ITE Nephrology and Hypertension 2 — Questions and Answers
Question 1: A 55-year-old woman with IgA nephropathy has a urine protein-to-creatinine ratio of 1.8 g/g and eGFR of 52 mL/min/1.73m². Which additional therapy beyond RAS blockade has demonstrated benefit in slowing CKD progression in this condition?
- Hydroxychloroquine
- Sparsentan (Correct answer)
- Mycophenolate mofetil
- Rituximab
Correct answer: Sparsentan
Sparsentan, a dual endothelin-angiotensin receptor antagonist, has demonstrated significant proteinuria reduction and renal protective effects in IgA nephropathy.
Question 2: A 40-year-old man presents with hematuria, flank pain, and a palpable abdominal mass. Imaging shows bilateral enlarged kidneys with multiple cysts. His father had the same condition and died from a ruptured intracranial aneurysm. Which gene mutation is most likely responsible?
- PKD2
- PKD1 (Correct answer)
- TSC1
- VHL
Correct answer: PKD1
PKD1 mutations account for approximately 85% of autosomal dominant polycystic kidney disease cases and are associated with more severe disease and earlier ESRD.
Question 3: A 30-year-old pregnant woman at 32 weeks develops BP of 158/102 mmHg, 3+ proteinuria, and a platelet count of 82,000/µL with elevated LDH. What is the most appropriate next step?
- IV labetalol and expectant management until 37 weeks
- Emergent delivery after maternal stabilization (Correct answer)
- Oral nifedipine and close outpatient monitoring
- IV magnesium only and recheck labs in 24 hours
Correct answer: Emergent delivery after maternal stabilization
HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) at ≥32 weeks warrants delivery after maternal stabilization with magnesium and antihypertensives.
Question 4: A patient with nephrotic syndrome develops sudden flank pain and gross hematuria. Doppler ultrasound reveals absent flow in the left renal vein. Which underlying condition most predisposes to this complication?
- Focal segmental glomerulosclerosis
- Membranous nephropathy (Correct answer)
- Minimal change disease
- IgA nephropathy
Correct answer: Membranous nephropathy
Membranous nephropathy carries the highest risk of renal vein thrombosis among nephrotic syndromes due to urinary loss of anticoagulant proteins like protein C, S, and antithrombin III.
Question 5: A 62-year-old man with type 2 diabetes and CKD stage 3b (eGFR 38) is on maximally tolerated ACEI. His most recent urine albumin-to-creatinine ratio is 420 mg/g. Which agent should be added to further reduce cardiorenal risk?
- Amlodipine
- Spironolactone
- Finerenone (Correct answer)
- Hydralazine
Correct answer: Finerenone
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, has demonstrated reduction in CKD progression and cardiovascular events in diabetic CKD when added to RAS blockade.
Question 6: A 45-year-old man presents with acute oliguric kidney injury, hemoptysis, and pANCA positivity. Kidney biopsy shows pauci-immune crescentic glomerulonephritis. What is the most appropriate induction therapy?
- Rituximab alone
- High-dose glucocorticoids plus cyclophosphamide or rituximab (Correct answer)
- Mycophenolate mofetil plus prednisone
- Plasmapheresis alone
Correct answer: High-dose glucocorticoids plus cyclophosphamide or rituximab
ANCA-associated vasculitis with rapidly progressive GN requires induction with high-dose glucocorticoids combined with either cyclophosphamide or rituximab.
Question 7: A 70-year-old man with hypertension, CKD stage 3 (eGFR 42), and recent MI is found to have serum potassium of 5.9 mEq/L on lisinopril and spironolactone. What is the most appropriate management?
- Discontinue lisinopril and continue spironolactone
- Discontinue spironolactone and continue lisinopril
- Add patiromer and continue both medications (Correct answer)
- Switch to hydralazine and isosorbide dinitrate
Correct answer: Add patiromer and continue both medications
Patiromer (or sodium zirconium cyclosilicate) can lower serum potassium sufficiently to allow continuation of both cardiorenal protective agents in patients with hyperkalemia.
ITE Nephrology and Hypertension 2
A 55-year-old woman with IgA nephropathy has a urine protein-to-creatinine ratio of 1.8 g/g and eGFR of 52 mL/min/1.73m².
Which additional therapy beyond RAS blockade has demonstrated benefit in slowing CKD progression in this condition?