NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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October 7, 2025
MKSAP 19 Nephrology, Question 43
A 66-year-old man is evaluated in the hospital for acute kidney injury following percutaneous coronary angiography and stent placement 48 hours ago. His medical history is also significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, and diabetic kidney disease. Medications are lisinopril, hydrochlorothiazide, basal and prandial insulin, atorvastatin, metoprolol, clopidogrel, and aspirin.
On physical examination, blood pressure is 132/88 mm Hg, and pulse rate is 58/min without postural changes. Skin is warm and dry. The remainder of the examination is normal.
Kidney ultrasound shows a 10.5-cm right kidney, 11.3-cm left kidney, and normal cortical echogenicity; there is no hydronephrosis.
Which of the following is the most likely diagnosis?
A. Acute tubular necrosis
B. Atheroembolic-induced acute kidney injury
C. Hemolytic uremic syndrome
D. Prerenal acute kidney injury
Responses Received from Members (530 responses):
The Correct Answer is: A. Acute tubular necrosis
Educational Objective:
Diagnose contrast-associated acute tubular necrosis.
The most likely diagnosis is acute tubular necrosis (ATN) (Option A) due to contrast-associated nephropathy (CAN). CAN is characterized by an abrupt increase in the serum creatinine level 24 to 48 hours after contrast exposure. This patient's risk factors for CAN include chronic kidney injury, type 2 diabetes mellitus, and a presumptive large volume contrast exposure. Laboratory findings consistent with the diagnosis include a blood urea nitrogen (BUN)-creatinine ratio of 15:1, urine specific gravity of 1.010 (isosthenuria), urine sodium >40 mEq/L (40 mmol/L), and a urine sediment with a few granular casts; notably, pigmented granular casts do not have to be present to diagnose ATN.
Atheroembolic-induced acute kidney injury (Option B) after a vascular intervention is characterized by a slow, stuttering rise in the serum creatinine level, often not apparent until several days or weeks after the procedure. It is often accompanied by stigmata of atheroemboli to the lower extremities, including livedo reticularis. In this patient, serum creatinine levels began rising 24 hours after the procedure and he has no skin findings.
Clopidogrel can be a cause of hemolytic uremic syndrome (Option C). However, this syndrome is typically characterized by a profound decrease in hemoglobin levels and platelet counts, and a longer exposure to the offending agent would be expected before the full manifestations develop. In this patient, the anemia and thrombocytopenia are modest and nonspecific.
Prerenal acute kidney injury (Option D) is unlikely in the absence of physical findings supporting hypovolemia or reduced cardiac output. Additionally, BUN-creatinine ratio >20:1, urine specific gravity >1.020, and a normal microscopic urinalysis or presence of hyaline casts are more typical.
Key Point
Contrast-associated nephropathy is a cause of acute tubular necrosis and is characterized by an increase in the serum creatinine 24 to 48 hours after contrast exposure.
Bibliography
Mehran R, Dangas GD, Weisbord SD. Contrast-associated acute kidney injury. N Engl J Med. 2019;380:2146-2155. PMID: 31141635 doi:10.1056/NEJMra1805256
Copyright 2019, American College of Physicians.
September 23, 2025
MKSAP 19 Nephrology, Question 32
A 46-year-old man is evaluated for confirmed primary hypertension. The patient is asymptomatic and takes no medications. He is a current smoker with a 20-pack-year history. Family history is significant for hypertension in his mother and father; his father had a stroke at age 55 years.
On physical examination, blood pressure is 154/96 mm Hg in both arms, pulse rate is 74/min, and respiration rate is 18/min. BMI is 30. The remainder of the examination is normal.
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A 12-lead ECG is normal.
The patient is instructed in lifestyle modifications, including smoking cessation, exercise, and a low sodium diet. Moderate-intensity atorvastatin is initiated.
Which of the following is the most appropriate additional therapy?
A. Amlodipine
B. Amlodipine-valsartan
C. Chlorthalidone
D. Valsartan
Responses Received from Members (668 responses):
The Correct Answer is: B. Amlodipine-valsartan
Educational Objective:
Treat stage 2 hypertension with combination drug therapy.
The most appropriate additional therapy is amlodipine-valsartan (Option B). This patient has stage 2 hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg). For patients with stage 2 hypertension with or without cardiovascular risk or disease, pharmacologic management in addition to therapeutic lifestyle interventions is recommended. The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends combination therapy with two first-line antihypertensive drugs of different classes for adults with stage 2 hypertension and an average BP that is 20/10 mm Hg above their BP target. Based on the presence of hypertension, dyslipidemia, and cigarette smoking, this patient has a calculated 10-year atherosclerotic cardiovascular disease (ASCVD) event risk of 10%. The target BP for patients with established cardiovascular disease or for patients with an estimated ASCVD event risk ≥10% is 130/80 mm Hg. This patient has an elevated 10-year ASCVD event risk and his BP is >20/10 mm Hg above target; therefore, combination drug therapy is indicated. To maximize adherence, using a fixed-dose combination agent may be more effective than adding two separate antihypertensive agents.
Starting chlorthalidone, amlodipine, or valsartan (Options A, C, D) as single-agent therapy would each be appropriate as first-line therapy for patients with stage 1 hypertension (systolic BP of 130-139 mm Hg or diastolic BP of 80–89 mm Hg). Combination therapy is recommended for patients with stage 2 hypertension and an average BP that is 20/10 mm Hg above their BP target.
Key Point
A blood pressure <130/80 mm Hg is recommended for adults with hypertension and cardiovascular disease or a 10-year atherosclerotic cardiovascular disease event risk ≥10%.
Combination therapy with two first-line antihypertensive medications of different classes is recommended for adults with stage 2 hypertension and an average blood pressure (BP)
of >20/10 mm Hg above BP target.
Bibliography
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248. PMID: 29146535
Copyright 2019, American College of Physicians.