsorption in the distal convoluted tubule
- E. Inhibition of chloride reabsorption in the thick ascending loop of Henle
Distal tubule and collecting duct function Explanation: ***Inhibition of bicarbonate reabsorption in the proximal tubule***
- **Acetazolamide** is a **carbonic anhydrase inhibitor** that primarily acts on the **proximal tubule** of the kidney.
- Its action here prevents the reabsorption of **bicarbonate (HCO3-)**, leading to its increased excretion in the urine and thus making the urine alkaline.
*Inhibition of chloride reabsorption in the distal convoluted tubule*
- This effect is typically associated with **thiazide diuretics**, which inhibit the **Na-Cl cotransporter** in the distal convoluted tubule.
- While it affects electrolyte balance, it does not directly lead to the observed **alkaline urine** in the manner described.
*Inhibition of bicarbonate reabsorption in beta-intercalated cells*
- **Beta-intercalated cells** in the collecting duct secrete bicarbonate, and their inhibition would lead to **acidic urine**, not alkaline.
- They play a role in **bicarbonate secretion**, not reabsorption as seen with acetazolamide's primary action.
*Inhibition of acid secretion in alpha-intercalated cells*
- **Alpha-intercalated cells** secrete acid (H+) into the urine. Inhibiting their function would reduce acid excretion, making the urine less acidic or even alkaline.
- However, the primary mechanism of acetazolamide's effect on urine pH is through **bicarbonate wasting** in the proximal tubule, not direct inhibition of acid secretion in the collecting duct.
*Inhibition of chloride reabsorption in the thick ascending loop of Henle*
- This is the mechanism of action for **loop diuretics** like furosemide, which inhibit the **Na-K-2Cl cotransporter**.
- While loop diuretics cause significant diuresis, they do not directly lead to the pronounced **urinary alkalinization** seen with acetazolamide.
Distal tubule and collecting duct function US Medical PG Question 2: An investigator is studying patients with acute decompensated congestive heart failure. He takes measurements of a hormone released from atrial myocytes, as well as serial measurements of left atrial and left ventricular pressures. The investigator observes a positive correlation between left atrial pressures and the serum level of this hormone. Which of the following is most likely the mechanism of action of this hormone?
- A. Increases potassium excretion at the collecting ducts
- B. Constricts afferent renal arteriole
- C. Decreases sodium reabsorption at the collecting tubules (Correct Answer)
- D. Decreases reabsorption of bicarbonate in the proximal convoluted tubules
- E. Increases free water reabsorption from the distal tubules
Distal tubule and collecting duct function Explanation: ***Decreases sodium reabsorption at the collecting tubules***
- The hormone described, exhibiting a positive correlation with left atrial pressure and released from atrial myocytes, is **Atrial Natriuretic Peptide (ANP)**.
- ANP promotes **natriuresis** (sodium excretion) and **diuresis** by directly inhibiting sodium reabsorption in the collecting tubules, thereby reducing blood volume and cardiac preload.
*Increases potassium excretion at the collecting ducts*
- While ANP does promote fluid and electrolyte excretion, its primary effect is on sodium and water, not a direct increase in **potassium excretion**. **Aldosterone**, not ANP, primarily increases potassium secretion in the collecting ducts.
- This option describes a mechanism more consistent with **mineralocorticoid activity**, which is counteracted by ANP.
*Constricts afferent renal arteriole*
- ANP generally causes **vasodilation** of the afferent arteriole and constriction of the efferent arteriole, increasing glomerular filtration rate (GFR).
- **Angiotensin II** is a primary constrictor of the afferent and efferent renal arterioles, which is the opposite effect of ANP.
*Decreases reabsorption of bicarbonate in the proximal convoluted tubules*
- This mechanism is primarily involved in **acid-base balance** and is influenced by factors like parathyroid hormone or respiratory/metabolic acidosis/alkalosis.
- ANP's main action is on **sodium and water balance**, not directly on bicarbonate reabsorption.
*Increases free water reabsorption from the distal tubules*
- **Vasopressin (Antidiuretic Hormone, ADH)** is responsible for increasing free water reabsorption in the distal tubules and collecting ducts.
- ANP's action is to *increase* water excretion, working in opposition to ADH to reduce circulating fluid volume.
Distal tubule and collecting duct function US Medical PG Question 3: A 54-year-old woman comes to the physician for a follow-up examination after presenting with elevated blood pressure readings during her last two visits. After her last visit 2 months ago, she tried controlling her hypertension with weight loss before starting medical therapy, but she has since been unable to lose any weight. Her pulse is 76/min, and blood pressure is 154/90 mm Hg on the right arm and 155/93 mm Hg on the left arm. She agrees to start treatment with a thiazide diuretic. In response to this treatment, which of the following is most likely to decrease?
- A. Serum uric acid levels
- B. Urinary calcium excretion (Correct Answer)
- C. Serum glucose levels
- D. Urinary potassium excretion
- E. Urinary sodium excretion
Distal tubule and collecting duct function Explanation: ***Urinary calcium excretion***
- Thiazide diuretics work by inhibiting the **Na-Cl cotransporter** in the **distal convoluted tubule**, which leads to decreased sodium reabsorption and subsequently increased calcium reabsorption.
- This property makes thiazides useful in treating conditions like **hypercalciuria** and preventing **calcium-containing kidney stones**.
*Serum uric acid levels*
- Thiazide diuretics are known to **increase serum uric acid levels** by inhibiting its secretion in the proximal tubule.
- This can precipitate or worsen **gout attacks**, a known side effect of these medications.
*Serum glucose levels*
- Thiazide diuretics can cause **increased serum glucose levels** by impairing insulin secretion and promoting insulin resistance.
- This effect is more pronounced at higher doses and in patients with pre-existing metabolic risk factors.
*Urinary potassium excretion*
- Thiazide diuretics **increase urinary potassium excretion**, often leading to **hypokalemia**.
- This occurs because decreased sodium reabsorption in the distal convoluted tubule leads to increased sodium delivery to the collecting duct, stimulating an exchange for potassium.
*Urinary sodium excretion*
- The primary mechanism of action of thiazide diuretics is to inhibit sodium reabsorption in the distal convoluted tubule, which directly leads to an **increase in urinary sodium excretion**.
- This increased sodium excretion is what drives their diuretic and antihypertensive effects.
Distal tubule and collecting duct function US Medical PG Question 4: A researcher is studying the effects of a new antihypertensive medication on urine osmolality. She first measures urine osmolality in different parts of the nephron of a healthy human control. The findings are shown below:
Portion of nephron Urine osmolality (mOsmol/kg)
Proximal convoluted tubule 300
Loop of Henle, descending limb 1200
Loop of Henle, ascending limb 200
Distal convoluted tubule 100
Collecting duct 600
Which of the following is the most likely explanation for the urine osmolality in the ascending limb of the loop of Henle?
- A. Increased urea excretion
- B. Increased transcription of water channels
- C. Impermeability to water (Correct Answer)
- D. Increased bicarbonate reabsorption
- E. Impermeability to sodium
Distal tubule and collecting duct function Explanation: ***Impermeability to water***
- The **ascending limb of the loop of Henle** is notable for its **water impermeability** due to the absence of aquaporins.
- This impermeability, coupled with active reabsorption of solutes, leads to the production of **hypoosmotic fluid** (200 mOsmol/kg) in this segment.
*Increased urea excretion*
- While urea is a major contributor to medullary osmolality and is excreted, it is primarily reabsorbed in the **collecting duct** and secreted into the loop of Henle, not directly explaining the low osmolality in the ascending limb.
- Increased urea excretion on its own would likely lead to a higher, not lower, osmolality of the urine exiting the kidney.
*Increased transcription of water channels*
- Increased transcription of water channels (**aquaporins**) would make the tubule more permeable to water, leading to water reabsorption and an **increase in osmolality**, which contradicts the observed hypoosmotic fluid.
- The ascending limb is primarily involved in **solute reabsorption** without water, making it dilute.
*Increased bicarbonate reabsorption*
- **Bicarbonate reabsorption** primarily occurs in the **proximal tubule** and is crucial for acid-base balance, not directly impacting the dramatic osmolality changes in the ascending limb.
- While some bicarbonate is reabsorbed in the ascending limb, it does not explain the significant decrease in fluid osmolality.
*Impermeability to sodium*
- The ascending limb is **highly permeable to sodium** and actively reabsorbs it via the **Na-K-2Cl cotransporter**, which is crucial for diluting the tubular fluid.
- If it were impermeable to sodium, the reabsorption of solutes would cease, and the osmolality would not decrease as observed.
Distal tubule and collecting duct function US Medical PG Question 5: On cardiology service rounds, your team sees a patient admitted with an acute congestive heart failure exacerbation. In congestive heart failure, decreased cardiac function leads to decreased renal perfusion, which eventually leads to excess volume retention. To test your knowledge of physiology, your attending asks you which segment of the nephron is responsible for the majority of water absorption. Which of the following is a correct pairing of the segment of the nephron that reabsorbs the majority of all filtered water with the means by which that segment absorbs water?
- A. Distal convoluted tubule via passive diffusion following ion reabsorption
- B. Distal convoluted tubule via aquaporin channels
- C. Thick ascending loop of Henle via passive diffusion following ion reabsorption
- D. Proximal convoluted tubule via passive diffusion following ion reabsorption (Correct Answer)
- E. Collecting duct via aquaporin channels
Distal tubule and collecting duct function Explanation: ***Proximal convoluted tubule via passive diffusion following ion reabsorption***
- The **proximal convoluted tubule (PCT)** is responsible for reabsorbing approximately **65-70% of filtered water**, making it the primary site of water reabsorption in the nephron.
- This water reabsorption primarily occurs **passively**, following the active reabsorption of solutes (especially **sodium ions**), which creates an osmotic gradient.
*Distal convoluted tubule via passive diffusion following ion reabsorption*
- The **distal convoluted tubule (DCT)** reabsorbs a much smaller percentage of filtered water (around 5-10%) and its water reabsorption is largely **regulated by ADH**, not primarily simple passive diffusion following bulk ion reabsorption.
- While some passive water movement occurs, it is not the main mechanism or location for the majority of water reabsorption.
*Distal convoluted tubule via aquaporin channels*
- While aquaporin channels do play a role in water reabsorption in the DCT, particularly under the influence of **ADH**, the DCT is not the segment responsible for the **majority of all filtered water absorption**.
- The bulk of water reabsorption occurs earlier in the nephron, independently of ADH for the most part.
*Thick ascending loop of Henle via passive diffusion following ion reabsorption*
- The **thick ascending loop of Henle** is primarily involved in reabsorbing ions like Na+, K+, and Cl- but is largely **impermeable to water**.
- Its impermeability to water is crucial for creating the **osmotic gradient** in the renal medulla, which is necessary for later water reabsorption.
*Collecting duct via aquaporin channels*
- The **collecting duct** is critically important for **regulated water reabsorption** via **aquaporin-2 channels** under the influence of **ADH**, allowing for fine-tuning of urine concentration.
- However, it reabsorbs only a variable portion (typically 5-19%) of the remaining filtered water, not the **majority of all filtered water**.
Distal tubule and collecting duct function US Medical PG Question 6: A new drug X is being tested for its effect on renal function. During the experiments, the researchers found that in patients taking substance X, the urinary concentration of sodium decreases while urine potassium concentration increase. Which of the following affects the kidneys in the same way as does substance X?
- A. Aldosterone (Correct Answer)
- B. Furosemide
- C. Spironolactone
- D. Atrial natriuretic peptide
- E. Hydrochlorothiazide
Distal tubule and collecting duct function Explanation: ***Aldosterone***
- **Aldosterone** acts on the **principal cells** of the **collecting duct** to increase sodium reabsorption and potassium secretion.
- This action leads to a decrease in urinary sodium concentration and an increase in urinary potassium concentration, matching the effects of drug X.
*Furosemide*
- **Furosemide** is a **loop diuretic** that inhibits the **Na-K-2Cl cotransporter** in the **thick ascending limb** of the loop of Henle.
- This inhibition leads to increased excretion of sodium, potassium, and water, resulting in higher urinary sodium concentration.
*Spironolactone*
- **Spironolactone** is an **aldosterone antagonist** that blocks aldosterone's effects on the collecting duct.
- This leads to increased sodium excretion and decreased potassium excretion (potassium-sparing effect), which is the opposite of drug X.
*Atrial natriuretic peptide*
- **Atrial natriuretic peptide (ANP)** is released in response to atrial stretch and causes **natriuresis** (increased sodium excretion) and **diuresis**.
- It works by dilating afferent arterioles and constricting efferent arterioles, increasing GFR, and inhibiting sodium reabsorption, thus increasing urinary sodium concentration.
*Hydrochlorothiazide*
- **Hydrochlorothiazide** is a **thiazide diuretic** that inhibits the **Na-Cl cotransporter** in the **distal convoluted tubule**.
- This leads to increased sodium and chloride excretion but typically causes potassium wasting (hypokalemia), which differs from the increased urinary potassium concentration seen with drug X.
Distal tubule and collecting duct function US Medical PG Question 7: A 17-year-old boy is brought to the physician by his father because of a 7-month history of fatigue, recurrent leg cramps, and increased urinary frequency. His pulse is 94/min and blood pressure is 118/85 mm Hg. Physical examination shows dry mucous membranes. Laboratory studies show:
Serum
Na+ 130 mEq/L
K+ 2.8 mEq/L
Cl- 92 mEq/L
Mg2+ 1.1 mEq/L
Ca2+ 10.6 mg/dL
Albumin 5.2 g/dL
Urine
Ca2+ 70 mg/24 h
Cl- 375 mEq/24h (N = 110–250)
Arterial blood gas analysis on room air shows a pH of 7.55 and an HCO3- concentration of 45 mEq/L. Impaired function of which of the following structures is the most likely cause of this patient's condition?
- A. Ascending loop of Henle
- B. Collecting duct
- C. Distal convoluted tubule (Correct Answer)
- D. Descending loop of Henle
- E. Proximal convoluted tubule
Distal tubule and collecting duct function Explanation: ***Distal convoluted tubule***
- The patient presents with **hypokalemia**, **metabolic alkalosis**, **hypomagnesemia**, and **hypocalciuria** (24-hour urine Ca2+ 70 mg, normal up to 250 mg), which are characteristic findings of **Gitelman syndrome**.
- **Gitelman syndrome** is caused by a loss-of-function mutation in the **thiazide-sensitive Na-Cl cotransporter (NCC)**, located in the **distal convoluted tubule**, leading to impaired reabsorption of Na+ and Cl- at this segment.
*Ascending loop of Henle*
- Impaired function of the **Na-K-2Cl cotransporter (NKCC2)** in the **thick ascending limb of the loop of Henle** causes **Bartter syndrome**.
- Bartter syndrome typically presents with **hypercalciuria**, in contrast to the hypocalciuria seen in this patient.
*Collecting duct*
- Dysfunction of the **collecting duct** can lead to various conditions, such as **renal tubular acidosis** or **diabetes insipidus**, depending on which channels or receptors are affected.
- However, the specific combination of **hypokalemia**, **metabolic alkalosis**, **hypomagnesemia**, and **hypocalciuria** points away from primary collecting duct dysfunction.
*Descending loop of Henle*
- The **descending loop of Henle** is primarily permeable to **water** and has a limited role in electrolyte reabsorption.
- Impairment here would primarily affect **urine concentration** and dilution but would not account for the specific electrolyte imbalances observed.
*Proximal convoluted tubule*
- The **proximal convoluted tubule** is responsible for reabsorbing a large fraction of filtered electrolytes, glucose, and amino acids.
- Dysfunction here (e.g., **Fanconi syndrome**) would typically present with **generalized aminoaciduria**, **glycosuria**, **phosphaturia**, and **proximal renal tubular acidosis**, which are not seen in this patient.
Distal tubule and collecting duct function US Medical PG Question 8: A 57-year-old male is found to have an elevated prostate specific antigen (PSA) level on screening labwork. PSA may be elevated in prostate cancer, benign prostatic hypertrophy (BPH), or prostatitis. Which of the following best describes the physiologic function of PSA?
- A. Regulation of transcription factors and phosphorylation of proteins
- B. Maintains corpus luteum
- C. Response to peritoneal irritation
- D. Sperm production
- E. Liquefaction of semen (Correct Answer)
Distal tubule and collecting duct function Explanation: ***Liquefaction of semen***
- Prostate-specific antigen (PSA) is a **serine protease** produced by the epithelial cells of the prostate gland.
- Its primary physiological role is to **liquefy the seminal coagulum** formed after ejaculation, allowing sperm to become motile and navigate the female reproductive tract.
*Regulation of transcription factors and phosphorylation of proteins*
- This function is characteristic of **kinases** and **phosphatases**, which are involved in intracellular signaling pathways.
- While essential for cellular function, it does not describe the specific role of PSA.
*Maintains corpus luteum*
- The maintenance of the corpus luteum is primarily the role of **luteinizing hormone (LH)** and, in pregnancy, **human chorionic gonadotropin (hCG)**.
- These hormones are involved in the female reproductive cycle, unrelated to PSA.
*Response to peritoneal irritation*
- Peritoneal irritation triggers an inflammatory response involving various immune cells and mediators, but not specifically PSA.
- PSA itself is not directly involved in the systemic or local response to peritoneal inflammation.
*Sperm production*
- **Sperm production (spermatogenesis)** occurs in the seminiferous tubules of the testes under the influence of hormones like FSH and testosterone.
- While semen is the vehicle for sperm, PSA's role is in the post-ejaculatory processing of semen, not in the initial production of sperm.
Distal tubule and collecting duct function US Medical PG Question 9: A 28-year-old research assistant is brought to the emergency department for severe chemical burns 30 minutes after accidentally spilling hydrochloric acid on himself. The burns cover both hands and forearms. His temperature is 37°C (98.6°F), pulse is 112/min, respirations are 20/min, and blood pressure is 108/82 mm Hg. Initial stabilization and resuscitation is begun, including respiratory support, fluid resuscitation, and cardiovascular stabilization. The burned skin is irrigated with saline water to remove the chemical agent. Which of the following is the most appropriate method to verify adequate fluid infusion in this patient?
- A. The Parkland formula
- B. Blood pressure
- C. Pulmonary capillary wedge pressure
- D. Heart rate
- E. Urinary output (Correct Answer)
Distal tubule and collecting duct function Explanation: ***Urinary output***
- Maintaining a specific **urinary output** (e.g., adult with major burns: 0.5-1.0 mL/kg/hr or 30-50 mL/hr) is the most reliable clinical indicator of adequate fluid resuscitation in burn patients.
- This ensures sufficient end-organ perfusion and avoids both under-resuscitation (leading to shock and organ damage) and over-resuscitation (risk of compartment syndrome and pulmonary edema).
*The Parkland formula*
- The **Parkland formula** is used to *calculate* the initial fluid volume needed, but it does not *verify* the adequacy of the infusion once started.
- This formula provides a starting point for fluid administration, which then needs to be adjusted based on the patient's response.
*Blood pressure*
- **Blood pressure** can be misleading in burn patients; it may remain deceptively normal due to compensatory mechanisms even with significant fluid deficits.
- It is a late indicator of hypovolemic shock, and relying solely on it can lead to under-resuscitation.
*Pulmonary capillary wedge pressure*
- **Pulmonary capillary wedge pressure (PCWP)** requires invasive monitoring via a pulmonary artery catheter, which is rarely indicated for routine fluid management in burn patients due to its invasiveness and associated risks.
- Less invasive and equally effective methods, like urinary output, are preferred for monitoring resuscitation.
*Heart rate*
- **Heart rate** is a sensitive but non-specific indicator of fluid status; it can be elevated due to pain, anxiety, or infection, not solely hypovolemia.
- While a decreasing heart rate can indicate improved fluid status, it is not as reliable or direct an indicator of end-organ perfusion as urinary output.
Distal tubule and collecting duct function US Medical PG Question 10: Renal clearance of substance Y is experimentally studied. At a constant glomerular filtration rate, it is found that the amount of substance Y excreted is greater than the amount filtered. This holds true across all physiologic values on the titration curve. Substance Y is most similar to which of the following?
- A. Para-amino hippuric acid (Correct Answer)
- B. Albumin
- C. Bicarbonate
- D. Magnesium
- E. Glucose
Distal tubule and collecting duct function Explanation: ***Para-amino hippuric acid***
- If the amount of a substance excreted is **greater than the amount filtered**, it indicates that the substance undergoes both **glomerular filtration** and **tubular secretion**.
- **Para-amino hippuric acid (PAH)** is a classic example of a substance that is extensively filtered and actively secreted by the renal tubules, making its clearance rate very high and a good estimate of **renal plasma flow**.
*Albumin*
- **Albumin** is a large protein that is normally **not filtered** by the glomerulus due to its size and negative charge.
- Its presence in the urine, indicating a greater amount excreted than filtered (which is normally zero), would suggest **glomerular damage**, but it does not undergo active tubular secretion.
*Bicarbonate*
- **Bicarbonate** is freely filtered at the glomerulus and is primarily **reabsorbed** in the renal tubules, particularly in the proximal tubule.
- Therefore, the amount of bicarbonate excreted is typically **much less than** the amount filtered, not greater.
*Magnesium*
- **Magnesium** is filtered by the glomeruli and undergoes complex regulation involving both **reabsorption and secretion** in various parts of the renal tubule, though reabsorption predominates.
- While magnesium balance is maintained by the kidneys, its excretion does not typically exceed filtration to the extent described for substances primarily handled by secretion.
*Glucose*
- **Glucose** is freely filtered at the glomerulus and is almost **completely reabsorbed** in the proximal tubule under normal physiological conditions.
- The amount of glucose excreted is typically zero, and only exceeds filtration when the **tubular reabsorptive capacity is saturated**, as in uncontrolled diabetes, but it is reabsorbed, not secreted.
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