Renal azotemia Quiz: Ace Your Exams

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A 30-year-old woman, gravida 2 para 1, at 26 weeks gestation is brought to the emergency department for evaluation of abdominal pain and vaginal bleeding following a motor vehicle accident three hours ago. A stat transvaginal ultrasound reveals placental abruption. After adequate resuscitation, the patient is brought to the operating room for emergent c-section. Approximate blood loss is 2500 mL. Several hours following the surgery, she endorses sudden onset bilateral flank pain. Physical examination shows bilateral costovertebral angle tenderness. Urine output in the last 6 hours is measured at 30mL. Laboratory results are shown.

 
 Laboratory value  Result 
 Complete blood count 
 Hemoglobin  8.5 g/dL 
 Leukocytes  10,000 /mL 
 Platelets  330,000/mm3 
 Serum chemistry 
 Sodium  136 mEq/L 
 Potassium  5.8 mEq/L 
 Chloride  85 mEq/L 
 Bicarbonate  19 mEq/L 
 Creatinine  1.7 mg/dL 
 Blood urea nitrogen (BUN)  40 mg/dL 
 Urinalysis 
 Erythrocytes  30-32/hpf 
 Leukocyte esterase  Negative 
 Leukocytes  2/hpf 
 Protein  1.0 g/day 
 Urine osmolality  650 mOsm/kg 
 Dysmorphic red blood cells  Absent 
 Cast  Tubular cell casts 
   
A renal ultrasound demonstrates hypoechoic areas in the renal cortex. Which of the following pathologic processes is responsible for this patient’s clinical presentation?  

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