Acute kidney injury — MCQs

A 53-year-old woman presents to the emergency room with severe chest pain radiating to the back. She was diagnosed with acute aortic dissection. A few hours into the resuscitation, she was having oliguria. Laboratory findings show a serum creatinine level of 5.3 mg/dL. Which of the following casts are most likely to be seen on urinalysis?

A 32-year-old man is brought to the emergency department after a car accident; he was extricated after 4 hours. He did not lose consciousness and does not have headache or nausea. He is in severe pain. He sustained severe injuries to both arms and the trauma team determines that surgical intervention is needed. Urinary catheterization shows dark colored urine. His temperature is 38°C (100.4°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. The patient is alert and oriented. Examination shows multiple injuries to the upper extremities, contusions on the trunk, and abdominal tenderness. Laboratory studies show: Hemoglobin 9.2 g/dL Leukocyte count 10,900/mm3 Platelet count 310,000/mm3 Serum Na+ 137 mEq/L K+ 6.8 mEq/L Cl- 97 mEq/L Glucose 168 mg/dL Creatinine 1.7 mg/dL Calcium 7.7 mg/dL Arterial blood gas analysis on room air shows a pH of 7.30 and a serum bicarbonate of 14 mEq/L. An ECG shows peaked T waves. A FAST scan of the abdomen is negative. Two large bore cannulas are inserted and intravenous fluids are administered. Which of the following is the most appropriate next step in management?

A 52-year-old man is brought to the emergency department by ambulance after a motor vehicle accident. He was an unrestrained passenger who was ejected from the vehicle. On presentation, he is found to be actively bleeding from numerous wounds. His blood pressure is 76/42 mmHg and pulse is 152/min. Attempts at resuscitation fail, and he dies 25 minutes later. Autopsy shows blood in the peritoneal cavity, and histology of the kidney reveals swelling of the proximal convoluted tubule epithelial cells. Which of the following is most likely the mechanism underlying the renal cell findings?

A 58-year-old man presents to the emergency department following a motor vehicle accident where he was an unrestrained passenger. On initial presentation in the field, he had diffuse abdominal tenderness and his blood pressure is 70/50 mmHg and pulse is 129/min. Following administration of 2 L of normal saline, his blood pressure is 74/58 mmHg. He undergoes emergency laparotomy and the source of the bleeding is controlled. On the second post-operative day, his blood pressure is 110/71 mmHg and pulse is 90/min. There is a midline abdominal scar with no erythema and mild tenderness. Cardiopulmonary examination is unremarkable. He has had 300 mL of urine output over the last 24 hours. Urinalysis shows 12-15 RBC/hpf, 2-5 WBC/hpf, and trace protein. What additional finding would you expect to see on urinalysis?

A 67-year-old man comes to the emergency department for the evaluation of two episodes of red urine since this morning. He has no pain with urination. He reports lower back pain and fever. Six months ago, he was diagnosed with osteoarthritis of the right knee that he manages with 1–2 tablets of ibuprofen per day. He has smoked one pack of cigarettes daily for the past 45 years. He does not drink alcohol. His temperature is 38.5°C (101.3°F), pulse is 95/min, and blood pressure is 130/80 mm Hg. Physical examination shows faint, diffuse maculopapular rash, and bilateral flank pain. The remainder of the examination shows no abnormalities. Urinalysis shows: Blood +3 Protein +1 RBC 10–12/hpf RBC cast negative Eosinophils numerous Which of the following is the most likely diagnosis?

A 48-year-old man is brought to the emergency department by his wife because of a 3-day history of increasing confusion and lethargy. He complains of decreased urine output and abdominal pain for the past month. Two months ago, he was hospitalized for pyelonephritis and treated with ceftriaxone. He has a history of chronic hepatitis C. He does not take any medications. He appears pale and irritable. His temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 98/60 mm Hg. On mental status examination, he is oriented to person but not to time or place. Physical examination shows scleral icterus and jaundice. There is 2+ pitting edema of the lower extremities. The abdomen is distended with a positive fluid wave. Laboratory studies show: Hemoglobin 10.1 g/dL Leukocyte count 4300/mm3 Platelet count 89,000/mm3 Prothrombin time 19 sec Serum Urea nitrogen 71 mg/dL Glucose 99 mg/dL Creatinine 3.5 mg/dL ALT 137 mg/dL AST 154 mg/dL Urinalysis shows no abnormalities. The FeNa is < 1%. Ultrasound of the kidneys is unremarkable. Intravenous fluids are administered for 36 hours but do not improve urine output. Which of the following is the most likely cause of the kidney dysfunction in this patient?

A 32-year-old man is brought to the Emergency Department after 3 consecutive days of diarrhea, fatigue and weakness. His stool has been soft and mucoid, with no blood stains. The patient just came back from a volunteer mission in Guatemala, where he remained asymptomatic. His personal medical history is unremarkable. Today his blood pressure is 98/60 mm Hg, pulse is 110/min, respiratory rate is 19/min, and his body temperature is 36.7°C (98.1°F). On physical exam, he has sunken eyes, dry mucosa, mild diffuse abdominal tenderness, and hyperactive bowel sounds. Initial laboratory tests are shown below: Serum creatinine (SCr) 1.8 mg/dL Blood urea nitrogen (BUN) 50 mg/dL Serum sodium 132 mEq/L Serum potassium 3.5 mEq/L Serum chloride 102 mEq/L Which of the following phenomena would you expect in this patient?

A 63-year-old man undergoes uncomplicated laparoscopic cholecystectomy for acute cholecystitis and is admitted to the surgical ward for postoperative management. On postoperative day 1, routine laboratory studies reveal an increase in serum creatinine to 1.46 mg/dL from 0.98 mg/dL before the operation; BUN is 37 mg/dL, increased from 18 mg/dL on prior measurement; K is 4.8 mEq/L and CO2 is 19 mEq/L. The patient has an indwelling urinary catheter in place, draining minimal urine over the last few hours. Which of the following is the most appropriate next step in management?

A 49-year-old woman presents to the emergency room with bloody stool and malaise. She developed a fever and acute left lower quadrant abdominal pain earlier in the day. She has had 2 bowel movements with bright red blood. Her past medical history is notable for hyperlipidemia, hypertension, and diabetes mellitus. She takes lovastatin, hydrochlorothiazide, metformin, glyburide, and aspirin. Her temperature is 102.9°F (39.4°C), blood pressure is 101/61 mmHg, pulse is 110/min, and respirations are 22/min. On exam, she is fully alert and oriented. She is tender in the left lower quadrant. A computerized tomography (CT) scan is performed demonstrating acute diverticulitis. She is admitted and started on broad-spectrum antibiotics. 48 hours later, her urine output is significantly decreased. Her abdominal pain has improved but she has started vomiting and appears confused. She has new bilateral lower extremity edema and decreased breath sounds at the lung bases. Laboratory analysis upon admission and 48 hours later is shown below: Admission: Hemoglobin: 11.9 g/dl Hematocrit: 34% Leukocyte count: 11,500/mm^3 Platelet count: 180,000/ mm^3 Serum: Na+: 141 mEq/L Cl-: 103 mEq/L K+: 4.5 mEq/L HCO3-: 23 mEq/L BUN: 21 mg/dL Glucose: 110 mg/dL Creatinine: 0.9 mg/dL 48 hours later: Hemoglobin: 10.1 g/dl Hematocrit: 28% Leukocyte count: 11,500 cells/mm^3 Platelet count: 195,000/ mm^3 Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 5.1 mEq/L HCO3-: 24 mEq/L BUN: 30 mg/dL Glucose: 120 mg/dL Creatinine: 2.1 mg/dL Which of the following findings would most likely be seen on urine microscopy?

A 45-year-old homeless man is brought to the emergency department by the police. He was found intoxicated and passed out in a library. The patient has a past medical history of IV drug abuse, diabetes, alcohol abuse, and malnutrition. The patient has been hospitalized previously for multiple episodes of pancreatitis and sepsis. Currently, the patient is minimally responsive and only withdraws his extremities in response to painful stimuli. His temperature is 99.5°F (37.5°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam is notable for tachycardia, a diastolic murmur at the left lower sternal border, and bilateral crackles on pulmonary exam. The patient is started on IV fluids, vancomycin, and piperacillin-tazobactam. Laboratory values are ordered as seen below. Hemoglobin: 9 g/dL Hematocrit: 30% Leukocyte count: 11,500/mm^3 with normal differential Platelet count: 297,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.0 mEq/L HCO3-: 28 mEq/L BUN: 33 mg/dL Glucose: 60 mg/dL Creatinine: 1.7 mg/dL Ca2+: 9.7 mg/dL PT: 20 seconds aPTT: 60 seconds AST: 1,010 U/L ALT: 950 U/L The patient is admitted to the medical floor. Five days later, the patient's neurological status has improved. His temperature is 99.5°F (37.5°C), blood pressure is 130/90 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 99% on room air. Laboratory values are repeated as seen below. Hemoglobin: 10 g/dL Hematocrit: 32% Leukocyte count: 9,500/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 102 mEq/L K+: 4.3 mEq/L HCO3-: 24 mEq/L BUN: 31 mg/dL Glucose: 100 mg/dL Creatinine: 1.6 mg/dL Ca2+: 9.0 mg/dL PT: 40 seconds aPTT: 90 seconds AST: 150 U/L ALT: 90 U/L Which of the following is the best description of this patient’s current status?