FLUID & ACID BASE MCQS FROM HARRISON 17TH EDITION

1 : All the following statements are true, except: A: the ECF is divided into intravascular and extravascular space in the ratio of 1:4 B: Na, Cl and HCO3 are predominant ECF osmoles C: K and organic phosphates are predominant ICF osmoles D: ECF osmolality = ICF osmolality ANS : A, Harrison pg 274

2: about Ineffective osmole all are true except: A: they cross across the cell membrane, and hence donot cause water shift across the cell membrane. B: Urea, mannitol are ineffective osmoles C: Glucose is ineffective osmole D: Play a role in stimulating thirst ANS: D. Harrison pg 275

3: which of the following statements is correct: A: normal plasma osmolality is 300 mosmol/kg B: Evaporative water loss has no functional role C: normally 1200 mosmols must be excreted per day, and hence maximum urine osmolality is 1200 mosmol/kg D: minimum urine output of 500 mL/d is required for neutral solute balance. ANS: D Harrison pg 275

4: All statements are True about water intake, except: A: thirst is either by an decrease in effective osmolality or a decrease in ECF volume or blood pressure. B: Osmoreceptors, located in the anterolateral hypothalamus, are stimulated by a rise in tonicity. C: Ineffective osmoles, such as urea and glucose, do not play a role in stimulating thirst. D: The average osmotic threshold for thirst is approximately 295 mosmol/kg and varies among individuals. ANS: A Harrison pg 275

5: TRUE about AVP, all except : A: AVP is the principal determinant of renal water excretion B: a polypeptide synthesized in the supraoptic and paraventricular nuclei of the hypothalamus C: The major stimulus for AVP secretion is hypertonicity. D: Causes active water absortion in collecting duct by stimulating aquaporin channel insertion. ANS: D Harrison pg 275

6: TRUE about BUN: creatinine ratio : A: normal ratio is 10:1 B: > 20: 1 implies prerenal azotemia C: ratio also increased with high protein diet, glucocorticoid treatment, GI bleed D: all are true ANS: D Harrison pg 276 7: True about prerenal azotemia, all except: A: the urine Na+ concentration should usually be <20 mmol/L B: urine Na is > 20 mmol/L if ATN is associated C: urine Cl > 20 mmol/L in prerenal azotemia due to vomiting D: urine osmolality > 450 mosm/l ANS: C, Harrison pg 276 8: True about hyponatremia, all except: A: Na < 135 mmol/l B: Bladder irrigation with mannitol cause hypertonic hyponatremia C: IV mannitol cause hypertonic hyponatremia D: Hyperglycemia cause hypertonic hyponatremia ANS: B, Harrison pg 276

9: True about euvolemic hyponatremia, all except: A: SIADH most common cause B: Adrenal insufficiency causes euvolemic hyponatremia C: hypothyroidism cause euvolemic hyponatremia D: urine osmolality is < 100 mosmol/kg ANS: D Harrison pg 278 10: TRUE ABOUT SIADH ALL EXCEPT: A: Hyposmotic hyponatremia B: urine osmolality > 100 mosm/l C: normal K and acid base balance D: increased uric acid level ANS: D Harrison pg 278

11: regarding osmotic demyelination syndrome, all are true except: A: Rapid correction of hyponatrmia is the cause

B: prior cerebral anoxic injury, hypokalemia and malnutrition are risk factors C: characterized by flaccid paralysis,dysarthria, and dysphagia D: is reversible ANS: D Harrison pg 278 12: Regarding Poassium balance, all are true except: A: The ICF : ECF potassium is 38: 1 B: Renal excretion is the major route of elimination of dietary and other sources of excess K+ C: 90% of filtered K+ is reabsorbed by the proximal convoluted tubule and loop of Henle D: In DCT, and collecting tubules, K is absorbed by Principal cells ANS : D Harrison 279. 280 13: Hypokalemia in vomiting is due to: A: Metabolic alkalosis causing redistribution of K into cells B: GI loss of potassium C: Metabolic alkalosis causing renal loss of potassium , due to bicarbonaturia d: all of the above ANS : C Harrison 281 14: Hypokalemia , true is: A: ECG changes correlates with degree of hypokalemia B: Potassium bicarbonate or citrate are preferred agents for correcting hypokalemia C: KCl should be preferably administered with dextrose D: TTKG of > 4 suggest renal K loss ANS D, 282 15: Hyperkalemia: true is A: trimethoprim cause hyperkalemia, mechanism being similar to heparin induced hyperkalemia B: Heparin decreases aldosterone synthesis, causing hyperkalemia in a subset of patients C: only unfractionated heparin cause hyperkalemia D: pentamidine cause hyperkalemia by inhibiting mineralocorticoid receptor ANS : c 283 16: regarding hyperkalemia management: A: Hemodialysis is the most rapid and effective way of reducing K concentration B: Peritoneal dialysis is as effective as hemodialysis C: In post operative patients , retention enema of Na polysterene sulfonate & sorbitol is recommended to decrease K D: calcium gluconate to be given in all patients ANS: A 284 17: Regarding PTHrP, true is : A: Shares homology with PTH in the first 14 amino acids. B: Binds to PTHrP receptor C: PTHrP associated Hypercalcemia, PTH levels are increased D: Secreted by solid tumors ANS: D pg 286

18: Regarding Hypercalcemia, true is: A: hypophosphatemia & normal PTH rules out primary hyperparathyroidism B: mild increased PTH and Ca: creatinine ratio of > 0.01 implies Familial hyocalciuric Hypercalcemia C: Activating mutation in CaSR cause FHH D: Glucocorticoids are preferred therapy in Hypercalcemia due to sarcoidosis ANS: D pg 286

19: Regarding Hypocalcemia, all are true except: A: Hypoparathyroidism is the most common cause, B: hypomagnesemia cause hypocalcemia by causing reduced parathyroid function C: inactivating mutation in CaSR cause hypocalcemia D: Chvosteks sign may be seen in 10 % normal individuals. ANS: C pg 287

20: TRUE statement is ; A: intracellular pH is 7- 7.3 B: HCO3- is measured by ABG analyser C: An increase in Anion gap is most commonly due to increase in unmeasured cation D: A decrease in serum albumin by 1g/dl from normal value, increases the anion gap by 2.5 mEq/L ANS: A pg 288, 289 21: Regarding Anion gap, all are true except: A: increase anion gap seen in lithium intoxication B: metabolic alkalosis, anion gap is increased C: AG increased in nephrotic syndrome D: A decrease in serum albumin by 1g/dl from normal value, decreases the anion gap by 2.5 mEq/L ANS: B pg 289

22: all the following statements are true, except: A: in patients with normal AG metabolic acidosis, alkali therapy is given to increase serum bicarbonate to 20-22 mmol/L range B: in High anion gap metabolic acidosis, alkali therapy is indicated only when pH < 7.15 C: IV alkali therapy is given to normalise arterial pH D: IV alkali is given to increase HCO3 to 10 mEq/l ANS : C pg 290 21: Regarding alcoholic ketoacidosis, all are true, except: : A: ketones are predominantly beta hydroxybutyrate B: with treatment, urine for ketones by nitroprusside assay becomes negative C: insulin levels are low D: seen in chronic alcoholics with poor nutrition when alcohol is abruptly curtailed ANS : B pg 291 22: Regarding urine anion gap, true is : A: urine anion gap is calculated by subtracting urinary chloride level from sum of urinary Na and potassium B: Positive urine anion gap implies renal cause of non anion gap metabolic acidosis

C: negative urine anion gap indicates non renal cause of non anion gap metabolic acidosis D: urine anion gap is positive implies high ammonium excretion in urine ANS: A pg 292

23: regarding renal tubular acidosis, true is: A: urine pH is > 5.5 in type 2 RTA B: nephrolithiasis and bone disease seen in type 2 RTA C: urine pH is < 5.5 in type 1 RTA D: in diabetic nephropathy hyperkalemic distal renal tubular acidosis is seen ANS: D pg 292 24: All the statements are true, except: A: dipstick for urine albumin gives false positive result with pH< 7 B: dipstick for urine albumin gives false positive result when urine is contaminated with blood C: Microalbuminuria implies early glomerular injury D: normally < 30mg/g of albumin is excreted in urine ANS: A pg 272 25: all are true except: A: upto 2 million RBCs are excreted in urine per day B: single episode of gross hematuria needs thorough evaluation C: Isolated hematuria in pediatric population is indicator of serious underlying disease D: hypercalciuria causes unexplained hematuria in adults ANS: C pg 273 26: all are true regarding glomerular hematuria except: A: > 80 % RBCs aredysmorphic B: RBC casts indicate glomerular source C: > 500 mg/d proteinuria may be associated D: isolated hematuria doesnt occur in glomerular disease ANS: D pg 273 27: which of the statements is true: A: polyuric patient with urine osmolality of > 300 mosm/l imply primary polydipsia B: high protein diet is associated with polyuria with urine osmolality of < 250mosmol/L C: best method for distinguishing central diabetes insipidus from nephrogenic diabetes insipidus is plasma vasopressin level D: sickle cell anemia cause central diabetes insipidus ANS C pg 274

28: All are True statement, except: A: preeclampsia is BP > 140/90 mm Hg with proteinuria of > 300 mg/d after 20 weeks of gestation B: soluble fms like tyrosine kinase 1 is reduced in preeclampsia C: soluble fms like tyrosine kinase 1is naturally occurring VEGF antagonist D: proteinuria of > 5g/day implies severe preeclampsia ANS: B pg 44

29: All are true, except A: Heart rate, cardiac output, GFR increase during normal pregnancy B: BP should be measured in supine position in pregnant female C: DM is a risk factor for preeclampsia D: preeclampsia resolves within few weeks of delivery ANS: B pg 44 30: ALL are true except: A: pre pregnancy creatinine of < 1.5 mg% is associated with a favourable prognosis B: gestational hypertension progresses to preeclampsia C: worsening of hypertension and renal function seen in pregnant females with underlying renal disease D: preeclampsia associated with increased risk of stroke ANS: B pg 45 31: all are true except: A: cystatic C is produced at a constant rate from all thenucleated cells in the body B: cystatin C is not affected by diet or nutritional status C: INULIN clearance gives more accurate determination of GFR D: Urea clearance overestimates GFR ANS: D pg 269, 270 32: Regarding Acute renal failure, all are true except: A: 40-80 % of ARF are pre renal B: 90 % of intrinsic renal failure is due to ATN C: FENa is < 1% in ATN D: urine osmolality is > 500 mosm/L in prerenal azotemia ANS: C pg 271 33: All are true except: A: oliguria is 24 hour urine output < 500 ml/day B: Anuria is 24 hour urine output of < 50 ml/d C: Urinary tract obstruction causes complete anuria D: in nonoliguric ATN, recovery to normal renal function is delayed ANS : D pg 271

34: Regarding LIDDLEs syndrome, all are true, except A: Autosomal dominant disease B: causes hypertension C: hypokalemia with metabolic acidosis is seen D: there is low renin and aldosterone secretion ANS: C pg 281. 282 35: All are true about Bartters syndrome, except: A: hypokalemia B: Metabolic alkalosis C: JG apparatus hypoplasia D: hyperaldosteronism ANS: D pg 282

36: Atheroembolic renal failure, all are true except: A: most often associated with recent aortic instrumenatation B: Cholesterol rich emboli lodge in medium and small sized renal arteries C: Renal biopsy is must for diagnosis D: Urine may be normal, or may have high eosinophils ANS: C pg 271 37: ALL are true except: A: eosinophiluria occurs in allergic interstitial nephritis and atheroembolic renal disease B: Hansels stain detects neutrophils in urine C:Renal Biopsy should be performed in pt presenting with hematuria having RBC cast on urine analysis D: NSAIDS cause allergic interstitial nephritis ANS : B pg 271 38: Following statements are true, except: A: Bartters, Gitelmans and Biuretic abuse all cause: hypokalemia, alkalosis, in a normotensive non edematous person B: hypocalciuria seen in Bartters syndrome C: hypomagnesemia seen in Gitelmans syndrome D: loss of function mutation in NCCT in DCT cause Gitelmans syndrome ANS : B pg 293 39: Regarding Icodextrin following are true, except: A: A nonabsorbable carbohydrate, used as alternate osmotic agent in PD solutions B: provides more efficient ultrafiltration compared to dextrose containing solutions C: used as last fill for patients on CCPD D: preferred solution in patients on APD Ans: d PG 1775 40: Regarding polyoma virus BK virus, all are true except: A: is a RNA virus B: remains dorman in kidney and is activated by immuno suppression C: Tacrolimus use associated with high risk of activation D: reactivation results in high chance of graft failure ANS: A pg 1781 41: regarding acute rejection of renal aloograft following statements are true, except: A: C4d deposition in tubular basement membrane imply cell mediated rejection B: plasmapheresis, IVIG, Rituximab used in treating antibody mediated rejection C: IV methylprednisolone is first line of treatment in Acute cell mediated renal allograft injury D: Antibody mediated renal rejection has poor prognosis ANS: A pg 1780

42: regarding membranous nephropathy, all are true except: A: female gender is associated with worse prognosis and requires aggressive therapy B: Spontaneous remission occurs in 30 % of patients, even late in the disease course C: presence of subendothelial immune deposits or tubuloreticular inclusions imply membranous lupus nephritis D: immunosuppression treatment required in individuals with persistent proteinuria of >3g/d

ANS : A pg 1791 43: regarding CMV infection in post transplant patient, following are true, except: A: CMV infection precipitates rejection B: CMV retinitis occur early in the post transplant period C: Valganciclovir is cost effective in prophylaxis of CMV infection D: Culture of CMV from blood is less sensitive ANS: B pg 1781 44: all are true except: A: Heroin causes FSGS B: steroids effectively control proteinuria in FSGS due to oligomeganephronia C: primary FSGS recurs in 25-40 % of patients who undergo renal transplant D: spontaneous remission in FSGS is rare ANS: B pg 1791 45: All are true except: A:: diabetic nephropathy is seen in 40% of patients with diabetes mellitus B: proteinuria of > 500 mg/day in diabetic patients is defined as diabetic nephropathy C: in type 1 DM, screening for albuminuria should be started 5 years after the disease onset D: Pts with diabetic nephropathy have enlarged kidney ANs: B pg 1792 46:: true statements are all except: A: in alports syndrome, the glomerular basement membrane is thick and is split B: Alports syndrome is X linked disease C: Hematuria is the most common initial manifestation D: sensorineural deafness occurs by 30 yrs ANS: A pg 1794 47: Regarding HIV nephropathy, true statement are all except: A: FSGS is the most common lesion on renal biopsy B: MPGN or DPGn seen in patients coinfrected with HBV or HCV C: Hypertension and edema are most common manifestation D: effective antiretroviral therapy is the treatment of choice ANS : C pg 1796

48: TRUE STATEMENTS ARE aLL except: A: Chronic HBV infection cause PAN more in adults than in children B: MN is the renal manifestation seen in children with HBV infection C: Children have good prognosis D: Adults have worse prognosis and steroid therapy is needed to control proteinuria and prevent renal failure ANS: D 1796 49: True statement is : A: NCCT mutation causes type 1 Bartters syndrome: B: Bartters syndrome associated with Hyperkalemia C: hypocalciuria and hypomagnesemia seen in Gittelman syndrome

D: JG apparatus hypoplasia seen in Bartters syndrome ANS: C 1801 50: ALL ARE TRUE STATEMENTs, exception IS: A: TSC1 codes for hamartin, mutation of which cause tuberous sclerosis B: angiomyolipoma seen in VHL syndrome C: UTI is frequent in ADPKD patients D: ADPKD patients with family history of CVA should be screened for intracranial aneurysm ANS: B 1798