{"id":10551,"date":"2026-08-03T00:05:41","date_gmt":"2026-08-03T08:05:41","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=10551"},"modified":"2026-07-02T16:44:09","modified_gmt":"2026-07-03T00:44:09","slug":"usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury","title":{"rendered":"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Postoperative acute kidney injury"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_85 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-postoperative-acute-kidney-injury\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>A 58-year-old man on the medical floor has an acute kidney injury. Do you know the most likely cause? Let&#8217;s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 58-year-old man is seen on the medical floor on\u00a0<strong>post-op day 4<\/strong>\u00a0after\u00a0<strong>emergent aortic valve repair<\/strong>\u00a0for\u00a0acute infective endocarditis\u00a0complicated by\u00a0aortic regurgitation.\u00a0He tolerated the surgery well. His\u00a0<strong>urine output has decreased to 15 mL\/hour<\/strong>. He received\u00a0<strong>iodinated contrast dye<\/strong>\u00a0for a preoperative CT scan performed on the same day as the surgery. He has a history of gastroesophageal reflux and hypertension for which he takes\u00a0<strong>omeprazole<\/strong>,\u00a0<strong>metoprolol<\/strong>, and\u00a0<strong>lisinopril<\/strong>. He is started on intravenous (IV)\u00a0<strong>furosemide\u00a0<\/strong>and a combination of IV\u00a0<strong>vancomycin\u00a0<\/strong>and\u00a0<strong>gentamicin<\/strong>. Temperature is 37.5\u00b0C (99.5\u00b0F), heart rate is 86\/min,\u00a0<strong>blood pressure is 140\/85 mm\u00a0Hg<\/strong>, respiratory rate is 19\/min, and oxygen saturation is 97% on room air. Physical examination is notable for\u00a0<strong>bilateral lower extremity edema<\/strong>; and a tender, healing surgical site\u00a0<strong>without signs of infection<\/strong>. Laboratory evaluation reveals a\u00a0<strong>rise in serum creatinine<\/strong>\u00a0to 3.4 mg\/dL\u00a0from a baseline of 1.2 mg\/dL, and a\u00a0<strong>blood urea nitrogen (BUN)<\/strong>\u00a0of\u00a030 mg\/dL. Urinalysis shows\u00a0<strong>muddy brown granular casts<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following is the most\u00a0likely\u00a0<em>cause\u00a0<\/em>of this patient\u2019s\u00a0<em>acute kidney injury<\/em>?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Omeprazole<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Lisinopril<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Iodinated contrast dye<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Gentamicin<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Furosemide<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Gentamicin<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Omeprazole<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient with muddy brown casts in the urine likely has acute tubular necrosis (ATN). Proton pump inhibitors (PPIs) like omeprazole can cause acute interstitial nephritis; however, this condition typically presents with fever, rash, and eosinophilia. The absence of these findings and the presence of muddy brown granular casts is more suggestive of ATN from gentamicin.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Lisinopril<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient with muddy brown casts in the urine likely has acute tubular necrosis (ATN) from gentamicin. ACE inhibitors, like lisinopril, can contribute to acute kidney injury (AKI) by reducing the glomerular filtration rate\u2013 especially in the setting of renal artery stenosis, heart failure, or diuretic use. However, they are less likely to cause ATN and muddy brown casts.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Iodinated contrast dye<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient with muddy brown casts in the urine likely has acute tubular necrosis (ATN) from gentamicin. While iodinated contrast dye can cause ATN, it generally leads to a rise in serum creatinine within 48 hours post-exposure not 4-5 days later.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Furosemide<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This patient with muddy brown casts in the urine likely has acute tubular necrosis (ATN). Furosemide can lead to intravascular volume depletion and prerenal azotemia but is less likely to cause ATN with muddy brown casts unless there is significant hypotension.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image alignleft size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"936\" height=\"769\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image.png\" alt=\"Table summarizing the causes of acute tubular necrosis (ATN), grouped into three categories: ischemic, nephrotoxic, and toxic\/environmental. Ischemic causes include severe hypotension, sepsis, major surgery, severe dehydration, and cardiac failure. Nephrotoxic causes include medications (such as aminoglycosides, amphotericin B, cisplatin, and radiocontrast agents) and endogenous toxins (including myoglobin from rhabdomyolysis, free hemoglobin from hemolysis, and tumor lysis syndrome). Toxic\/environmental causes include heavy metals, ethylene glycol, recreational drugs, and organic solvents.\" class=\"wp-image-10554\" style=\"aspect-ratio:1.2171725857769369;width:454px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image.png 936w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image.png?resize=300,246 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image.png?resize=768,631 768w\" sizes=\"auto, (max-width: 936px) 100vw, 936px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient\u2019s presentation of&nbsp;<strong>acute kidney injury (AKI)<\/strong>&nbsp;with&nbsp;<strong>muddy brown granular&nbsp;casts<\/strong>,&nbsp;suggests&nbsp;<strong>acute tubular necrosis (ATN)<\/strong>.&nbsp;<strong>ATN<\/strong>&nbsp;typically results from ischemic or nephrotoxic injury to the tubular epithelial cells. Aminoglycosides like&nbsp;<strong>gentamicin,&nbsp;<\/strong>can be&nbsp;<strong>nephrotoxic<\/strong>&nbsp;and cause ATN. Gentamicin can lead to ATN by accumulating in the renal tubular cells, causing cellular damage and dysfunction.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Acute tubular necrosis (ATN) results in a&nbsp;<strong>sudden decline in kidney function<\/strong>,&nbsp;evidenced&nbsp;by&nbsp;<strong>reduced urine output<\/strong>&nbsp;and a&nbsp;<strong>rise in serum creatinine and blood urea nitrogen (BUN)<\/strong>. Clinically, patients may&nbsp;present with&nbsp;symptoms of&nbsp;<strong>uremia&nbsp;<\/strong>such as nausea, fatigue, and confusion, with physical signs like&nbsp;<strong>edema&nbsp;<\/strong>and&nbsp;<strong>hypertension&nbsp;<\/strong>due to&nbsp;<strong>fluid overload<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Urinalysis will show the presence of<strong>&nbsp;muddy brown granular casts<\/strong>, often accompanied by renal tubular epithelial cells or cell casts.<strong>&nbsp;<\/strong>A<strong>&nbsp;BUN\/Cr ratio &lt;15 and a fractional excretion of sodium (FeNa) greater than 2%<\/strong>&nbsp;confirms a tubular source of kidney injury. Management of ATN centers on supportive care, addressing fluid and electrolyte imbalance,&nbsp;discontinuing&nbsp;nephrotoxic agents, and providing renal replacement therapy if&nbsp;indicated.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"936\" height=\"549\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image-2.png\" alt=\"Educational graphic on acute tubular necrosis (ATN) highlighting nephrotoxicity as a cause of kidney injury. It lists nephrotoxic agents\u2014including NSAIDs, intravenous antibiotics, and intravenous contrast\u2014as causes of parenchymal damage. A healthcare professional reminds viewers that these medications are commonly given to surgical patients and should be identified when obtaining a patient's medication history.\" class=\"wp-image-10556\" style=\"aspect-ratio:1.7049506143098048;width:516px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image-2.png 936w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image-2.png?resize=300,176 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/08\/image-2.png?resize=768,450 768w\" sizes=\"auto, (max-width: 936px) 100vw, 936px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Acute kidney injury\u00a0(AKI)<\/strong>\u00a0and the presence of\u00a0<strong>muddy brown granular casts<\/strong>\u00a0on urinalysis strongly suggest\u00a0<strong>acute tubular necrosis (ATN)<\/strong>.\u00a0<strong>Nephrotoxic medications<\/strong>, including aminoglycosides like\u00a0<strong>gentamicin<\/strong>, are a common causative agent.\u00a0<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video: <\/strong><a href=\"https:\/\/www.osmosis.org\/learn\/Approach_to_postoperative_acute_kidney_injury:_Clinical_sciences\">Approach to postoperative acute kidney injury: Clinical sciences<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Prowle JR, Forni LG, Bell M, et al. <strong>Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative<\/strong>. Nat Rev Nephrol. 2021;17(9):605-618. doi:10.1038\/s41581-021-00418-2<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\"><\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"http:\/\/osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Get your <strong>Osmosis from Elsevier<\/strong> <a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>&nbsp;to discover why millions of <strong>clinicians and caregivers<\/strong> love <strong>learning by Osmosis<\/strong><\/em>!<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A postoperative patient develops worsening kidney function after surgery. Can you identify the most likely cause of acute kidney injury in this high-yield USMLE-style clinical scenario?<\/p>\n","protected":false},"author":208,"featured_media":10557,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,1370,45],"tags":[1026,3241,2967,489,3108,3240,3177,3244,3242,462,149,1435,3243,2786,671],"class_list":["post-10551","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-2-questions","category-step-2","tag-acute-kidney-injury","tag-acute-tubular-necrosis","tag-board-exam-prep","tag-clinical-reasoning","tag-clinical-vignette","tag-gentamicin","tag-internal-medicine","tag-nephrology","tag-nephrotoxicity","tag-osmosis","tag-patient-care","tag-postoperative-complications","tag-renal-disease","tag-urinalysis","tag-usmle-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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Test your clinical knowledge and improve your diagnostic skills for effective patient care!","rel":"","context":"In &quot;Allopathic Medicine (MD)&quot;","block_context":{"text":"Allopathic Medicine (MD)","link":"https:\/\/www.osmosis.org\/blog\/category\/medicine"},"img":{"alt_text":"USMLE Step 2 CK Question of the Day Second Degree Mobitz type II AV block","src":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/31.webp","width":350,"height":200,"srcset":"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/31.webp 1x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/31.webp 1.5x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/31.webp 2x, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/31.webp 3x"},"classes":[]},{"id":3634,"url":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-ventral-hernia-repair","url_meta":{"origin":10551,"position":5},"title":"USMLE\u00ae Step 2 CK Question of the Day: Ventral hernia repair","author":"Marina Horiates Kerekes, MD &amp; Team","date":"August 9, 2023","format":false,"excerpt":"Learn the cause of post-operative symptoms in a 62-year-old woman following a ventral hernia repair with mesh. 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