58. Struvite stones occurs in patients of repeated urinary tract infections (UTI) from bacteria that produce the enzyme urease, including both gram-positive and gram-negative species. Which is the least possible micropathogen causing struvite stone and repeated UTI?
(A) Klebsiella spp。
(B) Escherichia coli。
(C) Mycoplasma spp。
(D) Staphylococcus epidermidis。
(E) Proteus。

54. 患者因上腹痛反射至背部，合併噁心、嘔吐至急診，血液檢查amylase和lipase值均有3倍以上的增加，下 列何者不屬於判斷此病嚴重度的BISAP score？(A) BUN＞25mg/dL。 (B) Impaired mental status。 (C) SIRS:2 ≧ of 4 present。 (D) Amylase＞2000 IU/L。 (E) Pleural effusion。

55. Statement on management strategy for patients with autosomal dominant polycystic kidney disease (ADPKD), which is incorrect: (A) Dietary salt restriction may be beneficial in the management of ADPKD。 (B) Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are the first-line antihypertensive drugs in ADPKD。 (C) Nonsteroidal anti-inflammatory drugs (NSAIDs) is more effective and safe than acetaminophen or tramadol for cystic pain relief in ADPKD patients。 (D) Oral tolvaptan can slow the increase in total kidney volume and the decline in kidney function of ADPKD patients。 (E) ADPKD patients can be a recipient for renal transplantation。

56. A 54 y/o diabetic female patient with 4 days of fever, respiratory symptoms and dyspnea. At emergency service, physical examination revealed postural hypotension, tachycardia, and Kussmaul respiration. Laboratory tests were: blood glucose level of 385 mg/dL. The arterial pH is 7.35, pCO₂ is 22 mm Hg, pO286 mmHg, 14 mEq/L. Serum electrolyte values were: Na 130 meq/L； K 5.1 meq/L； Cl 96 meq/L； Chest x-ray film indicated consolidation of bilateral lower lobe. Which of the following statements is most likely to be true? (1)The patient has respiratory acidosis, possibly related to pneumonia (2)The patient has metabolic acidosis, possibly related to diabetes (3)The patient has respiratory alkalosis, possibly related to pneumonia (4)The anion gap is still within normal range (5)Be cautious with hyperphospatemia during combined insulin and glucose therapy  (A) (1)+(2)+(5)。 (B) (1)+(2)+(4)+(5)。 (C) (2)+(3)+(5)。 (D) (2)+(3)。 (E) (2)+(3)+(4)。

57. A middle aged woman was referred to renal clinic for evaluation of her renal disorder. She had intermittent pre-tibial swelling for almost 3 months. She has mild hypertension, but no diabetes. Neither viral hepatitis B nor C history. Laboratory tests were: albumin 3.1 g/dL, creatinine 1.7 mg/dL, Both serum complement levels (C3 and C4) are low, with a particularly depressed C4 compared with C3. Which of the following should be considered ? (A) Cryoglobulinemia。 (B) Post-streptococcal glomerulonephritis。 (C) Membranoproliferative glomerulonephritis。 (D) Lupus nephritis, stage III or V。 (E) Infectious endocarditis or shunt nephritis。

59. Which are correct statements regarding hyperuricemia and related nephropathy? (1)The renal tubular transporters responsible for determining how much of the filtered uric acid is actually excreted are located in the distal nephron (2)Renal clearance of uric acid can be inhibited by the angiotensin-converting-enzyme inhibitors or by β-Blockers. (3)Initiation of colchicine can induce acute flares of gout (4)Initiation of allopurinol or febuxostat can induce acute flares of gout (5)Routine use of allopurinol (100-300 mg/day) in patients with stage 3-4 CKD can slow kidney disease progression  (A) (1)+(2)+(4)+(5)。 (B) (1)+(4)+(5)。 (C) (2)+(3)。 (D) (2)+(4)。 (E) (2)+(4)+(5)。

60. A 26-year-old girl of type I diabetes had poor appetite and body weight loss for 3 kg (6%) in recent one month. After admission, she received partial parenteral nutrition due to anorexia and poor oral intake. Hypophosphatemia (0.8 mg/dL) was notcied on the third day of admission . The most likely mechanism for her acute hypophosphatemia is:  (A) Acute stage of diabetic ketoacidosis。 (B) Hungry bone syndrome。 (C) Primary hypoparathyroidism。 (D) Renal phosphate wasting。 (E) Shift of phosphorus into intracellular stores。

61. A 50-year-old male visited outpatient clinic due to difficult-to-control hypertension. After initial work up, hypokalemic hypertensive disorder was impressed, Further laboratory evaluation of adrenal hormones including plasma renin, aldosterone, cortisol, and androgen levels were arranged to distinguish among specific diagnoses. The results are: high renin level, high aldosterone level, an aldosterone-to-renin ratio of 10 : 1 ； and a normal serum cortisol level Which is the most possible diagnosis? (A) ACTH-secreting tumor。 (B) Bartter syndrome。 (C) Liddle syndrome。 (D) Primary hyperaldosteronism。 (E) Unilateral renal artery stenosis。

62. Laboratory indices for differentiation of prerenal versus Intrinsic renal azotemia. Which of the followings prefers pre-renal azotemia? (A) High urine Na concentration ＞20 (mmol/L)。 (B) High Urine specific gravity ＞1.020。 (C) Low urine osmolality ＜300 (mosmol/kg H2O)。 (D) High renal failure index (UNa/UCr/PCr) ＞1。 (E) Urinary sediment analysis reveals a lot of muddy-brown granular casts and casts containing tubular epithelial cells。

63. 下列何種情況會造成高血磷症（Hyperphosphatemia）? (1)維生素D中毒 (2)代謝性鹼中毒 (3)原發性副甲 狀腺機能亢進 (4)嚴重低血鎂症（Severe hypomagnesemia)） (5)腫瘤溶解症候群(tumor lysis syndrome, TLS) (A) (1)+(2)+(4)。 (B) (1)+(3)+(5)。 (C) (2)+(3)+(4)。 (D) (2)+(3)+(5)。 (E) (1)+(4)+(5)。

64. 一位74歲糖尿病女性患者合併慢性腎臟病第四期，長期服用口服降血糖用藥搭配胰島素控制，由於意識不 清醒被送到急診就醫，經檢查有代謝性酸中毒(metabolic acidosis)，其陰離子隙(anion gap)為26 mmol/L，經積極使用碳酸氫鈉（sodium bicarbonate)矯正，仍無法控正，下列何種用口服降血糖藥物可 能為誘發的原因？ (A) 二肽基肽酶-4抑制劑（Dipeptidyl peptidase-4 inhibitor）。 (B) 過氧化物酶體增殖物活化受體γ（PPAR-γ）。 (C) α-葡萄糖苷酶抑制劑(α-glucosidase inhibitor)。 (D) 二甲雙胍類降血糖藥物 (Metformin)。 (E) 磺醯基尿素(sulfonylurea)。