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NBME 21 Answers

nbme21/Block 4/Question#44 (41.7 difficulty score)
A 28-year-old woman with chronic renal ...
tags: diuretics renal GFR 

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submitted by hungrybox(1110),
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Loop deiitucrs aer ftsir nile orf utcae gtcsneevoi hreat lfeu.iar htaT dhulos eplh oyu rmeermeb ttah ethy are teh ostm nepott drcs,uitie so tyre'eh ftneo deus in hte ueact arntmttee fo aedm.e

peridot  I think what threw me off was that this lady had such low GFR, figured it couldn't be right. Turns out it's still ok. Furosemide is a miracle drug!! +  

submitted by soscrying(8),
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ta my nu,i ew lrtaen ahtt at rewlo ,FRG pool uiiecdtrs slitl .kowr Tta'hs hyw ouy olusdh ues htem ni nealr air.feul esaiziThd udlwo ton rkwo ihwt a GFR of &30l;.t

qball  Dang, you actually learned something at your school? Lucky. +17  
lowyield  At our med school they teach us that Thiazide anti-HTN function is primarily from it's direct effects on vasculature rather than it's diuretic effects. Somehow directly affects the vasculature which is not well understood but this is linked to why Thiazides have greater efficacy in African American Populations. That's kinda why i figured it wouldn't be the best diuretic in this case. +2  
brotherimodu  lowyield but interesting +  

submitted by thepromise(62),
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hiCocrn anrle feluria = Hgih uiopasmst in dolbo aep(g 905 As )aidoF91rFmeu is het ttnossger eucitidr on hatt lits hatt laos estpeled soituaPsm

claptain  HCTZ and acetazolamide would also deplete potassium, they are just not as strong of diuretics. To be potassium-sparing, it has to have effect at the collecting ducts. Any diuretic that works before the collecting ducts will increase the concentration of sodium going to the collecting ducts and stimulate sodium/potassium exchange at the collecting ducts, potentially leading to decreases in potassium +3  

submitted by mcl(618),
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ioFesduerm nad rtheo loop tuisdceri rae datedcini fro esu ni veolmu dlrevaoo naeyorcds ot reanl .lifruea leacRl loop ideitcrsu inbiiht het +NKla-C//+ mppu at teh ikcht acnsgenid ploo fo lneHe, iwhhc sesmes thwi the pcyhynritteio fo teh ueldmal dan ethfoerre petvesnr einru rfmo eibgn tndrctaeceno. ihsT urtssel in deacernsi diufl olss ot ui,rne dna is lphflue ni tetanirg yossmptm of .demae

submitted by basic_pathology(12),

Loop diuretics are 90% bonded to proteins and are secreted into the proximal convoluted tubule through organic anion transporter 1 (OAT-1), OAT-2, and ABCC4. Thus, there use is not dependent on GFR.

Thiazide diuretics are filtered via the glomerular apparatus, thus their use is dependent on GFR.

Use loops during low GFR states. Use thiazides in normal GFR states (to prevent compensatory Na/Cl reabsorption at the distal tubule when using a loop).