First Aid Express 2018 workbook: RENAL page 1

Renal
Questions

EMBRYOLOGY
1. What are the four causes of Potter sequence? (p 562) ____________________________________

2. Which genetic diseases are associated with horseshoe kidney? (p 563) _______________________

3. What error in development occurs that results in unilateral renal agenesis? (p 563) _____________

______________________________________________________________________________

4. What is the most common cause of bladder outlet obstruction in male infants? (p 563) __________

______________________________________________________________________________

ANATOMY
5. Why is the left kidney harvested for transplantation rather than the right? (p 564) ______________

______________________________________________________________________________

6. Ureters pass ______________ (over/under) the uterine artery and the ductus deferens. (p 564)

PHYSIOLOGY
7. What is the 60-40-20 rule of total body weight? (p 565) __________________________________

______________________________________________________________________________

8. The fenestrated capillary endothelium of the glomerular filtration barrier is responsible for the filtration
of plasma by which characteristic: size or charge? (p 565) ________________________________

______________________________________________________________________________

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9. The epithelial layer of the glomerular filtration barrier is formed by which cells? (p 565) _________

______________________________________________________________________________

10. What is the formula for calculating the clearance of substance X, the volume of plasma from which
the substance is cleared completely per unit of time? (p 566) _____________________________

______________________________________________________________________________

11. If renal clearance is greater than the glomerular filtration rate (GFR) of substance X, then there is a

net tubular ____________ (reabsorption/secretion) of substance X. (p 566)

12. Creatinine clearance slightly ____________ (overestimates/underestimates) the GFR rate because

creatinine is ____________ (secreted/reabsorbed) by the renal tubules. (p 566)

13. What is the formula for estimating renal blood flow if renal plasma flow is known? (p 566)

_____________________________________________________________________________

14. What are the effects of prostaglandins on the glomerulus? (p 567) _________________________

______________________________________________________________________________

15. What are the effects of angiotensin II on the glomerulus? (p 567) __________________________

______________________________________________________________________________

16. Decreased plasma protein concentration causes ____________ (decrease/increase/no change) in

renal plasma flow and ____________ (decrease/increase/no change) in GFR, which in turn results
in ____________ (decrease/increase/no change) in the filtration fraction. (p 567)

17. Constriction of the afferent arteriole causes ____________ (decrease/increase/no change) in renal
plasma flow and ____________ (decrease/increase/no change) in GFR, which in turn results in
____________ (decrease/increase/no change) in the filtration fraction. (p 567)

18. What is the formula for excretion rate? (p 568) _________________________________________

______________________________________________________________________________

19. In the nephron, glucose at normal plasma concentrations is reabsorbed in which structure? And by
which transporter? (p 568) _________________________________________________________

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 First Aid Express 2018 workbook: RENAL page 3

20. At what plasma glucose concentration is the transport mechanism of the proximal tubule completely
saturated, leading to glucose spilling into the urine? (p 568) _______________________________

21. What ion is secreted into the lumen of the early proximal convoluted tubule and acts to reabsorb
bicarbonate? (p 569) _____________________________________________________________

22. Which three ions are actively reabsorbed in the thick ascending loop of Henle? (p 569) _________

______________________________________________________________________________

23. Which two ions are indirectly reabsorbed in the thick ascending loop of Henle? (p 569) __________

______________________________________________________________________________

24. Which hormone controls the reabsorption of calcium in the early distal convoluted tubule? (p 569)

______________________________________________________________________________

25. On which segment of the nephron does the hormone aldosterone act? (p 569) ________________

______________________________________________________________________________

26. ADH’s effect at V2 receptors results in what action? (p 569) _______________________________

______________________________________________________________________________

27. The ratio of solute concentration in the tubular fluid versus plasma (TF/P) can indicate the level of
secretion or reabsorption of that solute along the proximal renal tubule. If the TF/P ratio of that solute
is less than that of inulin, there is net ____________ (reabsorption/secretion) along the proximal
tubule. (p 571)

28. Along the length of the proximal tubule, does the relative concentration of chloride increase,
decrease, or stay the same? (p 571) _________________________________________________

29. Which five actions of angiotensin II serve to increase intravascular volume and blood pressure?
(p 572) _________________________________________________________________________

______________________________________________________________________________

30. Where is angiotensin-converting enzyme primarily located? (p 572) _________________________

31. When blood pressure falls, the kidneys release which proteolytic enzyme? (p 572) ____________

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32. ADH primarily regulates __________ (serum osmolarity/blood volume), whereas aldosterone
primarily regulates __________ (serum osmolarity/blood volume). However, in __________
(low/high) volume states, both ADH and aldosterone act to protect __________ (serum
osmolarity/blood volume). (p 572)

33. What are the effects of aldosterone secretion? (p 572) ___________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

34. Atrial natriuretic peptide ____________ (decreases/increases) renin secretion and ____________
(decreases/increases) the GFR. (p 572)

35. Which cells in the kidney secrete renin? (p 573) ________________________________________

36. Which hormone is released by the interstitial cells of renal peritubular capillaries in response to
hypoxia? (p 573) _________________________________________________________________

37. Which enzyme from the kidney is activated by PTH, and what is the function of that enzyme? (p 573)

______________________________________________________________________________

38. In the chart below, check the effect that each condition has on the potassium shift. (p 574)

Shifts K+ into Cell Shifts K+ out of Cell

Effect
→ Hypokalemia → Hyperkalemia
Acidosis
Alkalosis
β-adrenergic agonists
β-blocker
Cell lysis
Digitalis
Hyperosmolarity
Hypo-osmolarity
Insulin
Insulin deficiency

39. By what mechanism does insulin cause hypokalemia? (p 574) ______________________________

______________________________________________________________________________

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 First Aid Express 2018 workbook: RENAL page 5

40. What is the primary electrolyte disturbance in metabolic acidosis? (p 576) ___________________

41. What is the compensatory respiratory response to metabolic acidosis, and does PCO2 increase or
decrease? (p 576) _______________________________________________________________

42. What are the nine causes of increased anion gap metabolic acidosis? (p 576) _________________

______________________________________________________________________________

PATHOLOGY
43. What glomerular diseases can be considered both nephritic and nephrotic syndromes? (p 579)
______________________________________________________________________________

44. What four clinical findings are associated with nephritic syndrome? (p 579) __________________

______________________________________________________________________________

______________________________________________________________________________

45. What four clinical findings are associated with nephrotic syndrome? (p 580) __________________

______________________________________________________________________________

46. Match the nephrotic syndrome with its characteristic findings. (p 580)

_____ A. Amyloidosis 1. Associated with chronic disease

_____ B. Diabetic glomerulonephropathy 2. Foot process effacement on EM

_____ C. Focal segmental glomerulosclerosis 3. Hyalinosis on LM

_____ D. Membranous nephropathy 4. Kimmelstiel-Wilson lesion on LM

_____ E. Minimal change disease . 5. “Spike-and-dome appearance” on EM

47. What is the most common cause of nephrotic syndrome in African Americans and Hispanics? (p 580)
______________________________________________________________________________

48. In diabetic glomerulonephropathy, what causes mesangial expansion? (p 580) _______________

______________________________________________________________________________

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49. A 10-year-old boy presents with periorbital edema and cola-colored urine, which are both beginning
to resolve without intervention. Electron microscopy of a kidney biopsy specimen shows subepithelial
immune complex humps. Which form of nephritic syndrome does he most likely have? (p 581)

______________________________________________________________________________

50. Match the nephritic syndrome with its characteristic finding on microscopy. (p 581)

_____ A. Acute poststreptococcal glomerulonephritis 1. Crescent-moon shape

_____ B. Alport syndrome 2. Immune complexes in mesangium

_____ C. Diffuse proliferative glomerulonephritis 3. Subepithelial immune complex humps

_____ D. IgA nephropathy 4. Split basement membrane

_____ E. Rapidly progressive glomerulonephritis 5. “Wire looping” of capillaries

_____ F. Membranoproliferative glomerulonephritis 6. “Tram-track” appearance on EM

51. Granulomatosis with polyangiitis (Wegener) is ____________ (PR3-ANCA/c-ANCA or MPO-

ANCA/p-ANCA) positive, whereas microscopic polyangiitis is ____________ (PR3-ANCA/c-ANCA

or MPO-ANCA/p-ANCA) positive. (p 581)

52. For which systemic disease is diffuse proliferative glomerulonephritis the most common cause of

death? (p 581) __________________________________________________________________

53. Kidney stones are most commonly composed of what element? (p 582) _____________________

______________________________________________________________________________

54. Both antifreeze and vitamin C abuse can result in the formation of which type of crystals? (p 582)

______________________________________________________________________________

55. An 80-year-old man with leukemia presents with hematuria and right-sided flank pain. Which type of
kidney stone is he most likely to have? And how would this stone appear on x-ray? (p 582)

______________________________________________________________________________

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 First Aid Express 2018 workbook: RENAL page 7

56. Match the renal pathology with its characteristic findings. (pp 583-587)

_____ A. Acute pyelonephritis 1.Associated with aniline dye exposure

_____ B. Acute tubular necrosis 2. Associated with diabetes

_____ C. Bladder cancer 3. Associated with obstetric catastrophe

_____ D. Chronic pyelonephritis 4. Associated with vHL syndrome

_____ E. Diffuse cortical necrosis 5. Muddy brown casts in urine

_____ F. Drug-induced interstitial nephritis 6. Nephroblastoma

_____ G. Renal cell carcinoma 7. Painless hematuria

_____ H. Renal papillary necrosis 8. Pyuria and azotemia

_____ I. Transitional cell carcinoma 9. Thyroidization of kidney

_____ J. Wilms tumor 10. WBC casts in urine

57. Name the four components of the WAGR complex. (p 584) _______________________________

______________________________________________________________________________

58. Which three general types of renal dysfunction can lead to acute kidney injury? (p 586) ___________

______________________________________________________________________________

59. True or false: Unilateral postrenal outflow obstruction can lead to acute kidney injury. (p 586) ______

______________________________________________________________________________

60. A patient's urine osmolarity is <350 mOsm/kg, urine sodium level is >40 mEq/L, fractional excretion

of sodium is >4%, and BUN/creatinine ratio is >15:1. Is the cause of the acute renal failure most

likely to be prerenal, renal, or postrenal? (p 586) _______________________________________

61. A patient’s urine osmolarity is >500 mOsm/kg, urine sodium level is <10 mEq/L, fractional excretion

of sodium is <1%, and BUN/creatinine ratio is >20:1. Is the cause of the acute renal failure most

likely to be prerenal, renal, or postrenal? (p 586) _______________________________________

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62. What are the eight consequences of renal failure? (p 586) _______________________________

______________________________________________________________________________

______________________________________________________________________________

63. Which type of mutation causes autosomal-dominant polycystic kidney disease (formerly adult

polycystic kidney disease)? (p 588) _________________________________________________

64. What are the two major causes of death associated with autosomal-dominant polycystic kidney

disease? (p 588) ________________________________________________________________

______________________________________________________________________________

65. What are the complications of autosomal-recessive polycystic kidney disease in utero and after the
neonatal period? (p 588) __________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

PHARMACOLOGY

66. What is the mechanism of action of acetazolamide? (p 590) ______________________________

______________________________________________________________________________

67. What is the mechanism of action of furosemide? (p 590) _________________________________

______________________________________________________________________________

______________________________________________________________________________

68. Which loop diuretic is used for diuresis in patients who are allergic to sulfa drugs? (p 590) ______

______________________________________________________________________________

69. What are the effects of hydrochlorothiazide toxicity? (p 591) ______________________________

______________________________________________________________________________

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70. What is the mechanism of action of spironolactone? (p 591) ______________________________

______________________________________________________________________________

71. What is the mechanism by which ACE inhibitors can cause angioedema? (p 592) _____________

______________________________________________________________________________

______________________________________________________________________________

72. What are three clinical uses of ACE inhibitors? (p 592) __________________________________

______________________________________________________________________________

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Answers

EMBRYOLOGY

1. ARPKD, posterior urethral valves, bilateral renal agenesis, and chronic placental insufficiency.

2. Turner syndrome; trisomies 13, 18, 21

3. Ureteric bud fails to develop and induce differentiation of metanephric mesenchyme.

4. Posterior urethral valves

ANATOMY

5. Because the left kidney has a longer renal vein.

6. Under. (Remember: "water [ureters] under the bridge [uterine artery and ductus deferens]").

PHYSIOLOGY

7. 60% of total body weight is made up of total body water, 40% is made up of intracellular fluid, and
20% is made up of extracellular fluid.

8. Size.

9. Podocyte foot processes.

10. Renal clearance of X = the urine concentration of X times the urine flow rate, divided by the plasma
concentration of X [Cx = (Ux × V)/Px].

11. Secretion.

12. Overestimates; secreted. (The plasma concentration of creatinine is slightly lower than it would be
from filtration alone.)

13. Renal blood flow = renal plasma flow divided by (1 – the hematocrit), or RBF = RPF/(1 – Hct). In a
normal individual, renal blood flow will be approximately double the renal plasma flow.

14. Prostaglandins cause dilation of the afferent arteriole and an increase in the GFR.

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 First Aid Express 2018 workbook: RENAL page 11

15. Angiotensin II causes constriction of the efferent arteriole and an increase in the GFR.

16. No change; increase; increase.

17. Decrease; decrease; no change.

18. Excretion rate = V × Ux; where V is the urine flow rate and Ux is the urine concentration of X.

19. Glucose is reabsorbed in the proximal tubule by a sodium/glucose cotransporter.

20. ~375 mg/dL.

21. Hydrogen ions.

22. Sodium, potassium, and chloride.

23. Magnesium and calcium.

24. PTH.

25. Collecting tubule.

26. Insertion of aquaporin water channels on the apical side of the collecting tubules, resulting in
increased water reabsorption.

27. Reabsorption.

28. Increase. (Chloride reabsorption occurs at a slower rate in the early PCT causing an initial rise in the
TF/P ratio relative to other ions)

29. Vasoconstriction; stimulation of sodium resorption in the proximal tubule; release of aldosterone from
the adrenal cortex; release of ADH from the posterior pituitary; and simulation of thirst via the
hypothalamus.

30. Lungs.

31. Renin.

32. Osmolarity; blood volume; low; blood volume.

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33. Aldosterone secretion from the adrenal cortex increases sodium channel and sodium/potassium
pump insertion in principal cells and enhances potassium and hydrogen excretion by upregulating
potassium channels in the principal cells and hydrogen ion channels in the intercalated cells. These
actions create a favorable gradient for sodium and water reabsorption.

34. Decreases; increases.

35. Juxtaglomerular cells.

36. Erythropoietin.

37. 1α-Hydroxylase, which converts 25-OH vitamin D3 to 1,25-(OH)2 vitamin D3.

38.
Shifts K+ Into Cell Shifts K+ Out of Cell
Effect
→Hypokalemia → Hyperkalemia
Acidosis √
Alkalosis √
β-adrenergic agonists √
β-adrenergic antagonists √
Cell lysis √
Digitalis √
Hyperosmolarity √
Hypo-osmolarity √
Insulin √
Insulin deficiency √

39. Insulin increases activity of the Na+/K+ ATPase pump. This increases the amount of K+ pumped into
the cell in exchange for Na+, thus leaving less K+ outside the cell.

40. Decreased serum bicarbonate.

41. Hyperventilation, which causes PCO2 to decrease.

42. Methanol (formic acid), Uremia, Diabetic ketoacidosis, Propylene glycol, Iron tables or Isoniazid,
Lactic acidosis, Ethylene glycol (oxalic acid), and Salicylates. (Remember: MUDPILES.)

PATHOLOGY

43. Diffuse proliferative glomerulonephritis and membranoproliferative glomerulonephritis.

44. Azotemia (↑ BUN and Cr), oliguria, hypertension, and proteinuria <3.5 g/day.

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 First Aid Express 2018 workbook: RENAL page 13

45. Massive proteinuria (>3.5 g/day), hyperlipidemia, hypoalbuminemia, and edema.

46. A-1, B-4, C-3, D-5, E-2.

47. Focal segmental glomerular sclerosis.

48. Nonenzymatic glycosylation of the efferent arterioles, leading to an increased GFR and thus
mesangial expansion.

49. Acute poststreptococcal glomerulonephritis.

50. A-3, B-4, C-5, D-2, E-1, F-6.

51. PR3-ANCA/c-ANCA; MPO-ANCA/p-ANCA.

52. Systemic lupus erythematosus.

53. Calcium in the form of calcium oxalate, calcium phosphate, or both.

54. Oxalate crystals.

55. The patient’s leukemia (a disease with high cell turnover) can result in hyperuricemia, so he is at risk
for developing uric acid stones, which are radiolucent and do not appear on x-ray studies, but are
visible on CT and ultrasound.

56. A-10, B-5, C-7, D-9, E-3, F-8, G-4, H-2, I-1, J-6.

57. WAGR complex = Wilms tumor, Aniridia, Genitourinary malformation, and Retardation (intellectual
disability).

58. Prerenal (eg, hypotension and reduced renal blood flow), intrinsic renal (eg, tubular necrosis), and
postrenal (outflow obstruction).

59. False; bilateral (not unilateral) postrenal outflow obstruction leads to acute renal failure.

60. Postrenal.

61. Prerenal.

62. Metabolic Acidosis, Dyslipidemia, Hyperkalemia, Uremia, Na+/H2O retention, Growth retardation and
developmental delay (in children), Erythropoietin failure, Renal osteodystrophy. Remember MAD
HUNGER.

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page 14 First Aid Express 2018 workbook: RENAL

63. An autosomal dominant mutation in the PKD1 or PKD2 gene.

64. Death usually results from complications of chronic kidney disease or hypertension (due to increased
renin production).

65. Renal failure in utero, from autosomal recessive polycystic kidney disease, can lead to Potter
sequence (see page 562). After the neonatal period, potential complications include hypertension,
portal hypertension, and progressive renal insufficiency.

PHARMACOLOGY

66. Acetazolamide acts as a carbonic anhydrase inhibitor, causing self-limited sodium bicarbonate
diuresis and a reduction in total-body bicarbonate stores.

67. Furosemide inhibits the Na+/K+/2Cl– cotransport system in the thick ascending limb of the loop of
Henle, thereby abolishing the hypertonicity of the medulla and preventing the concentration of urine.

68. Ethacrynic acid.

69. GLUCose (hyperGlycemia), lipids (hyperLipidemia), uric acid (hyperUricemia), and calcium
(hyperCalcemia). (Remember: HyperGLUC.)

70. Spironolactone competitively antagonizes the aldosterone receptor in the cortical collecting tubule.

71. ACE inhibitors prevent the inactivation of bradykinin, a potent vasodilator. Increased bradykinin levels
can lead to angioedema in susceptible individuals.

72. To treat hypertension, to treat heart failure, and to slow the progression of diabetic renal disease.

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