Renal System Overview

1. In adults, which of the following is greater in the pulmonary circulation compared to the renal circulation?

(A) Arterial pressure (D) Capillary oncotic pressure

(B) Blood flow (E) Vascular resistance
(C) Capillary hydrostatic pressure

2. A 25-year-old man qualifies to run in the Boston Marathon. He presents at his physician’s office with a request
to have his oxygen consumption measured. Which of the following is correct regarding the consumption of
oxygen by the kidney?

(A) It decreases as blood flow increases (D) It directly reflects the level of sodium transport
(B) It is regulated by erythropoietin (E) It is greatest in the medulla
(C) It remains constant as blood flow increases

3. A patient with renal failure develops symptoms caused by the loss of a hormone produced by the kidney.
Which of the following is the most likely diagnosis?

(A) Edema (C) Anemia (E) Acidosis

(B) Hypertension (D) Uremia

Osmolarity/Tonicity

4. Which of the following solutions has the highest osmolal concentration?

(A) 300 mM sucrose solution (D) 300 mM NaCl solution

(B) 300 mM sucrose solution (E) 400 mM urea solution
(C) 300 mM NaCl solution

5. Which of the following statements regarding osmosis is correct?

(A) Osmotic pressure gradients are proportional to the gradient of permeable ions.
(B) Osmosis is the new movement of water from an area of high osmolarity to one of low osmolarity.
(C) Osmotic pressure is decreased by the Na+-K+-ATPase pump
(D) Water usually flows against its concentration gradient.
(E) The osmotic pressure gradient is zero when all molecules are permeable.
 6. Which of the following has similar values for both intracellular and interstitial body fluids?

(A) Potassium ion concentration (D) Chloride ion concentration

(B) Colloid osmotic pressure (E) Total osmolarity
(C) Sodium ion concentration

Body Fluid Volume

7. A normal 60-kg person has an extracellular fluid (ECF) volume of 12.8 L, a blood volume of 4.3 L, and a
hematocrit of 40%. His body is 57% water by weight. The plasma volume (Evans blue space) [in L] is
approximately…

(A) 2.0 (B) 2.3 (C) 2.6 (D) 3.0 (E) 3.3

8. One gram of mannitol was injected into a woman. After equilibration, a plasma sample had a mannitol
concentration of 0.08 g/L. During the equilibration period, 20% of the injected mannitol was excreted in the
urine. The subject’s

(A) ECF volume is 1 L (C) ECF volume is 10 L (E) Interstitial volume is 12.5 L
(B) ICF volume is 1 L (D) ICF volume is 10 L

9. Effective circulating volume (ECV)…

(A) Is part of the extracellular fluid (D) Can be measured by the dilution principle
(B) Is in the venous system (E) Is constant with changes in the extracellular
(C) Is independent of Nat intake fluid (ECF) volume

10. A reduction in the effective circulating volume (ECV)…

(A) Leads to increased Na+ excretion (D) Leads to increased water excretion
(B) Is observed in congestive heart failure (E) Causes reduction in renin secretion
(C) Does not cause edema
11. Measurements taken after an intravenous injection of inulin indicate that the substance appears to be distributed
throughout 30% to 35% of the total body water (TBW). This finding suggests that inulin most likely is…

(A) Excluded from the cells

(B) Distributed uniformly throughout the TBW volume
(C) Restricted to the plasma volume
(D) Neither excreted nor metabolized by the body
(E) Not freely diffusible through capillary membranes

12. Which of the following substances or combinations of substances could be used to measure interstitial fluid
volume?

(A) Mannitol (C) Evans blue (E) Inulin and radioactive

(B) D2O alone (D) Inulin and D2O albumin

13. Which of the following substances are best suited to measure interstitial fluid volume?

(A) Inulin and heavy water (D) Inulin and 125I-albumin

(B) Inulin and 22Na (E) 51Cr red blood cells and 125I-albumin
(C) Heavy water and 125I-albumin

A person with normal body fluid volumes weights 60 kg and has an extracellular fluid volume of
approximately 12.8 L, a blood volume of 4.3 L, and a hematocrit of 0.4; 57% of his body weight is water.
Answer the following 3 questions based on this information.

14. What is the approximate intracellular fluid volume?

(A) 17.1 L (B) 19.6 L (C) 21.4 L (D) 23.5 L (E) 25.6 L

15. What is the approximate plasma volume?

(A) 2.0 L (B) 2.3 L (C) 2.6 L (D) 3.0 L (E) 3.3 L

16. What is the approximate interstitial fluid volume?

(A) 6.4 L (B) 8.4 L (C) 10.2 L (D) 11.3 L (E) 12.0 L
17. A woman runs a marathon in 90°F weather and replaces all volume lost in sweat by drinking distilled water.
After the marathon, she will have

(A) Decreased total body water (TBW) (D) Decreased plasma osmolarity
(B) Decreased hematocrit (E) Increased intracellular osmolarity
(C) Decreased ICF volume

18. A woman runs a marathon in 90°F heat and replaces the 3 L of sweat lost by drinking 3 L of distilled water.
Compared to her pre-exercise condition, she has…

(A) Decreased total body water (TBW) (D) Decreased plasma osmolality
(B) Hypernatremia (E) Increased intracellular osmolality
(C) Decreased hematocrit

19. Following the intravenous administration of 1 L of 5% glucose, which of the following will occur?

(A) The extracellular fluid (ECF) volume will increase by about 330 ml
(B) The interstitial fluid volume will increase by about 80 ml
(C) The ECF volume will increase by about 670 ml
(D) The ECF volume will increase by about 1 L
(E) The intracellular fluid (ICF) volume will remain unchanged

20. Which of the following solutions when infused intravenously would result in an increase in extracellular fluid
volume, a decrease in intracellular fluid volume, and an increase in total body water after osmotic equilibrium?

(A) 1 L of 0.9% sodium chloride solution (D) 1 L of 5% dextrose solution

(B) 1 L of 0.45% sodium chloride solution (E) 1 L of pure water
(C) 1 L of 3% sodium chloride solution

21. Which one of the following conditions causes a decrease in the extracellular fluid (ECF) volume, an increase in
the intracellular fluid (ICF) volume, and a decrease in the osmolar concentration of both compartments?

(A) Hyperosmotic dehydration (D) Hyperosmotic overhydration

(B) Hyposmotic dehydration (E) Hyposmotic overhydration
(C) Isosmotic dehydration
 Next 4 questions are based on the diagrams below, which represent the volumes and osmolarities of the
extracellular (ECF) and intracellular (ICF) fluid compartments in a normal subject (solid lines). The height of
the rectangles denotes osmolarity, and the width represents volume. The dashed lines indicate change in the
osmolarity and/or volume of the intracellular and extracellular compartments. For each of the procedures or
disease states that follows, select the lettered diagram that best describes the changes that would result.

22. Infusion of 500 ml of an isotonic NaCl solution

23. Infusion of 1 L of a 300 mmol/L saline solution

24. Drinking 1 L of tap water

25. Chronic elevated secretion of antidiuretic hormone (ADH)

 The diagrams represent various states of abnormal hydration. In each diagram, the normal state (orange and
lavender) is superimposed on the abnormal state (dashed lines) to illustrate the shifts in the volume (width of
rectangles) and total osmolarity (height of rectangles) of the extracellular and intracellular fluid compartments.
(Next 5 questions)

26. Which of the diagrams represents the changes (after osmotic equilibrium) in extracellular and intracellular fluid
volumes and osmolarities after the infusion of 1% dextrose?

27. Which of the diagrams would represent the changes (after osmotic equilibrium) in extracellular and
intracellular fluid volumes and osmolarities after infusion of 2 L of 3.0% dextrose?

28. Which of the diagrams represents the changes (after osmotic equilibrium) in extracellular and intracellular fluid
volumes and osmolarities after the infusion of 3% sodium chloride?

29. Which of the diagrams represents the changes (after osmotic equilibrium) in extracellular and intracellular fluid
volumes and osmolarities in a patient with the syndrome of inappropriate antidiuretic hormone (excessive
secretion of antidiuretic hormone)?

30. Which of the diagrams would represent the changes (after osmotic equilibrium) in extracellular and
intracellular fluid volumes and osmolarities in a patient with severe “central” diabetes insipidus?
 Assume the following initial conditions for next 2 questions: intracellular fluid volume = 40% of body weight
before fluid administration, extracellular fluid volume = 20% of body weight before fluid administration,
molecular weight of NaCl = 58.5 g/mol, and no excretion of water or electrolytes.

31. A male patient appears to be dehydrated, and after obtaining a plasma sample, you find that he has
hyponatremia, with a plasma sodium concentration of 130 mmol/L and a plasma osmolarity of 260 mOsm/L.
You decide to administer 2 L of 3% sodium chloride (NaCl). His body weight was 60 kilograms before giving
the fluid. What is his approximate plasma osmolarity after administration of the NaCl solution and after
osmotic equilibrium? Assume the initial conditions described above.

(A) 273 mOsm/L (C) 300 mOsm/L (E) 326 mOsm/L

(B) 286 mOsm/L (D) 310 mOsm/L

32. What is the approximate extracellular fluid volume in this patient after administration of the NaCl solution and
after osmotic equilibrium?

(A) 15.1 L (B) 17.2 L (C) 19.1 L (D) 19.8 L (E) 21.2 L

33. Intravenous infusion of 1 L of 0.45% sodium chloride (NaCl) solution (molecular weight of NaCl = 58.5)
would cause which of the following changes, after osmotic equilibrium?

Intracellular fluid Intracellular fluid Extracellular fluid Extracellular fluid

volume osmolarity volume osmolarity
(A) ↑ ↑ ↑ ↑
(B) ↑ ↓ ↑ ↓
(C) ↔ ↑ ↑ ↑
(D) ↓ ↑ ↑ ↑
(E) ↓ ↓ ↓ ↓

34. A 23-year-old male runs a 10-km race in July and loses 2 L of fluid by sweating. He also drinks 2 L of water
during the race. Which of the following changes would you expect, compared to normal, after he absorbs the
water and assuming osmotic equilibrium and no excretion of water or electrolytes?

Intracellular Volume Intracellular Osmolarity Extracellular Volume Extracellular Osmolarity

(A) ↓ ↑ ↓ ↑
(B) ↓ ↓ ↓ ↓
(C) ↔ ↓ ↔ ↓
(D) ↔ ↑ ↓ ↑
(E) ↑ ↓ ↓ ↓
(F) ↑ ↓ ↑ ↓
 Glomerular Filtration

35. Which of the following statements that refers to the glomerulus is correct?

(A) It filters Na+ mainly by diffusion

(B) It contains no active transport systems that produce an important effect on the composition of filtrate
(C) It produces a filtrate with a lower concentration of amino acids than found in plasma
(D) It produces a filtrate with a higher concentration of urea than found in plasma
(E) It does not contain fenestrated capillaries

36. Which of the following is filtered most readily by the glomerular capillaries?

(A) Albumin in plasma

(B) Neutral dextran with a molecular weight of 25,000
(C) Polycationic dextran with a molecular weight of 25,000
(D) Polyanionic dextran with a molecular weight of 25,000
(E) Red blood cells

37. A patients GFR has decreased 4-fold due to renal failure. This would lead to a (1) in plasma creatinine
and a (2) in creatinine clearance.

(1) (2)
(A) 4-fold decrease No change
(B) No change 4-fold decrease
(C) 4-fold increase 4-fold increase
(D) 4-fold increase 4-fold decrease
(E) 4-fold decrease 4-fold increase

38. After receiving a renal transplant, a patient develops severe hypertension (170/110 mm Hg). A renal
arteriogram indicates severe renal artery stenosis in his single remaining kidney, with a reduction in GFR to
25% of normal. Which of the following changes, compared with normal, would be expected in this patient,
assuming steady-state conditions?

(A) Large increase in plasma sodium concentration

(B) Reduction in urinary sodium excretion to 25% of normal
(C) Reduction in urinary creatinine excretion to 25% of normal
(D) Increase in serum creatinine to about four times normal
(E) Normal renal blood flow in the stenotic kidney due to autoregulation
39. Which of the following changes, compared with normal, would be expected to occur, under steady-state
conditions, in a patient whose severe renal disease has reduced the number of functional nephrons to 25% of
normal?

(A) Increased GFR of the surviving nephrons (D) Decreased urinary excretion of sodium
(B) Decreased urinary creatinine excretion rate (E) Increased urine concentrating ability
(C) Decreased urine flow rate in the surviving
nephrons

40. Three patients have been diagnosed with chronic renal failure. These patients all exhibit steady state plasma
creatinine concentrations exceeding 6 mg/dL, hematocrit of less than 38%, plasma potassium concentrations of
4.3 - 5.6 mEq/L. Assuming a normal diet and physical activity for these patients, you would expect their
creatinine excretion rates to be:

(A) Widely disparate (D) Greater than those of a normal individual

(B) Similar to normal GFR (E) Similar to those of a normal individual
(C) Less than those of a normal individual

41. If GFR suddenly decreases from 150 ml/min to 75 ml/min and tubular fluid reabsorption simultaneously
decreases from 149 ml/min to 75 ml/min, which of the following changes will occur (assuming that the
changes in GFR and tubular fluid reabsorption are maintained)?

(A) Urine flow rate will decrease to 0 (C) Urine flow rate will not change
(B) Urine flow rate will decrease by 50% (D) Urine flow rate will increase by 50%

42. A patient with renal disease had a plasma creatinine of 2 mg/dL during an examination 6 months ago. You note
that his blood pressure has increased about 30 mm Hg since his previous visit, and the lab tests indicate that his
plasma creatinine is now 4 mg/dL. Which of the following changes, compared with his previous visit, would
you expect to find, assuming steady-state conditions and no changes in electrolyte intake or metabolism?

Sodium Excretion Creatinine Excretion Creatinine Filtered Load of

Rate Rate Clearance Creatinine
(A) ↔ ↔ ↓by 50% ↓
(B) ↔ ↔ ↓by 50% ↔
(C) ↔ ↔ ↓by 75% ↓
(D) ↓ ↓ ↔ ↔
(E) ↓ ↓ ↓by 50% ↓
43. You have been following a patient with type 2 diabetes and chronic renal disease and his GFR has decreased
from 80 ml/min to 40 ml/min over the past 4 years. Which of the following changes would you expect to find
compared to 4 years ago, before the decline in GFR, assuming steady-state conditions and no change in
electrolyte intake or protein metabolism?

Sodium Creatinine Creatinine Filtered Load Plasma Creatinine

Excretion Rate Excretion Rate Clearance Creatinine Concentration
(A) ↓ ↓ ↔ ↔ ↑
(B) ↓ ↓ ↓ ↓ ↑
(C) ↔ ↔ ↓ ↓ ↑
(D) ↔ ↔ ↓ ↓ ↔
(E) ↔ ↔ ↓ ↔ ↑
(F) ↔ ↔ ↔ ↔ ↑

44. A diabetic patient has developed chronic renal disease and is referred to your nephrology clinic. According to
his family physician, his creatinine clearance has decreased from 100 ml/min to 40 ml/min over the past 4
years. His glucose has not been well controlled, and his plasma pH is 7.14. Which of the following changes,
compared with before the development of renal disease, would you expect to find, assuming steady-state
conditions and no change in electrolyte intake?

Sodium Excretion Creatinine Plasma Plasma NH4+ Excretion

Rate Excretion Creatinine HCO3– Rate
Rate Concentration Concentration
(A) ↓ ↓ ↑ ↑ ↑
(B) ↔ ↔ ↑ ↓ ↑
(C) ↔ ↔ ↑ ↓ ↔
(D) ↔ ↓ ↑ ↓ ↔
(E) ↓ ↓ ↓ ↓ ↑
(F) ↓ ↓ ↓ ↓ ↓

45. A person suffers from a vascular spasm of their afferent arteriole. The physiological response to this is dilation
that prevents a (1) in GFR. This dilation is produced by stretch -activated calcium channels on the
afferent arteriole smooth muscle (2) and Na+ reabsorption at the ascending limb of the Loop of Henle
(3) .
(1) (2) (3)
(A) Decrease Opening Decreasing
(B) Increase Closing Increasing
(C) Decrease Closing Decreasing
(D) Decrease Opening Increasing
(E) Decrease Closing Increasing
46. A patient’s one remaining kidney has moderate renal artery stenosis that reduces renal artery pressure distal to
the stenosis to 85 mm Hg, compared with the normal level of 100 mm Hg. Which of the following is most
likely decreased in this patient 2 weeks after the stenosis has occurred, assuming that his diet is unchanged?

(A) Efferent arteriolar resistance (D) Sodium excretion rate

(B) Afferent arteriolar resistance (E) Plasma aldosterone concentration
(C) Renin secretion

47. Which of the following pressures which contributes nothing to normal net filtration pressure?

(A) Hydrostatic pressure of the glomerular capillary (C) Oncotic pressure of the glomerular capillary
(B) Hydrostatic pressure of the Bowmans space (D) Oncotic pressure of the Bowmans space

48. In the capsular fluid of Bowman's space, the concentration of all but which of the following is equal to its
plasma concentration?

(A) Glucose (C) Urea (E) Potassium

(B) Sodium (D) Protein bound calcium

49. A 76-year-old man presents as the emergency department with headache, vomiting shortness of breath,
insomnia, and confusion. He is found to be oliguric with an increased BUN and creatinine. Urine specific
gravity is low and there is proteinuria. Which of the following statements concerning the normal renal handling
of proteins is correct?

(A) Proteins are more likely to be filtered if they are negatively charged than if they are uncharged.
(B) Proteins can be filtered and secreted but not reabsorbed by the kidney.
(C) Most of the protein excreted each day is derived from tubular secretion.
(D) Protein excretion is directly related to plasma protein concentration.
(E) Protein excretion is increased by sympathetic stimulation of the kidney.

50. Which of the following changes tends to increase GFR?

(A) Increased afferent arteriolar resistance

(B) Decreased efferent arteriolar resistance
(C) Increased glomerular capillary filtration coefficient
(D) Increased Bowman’s capsule hydrostatic pressure
(E) Decreased glomerular capillary hydrostatic pressure
51. Which one of the following factors best explains an increase in the glomerular filtration rate (GFR)?

(A) Increased arterial plasma oncotic pressure

(B) Increased hydrostatic pressure in Bowman’s capsule
(C) Increased glomerular capillary hydrostatic pressure
(D) Decreased net filtration pressure
(E) Vasoconstriction of the afferent arteriole

52. Which of the following is most likely to produce an increase in GFR?

(A) Administration of angiotensin II (C) Contraction of glomerular mesangial cells

(B) Increased renin release from the (D) Dilation of afferent arterioles
juxtaglomerular apparatus (E) Volume depletion

53. A decrease in GFR would result from which of the following?

(A) Constriction of the efferent arteriole (D) A decrease in the concentration of plasma
(B) An increase in afferent arteriolar pressure protein
(C) Compression of the renal capsule (E) An increase in renal blood flow

54. A patient with atherosclerosis shows signs of chronic renal failure attributed to poor renal perfusion and
ischemic necrosis of the nephrons. Which of the following endogenous substances causes blood flow to
decrease?

(A) Nitric oxide (C) Acetylcholine (E) Dopamine

(B) Atrial natriuretic peptide (D) Angiotensin II

55. Which of the following would cause an increase in both glomerular filtration rate (GFR) and renal plasma flow
(RPF)?

(A) Hyperproteinemia (D) Dilation of the efferent arteriole

(B) A ureteral stone (E) Constriction of the efferent arteriole
(C) Dilation of the afferent arteriole
56. Increases in both renal blood flow and GFR are caused by which of the following?

(A) Dilation of the afferent arterioles

(B) Increased glomerular capillary filtration coefficient
(C) Increased plasma colloid osmotic pressure
(D) Dilation of the efferent arterioles
(E) Increased blood viscosity due to increased hematocrit

57. A 35-year-old man with polycystic kidney disease has a decrease in both GFR and RBF. The nephrologist
wants to administer a drug that will increase both GFR and RBF. GFR and RBF would both increase if which
of the following occurred?

(A) The efferent and afferent arterioles are both dilated

(B) The efferent and afferent arterioles are both constricted
(C) Only the afferent arteriole is constricted
(D) Only the efferent arteriole is constricted
(E) The afferent arteriole is constricted and the efferent arteriole is dilated

58. A 55-year-old male patient with hypertension has had his blood pressure reasonably well controlled by
administration of a thiazide diuretic. During his last visit (6 months ago) his blood pressure was 130/75 mm Hg
and his serum creatinine was 1 mg/100 ml. He has been exercising regularly for the past 2 years, but recently
has complained of knee pain and began taking large amounts of a nonsteroidal anti-inflammatory drug. When
he arrives at your office, his blood pressure is 155/85 and his serum creatinine is now 2.5 mg/100 ml. Which of
the following best explains his increased serum creatinine?

(A) Increased efferent arteriolar resistance that reduced GFR

(B) Increased afferent arteriolar resistance that reduced GFR
(C) Increased glomerular capillary filtration coefficient that reduced GFR
(D) Increased angiotensin II formation that decreased GFR
(E) Increased muscle mass due to the exercise

59. Which of the following would tend to decrease GFR by more than 10% in a normal kidney?

(A) Decrease in renal arterial pressure from 100 to 85 mm Hg

(B) 50% decrease in afferent arteriolar resistance
(C) 50% decrease in efferent arteriolar resistance
(D) 50% increase in the glomerular capillary filtration coefficient
(E) Decrease in plasma colloid osmotic pressure from 28 to 20 mm Hg
60. A 58-year-old man is hospitalized following an acute myocardial infarction. Several days later, the patient’s
24-hour urine output is lower-than-normal. An increase in which of the following contributes to a reduced
urine flow in a patient with congestive heart failure and reduced effective circulating volume?

(A) Atrial natriuretic peptide (D) Renal sympathetic nerve activity

(B) Renal natriuretic peptide (urodilantin) (E) Sodium delivery to the macula densa
(C) Renal perfusion pressure

61. Which of the following changes would you expect to find after administering a vasodilator during that caused a
50% decrease in afferent arteriolar resistance and no change in arterial pressure?

(A) Decreased renal blood flow, decreased GFR, And decreased peritubular capillary hydrostatic pressure
(B) Decreased renal blood flow, decreased GFR, and increased peritubular capillary hydrostatic pressure
(C) Increased renal blood flow increased GFR, and increased peritubular capillary hydrostatic pressure
(D) Increased renal blood flow, increased GFR, and no change in peritubular capillary hydrostatic pressure
(E) Increased renal blood flow, increased GFR, and decreased peritubular capillary hydrostatic pressure

62. Renal autoregulation explains changes in resistance to blood flow without the involvement of the nervous
system. The major site of autoregulatory resistance changes is the…

(A) Renal artery (C) Afferent arteriole (E) Peritubular capillary

(B) Interlobular artery (D) Efferent arteriole

63. According to the myogenic theory of autoregulation, an elevation in renal perfusion pressure immediately
causes…

(A) A reduction in extravascular (interstitial) hydrostatic pressure

(B) A reduction in transmural pressure in the afferent arteriole
(C) A reduction in intravascular hydrostatic pressure
(D) An increase in afferent arteriolar radius followed by afferent arteriolar vasoconstriction
(E) A reduction in afferent arteriolar wall tension
64. Two weeks after constricting the renal artery of a sole remaining kidney to initially reduce renal artery pressure
by 20 mm Hg (from 100 to 80 mm Hg), which of the following changes would you expect, compared with
before constriction of the artery?

(A) Large decrease in sodium excretion (>20%)

(B) Large increase in renin secretion (more than twofold)
(C) Return of renal artery pressure to nearly 100 mm Hg
(D) Large decrease in GFR (>20%)
(E) Large reduction in renal blood flow (>20%)

65. Which of the following changes, compared with normal, would you expect to find 3 weeks after a patient
ingested a toxin that caused sustained impairment of proximal tubular sodium chloride (NaCl) reabsorption?
Assume that there has been no change in diet or ingestion of electrolytes.

Glomerular filtration rate Afferent arteriolar resistance Sodium excretion

(A) ↔ ↔ ↑
(B) ↔ ↔ ↑
(C) ↓ ↑ ↑
(D) ↓ ↑ ↔
(E) ↑ ↓ ↔

66. An elderly woman presents with spiking fever, shaking chills, nausea, and costovertebral angle tenderness.
Urine cultures are positive and she is hospitalized for pyelonephritis. Her GFR decreases with a resultant
increase in the concentration of NaCl delivered in the intraluminal fluid to the thick ascending limb of the loop
of Henle. Under these conditions, the macula densa will increase the formation and release if which of the
following substance?

(A) Adenosine (C) Antidiuretic hormone (E) Renin

(B) Aldosterone (D) Angiotensinogen

67. Which of the following changes tends to increase peritubular capillary fluid reabsorption?

(A) Increased blood pressure (D) Decreased angiotensin II

(B) Decreased filtration fraction (E) Increased renal blood flow
(C) Increased efferent arteriolar resistance

68. Filtration fraction can be increased by an increase in which of the following?

(A) Afferent arteriolar resistance (D) Plasma oncotic pressure

(B) Efferent arteriolar resistance (E) Renal blood flow
(C) Hydrostatic pressure within Bowman capsule
69. Which of the following changes would you expect to find after acute administration of a vasodilator drug that
caused a 50% decrease in renal efferent arteriolar resistance and no change in afferent arteriolar resistance or
arterial pressure?

Renal Glomerular Glomerular Capillary Peritubular Capillary

Blood Flow Filtration Rate Hydrostatic Pressure Hydrostatic Pressure
(A) ↑ ↑ ↑ ↔
(B) ↑ ↑ ↑ ↑
(C) ↑ ↔ ↔ ↔
(D) ↑ ↓ ↓ ↓
(E) ↑ ↓ ↓ ↑

70. Which of the following would tend to increase glomerular filtration rate?

(A) An increase in glomerular capillary oncotic pressure

(B) Vasoconstriction of the afferent arteriole
(C) An increase in hydraulic pressure in Bowman’s capsule
(D) An increase in renal blood flow

71. Which of the following causes an increase in both glomerular filtration rate (GFR) and renal plasma flow?

(A) Hyperproteinemia (D) Dilation of the efferent arteriole

(B) A ureteral stone (E) Constriction of the efferent arteriole
(C) Dilation of the afferent arteriole

72. Which of the following changes would you expect to find in a newly diagnosed 10-year-old patient with type I
diabetes and uncontrolled hyperglycemia (plasma glucose = 300 mg/dL).

Thirst Urine Volume Glomerular Afferent

(Water Intake) Filtration Rate Arteriolar Resistance
(A) ↑ ↓ ↑ ↓
(B) ↑ ↑ ↓ ↑
(C) ↑ ↑ ↑ ↓
(D) ↓ ↑ ↑ ↑
(E) ↓ ↓ ↓ ↓

73. Of the following pressures which increases along the length of the glomerular capillary?

(A) Oncotic pressure of the glomerular capillary (C) Hydrostatic pressure of the glomerular capillary
(B) Oncotic pressure of the Bowmans space (D) Hydrostatic pressure of the Bowmans space
74. A 73-year-old woman develops a thready pulse, tachycardia, and hypotension 6 minutes following a
hysterectomy. Laboratory analysis shown an increase in plasma renin activity and angiotensin II accompanied
by a decrease in creatinine clearance. Under euvolemic conditions, a decrease in GFR would decrease proximal
tubular reabsorption of salt and water by a process called glomerulotubular balance. One of the mechanisms for
glomerulotubular balance is related to the Starling forces. According to this mechanism, how would a decrease
in GFR promote a decrease in proximal tubular reabsorption of salt and water?

(A) Via a decrease in peritubular capillary hydrostatic pressure

(B) Via a decrease in peritubular oncotic pressure
(C) Via a decrease in proximal tubular flow
(D) Via a decrease in peritubular capillary flow
(E) Via a increase in peritubular sodium concentration

75. During severe dehydration, which of the following is true of the Starling forces operating at the proximal
tubule compared to a normal hydration state?

(A) Peritubular capillary oncotic pressure is greater

(B) Peritubular capillary oncotic pressure is less
(C) Peritubular capillary oncotic pressure is unaltered
(D) Peritubular capillary hydrostatic pressure is unaltered
(E) Peritubular capillary hydrostatic pressure is greater

76. An 8-year-old boy is brought to your office with extreme swelling of the abdomen. His parents indicate that he
had a very sore throat a “month or so” ago and that he has been “swelling up” since that time. He appears to be
edematous, and when you check his urine, you find large amounts of protein being excreted. Your diagnosis is
nephrotic syndrome subsequent to glomerulonephritis. Which of the following changes would you expect to
find, compared with normal?

Thoracic Lymph Interstitial Fluid Protein Interstitial Fluid Plasma Renin

Flow Concentration Hydrostatic Pressure Concentration
(A) ↑ ↓ ↑ ↑
(B) ↑ ↓ ↑ ↔
(C) ↑ ↓ ↔ ↑
(D) ↓ ↑ ↔ ↔
(E) ↓ ↓ ↓ ↓
77. A 20-year-old woman arrives at your office complaining of rapid weight gain and marked fluid retention. Her
blood pressure is 105/65 mm Hg, her plasma protein concentration is 3.6g/dL (normal = 7.0), and she has no
detectable protein in her urine. Which of the following changes would you expect to find, compared with
normal?

Thoracic Interstitial Fluid Capillary Interstitial

Lymph Flow Protein Concentration Filtration Fluid Pressure
(A) ↓ ↓ ↓ ↓
(B) ↓ ↑ ↔ ↔
(C) ↑ ↓ ↑ ↑
(D) ↑ ↓ ↑ ↔
(E) ↑ ↑ ↑ ↑

78. In a patient with complete obstruction of the left ureter, which of the following changes in the left kidney
would most likely be observed?

(A) Net ultrafiltration pressure is reduced

(B) Net ultrafiltration pressure is increased
(C) Glomerular capillary hydrostatic pressure is reduced
(D) Glomerular capillary oncotic pressure is increased
(E) GFR would rise in an effort to remove the obstruction

79. A16-year-old pregnant girl is admitted to the hospital in labor. Her blood pressure is 130/85 mm Hg and her
plasma creatinine is 2.7 mg/dL (normal 0.6-1.2 mg/dL.) Renal ultrasonography demonstrates severe bilateral
hydronephrosis (enlarges kidney). Which of the following is the most likely cause of this patient’s high
creatinine levels?

(A) Increased sympathetic nerve activity (D) Ureteral obstruction

(B) Coarctation of the renal artery (E) Hypovolemia
(C) Hyperproteinemia

80. Which of the following would be expected to cause a reduction in glomerular filtration rate (GFR)?

(A) A reduction in mean arterial pressure (MAP) from 100 mm Hg to 95 mm Hg

(B) A marked reduction in plasma protein concentration
(C) A decrease in sympathetic outflow to the afferent arteriole
(D) An increase in glomerular capillary hydro-static pressure
(E) Complete ureteral obstruction
81. Use the values below to answer the following question.

Glomerular capillary hydrostatic pressure = 47 mm Hg

Bowman’s space hydrostatic pressure = 10 mm Hg
Bowman’s space oncotic pressure = 0 mm Hg

At what value of glomerular capillary oncotic pressure would glomerular filtration stop?

(A) 57 mm Hg (B) 47 mm Hg (C) 37 mm Hg (D) 10 mm Hg (E) 0 mm Hg

82. The following data were obtained from an experimental animal. Which of the following is the net filtration
pressure in mm Hg?

Afferent Arteriole Bowman's Space

Glomerular capillary hydrostatic pressure 60 mm Hg 14 mm Hg
Oncotic pressure 21 mm Hg 0 mm Hg

(A) 0 (B) 7 (C) 25 (D) 39 (E) 46

83. If the average hydrostatic pressure in the glomerular capillaries is 50 mm Hg, the hydrostatic pressure in the
Bowman’s space is 12 mm Hg, the average colloid osmotic pressure in the glomerular capillaries is 30 mm Hg,
and there is no protein in the glomerular ultrafiltrate, what is the net pressure driving glomerular filtration?

(A) 8 mmHg (C) 48 mm Hg (E) 92 mm Hg

(B) 32 mm Hg (D) 60 mm Hg

The Clearance Concept

The following graph applies to Questions 17-19. The curves show the percentage of the filtered load remaining
in the tubular fluid at various sites along the specimen.
84. Which curve describes the inulin profile along the nephron?

(A) Curve A (B) Curve B (C) Curve C (D) Curve D

85. Which curve describes the alanine profile along the nephron?

(A) Curve A (B) Curve B (C) Curve C (D) Curve D

86. Which curve describes the para-aminohippuric acid (PAH) profile along the nephron?

(A) Curve A (B) Curve B (C) Curve C (D) Curve D

87. The clearance of which substance best approximates GFR?

(A) Inulin (C) Para-aminohippuric acid

(B) Blood urea nitrogen (D) Creatinine

88. Which of the following substances will be more concentrated at the end of the proximal tubule than at the
beginning of the proximal tubule?

(A) Glucose (B) Creatinine (C) Sodium (D) Bicarbonate (E) Phosphate

89. At which renal tubular sites would the concentration of creatinine be expected to be highest in a normally
hydrated person?

(A) The concentration would be the same in all of the above, since creatinine is neither secreted or reabsorbed
(B) Glomerular filtrate (D) End of the loop of Henle (F) Collecting duct
(C) End of the proximal tubule (E) Distal tubule

90. A 23-year-old woman presents with burning epigastric pain. A careful history reveals that the burning is
exacerbated by fasting and improved with meals. The woman is prescribed the H2 receptor antagonist,
cimetidine, for suspected peptic ulcer disease (PUD). Cimetidine may also have an adverse effect on proximal
tubular function. Which of the following substances will be more concentrated at the end of the proximal
tubule than at the beginning of the proximal tubule?

(A) Bicarbonate (C) Glucose (E) Sodium

(B) Creatinine (D) Phosphate
91. A 26-year-old man develops glomerulonephritis, and his GFR decreases by 50% and remains at that level. For
which of the following substances would you expect to find the greatest increase in plasma concentration?

(A) Creatinine (C) Glucose (E) Phosphate

+ +
(B) K (D) Na (F) H+

92. The clearance of which substance best approximately RPF?

(A) Inulin (C) Para-aminohippuric acid

(B) Blood urea nitrogen (D) Creatinine

93. If a substance is freely filtered and 90% of the remaining substance in the peritubular capillary is secreted at the
proximal tubule, what will clearance of that substance most closely measure?

(A) Excretion rate (B) Filtration fraction (C) GFR (D) RPF

94. The maximum clearance rate possible for a substance that is totally cleared from the plasma is equal to which
of the following?

(A) GFR (D) Renal plasma flow

(B) Filtered load of that substance (E) Filtration fraction
(C) Urinary excretion rate of that substance

95. Which of the following substances has the highest renal clearance?

(A) PAH (B) Inulin (C) Glucose (D) Na+ (E) Cl–

96. Which of the following substances has the lowest renal clearance?

(A) Glucose (C) Inulin (E) Para-aminohippuric acid

(B) Urea (D) Creatinine (PAH)

97. If a substance if freely filtered and neither absorbed nor secreted or metabolized in the nephron how will its
clearance change with increasing plasma concentrations?

(A) Clearance will not change (B) Clearance increases (C) Clearance decreases
 98. The following data were obtained from a patient.

Plasma Urine
Inulin concentration 1 mg/ml 150 mg/ml
Concentration of substance X 2 mg/ml 100 mg/ml
Urine flow rate 1ml/min

(A) There is net secretion of X

(B) There is net reabsorption of X
(C) The clearance of X can be used to measure glomerular filtration rate (GFR)
(D) There is both reabsorption and secretion of X
(E) The clearance of X is greater than the clearance of creatinine

99. The following information was obtained in a 20-year-old college student who was participating in a research
study in the Clinical Research Unit: Assuming that X is freely filtered, which of the following statements is
most correct?

Plasma Urine
[Inulin] = 1mg/mL [Inulin] = 150 mg/mL
[X] = 2mg/mL [X] = 100mg/mL
Flow rate = 1 mL/min

(A) There is net secretion of X

(B) There is net reabsorption of X
(C) There is both reabsorption and secretion of X
(D) The clearance of X could be used to measure the glomerular filtration rate (GFR)
(E) The clearance of X is greater than the clearance of inulin

100. In a micropuncture study, the tubular fluid-to-plasma ratios (TF/Ps) for substance X and inulin are determined
at three locations.

TFx/Px TFin/Pin
Bowman's capsule 1 1
End of proximal tubule 6 3
End of collecting duct 240 120

On the basis of these data, you can conclude that substance X…

(A) Is reabsorbed in the collecting duct (D) Is not secreted nor reabsorbed by the tubule
(B) Shows a net secretion in the proximal tubule (E) Is reabsorbed at a higher rate than water in the
(C) Shows a net secretion in the loop of Henle proximal tubule
101. An 83-year-old woman with a history of hypertension presents to her family physician’s office with oliguria.
Serum creatinine and BUN are elevated and a CT reveals that the patient’s left kidney is hypoplastic. Renal
function studies are performed to assess the renal handing of various substances. Substance X is injected into
an arterial line. All of substance X appears in the urine and none is detected in the renal vein. What do these
findings indicate about the renal handling of substance X?

(A) It must be filtered by the kidney

(B) It must be reabsorbed by the kidney
(C) Its clearance is equal to the glomerular filtration rate
(D) Its clearance is equal to the renal plasma flow
(E) Its urinary concentration must be higher than its plasma concentration

102. A 24-year-old man with a history of renal insufficiency is admitted to the hospital after taking a large amount
of ibuprofen. His BUN is 150 mg/dL. This patient’s high serum urea nitrogen was most likely caused by which
of the following?

(A) Decreased secretion of urea by the distal tubules (D) Increased reabsorption of urea by the proximal
(B) Decreased glomerular filtration rate tubules
(C) Increased synthesis of urea by the liver (E) Increased renal blood flow

103. If the cortical collecting tubule tubular fluid inulin concentration is 40 mg/100 ml and plasma concentration of
inulin is 2.0 mg/100 ml, what is the approximate percentage of the filtered water that remains in the tubule at
that point?

(A) 0% (B) 2% (C) 5% (D) 10% (E) 20% (F) 100%

Renal Calculations

104. What is the filtered load of a freely filtered substance?

(A) [U] × urine flow (B) RPF × [plasma] (C) GFR × [plasma] (D) GFR × [urine]

105. If a patient has a creatinine clearance of 90 ml/min, a urine flow rate of 1 ml/min, a plasma K + concentration of
4mEq/L, and a urine K+ concentration of 60 mEq/L, what is the approximate rate of K+ excretion?

(A) 0.06 mEq/min (C) 0.36 mEq/min (E) 60 mEq/min

(B) 0.30 mEq/min (D) 3.6 mEq/min
106. The following renal function data were obtained for substance X:

Urine flow rate = 90 ml/hr

Urine concentration of substance X (Ux) = 480 mg/ml
Plasma concentration of substance X (Px) = 6 mg/ml

What is the clearance of substance X?

(A) 12 ml/min (B) 100 ml/min (C) 120 ml/min (D) 240 ml/min (E) 480 m1/min

107. A previously well 12-year-old boy is brought to the emergency department with vomiting and severe
abdominal cramps after a prolonged period of exercise. Elevated levels of serum creatinine and blood urea
nitrogen suggest acute renal failure. Following treatment and recovery, his serum uric acid concentration (0.6
mg/dL) remains consistently below normal. To determine if his low serum uric acid level is related to renal
dysfunction, uric acid clearance studies are conducted and the following data are obtained:

Urine flow rate = 1 mL/min Urine (uric acid) = 36 mg/dL

Which of the following is the patient’s uric acid clearance?

(A) 6 mL/min (B) 12 mL/min (C) 24 mL/min (D) 48 mL/min (E) 60 mL/min

108. A 32-year-ols man complaining of fatigue and muscle weakness is seen by his physician. Blood tests reveal a
serum glucose level of 325 mg/dL and serum creatinine of 0.8 mg/dL. Results of a 24-hour urine analysis are
as follows:

Total volume = 5 L Total glucose = 375 g Total creatinine = 2.4 g

The patient’s GFR is approximately which of the following?

(A) 75 mL/min (B) 100 mL/min (C) 125 mL/min (D) 200 mL/min (E) 275 mL/min

To evaluate kidney function in a 45-year-old woman with type II diabetes, you ask her to collect her urine over
24 hours. She collects 2,600 ml of urine in that period. The clinical laboratory returns the following result after
analyzing the patient’s urine and plasma samples: plasma creatinine = 4 mg/dL, urine creatinine = 32 mg/dL,
plasma potassium = 5 mmol/L, and urine potassium = 10 mmol/L. (Next 2 questions)

109. What is this patient’s approximate GFR, assuming that she collected all her urine in the 24-hour period?

(A) 10 ml/min (B) 20 ml/min (C) 30 ml/min (D) 40 ml/min (E) 80 ml/min
110. What is the net renal tubular reabsorption rate of potassium in this patient?

(A) 1.050 mmol/min (C) 0.037 mmol/min (E) Potassium is not reabsorbed
(B) 0.100 mmol/min (D) 0.075 mmol/min in this example

The following test results were obtained for next 3 questions: urine flow rate = 2.0 ml/min; urine inulin
concentration = 60 mg/mL; plasma inulin concentration = 2 mg/ml; urine potassium concentration = 20
µmol/ml; plasma potassium concentration = 4.0 µmol/ml; urine osmolarity = 150 mOsm/L; and plasma
osmolarity = 300 mOsm/L.

111. What is the approximate GFR?

(A) 20 ml/min (C) 30 ml/min (E) 75 ml/min

(B) 25 ml/min (D) 60 ml/min (F) 150 ml/min

112. What is the net potassium reabsorption rate?

(A) 0 µmol/min (D) 200 µmol/min (G) Potassium not reabsorbed

(B) 20 µmol/min (E) 240 µmol/min in this case
(C) 60 µmol/min (F) 300 µmol/min

113. What is the free water clearance rate?

(A) + 1.0 ml/min (C) + 2.0ml/min (E) – 1.5 ml/min

(B) + 1.5 ml/min (D) – 1.0 ml/min (F) – 2.0 ml/min

114. A 68-year-old woman presents with hypertension and oliguria. ACT of the abdomen reveals a hypoplastic left
kidney. Based on the following laboratory data, which of the following her estimated renal plasma flow (RPF)?

Renal artery PAH = 6 mg/dL Urinary PAH = 25 mg/mL Hematocrit = 40%

Renal vein PAH = 0.6 mg/dL Urine flow = 1.5 mL/min

(A) 475 mL/min (B) 550 mL/min (C) 625 mL/min (D) 700 mL/min (E) 775 mL/min
115. A patient is infused with para-aminohippuric acid (PAH) to measure renal blood flow (RBF). She has a urine
flow rate of 1 mL/min, plasma [PAH] of 1 mg/mL, urine [PAH] of 600 mg/mL, and a hematocrit of 45%. What
is her “effective” RBF?

(A) 600 mL/min (B) 660 mL/min (C) 1,091 mL/min (D) 1,333 mL/min

116. The effective renal plasma flow (RPF), determined, from the clearance of p-aminohippuric acid (PAH), is less
than the true RPF because of which of the following?

(A) The fraction of PAH filtered is less than the filtration fraction
(B) The plasma entering the renal vein contains a small amount of PAH
(C) The cortical and medullary collecting ducts are able to reabsorb some PAH
(D) The calculated clearance of PHA depends on the urinary flow rate
(E) The measured value of the plasma PAH concentration is less than the actual PAH concentration

117. Which of the following is the effective renal blood flow (mL/min) using the following values?

Plasma [PAH]: 0.2 mg/ml Urine flow rate: 2.0 ml/min

Urine [PAH]: 48 mg/ml Hematocrit: 40%

(A) 120 (B) 240 (C) 300 (D) 480 (E) 800

Use the following clinical laboratory test results for next 2 questions

Urine flow rate : 1 ml/min Urine urea concentration : 50 mg/ml

Urine inulin concentration : 100 mg/ml Plasma urea concentration : 2.5 mg/ml
Plasma inulin concentration : 2 mg/ml

118. What is the glomerular filtration rate (GFR)?

(A) 25ml/min (B) 50 ml/min (C) 100 ml/min (D) 125ml/min (E) Other

119. What is the net urea reabsorption rate?

(A)
(B) 0 mg/min (C) 25 mg/min (D) 50 mg/min (E) 75 mg/min (F) 100 mg/min
120. Use of the Fick principle and the following data allow for the calculation of the renal blood flow (in ml/min).

Indicator concentration (renal artery): 0.2 mg/ml Urine minute volume: 1.5 ml/min
Indicator concentration (renal vein): 0.05 mg/ml Indicator concentration (urine): 80 mg/ml

Which of the following values is correct?

(A) 400 (B) 600 (C) 800 (D) 1,000 (E) 1,200

121. What is the filtration fraction?

(A) Kf × P (B) RPF/RBF (C) GFR/RPF (D) RPF/GFR

122. Given the following measurements, calculate the filtration fraction: glomerular capillary hydrostatic pressure =
50 mm Hg; Bowman’s space hydrostatic pressure = 15 mm Hg; colloid osmotic pressure in the glomerular
capillaries = 30 mm Hg; glomerular capillary filtration coefficient (Kf) = 12 ml/min/mm Hg; and renal plasma
flow = 400 ml/min.

(A) 0.15 (B) 0.20 (C) 0.25 (D) 0.30 (E) 0.35 (F) 0.40

123. An 85-year-old woman presents with a fever and hypovolemic hypotension. To assess her renal function, the
filtration fraction is determined using a freely filterable substance X that is neither reabsorbed nor secreted. The
infusate yields a renal artery concentration of 12 mg/mL and a renal vein concentration of 9 mg/mL. Which of
the following is her filtration fraction?

(A) 0.05 (B) 0.15 (C) 0.25 (D) 0.35 (E) 0.45

The following table shows changes in the glomerular filtration rate (GFR) and in the filtration fraction (FF) in
various conditions. (Next 2 questions)

A B C D E
GFR ↑ ↓ ↓ ↑ ↑
FF ↑ ↑ No ↓ No
change change

124. Which column summarizes the changes in GFR and FF that occur with increased afferent arteriolar resistance?

125. Which column summarizes the changes in GFR and FF that occur with increased efferent arteriolar resistance?
126. A 38-year-old woman is admitted to the hospital by her physician because of decreased urine output. Prior to
admission, she was rehearsing for a dance performance and had been taking ibuprofen (Motrin) for pain.
Laboratory data reveal: blood urea nitrogen, 49 mg/dL; serum sodium, 135 mM/L; serum creatinine, 7.5
mg/dL; urine sodium, 33 mM/L, and urine creatinine, 90 mg/dL. Her fractional sodium excretion is
approximately which of the following?

(A) 0.5% (B) 1.0% (C) 1.5% (D) 2.0% (E) 3.0%

Transport Maximum

Use following figure for next 2 questions.

127. A 32-year-old man complains of frequent urination. He is overweight (280 lb, 5 ft 10 in tall), and after
measuring the 24-hr creatinine clearance, you estimate his GFR to be 150 ml/min. His plasma glucose is 300
mg/dL. Assuming that his renal transport maximum for glucose is normal, as shown in the figure above, what
would be this patient’s approximate rate of urinary glucose excretion?

(A) 0 mg/min (C) 150 mg/min (E) 300 mg/min

(B) 100 mg/min (D) 225 mg/min
(F) Information provided is inadequate to estimate the glucose excretion rate
128. A 55-year-old overweight male patient complains of frequent urination and his blood pressure is 165/98 mm
Hg. Based on 24-hour creatinine clearance, you estimate his GFR to be 150 ml/min. His plasma glucose is 400
mg/100 ml. Assuming that his renal transport maximum for glucose is normal, as shown in the figure, what
would be the approximate rate of urinary glucose excretion for this patient?

(A) 0 mg/min (C) 150 mg/min (E) 300 mg/min

(B) 100 mg/min (D) 225 mg/min
(F) Information provided is inadequate to estimate glucose excretion rate

129. Which one of the following does not continuously increase with increases in plasma glucose concentration?

(A) Renal threshold (C) Excreted glucose (E) Glucose clearance

(B) Filtered glucose (D) Reabsorbed glucose

130. The renal threshold for a solute denotes the…

(A) Maximum filtration rate

(B) Maximum reabsorption rate
(C) Plasma concentration at which a solute begins to appear in the urine
(D) Maximum secretion rate
(E) Maximum tubular secretory capacity (Ts)

131. If a freely filtered substance is absorbed across the proximal tubule, and the filtered load of that substance is
less than the transport maximum of the proximal tubule what will that substances clearance be?

(A) Clearance is zero (C) Clearance is medium

(B) Clearance is low (D) Clearance is high

132. The renal transport maximum (Tm) for a substance is defined as the maximal…

(A) Glomerular filtration rate (GFR)

(B) Urinary excretion rate
(C) Tubular reabsorption or secretion rate
(D) Renal clearance rate
(E) amount of a substance filtered by the glomeruli per minute
133. At plasma concentrations of glucose higher than occur at transport maximum (Tm), the…

(A) Clearance of glucose is zero

(B) Excretion rate of glucose equals the filtration rate of glucose
(C) Reabsorption rate of glucose equals the filtration rate of glucose
(D) Excretion rate of glucose increases with increasing plasma glucose concentrations
(E) Renal vein glucose concentration equals the renal artery glucose concentration

134. At plasma concentrations of glucose higher than those associated with the transport maximum (≈ 300 mg/dl),
which of the following statements is correct?

(A) The clearance of glucose is zero

(B) The excretion rate of glucose equals the filtered load of glucose
(C) The reabsorption rate of glucose equals the filtered load of glucose
(D) The excretion rate of glucose increases with increasing plasma glucose concentrations
(E) Renal venous glucose concentration equals the renal arterial glucose concentration

135. Juvenile (type I) diabetes mellitus is often diagnosed because of polyuria (high urine flow) and polydipsia
(frequent drinking) that occur because of which of the following?

(A) Increased delivery of glucose to the collecting duct interferes with the action of antidiuretic hormone
(B) Increased glomerular filtration of glucose increases Na+ reabsorption via the sodium-glucose co-transporter
(C) When the filtered load of glucose exceeds the renal threshold, a rising glucose concentration in the
proximal tubule decrease the osmotic driving force for water reabsorption
(D) High plasma glucose concentration decreases thirst
(E) High plasma glucose concentration stimulates antidiuretic hormone release from the posterior pituitary

136. At plasma para-aminohippuric acid (PAH) concentrations below the transport maximum (Tm), PAH…

(A) Reabsorption is not saturated

(B) Clearance equals inulin clearance
(C) Secretion rate equals PAH excretion rate
(D) Concentration in the renal vein is close to zero
(E) Concentration in the renal vein equals PAH concentration in the renal artery
137. When the secretion of para-aminohippuric acid (PAH) reaches the renal tubular transport maximum (Tm), a
further increase in plasma PAH concentration causes its clearance to do which of the following?

(A) Increase in proportion to its plasma concentration

(B) Approach glucose clearance asymptotically
(C) Remain constant
(D) Approach inulin clearance asymptotically
(E) Increase in proportion to the glomerular filtration rate (GFR)

The following graph shows the proximal tubular secretion of para-aminohippuric acid (PAH) versus the plasma
concentration of PAH. In these questions, assume that all the plasma flows through the nephron vasculature and
that the glomerular filtration rate (GFR) and the filtration fraction (FF) are normal. (Next 4 questions)

138. Which of the following points corresponds to the lowest clearance of para-aminohippuric acid (PAH)?

139. Which of the following points is associated with the greatest renal venous pares aminohippuric acid (PAH)
concentration?

140. Which of the following points represents the highest excretion rate of para-aminohip¬puric acid (PAH)?

141. Which of the following points corresponds to the greatest concentration in Bowman's capsule?
142. The dashed lines in the figures of net transport in the nephron represent the vascular and urinary routes
followed by various sub-stances.

Which of the five renal models represents the clearance of para-aminohippuric acid (PAH) at high plasma PAH
concentrations?

143. Given a glomerular filtration rate (GFR) of 125 ml/min, a plasma glucose concentration of 400 mg/100 ml, a
urine glucose concentration of 75 mg/ml, and a urine flow rate of 2 ml/min, what is the renal tubular transport
maximum (Tm) for glucose?

(A) 300 mg/min (B) 350 mg/min (C) 400 mg/min (D) 500 mg/min (E) 550 mg/min
144. A 65-year-ols man with uncontrolled type 2 diabetes and sustained hyperglycemia (serum glucose = 550
mg/dL) and polyuria (5 L/d) is evaluated in the hospital’s clinical laboratory because his urine glucose
concentration (< 100 mM) was much lower than expected. The graph below illustrates the relationship between
plasma glucose concentration and renal glucose reabsorption for this patient. The glomerular filtration rate
(GFR) is 100 mL/min. Which of the following is the Tmax for glucose?

(A) 100 mL/min (C) 300 mL/min (E) 500 mL/min

(B) 200 mL/min (D) 400 mL/min

145. If a person has a kidney transport maximum for glucose of 350 mg/min, a GFR of 100 ml/min, a plasma
glucose of 150 mg/dL, a urine flow rate of 2 ml/min, and no detectable glucose in the urine, what would be the
approximate rate of glucose reabsorption, assuming normal kidneys?

(A) Glucose reabsorption cannot be estimated from these data

(B) 0 mg/min (C) 50 mg/min (D) 150 mg/min (E) 350 mg/min

RAAS

146. Which of the following increases formation of both antidiuretic hormone (ADH) and angiotensin?

(A) Increased blood urea nitrogen (BUN) con (C) Increased effective circulating volume (ECV)
concentration (D) Decreased ECV
(B) Decreased BUN concentration (E) Decreased plasma Na+ concentration
147. Which of the following statements best describes the secretion or action of renin?

(A) It is secreted by cells of the proximal tubule

(B) Its secretion leads to loss of sodium and water from plasma
(C) Its secretion is stimulated by increased mean renal arterial pressure
(D) It coverts angiotensinogen to angiotensin I
(E) It converts angiotensin I to angiotensin II

148. Stimulation of renin secretion will increase the…

(A) K+ concentration in the blood (D) Plasma colloid oncotic pressure

(B) Volume of the extracellular fluid (ECF) (E) H+ concentration in the blood
(C) Hematocrit

149. A stimulus for increasing renal renin secretion is an increase in which of the following?

(A) Angiotensin II (C) Glomerular filtration rate (E) Sympathetic nerve activity
(B) Atrial natriuretic peptide (D) Mean blood pressure

150. A 36-year-old man suffers third-degree burns over 70% of his body while responding to a three-alarm fire. His
effective circulating volume and renal perfusion pressure drop precipitously and the concentration of NaCl in
the juxtaglomerular apparatus to release which of the following hormones?

(A) Adenosine (C) Angiotensinogen (E) Renin

(B) Aldosterone (D) Antidiuretic hormone

151. A 69-year-old man with chronic hypertension presents to his physician’s office. His blood pressure is 165/105
mm Hg despite treatment with a diuretic, β-blocker, and an angiotensin receptor antagonist. It is decided that a
fourth drug is needed for the patient’s resistant hypertension, and he is prescribed the vasodilator diltiazem, a
calcium channel antagonist. The effect of decreasing the resistance of the afferent arteriole in the glomerulus of
the kidney is to decrease which of the following aspects of renal function?

(A) Filtration fraction blood

(B) Glomerular filtration rate (D) Renal plasma flow
(C) Oncotic pressure of the peritubular capillary (E) Renin release from juxtaglomerular cells
152. A 36-year-old African American man presents with low renin essential hypertension. Renin release from the
juxtaglomerular apparatus is normally inhibited by which of the following?

(A) Aldosterone (D) Prostaglandins

(B) β-adrenergic agonists (E) Stimulation of the macula densa
(C) Increased pressure within the afferent arterioles

153. A patient complains of headaches, and an examination reveals that her blood pressure is 175/112 mm Hg.
Laboratory tests give the following results: plasma renin activity = 11.5 ng angiotensin I/ml/hr (normal = 1),
plasma Na+ = 144 mmol/L, and plasma K+ = 3.4 mmol/L. A magnetic resonance imaging procedure suggests
that she has a renin-secreting tumor. Which of the following changes would you expect, compared with
normal?

Renal Blood Flow Filtration Fraction Glomerular Capillary Peritubular Capillary

Hydrostatic Pressure Hydrostatic Pressure
(A) ↓ ↑ ↑ ↓
(B) ↓ ↑ ↑ ↑
(C) ↓ ↓ ↑ ↓
(D) ↓ ↑ ↓ ↑
(E) ↓ ↓ ↓ ↓

154. A patient with severe hypertension (blood pressure 185/110 mm Hg) is referred to you. A renal magnetic
resonance imaging scan shows a tumor in the kidney, and laboratory findings include a very high plasma renin
activity of 12 ng angiotensin 1/ml/hr (normal = 1). The diagnosis is a renin-secreting tumor. Which of the
following changes would you expect to find in this patient, under steady-state conditions, compared with
normal?

Plasma aldosterone Plasma excretion Plasma potassium Renal blood

concentration rate concentration flow
(A) ↔ ↓ ↓ ↑
(B) ↔ ↔ ↓ ↑
(C) ↑ ↔ ↓ ↓
(D) ↑ ↓ ↔ ↓
(E) ↑ ↓ ↓ ↔
155. A 26-year-old construction worker is brought to the emergency room with a change in mental status after
working a 10-hour shift on a hot summer day (average outside temperature was 97°F). The man had been
sweating profusely during the day but did not drink fluids. He has a fever of 102°F, heart rate of 140 beats/min,
and blood pressure of 100/55 mm Hg in the supine position. On examination he has no perspiration, appears to
have dry mucous membranes, and is poorly oriented to person, place, and time. Assuming that his kidneys were
normal yesterday, which of the following sets of hormone levels describes his condition, compared with
normal?

(A) High ADH, high renin, low angiotensin II, low aldosterone
(B) Low ADH, low renin, low angiotensin II, low aldosterone
(C) High ADH, low renin, high angiotensin II, low aldosterone
(D) High ADH, high renin, high angiotensin II, high aldosterone
(E) Low ADH, high renin, low angiotensin II, high aldosterone

156. Which of the following changes would you expect to find in a patient consuming a high-sodium diet (200
mEq/Day) compared with the same patient on a normal sodium diet (100 mEq/day), assuming steady-state
conditions?

(A) Increased plasma aldosterone concentration (D) Decreased plasma atrial natriuretic peptide
(B) Increased urinary potassium excretion (E) An increase in plasma sodium concentration of
(C) Decreased plasma renin activity at least 5 mmol/L

Baroreflex

157. After severe hemorrhage, a man's blood pressure drops to 50/35 mm Hg, his heart rate increases from 70 to 140
beats/min, and his pulse is weak. Immediately following infusion of 3 L of plasma, his blood pressure rises to
100/70 mm Hg, and his heart rate slows to 90 beats/min. As a result of the infusion of plasma, which one of the
following is decreased?

(A) Cardiac output (D) Plasma oncotic pressure

(B) Stroke volume (E) Glomerular filtration rate (GFR)
(C) Peripheral vascular resistance (PVR)
 Free Water Clearance

158. After ingestion of 1 L of water a subject produced dilute urine during the subsequent 90 min. Free water
clearance was determined and found to be:

(A) A negative number (C) Zero (E) Equal to GFR

(B) Equal to the urine flow rate (D) A positive number

159. Subjects A and B are 70-kg men. Subject A drinks 2L of distilled water, and subject B drinks 2L of isotonic
NaCl. As a result of these ingestions, subject B will have a…

(A) Greater change in intracellular fluid volume (D) Higher urine osmolarity
(B) Higher positive free-water clearance (Cwater) (E) Higher urine flow rate
(C) Greater change in plasma osmolarity

160. Compared with a person who ingests 2 L of distilled water, a person with water deprivation will have a…

(A) Higher free-water clearance (Cwater)

(B) Lower plasma osmolarity
(C) Lower circulating level of antidiuretic hormone (ADH)
(D) Higher tubular fluid/plasma (TF/P) osmolarity in the proximal tubule
(E) Higher rate of H2O reabsorption in the collecting ducts

161. An 82-year-old man presents with polyuria and polydipsia. Blood analysis reveals hypernatremia and urinalysis
shows hypotonicity and an increased free water clearance. If which of the following conditions id an increased
free water clearance a hallmark of the disease?

(A) Diabetes insipidus (C) Diuretic therapy (E) Renal failure

(B) Diabetes mellitus (D) Heart failure
162. A female patient has unexplained severe hypernatremia (plasma Na+ = 167 mmol/L) and complains of frequent
urination and large urine volumes. A urine specimen reveals that the Na+ concentration is 15 mmol/L (very
low) and the osmolarity is 155 mOsm/L (very low). Laboratory tests reveal: plasma renin activity = 3 ng
angiotensin I/ml/hr (normal = 1.0), plasma antidiuretic hormone (ADH) = 30 pg/ml (normal = 3 pg/ml), and
plasma aldosterone = 20 ng/dL (normal = 6 ng/dL). Which of the following is the most likely reason for her
hypernatremia?

(A) Simple dehydration due to decreased water (D) Syndrome of inappropriate ADH
intake (E) Primary aldosteronism
(B) Nephrogenic diabetes insipidus (F) Renin-secreting tumor
(C) Central diabetes insipidus

163. A 48-year-old woman complains of severe polyuria (producing about 0.5 L of urine each hour) and polydipsia
(drinking two to three glasses of water every hour). Her urine contains no glucose, and she is placed on
overnight water restriction for further evaluation. The next morning, she is weak and confused, her sodium
concentration is 160 mEq/L, and her urine osmolarity is 80 mOsm/L. Which of the following is the most likely
diagnosis?

(A) Diabetes mellitus (D) Renin-secreting tumor

(B) Diabetes insipidus (E) Syndrome of inappropriate antidiuretic
(C) Primary aldosteronism hormone

164. A negative free-water clearance (– Cwater) will occur in a person who…

(A) Drinks 2 L of distilled water in 30 minutes

(B) Begins excreting large volumes of urine with an osmolarity of 100 mOsm/L after a severe head injury
(C) Is receiving lithium treatment for depression, and has polyuria that is unresponsive to the administration of
antidiuretic hormone (ADH)
(D) Has an oat cell carcinoma of the lung, and excretes urine with an osmolarity of 1,000 mOsm/L
165. A 63-year-old woman is brought to the emergency department complaining of fatigue and headaches. She
appears confused and apathetic. She has been taking diuretics to treat her hypertension and paroxetine for her
depression. Laboratory results are as follows:

Urine flow = 1 L/d Urine osmolality = 385 Urine potassium = 25 mmol/L

Plasma sodium = 125 mmol/L mOsm/L
Plasma potassium = 4 mmol/L Urine sodium = 125 mmol/L

Which of the following is this patient’s approximate free water clearance?

(A) – 0.20 L/d (B) – 0.50 L/d (C) – 0.75 L/d (D) + 0.2 L/d (E) + 0.50 L/d

166. A patient’s urine is collected for 2 hr, and the total volume is 600 ml during this time. Her urine osmolarity is
150 mOsm/L, and her plasma osmolarity is 300 mOsm/L. What is her “free water clearance”?

(A) + 5.0 ml/min (C) 0.0 ml/min (E) – 5.0 ml/min

(B) + 2.5 ml/min (D) – 2.5 ml/min

Aldosterone and Na+

167. A patient undergoing surgery develops an increase in the secretion and plasma levels of ACTH, cortisol, and
aldosterone. What best characterizes the production and actions of aldosterone in the body?

(A) It produces its effect by activating cAMP

(B) It produces its effect by increasing distal tubular permeability to sodium
(C) It causes an increased reabsorption of hydrogen ion
(D) It has its main effect on the proximal tubule
(E) It is secreted in response to an increase in blood pressure

168. A 52-year-old man presents to his internist for a 6-month check-up following diuretic therapy and
recommended diet changes for his essential hypertension. His blood pressure is 145/95 mmHg and serum
aldosterone levels are increased. Aldosterone secretion is increased when there is a decrease in the plasma
concentration of which of the following?

(A) ACTH (C) Potassium (E) Sodium

(B) Angiotensin II (D) Renin
169. In a patient with very high levels of aldosterone and otherwise normal kidney function, approximately what
percentage of the filtered load of sodium would be reabsorbed by the distal convoluted tubule and collecting
duct?

(A) More than 66% (C) 20% to 40% (E) Less than 10%
(B) 40% to 60% (D) 10% to 20%

ANP

170. A patient has a tumor of the adrenal gland, causing hypersecretion of aldosterone. The plasma concentration of
which of the following variables is increased above that found in a normal individual on an identical diet?

(A) Renin (C) Potassium ions (E) Magnesium

(B) Angiotensin II (D) Atrial Natriuretic Peptide

171. A patient is inadvertently given 2 L of isotonic saline (0.9% NaCl) over a 4-hour period of time. This infusion
should cause an increase in…

(A) Antidiuretic hormone (B) Plasma oncotic pressure (D) Atrial natriuretic factor
(ADH) (C) Angiotensin II (E) Aldosterone

172. Which one of the following conditions is associated with an increase in the secretion of atrial natriuretic
peptide?

(A) Weightlessness (C) Hypovolemia (E) A reduction in effective

(B) Hemorrhage (D) Hypotension circulating volume

ADH and H2O

173. Which of the following would best distinguish an otherwise healthy person with severe water deprivation from
a person with the syndrome of inappropriate antidiuretic hormone (SIADH)?

(A) Free-water clearance (Cwater) (D) Circulating levels of ADH

(B) Urine osmolarity (E) Corticopapillary osmotic gradient
(C) Plasma osmolarity
174. A trauma patient with multiple rib fractures requires intubation and mechanical ventilation. Mechanical
ventilation causes an increase in the patient’s vasopressin secretion and plasma levels. Which of the following
is the effect of vasopressin on the kidney?

(A) Increased diameter of the renal artery (D) Increased excretion of water
(B) Increased glomerular filtration rate (E) Increased permeability of the distal nephron to
+
(C) Increased excretion of Na water

175. In addition to increasing the permeability of the collecting duct to water, ADH increased the permeability of the
collecting duct to which of the following?

(A) Hydrogen (B) Ammonium (C) Potassium (D) Sodium (E) Urea

176. In the presence of antidiuretic hormone (ADH), the filtrate will be isotonic to plasma in which of the following
parts of the kidney?

(A) Ascending limb of the loop of Henle (D) Medullary collecting tubule
(B) Decreasing limb of the loop of Henle (E) Renal pelvis
(C) Cortical collecting tubule

177. Which part of the renal tubule would have the lowest tubular fluid osmolarity in a patient who has complete
lack of antidiuretic hormone due to “central” diabetes insipidus?

(A) Medullary collecting duct (C) Early distal tubule (E) Proximal tubule
(B) Collecting tubule (D) Descending loop of Henle

178. Which of the following changes would you expect to find in a dehydrated person deprived of water for 24
hours?

(A) Decreased plasma renin activity

(B) Decreased plasma antidiuretic hormone concentration
(C) Increased plasma atrial natriuretic peptide concentration
(D) Increased water permeability of the collecting duct
(E) Increased water permeability in the ascending loop of Henle
179. Which of the following would likely lead to hyponatremia?

(A) Excessive antidiuretic hormone secretion (D) Administration of 2L of 3% NaCl solution

(B) Restriction of fluid intake (E) Administration of 2L of 0.9% NaCl solution
(C) Excess aldosterone secretion

180. In patients with the syndrome of inappropriate antidiuretic hormone (SIAHD), which of the following will
increase?

(A) The concentration of plasma (B) Intracellular volume (D) Plasma oncotic pressure
sodium (C) Urinary flow (E) Plasma osmolarity

181. A woman has plasma osmolarity of 300mOsm/L and a urine osmolarity of 1200mOsm/L. The correct diagnosis
is…

(A) SIADH (D) Nephrogenic diabetes insipidus

(B) Water deprivation (E) Drinking large volumes of distilled water
(C) Central diabetes insipidus

182. An elderly patient complains of muscle weakness and lethargy. A urine specimen reveals a Na+ concentration
of 600 mmol/L and osmolarity of 1,200 mOsm/L. Additional laboratory test provide the following information:
plasma Na+ concentration = 167 mmol/L, plasma renin activity = 4 ng angiotensin I/ml/hr (normal = 1), plasma
antidiuretic hormone (ADH) = 60 pg/ml (normal = 3 pg/ml), and plasma aldosterone = 15 ng/dL (normal = 6
ng/dL). Which of the following is the most likely reason for this patient’s hypernatremia?

(A) Dehydration caused by decreased fluid intake (D) Primary aldosteronism

(B) Syndrome of inappropriate ADH (E) Renin-secreting tumor
(C) Nephrogenic diabetes insipidus

183. A 46-year-old man presents to his physician with a 12-week history of frontal headaches. A CT scan of the
brain shows a mass in the posterior pituitary. The patient also complains of increased thirst and waking up
frequently during the night. Which of the following best describes his urine?

(A) A higher-than-normal flow of hypotonic urine (D) A lower-than-normal flow of hypotonic urine
(B) A higher-than-normal flow of hypertonic urine (E) A lower-than-normal flow of hypertonic urine
(C) A normal flow of hypertonic urine
184. Which of the following changes would be expected in a patient with diabetes insipidus due to a lack of
antidiuretic hormone (ADH) secretion?

Plasma osmolarity concentration Plasma sodium concentration Plasma renin Urine volume
(A) ↔ ↔ ↓ ↑
(B) ↔ ↔ ↑ ↑
(C) ↑ ↑ ↑ ↑
(D) ↑ ↑ ↔ ↔
(E) ↓ ↓ ↓ ↔

185. In a patient with sever syndrome of inappropriate antidiuretic hormone (excessive antidiuretic hormone
secretion), which of the following charges, compared with normal, would you expect find? Assume steady-
state conditions and that the intake of water and electrolytes has remained constant.

Plasma Renin Plasma Aldosterone Urine Plasma Sodium Plasma Protein

Concentration Concentration Flow Concentration Concentration
Rate
(A) ↔ ↔ ↓ ↓ ↓
(B) ↔ ↔ ↔ ↓ ↑
(C) ↓ ↓ ↔ ↓ ↓
(D) ↓ ↓ ↔ ↔ ↓
(E) ↑ ↑ ↓ ↓ ↔

Proximal Tubule

186. Which one of the following best represents the changes in the concentration of Na+ as the filtrate travels along
the proximal tubule?

2.0 1

1.5
2

[TFx/Px] 1.0 3
osm

0.5
4
5
0.0
Length of proximal tubule

.
 For each of the following substances, select the appropriate lettered tubular fluid-to-plasma (TF/P) curve on the
graph here. (Next 3 questions)

187. Inorganic phosphate (Pi) 188. Glucose 189. Glycine

190. The reabsorption of glucose from the renal tubular lumen into the cells…

(A) Depends on the presence of Na+ in the filtrate

(B) Occurs against an electrochemical gradient
(C) Is a primary active transport process
(D) Is inhibited by the simultaneous transport of para-aminohippuric acid (PAH)
(E) Occurs mainly in the distal tubule

191. Which of the following statements correctly describes glucose reabsorption by the kidney?

(A) Secondary active cotransport at the luminal membrane

(B) Below the renal threshold, the filtered load, and the reabsorption rate are different
(C) Glucose is actively transported across the basolateral membrane
(D) Renal glucose transport is Na+-independent
(E) Renal glucose transport is an electroneutral process
192. Amino acids are almost completely reabsorbed from the glomerular filtrate via secondary active transport in
the:

(A) Proximal tubule (C) Distal tubule (E) Medullary collecting duct
(B) Loop of Henle (D) Cortical collecting duct

193. In the figure showing five renal transport systems for various ions and a non-electrolyte (glucose), which of the
following transport processes is an example of secondary active transport (cotransport) only in the proximal
tubule?

194. Which of the following would produce an increase in the reabsorption of isosmotic fluid in the proximal
tubule?

(A) Increased filtration fraction

(B) Extracellular fluid (ECF) volume expansion
(C) Decreased peritubular capillary protein concentration
(D) Increased peritubular capillary hydrostatic pressure
(E) Oxygen deprivation

195. Which of the following structural features distinguishes the epithelial cells of the proximal tubule from those of
the distal tubule?

(A) The distal tubule has a thicker basement membrane

(B) The proximal tubule has a thicker basement membrane
(C) The proximal tubule has a more extensive brush border
(D) The proximal tubule forms the juxtaglomerular apparatus
(E) The distal tubule has fewer tight intercellular junctions
196. A 63-year-old hospitalized woman becomes oliguric and confused. Her blood glucose is found to be only 35
mg/dL. An IV access is obtained and an ampule of 50% dextrose is given followed by a continuous infusion of
10% dextrose. Most of the glomerulus undergoes reabsorption in which of the following?

(A) Proximal tubule (D) Distal tubule

(B) Descending limb of the loop of Henle (E) Collecting duct
(C) Ascending limb of the loop of Henle

197. A patient develops acute renal failure due to an autoimmune disorder affecting the proximal tubules. What
percentage of the filtered load of sodium is reabsorbed by tubule?

(A) 15% (B) 25% (C) 45% (D) 65% (E) 95%

198. Which one of the following statements regarding Na+ transport is correct?

(A) Active transport of Na+ across all cells consumes most of the energy derived from cellular metabolism
(B) The Na+ concentration is highest in the intracellular fluid (ICF)
(C) Na+ reabsorption across proximal tubular cells is mainly active and transcellular
(D) The Na+ concentration gradient provides energy for the cotransport of H+
(E) The transport of Na+ across the apical membrane of the nephron is an active transport process

199. Approximately one-third of the proximal Na+ reabsorption occurs through the paracellular pathway. The
primary driving force for this passive reabsorption of Na+ in the late proximal tubule is…

(A) A higher luminal than peritubular hydrostatic pressure

(B) A higher luminal than peritubular Na+ concentration
(C) A lumen-positive transepithelial voltage
(D) Created by paracellular Cl– transport
(E) A lower interstitial fluid than luminal oncotic pressure
(F) Operation of the Na+-H+ countertransporter

200. The transport of H+ into the proximal tubule is primarily associated with which of the following?

(A) Excretion of K+ (C) Reabsorption of Ca2+ (E) Reabsorption of HPO42–

(B) Excretion of H+ (D) Reabsorption of HCO3–
201. In acidosis, most of the hydrogen ions secreted by the proximal tubule are associated with which of the
following processes?

(A) Excretion of hydrogen ions (D) Reabsorption of phosphate ions

+
(B) Excretion of NH4 (E) Reabsorption of potassium ions
(C) Reabsorption of bicarbonate ions

202. Which of the following proximal tubular processes is linked to the reabsorption of Na+?

(A) Active proton reabsorption

(B) Bicarbonate reabsorption
(C) Active reabsorption of chloride
(D) Establishment of a lumen-negative transepithelial potential
(E) The efflux of K' through luminal conductive channels

203. When you are excreting a maximally concentrated urine, the greatest amount of water is being reabsorbed by
the:

(A) Proximal tubule (D) Thick ascending limb of Henle's loop

(B) Thin descending limb of Henle's loop (E) Collecting ducts
(C) Ascending thin limb of Henle's loop

204. A healthy 29-year-old man runs a 10-km race on a hot day and becomes very dehydrated. Assuming that his
antidiuretic hormone levels are very high, in which part of the renal tubule is the most water reabsorbed?

(A) Proximal tubule (C) Distal tubule (E) Medullary collecting duct
(B) Loop of Henle (D) Cortical collecting tubule

205. A patient is suffering from hyperaldosteronism. This will mean that the majority of the water absorption by
their kidney will occur in the:

(A) Proximal tubule (D) Early distal tubule

(B) Descending limb of the loop of Henle (E) Late distal tubule and collecting duct
(C) Ascending limb of the loop of Henle
206. Which of the following can increase the percentage of fluid reabsorbed by the proximal tubule?

(A) Aldosterone
(B) Angiotensin II
(C) An increase in peritubular capillary pressure
(D) Antidiuretic hormone (ADH)
(E) A decrease in oncotic pressure in the peritubular capillaries

207. The figure below shows the concentration of inulin at different points along the renal tubule, expressed as the
tubular fluid/plasma ratio of inulin concentration. If inulin is not reabsorbed, what is the approximate
percentage of the filtered water that has been reabsorbed prior to the distal convoluted tubule?

(A) 25% (B) 33% (C) 66% (D) 75% (E) 99% (F) 100%

208. Which of the following statements is correct?

(A) Urea reabsorption in the medullary collecting tubule is less than in the distal convoluted tubule during
antidiuresis
(B) Urea concentration in the interstitial fluid of the renal cortex is greater than in the interstitial fluid of the
renal medulla during antidiuresis
(C) The thick ascending limb of the loop of Henle reabsorbs more urea than the inner medullary collecting
tubule during antidiuresis
(D) Urea reabsorption in the proximal tubule is greater than in the cortical collecting tubule
209. Under conditions of normal renal function, which of the following is true of the concentration of urea in tubular
fluid at the end of the proximal tubule?

(A) It is higher than the concentration of urea in tubular fluid at the tip of the loop of Henle
(B) It is higher than the concentration of urea in the plasma
(C) It is higher than the concentration of urea in the final urine in antidiuresis
(D) It is lower than plasma urea concentration because of active urea reabsorption along the proximal tubule

210. Carbonic anhydrase inhibitors exert their diuretic effect by inhibiting the reabsorption of Na+ in which of the
following parts of the nephron?

(A) The proximal tubule (D) The cortical collecting duct

(B) The thick ascending limb of loop of Henle (E) The outer medullary collecting duct
(C) The distal convoluted tubule

211. Reabsorption of filtered bicarbonate…

(A) Contributes to the excretion of titratable acid (D) Requires carbonic anhydrase
(B) Is reduced during a state of acidosis (E) Is usually lower than Na+ reabsorption
(C) Is accomplished by the net secretion of Na+

Loop of Henle

212. A nephron segment was micro-dissected from the kidney of an experimental animal and studied in vitro. No
active sodium reabsorption was detected and the segment was impermeable to water. The segment is:

(A) Proximal tubule (D) Thick ascending limb of Henle's loop

(B) Thin descending limb of Henle's loop (E) Distal tubule
(C) Ascending thin limb of Henle's loop

213. A 92-year-old man presents with dehydration following four days of persistent diarrhea. Under these
circumstances, hypotonic fluid would be expected in which of the following?

(A) Glomerular filtrate (C) Loop of Henle (E) Distal collecting duct
(B) Proximal tubule (D) Cortical collecting tubule
214. The ability of the kidney to excrete concentrated urine will increase if which of the following occurs?

(A) The reabsorption of Na+ by the proximal tubule decreases

(B) The glomerular capillary pressure increase
(C) The flow of filtrate through the loop of Henle increases
(D) The activity of the Na+-K+ pump in the loop of Henle increases
(E) The permeability of the collecting duct to water decreases

215. In normal kidneys, which of the following is true of the osmolarity of renal tubular fluid that flows through the
early distal tubule in the region of the macula densa?

(A) Usually isotonic compared with plasma

(B) Usually hypotonic compared with plasma
(C) Usually hypertonic compared with plasma
(D) Hypertonic, compared with plasma, in antidiuresis

216. Which of the following is true of the tubular fluid that passes through the lumen of the early distal tubule in the
region of the macula densa?

(A) It is usually isotonic (C) It is usually hypertonic

(B) It is usually hypotonic (D) It is hypertonic in antidiuresis
(E) It is hypertonic when the filtration rate of its own nephron decreases to 50% below normal

217. Which of the following statements is true?

(A) Antidiuretic hormone (ADH) increases water reabsorption from the ascending loop of Henle
(B) Water reabsorption from the descending loop of Henle is normally less than that from the ascending loop of
Henle
(C) Sodium reabsorption from the ascending loop of Henle is normally less than that from the descending loop
of Henle
(D) Osmolarity of fluid in the early distal tubule would be less than 300 mOsm/L in a dehydrated person with
normal kidneys and increased ADH levels
(E) ADH decreases the urea permeability in the medullary collecting tubules

218. Which of the following diuretics inhibits Na+-2Cl–-K+ co-transport in the loop of Henle as its primary action?

(A) Thiazide diuretic (D) Osmotic diuretic

(B) Furosemide (E) Amiloride
(C) Carbonic anhydrase inhibitor (F) Spironolactone
219. Furosemide (Lasix) is a diuretic that also produces natriuresis. Which of the following is an undesirable side
effect of furosemide due to its site of action on the renal tubule?

(A) Edema (D) Decreased ability to concentrate the urine

(B) Hyperkalemia (E) Heart failure
(C) Hypercalcemia

220. You begin treating a hypertensive patient with a powerful loop diuretic (e.g., furosemide). Which of the
following changes would you expect to find, compared with pretreatment values, when he returns for a follow-
up examination 2 weeks later?

Urine Sodium Extracellular Blood Plasma Potassium

Excretion Fluid Volume Pressure Concentration
(A) ↑ ↓ ↓ ↓
(B) ↑ ↓ ↔ ↔
(C) ↔ ↓ ↓ ↓
(D) ↔ ↓ ↔ ↔
(E) ↑ ↔ ↓ ↑

221. Which of the following nephron segments is the primary site of magnesium reabsorption under normal
conditions?

(A) Proximal tubule (D) Distal convoluted tubule

(B) Descending limb of the loop of Henle (E) Collecting ducts
(C) Ascending limb of the loop of Henle

222. A patient with congestive heart failure was treated with a loop diuretic to help control edema. The mode of
action of this drug was to block the Na-K-Cl transporter on the ascending limb of the Loop of Henle. Her
renal function was within acceptable limits. Which of the following changes in fractional electrolyte excretion
would you predict during diuretic therapy?

(A) FENa increases more than FEMg (D) FEMg increases and FENa is unchanged
(B) FEMg increases more than FENa (E) FENa and FEMg are both unchanged
(C) FENa increases and FEMg is unchanged
 Calcium and Phosphate

223. Which of the following changes tends to increase urinary Ca2+ excretion?

(A) Extracellular fluid volume expansion (C) Decreased blood pressure

(B) Increased plasma parathyroid hormone (D) Increased plasma phosphate concentration
concentration (E) Metabolic acidosis

224. Which of the following causes a decrease in renal Ca2+ clearance?

(A) Hypoparathyroidism (D) ECF volume expansion

(B) Treatment with chlorothiazide (E) Hypermagnesemia
(C) Treatment with furosemide

225. Which of the following changes would tend to increase Ca2+ reabsorption in the renal tubule?

(A) Extracellular fluid volume expansion (C) Increased blood pressure

(B) Increased plasma parathyroid hormone (D) Decreased plasma phosphate concentration
concentration (E) Metabolic alkalosis

226. Which of the following is an action of parathyroid hormone (PTH) on the renal tubule?

(A) Stimulation of adenylate cyclase

(B) Inhibition of distal tubule K+ secretion
(C) Inhibition of distal tubule Ca2+ reabsorption
(D) Stimulation of proximal tubular phosphate reabsorption
(E) Inhibition of production of 1,25-dihydroxycholecalciferol

227. Phosphate reabsorption by the kidney:

(A) Occurs mainly along the distal tubule and collecting duct
(B) Depends on a trans-luminal fluid potential difference
(C) Is controlled by the secretion of angiotensin II
(D) Is inhibited by parathyroid hormone
(E) Occurs mainly in the thick ascending limb
228. The renal clearance of phosphate is increased by which of the following hormones?

(A) Aldosterone (C) Norepinephrine (E) Angiotensin

(B) Parathyroid hormone (D) Vasopressin

Potassium

229. Which of the following causes hyperkalemia?

(A) Exercise (C) Insulin injection (E) Treatment with β-agonists

(B) Alkalosis (D) Decreased serum osmolarity

230. Which of the following would be expected to cause a decrease in extracellular fluid potassium concentration
(hypokalemia) at least in part by stimulating potassium uptake into the cells?

(A) β-adrenergic blockade (C) Strenuous exercise (E) Metabolic alkalosis

(B) Insulin deficiency (D) Aldosterone deficiency

231. Which of the following would tend to decrease plasma potassium concentration by causing a shift of potassium
from the extracellular fluid into the cells?

(A) Strenuous exercise (C) Acidosis (E) Insulin excess

(B) Aldosterone deficiency (D) Beta adrenergic blockade

232. The amount of potassium excreted by the kidney will decrease if which of the following occurs?

(A) Distal tubular flow increase (D) Na+ reabsorption by the distal nephron
(B) Circulating aldosterone levels increase decreases
(C) Dietary intake of potassium increase (E) The excretion of organic ions decreases

233. Which of the following will produce the greatest increase in potassium secretion?

(A) A decrease in circulating blood volume (D) An increase in distal nephron sodium
(B) A decrease in renal blood flow concentration
(C) A decrease in urine flow rate (E) An increase in sympathetic nerve activity
234. Which of the following tends to increase potassium secretion by the cortical collecting tubule?

(A) A diuretic that inhibits the action of aldosterone (e.g., spironolactone)

(B) A diuretic that decreases loop of Henle sodium reabsorption (e.g., furosemide)
(C) Decreased plasma potassium concentration
(D) Acute metabolic acidosis
(E) Low sodium intake

235. Which of the following tends to decrease potassium secretion by the cortical collecting tubule?

(A) Increased plasma potassium concentration

(B) A diuretic that decreases proximal tubule sodium reabsorption
(C) A diuretic that inhibits the action of aldosterone (e.g., spironolactone)
(D) Acute alkalosis
(E) High sodium intake

236. Secretion of K+ by the distal tubule will be decreased by

(A) Metabolic alkalosis (D) Spironolactone administration

+
(B) A high-K diet (E) Thiazide diuretic administration
(C) Hyperaldosteronism

237. A 55-year-old hypertensive patient is placed on a potassium-sparing diuretic. Potassium-sparing diuretics

inhibit Na+ reabsorption in which of the following?

(A) Proximal tubule (D) Thick decreasing limb of loop of Henle

(B) Distal tubule (E) Thick ascending limb of loop of Henle
(C) Thin decreasing limb of loop of Henle

238. Which of the following would cause the greatest degree of hyperkalemia?

(A) Increase in potassium intake from 60 to 180 mmol/day in a person with normal kidneys and a normal
aldosterone system
(B) Chronic treatment with a diuretic that inhibits the action of aldosterone
(C) Decrease in sodium intake from 200 to 100 mmol/day
(D) Chronic treatment with a diuretic that inhibits loop of Henle Na+-2Cl--K+ co-transport
(E) Chronic treatment with a diuretic that inhibits sodium reabsorption in the collecting ducts
239. The most serious hypokalemia would occur in which of the following conditions?

(A) Decrease in potassium intake from 150 to 60 mEq/day

(B) Increase in sodium intake from 100 to 200 mEq/day
(C) Fourfold increase in aldosterone secretion plus high sodium intake
(D) Fourfold increase in aldosterone secretion plus low sodium intake
(E) Addison’s disease

240. When the dietary intake of K+ increases, body K+ balance is maintained by an increase in K+ excretion
primarily by which of the following?

(A) Decreased glomerular filtration of K+

(B) Decreased reabsorption of K+ by the proximal tubule
(C) Decreased reabsorption of K+ by the thick ascending limb of the loop of Henle
(D) Increased K+ secretion by the late distal and collecting tubules
(E) Shift of K+ into the intracellular compartment

241. In a person on a high (200 mmol/day) potassium diet, which part of the nephron would be expected to secrete
the most potassium?

(A) Proximal tubule (C) Ascending loop of Henle (E) Collecting tubules
(B) Descending loop of Henle (D) Early distal tubule

242. A man presents with hypertension and hypokalemia. Measurement of his arterial blood gases reveals a pH of
7.5 and a calculated HCO3– of 32mEq/L. His serum cortisol and urinary vanillylmandelic acid (VMA) are
normal, his serum aldosterone is increased, and his plasma renin activity is decreased. Which of the following
is the most likely cause of his hypertension?

(A) Cushing’s syndrome (C) Conn’s syndrome (E) Pheochromocytoma

(B) Cushing’s disease (D) Renal artery stenosis
243. A 16-year-old girl presents for her annual high school athletic physical. She states that she seems more tired
than usual, that she has been having muscle cramps in her calves, and that her legs get very weak and sore after
running and playing soccer. Her blood pressure is 160/100 mm Hg, and her EKG shows a prolonged QT
interval and the presence of a U wave. Blood analysis shows hypokalemia and metabolic alkalosis. Plasma
renin activity and aldosterone concentration are lower than normal. Her clinical condition is reversed after she
is placed on the diuretic amiloride, which blocks tubular epithelial sodium channels. Based on this finding,
which of the following renal transport processes is the major defect causing her metabolic disorder?

(A) Greater than normal sodium reabsorption by the proximal tubules

(B) Greater than normal sodium reabsorption by the distal tubules
(C) Inability of the distal nephron to secrete potassium ion
(D) Inability of the distal nephron to secrete hydrogen
(E) Inability of the distal nephron to concentrate urine

244. A patient is referred for treatment of hypertension. After testing, you discover that he has a very high level of
plasma aldosterone, and your diagnosis is Conn’s syndrome. Assuming no change in electrolyte intake, which
of the following changes would you expect to find, compared with normal?

Plasma Plasma K+ Urine K+ Urine Na+ Plasma Renin

pH Concentration Excretion Excretion Concentration
(A) ↑ ↓ ↔ ↔ ↓
(B) ↓ ↓ ↔ ↔ ↓
(C) ↑ ↓ ↑ ↓ ↓
(D) ↑ ↑ ↔ ↓ ↑
(E) ↑ ↑ ↑ ↑ ↑

245. Which of the following changes would you expect to find in a patient with primary aldosteronism (Conn’s
syndrome) under steady-state conditions, assuming that electrolyte intake remained constant?

Sodium Potassium Plasma renin Plasma potassium Blood

excretion rate excretion rate concentration concentration pressure
(A) ↔ ↔ ↔ ↓ ↑
(B) ↔ ↔ ↓ ↓ ↑
(C) ↔ ↑ ↓ ↓ ↑
(D) ↓ ↑ ↓ ↔ ↑
(E) ↑ ↓ ↑ ↑ ↔
246. A 26-year-old woman recently decided to adopt a healthier diet and eat more fruits and vegetables. As a result,
her potassium intake increased from 80 to 160 mmol/day. Which of the following conditions would you expect
to find 2 weeks after she increased her potassium intake, compared with before the increase?

Potassium Excretion Sodium Excretion Plasma Aldosterone Plasma Potassium

Rate Rate Concentration Concentration
(A) ↔ ↔ ↑ Large increase
(>1mmol/L)
(B) ↔ ↓ ↑ Small increase
(<1mmol/L)
(C) ↑2× ↔ ↑ Small increase
(<1mmol/L)
(D) ↑2× ↑ ↓ Large increase
(>1mmol/L)
(E) ↑2× ↑ ↔ Large increase
(>1mmol/L)

The following figure applies to Questions 247-254

247. PTH increases Ca2+ reabsorption at which nephron site?

248. At which nephron site does the amount of K+ in tubular fluid exceed the amount of filtered K+ in a person on a
high-K+ diet?

249. At which nephron site is the tubular fluid/plasma (TF/P) osmolarity lowest in a person who has been deprived
of water?
250. At which nephron site is the tubular fluid inulin concentration highest during antidiuresis is?

251. At which nephron site is the tubular fluid inulin concentration lowest?

252. At which nephron site is the tubular fluid glucose concentration highest?

253. Aldosterone increases Na+ reabsorption at which of the points depicted in this schematic diagram of the
nephron?

254. In the absence of ADH or when the kidney lacks responsiveness to ADH, the luminal Na+ concentration will be
lowest at which of the points along the nephron shown schematically in the diagram?

Questions 225–259 are based on the following figure.

255. Tubular fluid is always hyposmotic at which of the lettered sites?

256. The tubular fluid-to-plasma (TF/P) ratio for glucose is 1.0 at this site.

257. The urea concentration is highest at this site.

258. The urine osmolality (Uosm) can reach 1,200 to 1,400 mOsm/L at this site.

259. The macula densa is closest to this site.

 Questions 260-263 are based on the following figure. Select the correct lettered region on the diagram of the
nephron.

260. The point that represents the lowest tubular fluid-to-plasma (TF/P) concentration ratio for inulin

261. The point that represents the lowest TFosm/Posm ratio in a well-hydrated individual

262. The point that represents the highest TF concentration of para-aminohippuric acid (PAH)

263. The site of the highest TF glucose concentration

 Chose appropriate nephron site in the diagram below for next 4 questions.

264. In a patient with severe central diabetes insipidus caused by a lack of antidiuretic hormone secretion, which
part of the tubule would have the lowest tubular fluid osmolarity?

265. In a person on a very low potassium diet, which part of the nephron would be expected to reabsorbed the most
potassium?

266. Which part of the nephron normally reabsorbs the most water?

267. In a normally functioning kidney, which part of the tubule has the lowest permeability to water during
antidiuresis?

Basolateral Transport

268. Which one of the following transporters is associated with all Na+ reabsorption by the nephron?

(A) NHE3 (C) Na+-K+-ATPase (E) NCCT

(B) ENaC (D) NKCC2

269. A patient with uncontrolled hypertension is placed on a new diuretic targeted to the Na+ reabsorption site from
the basolateral surface of the renal epithelial cells. Which of the following transport processes is the drug
affecting?

(A) Na+/H+ exchange (C) Na+-K+ pump (E) Solvent drag

+
(B) Na -glucose cotransport (D) Facilitated diffusion
 Distal Nephron

270. A patient with congestive heart failure is given the loop diuretic, furosemide, along with the potassium sparing
diuretic, spironolactone. How does the distal nephron differ functionally from the proximal tubule?

(A) The distal nephron is more permeable to hydrogen ion than the proximal tubule
(B) The distal nephron is less responsive to aldosterone than the proximal tubule
(C) The distal nephron has a more negative intraluminal potential than the proximal tubule
(D) The distal nephron secretes less potassium than the proximal tubule does
(E) The distal nephron secretes more hydrogen ion than the proximal tubule does

271. A 38-year-old man presents in the emergency department with severe back pain. He is writhing around, unable
to find a comfortable position, and nauseated. A CT scan reveals nephrocalcinosis and urinalysis reveals
decreased urinary chloride and calcium. Blood analysis reveals hypokalemia and hypochloremic metabolic
alkalosis. The clinical findings suggest a defect in electrically neutral renal NaCl transport. Electrically neutral
active transport of sodium and chloride occurs in which of the following areas of the kidney?

(A) Distal tubule (D) Cortical collecting duct

(B) Decreasing limb of the Henle’s loop (E) Medullary collecting duct
(C) Thin ascending limb of Henle’s loop

272. Administration of thiazide diuretic (e.g., chlorothiazide) would be expected to cause which of the following
effects as its primary mechanism of action?

(A) Inhibition of NaCl co-transport in the early distal tubules

(B) Inhibition of NaCl co-transport in the proximal tubules
(C) Inhibition of Na+-2Cl–-K+ co-transport in the loop of Henle
(D) Inhibition of Na+-2Cl–-K+ co-transport in the collecting tubules
(E) Blockage of sodium channels in the collecting tubules

273. Which of the following changes would be expected in a patient with Liddle’s syndrome (excessive activity of
amiloride-sensitive sodium channel in the collecting tubule) under steady-state conditions, assuming that intake
of electrolytes remained constant?

Plasma renin concentration Blood pressure Sodium excretion concentration Plasma aldosterone
(A) ↔ ↑ ↓ ↔
(B) ↑ ↑ ↔ ↑
(C) ↑ ↑ ↓ ↓
(D) ↓ ↑ ↔ ↓
(E) ↓ ↑ ↓ ↓
(F) ↓ ↓ ↑ ↑
274. A patient with congestive heart failure presents with jugular venous distention, ascites, and peripheral edema.
Blood work shows elevated levels of plasma atrial natriuretic peptide (ANP). ANP decreases Na+ reabsorption
within which of the following?

(A) The proximal tubule (D) The cortical collecting duct

(B) The thick ascending limb of loop of Henle (E) The inner medullary collecting duct
(C) The distal convoluted tubule