Internal medicine - Nephrology

Question 1

INT - 10.1
The prevalence of diabetic nephropathy in Type 1 diabetes mellitus:
A) below 5%

B) 20–30%

C) 80–90%

D) it develops in all patients

Answer 1

ANSWER
B) 20–30%

EXPLANATION
Based on data in the literature, 20-30% of patients with Type 1 diabetes, and 40% of patients with Type 2 diabetes are found to develop diabetic nephropathy.

Question 2

INT - 10.2
In diabetic patients treated with metformin, metformin should not be administered prior to any scheduled examination using contrast agent if eGFR <30 ml/min/1,73m2:
A) administration should be continued

B) administration should be suspended only on the day of the examination

C) administration should be suspended by two days prior to the examination

D) administration should be suspended by one week prior to the examination

Answer 2

ANSWER
C) administration should be suspended by two days prior to the examination

EXPLANATION
Type 2 diabetic patients treated with Metformin should suspend taking the medicine by two days prior to any examination that uses contrast agent. In addition to monitoring the blood glucose levels closely, if necessary, insulin therapy may be transiently applied. It is essential to control the renal function after the procedure, and Metformin therapy could be continued after 48 hours from the examination only if the GFR is above 30 ml/min/1.73 m2; as if GFR is below that value the use of Metformin is contraindicated. Addition of iodinated contrast agents intravenously could be nephrotoxic, and the deterioration of renal function may lead to the accumulation of Metformin to toxic levels thus leading to lactic acidosis. In diabetic patients with renal failure as hypoglycemic treatment the sulphanylurea class drug Gliquidone (or possibly Gliclazide), pioglitazone, certain DPP-4 inhibitors, and insulin could be administered.

Question 3

INT - 10.3
The most important factor in the early diagnosis of diabetic nephropathy:
A) the appearance of hypertension

B) the appearance of microalbuminuria

C) the increase of serum creatinine level

D) the decrease of eGFR

Answer 3

ANSWER
B) the appearance of microalbuminuria

EXPLANATION
Stages in the development of diabetic nephropathy: I. Hyperfiltration, hypertrophy II. Glomerular tissue damage without clinical symptoms III. Incipient nephropathy (microalbuminuria) IV. Overt diabetic nephropathy V. Renal insufficiency

Question 4

INT - 10.4
Diabetic nephropathy is reversible:
A) even if eGFR is reduced

B) in the stage of macroalbuminuria

C) in the stage of microalbuminuria

D) even if the serum creatinine is increased

Answer 4

ANSWER
C) in the stage of microalbuminuria

EXPLANATION
Stages in the development of diabetic nephropathy: I. Hyperfiltration, hypertrophy II. Glomerular tissue damage without clinical symptoms III. Incipient nephropathy (microalbuminuria) IV. Overt diabetic nephropathy V. Renal insufficiency

Question 5

INT - 10.5
It is fundamental in the treatment of diabetic nephropathy to give:
A) renin–angiotensin–aldosterone system (RAAS) inhibitors

B) alpha-blockers

C) high-dose thiazide diuretics

D) direct vasodilator antihypertensives

Answer 5

ANSWER
A) renin–angiotensin–aldosterone system (RAAS) inhibitors

EXPLANATION
Stages in the development of diabetic nephropathy: I. Hyperfiltration, hypertrophy II. Glomerular tissue damage without clinical symptoms III. Incipient nephropathy (microalbuminuria) IV. Overt diabetic nephropathy V. Renal insufficiency

Question 6

INT - 10.6
The progression of diabetic nephropathy may be accelerated by:
A) euglycaemia

B) increased protein intake

C) reduced salt intake

D) antihypertensive therapy

Answer 6

ANSWER
B) increased protein intake

EXPLANATION
Stages in the development of diabetic nephropathy: I. Hyperfiltration, hypertrophy II. Glomerular tissue damage without clinical symptoms III. Incipient nephropathy (microalbuminuria) IV. Overt diabetic nephropathy V. Renal insufficiency

Question 7

INT - 10.7
In diabetic patients treated with metformin, metformin therapy can be continued after the contrast agent examination:
A) on the day of the examination

B) on the next day, irrespective of renal function

C) 48 hours after the examination, if GFR is below 30 ml/min/1,73m2

D) 48 hours after the examination, if GFR is above 30 ml/min/1,73m2

Answer 7

ANSWER
D) 48 hours after the examination, if GFR is above 30 ml/min/1,73m2

EXPLANATION
See the explanation of question 10.2.

Question 8

INT - 10.8
Patients with Type 1 diabetes have to be screened for diabetic nephropathy:
A) upon establishing the diagnosis

B) approx. 5 years after the diagnosis was established

C) approx. 10-15 years after the diagnosis was established

D) approx. 20-30 years after the diagnosis was established

Answer 8

ANSWER
B) approx. 5 years after the diagnosis was established

EXPLANATION
See the explanation of question 10.3.

Question 9

INT - 10.9
Patients with Type 2 diabetes have to be screened for diabetic nephropathy:
A) upon establishing the diagnosis

B) approx. 5 years after the diagnosis was established

C) approx. 10-15 years after the diagnosis was established

D) approx. 20-30 years after the diagnosis was established

Answer 9

ANSWER
A) upon establishing the diagnosis

EXPLANATION
See the explanation of question 10.3.

Question 10

INT - 10.10
Diabetic nephropathy is likely to have developed in a diabetic patient with proteinuria
A) in the absence of diabetic retinopathy

B) if the patient has diabetic retinopathy but no haematuria

C) if the patient has diabetic retinopathy and haematuria

D) it is likely in all the above cases

Answer 10

ANSWER
B) if the patient has diabetic retinopathy but no haematuria

EXPLANATION
See the explanation of question 10.3.

Question 11

INT - 10.11
Metformin is contraindicated in diabetic patients:
A) if the eGFR is below 30 ml/min

B) if the patient is obese

C) if the patient has hypertension

D) if the patient has thyroid disease

Answer 11

ANSWER
A) if the eGFR is below 30 ml/min

EXPLANATION
See the explanation of question 10.2.

Question 12

INT - 10.12
Nephrotic syndrome is defined as:
A) significant proteinuria

B) hypalbuminaemia

C) predisposition to oedema

D) the concurrent presence of all three factors above

Answer 12

ANSWER
D) the concurrent presence of all three factors above

EXPLANATION
The most common causes of symmetrical lower extremity oedema include right ventricular heart failure, nephrotic syndrome, malnutrition, malabsorption, liver failure and kidney failure. Nephrotic syndrome is defined as persistent proteinuria exceeding 3.5 g protein per day leading to resultant hypoproteinaemia and oedema. Pyuria is not characteristic. Several anticoagulant factors are lost via the urine due to the excessive proteinuria, thus the risk of thromboembolism largely increases in patients with nephrotic syndrome. In case of severe nephrotic syndrome which is accompanied by significant increases of plasma fibrinogen levels, the long-term anticoagulant therapy with Syncumar should be considered. To eliminate the oedemas in patients with nephrotic syndrome, combined diuretic treatment (loop diuretic, potassium-sparing-diuretic) beside low salt diet is used. The underlying cause of nephrotic syndrome may involve primary renal disease, or secondary causes. In nephrotic syndrome, the most frequent primary causes vary with age: during childhood the minimal change disease, while in older age the membranous GN is more common. From young adulthood, focal segmental glomerulosclerosis (FSGS) and also the mesangiocapillary (membranoproliferative) GN represent other causes in the background of nephrotic syndrome. Among different forms of nephrotic syndrome, based on the type of excreted proteins, minimal change disease could be easily differentiated, as here the protein excreted in the urine is mainly albumin (i.e. selective proteinuria).

Question 13

INT - 10.13
In case of the presence of glomerular type red blood cells in the urine sediment:
A) renal stone is suspected, the patient should be referred first to urology examination

B) tumour is suspected, the patient should be referred first to urology examination

C) glomerular disease is suspected, the patient should be referred first to nephrology examination

D) uroinfection is suspected, the patient should be referred first to urology examination

Answer 13

ANSWER
C) glomerular disease is suspected, the patient should be referred first to nephrology examination

EXPLANATION
In case of haematuria, the shape of red blood cells (RBCs) seen in the urine sediment refers to the origin of the haematuria. Because glomerular haematuria that leads to a typical misshape modification is characterized by membrane protrusions due to damage of their cell membrane. In the presence of intact RBCs with normal shape, extraglomerular causes of haematuria, such as bleeding, stone, tumour, haemophilia should be searched. Upon prolonged storage, RBCs take up spiky, mace-like, shrunken shape due to osmotic effects, which has to be distinguished from the glomerular type haematuria.

Question 14

INT - 10.14
Analgesic nephropathy:
A) is an acute kidney injury caused by NSAIDs

B) is a chronic kidney disease caused by NSAIDs

C) is a glomerulonephritis caused by NSAIDs

D) is an acute kidney injury caused by steroidal anti-inflammatory drugs

Answer 14

ANSWER
B) is a chronic kidney disease caused by NSAIDs

EXPLANATION
The occurrence of analgesic nephropathy is especially common in countries where different pain relievers are available ‘over the counter’ without prescription. Amongst analgesics, those ones that contain phenacetine or combined formulas possess nephrotoxic effects. In analgesic nephropathy, as a consequence of chronic analgesic effect (most commonly after taking phenacetine or combined medications, less often in the case of taking regularly NSAIDs for years) predominantly papillanecrosis and chronic tubulointerstitial damage develop (urine concentrating ability decreases, macroscopic haematuria and sterile pyuria are present etc.), and calcification of the necrotic papillae is also commonly observed. In overt nephropathy, progression of kidney involvement can be attenuated by the cessation of analgesic abuse, or it could be even prevented in the case of minor changes. For the early diagnosis of analgesic nephropathy, taking detailed history from the patient seems essential, and in suspect cases renal ultrasound or CT scan examination is required. Examinations of i.v. urography and cystography are not suitable for the diagnosis of analgesic nephropathy.

Question 15

INT - 10.16
Risk factors for acute kidney injury exclude:
A) old age

B) intravenous contrast agents

C) NSAIDs abuse

D) increased fluid intake

Answer 15

ANSWER
D) increased fluid intake

EXPLANATION
The prerenal causes are responsible in more than half of the cases for the development of acute kidney injury (especially absolute or relative hypovolaemia). In approximately 40% of cases there are renal causes in the aetiology (e.g. rapidly progressive glomerulonephritis), whereas postrenal causes (e.g. obstructed urinary flow) are only found in approximately 5% of cases. Dehydration, administration of i.v. contrast agents, drug toxicity (e.g. NSAIDs, cisplatin, aminoglycosides), elderly age, and heart failure are all predisposing factors for acute kidney injury. In differential diagnosis, different increases in the serum urea nitrogen and creatinine levels may be valuable. For example, in prerenal and postrenal kidney failure the increase of the urea nitrogen level is more pronounced that of the creatinine level. The polyuria is considered as positive prognostic sign in acute kidney injury (the kidneys compensate the decreased detoxifying ability by increasing the urine output). Lower (1005 or less) urine specific gravity is characteristic for this compensatory polyuria. In poor prognosis cases haemodialysis may be necessary permanently, although it may be also required temporarily in other cases.

Question 16

INT - 10.17
In acute kidney injury, renal cause may be suspected in the case of:
A) isolated or marked increase of the serum carbamide nitrogen level

B) bladder retention

C) marked increase of the serum creatinine level in conjunction with less marked increase of the serum carbamide nitrogen level

D) decreased turgor of the skin and dry tongue

Answer 16

ANSWER
C) marked increase of the serum creatinine level in conjunction with less marked increase of the serum carbamide nitrogen level

EXPLANATION
The prerenal causes are responsible in more than half of the cases for the development of acute kidney injury (especially absolute or relative hypovolaemia). In approximately 40% of cases there are renal causes in the aetiology (e.g. rapidly progressive glomerulonephritis), whereas postrenal causes (e.g. obstructed urinary flow) are only found in approximately 5% of cases. Dehydration, administration of i.v. contrast agents, drug toxicity (e.g. NSAIDs, cisplatin, aminoglycosides), elderly age, and heart failure are all predisposing factors for acute kidney injury. In differential diagnosis, different increases in the serum urea nitrogen and creatinine levels may be valuable. For example, in prerenal and postrenal kidney failure the increase of the urea nitrogen level is more pronounced that of the creatinine level. The polyuria is considered as positive prognostic sign in acute kidney injury (the kidneys compensate the decreased detoxifying ability by increasing the urine output). Lower (1005 or less) urine specific gravity is characteristic for this compensatory polyuria. In poor prognosis cases haemodialysis may be necessary permanently, although it may be also required temporarily in other cases.

Question 17

INT - 10.18
In the case of acute kidney injury and glomerular haematuria or the presence of RBC cylinders in the urine:
A) pre-renal causes should be searched

B) renal cause, e.g. acute glomerulonephritis is suspected

C) post-renal cause should be searched

Answer 17

ANSWER
B) renal cause, e.g. acute glomerulonephritis is suspected

EXPLANATION
See the explanations of questions 10.13 and 10.16.

Question 18

INT - 10.19
The most common cause of acute kidney injury out of the following:
A) pre-renal causes

B) renal causes

C) post-renal causes

Answer 18

ANSWER
A) pre-renal causes

EXPLANATION
See the explanation of question 10.16.

Question 19

INT - 10.20
The most common causes of primary nephrotic syndrome:
1) membranous glomerulonephritis

2) minimal change disease

3) focal segmental glomerulosclerosis

4) IgA nephropathy

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 19

ANSWER
A) answers 1., 2. and 3. are correct

EXPLANATION
See the explanation of question 10.12.

Question 20

INT - 10.21
In the case of glomerular type haematuria after respiratory infection the following pathology/pathologies may be suspected:
1) minimal change disease

2) IgA nephropathy

3) membranous glomerulonephritis

4) acute, post-streptococcal glomerulonephritis

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers are correct

Answer 20

ANSWER
C) answers 2. and 4. are correct

EXPLANATION
The light microscopy analysis of IgA nephropathy most frequently indicates mesangial proliferative glomerulonephritis that features both mesangial cell and matrix proliferation. The immunohistology shows IgA and C3 deposition mainly in the mesangium. By electronmicroscopy, the mesangial immune deposits are also apparent. The disease regularly begins and later resumes with macroscopic haematuria following an upper respiratory infection. Clinically, it is characterized by mild proteinuria and haematuria of typically glomerular origin with dysmorphic RBCs (‘Mickey mouse cells’). Nephrotic syndrome may be observed in less than 5% of cases. Long-term follow-up data revealed that majority of patients have slow progression to which the onset of hypertension is contributing as well. Acute post-streptococcal glomerulonephritis is caused by the so-called nephritogenic strains of the β-haemolytic streptococci. Clinical symptoms typically manifest 10-14 days after acute tonsillitis, and 14-21 days after skin infectious disease (pyoderma). At that time, inflammatory signs or fever could not be observed. Typical laboratory findings include the increase of Antistreptolysin O titers and the decrease of complement levels in the serum. Initial symptoms may be symmetrical eyelid oedema and headache due to the development of hypertension.

Question 21

INT - 10.22
If RAAS-inhibitor therapy was commenced for treating diabetic nephropathy, after the initiation, the following should be controlled:
1) serumcreatinine and eGFR

2) blood lipids

3) serum potassium level

4) RBC sedimentation rate

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 21

ANSWER
B) answers 1. and 3. are correct

EXPLANATION
See the explanation of question 10.3.

Question 22

INT - 10.23
Causes of symmetrical leg oedema may be:
1) marked proteinuria e.g. in nephrotic syndrome

2) malnutrition, malabsorption

3) liver failure

4) peripheral artery disease

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 22

ANSWER
A) answers 1, 2 and 3 are correct

EXPLANATION
See the explanation of question 10.12.

Question 23

INT - 10.24
A typical sign of systemic, vasculitis involving the kidneys may be:
1) acute kidney injury often accompanied by haematuria

2) urinary obstruction

3) appearance of purpura

4) concurrent presence of diabetic retinopathy

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 23

ANSWER
B) answers 1. and 3. are correct

EXPLANATION
In very high percentage of systemic vasculites (e.g. Wegener’s granulomatosis, Henoch-Schönlein purpura, polyarteritis nodosa) renal involvement is also present typically with glomerular haematuria and different levels of proteinuria. The c-ANCA positivity is particularly specific in Wegener’s granulomatosis (93-96% of cases are positive), but it may be detected other vasculites as well. The Henoch-Schönlein nephritis belongs to the group of vasculites that affects mainly the small blood vessels (in the skin as purpura, the intestine, and the kidney). The disease usually develops in children, although sometimes adults could be also diseased. The disease is often triggered by infection, and drug allergy. In some cases, renal involvement together with clinical symptoms develops. Alike to skin biopsies, renal biopsy specimen shows chiefly mesangial IgA immune complex deposits.

Question 24

INT - 10.25
The most common cause of secondary hypertension:
1) Cushing syndrome

2) acromegaly

3) hyperthyreosis

4) hypertension of renal origin

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 24

ANSWER
D) only answer 4 is correct

EXPLANATION
By aetiology, hypertension can be classified into two main groups: primary (formerly called essential) and secondary hypertension. The most common causes of secondary hypertension include (in the order of frequency) sleep apnoea syndrome, renoparenchymal hypertension, hyperaldosteronism, renovascular hypertension and thyroid gland disorders. Less frequent causes include pheochromocytoma, Cushing’s syndrome, acromegaly etc. Renovascular hypertension most often develops as a consequence of atherosclerosis; its examination is difficult as physical signs (abdominal bruits) could be rarely observed and Doppler ultrasound is technically difficult to perform. Angiography is still considered as the gold standard method.

Question 25

INT - 10.26
Choose the correct answers from the following statements characterising acute post-streptococcal glomerulonephritis.

1) the serum complement level decreases

2) the serum ASO titer decreases

3) oedema around the eyes can be observed

4) hypertension is never present

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 25

ANSWER
B) answers 1. and 3. are correct

EXPLANATION
See explanation for question 10.21.

Question 26

INT - 10.27
Choose the correct answers from the following statements suggesting causes of anaemia as a result ofchronic renal failure!
1) decreased erytropoietin production

2) decreased iron and B12 absorption

3) uraemic toxins depressing the bone marrow

4) increased life-span of RBC can be observed

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers are correct

Answer 26

ANSWER
A) answers 1., 2. and 3. are correct

EXPLANATION
Beside the gradual loss of tubular and glomerular functions, the concomitant loss of endocrine function also develops during the development of chronic renal failure. In the conservative treatment of chronic renal failure, the control and correction of anaemia, bone metabolism disorders (hypocalcaemia and hyperphosphataemia due to reduced vitamin D synthesis), potassium metabolism disturbances (hyperkalaemia), and fluid imbalance (compensatory polyuria) is mandatory. The primary cause of anaemia in chronic renal failure is the decreased production of erythropoietin by the medullary interstitial cells. To the development of anaemia, contributions of the bone marrow depressing effect by uraemic toxins (to which the developing metabolic acidosis also contributes), the short life-span of erythrocytes, and disturbed absorption of iron and B12 in uraemia are also present.

Question 27

INT - 10.29
The following renal-replacement therapy modalities may be chosen in end-stage renal failure:
1) haemodialysis

2) peritoneal dialysis

3) kidney transplantation

4) cyclophosphamide therapy

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 27

ANSWER
A) answers 1, 2 and 3 are correct

EXPLANATION
In chronic kidney disease, commencement of renal replacement therapy is required if GFR declines below ≈10 ml/min and/or the patient develops uraemic symptoms. Kidney transplantation provides the best survival rate and quality of life among the available renal replacement modalities. The efficacy of haemodialysis and peritoneal dialysis is comparable.

Question 28

INT - 10.30
Causes of systemic leg oedema may be:
1) heart failure

2) decompensated liver cirrhosis

3) nephrotic syndrome

4) none of the above

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 28

ANSWER
A) answers 1., 2. and 3. are correct

EXPLANATION
See explanation for question 10.12.

Question 29

INT - 10.31
Which of the following may indicate renal involvement is SLE?
1) skin lesions

2) bacteriuria

3) neurological signs

4) proteinuria

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers are correct

Answer 29

ANSWER
D) only answer 4. is correct

EXPLANATION
Kidney involvement develops in 25-75% of patients with SLE. Initially, proteinuria and the presence of cellular casts and erythrocytes in the urine sediment could suggest lupus nephritis. Bacteriuria is not characteristic. Subsequently, renal failure may develop as the disease progresses. Consequently, when kidney involvement is suspected, accurate histological diagnosis is warranted by which glucocorticoid + cyclophosphamide therapy is indicated. Renal manifestations are not associated obligatory with the presence of skin lesions and neurological abnormalities.

Question 30

INT - 10.32
Which of the following factors may be responsible for the development of diabetic nephropathy?
1) glycation end products

2) hyperfiltration

3) genetic factors

4) decreased negative charge of the glomerular basal membrane

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 30

ANSWER
E) all 4 answers arecorrect

EXPLANATION
The following factors involved in the pathogenesis of diabetic nephropathy: genetic factors (as nephropathy does not develop in large cohorts of diabetic patients with poor glycaemic control), hyperglycaemia (in part due to the hyperfiltration effect), overproduction and accumulation of advanced glycation end products in the kidney (AGEs, in part via the oxidative stress), decreased nitrogen monoxide and prostacyclin synthesis, decreased negative charge of the glomerular basal membrane, and increased intraglomerular pressure with intraglomerular hypertension and hyperfiltration.

Question 31

INT - 10.33
When does bacteriuria require treatment in young female patients?
1) in the case of complaints suggestive of a urinary tract infection

2) in the case of leukocyturia

3) in pregnancy

4) if haematuria is also present

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 31

ANSWER
B) answers 1. and 3. are correct

EXPLANATION
Significant bacteriuria in young women should be treated only if they are pregnant or have complaints suggesting urinary infection. The presence of haematuria per se is not indication for antibiotic treatment.

Question 32

INT - 10.34
Which of the following can be used for measuring the glomerular filtration rate?
1) 24-hour endogenous creatinine clearance

2) clearance measured with an isotope

3) estimated GFR

4) concentrating ability test

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 32

ANSWER
A) answers 1., 2. and 3. are correct

EXPLANATION
The kidney functions could be determined by the assessment of glomerular, tubular and endocrine functions. Glomerular function is defined by the GFR, which could be measured directly with creatinine clearance or isotope clearance techniques. The GFR could be estimated by different empirical formulas (e.g. MDRD, Cockroft, Mayo, CKD-epi), and these could be simply used in the general practice with not requiring urine sample collection.

Question 33

INT - 10.35
What characterises acute tubulointerstitial nephritis from among the following?
1) fever

2) eosinophilia/eosinophiluria

3) sterile pyuria

4) hypertension

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 33

ANSWER
A) answers 1, 2 and 3 are correct

EXPLANATION
Acute (hypersensitive) tubulointerstitial nephritis is usually caused by drugs which can act as haptenes (e.g. β-lactam antibiotics, sulphonamides, NSAIDs, diuretics, allopurinol etc.). As a result of immune response, the symptoms of fever, maculopapular rash, arthralgia, eosinophilia, eosinophiluria, sterile pyuria, and urinary leukocyte cylinders may develop. Hypertension is not typical in this disorder.

Question 34

INT - 10.36
What characterises renovascular hypertension?
1) bruits are always noticeable with physical examination

2) angiography is always needed as the gold standard

3) it is the most common form of secondary hypertension

4) it most frequently develops on the grounds of atherosclerosis

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 34

ANSWER
C) answers 2. and 4. are correct

EXPLANATION
See explanation for question 10.25.

Question 35

INT - 10.37
Which of the following results indicate good prognosis in acute renal injury?
1) polyuria

2) anuria

3) urine specific gravity: 1005

4) urine specific gravity: 1012

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers are correct

Answer 35

ANSWER
B) answers 1. and 3. are correct

EXPLANATION
See explanation for question 10.16.

Question 36

INT - 10.38
Which of the following factors can attenuate the progression of chronic kidney disease?
1) RAAS inhibitor therapy

2) dietary protein restriction

3) regular blood pressure control

4) statin therapy

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all of the answers are correct

Answer 36

ANSWER
E) all of the answers are correct

EXPLANATION
In chronic kidney disease, the development of renal failure could be prevented by attenuating the disease progression, thus commencement of renal replacement therapy may be delayed. In addition to specific treatments (e.g. efforts to maintain euglycaemia in diabetic nephropathy), non-specific therapeutic options also play important roles, including: 1. Antihypertensive treatment: decreases the systemic and glomerular hypertension 2. RAAS inhibitor treatment: additionally to decreasing the systemic and glomerular pressure it has other favourable effects 3. Dietary protein restriction: reduces hyperfiltration induced by excessive protein intake, and decreases the excretion of nitrogen metabolites 4. Optimal blood pressure control with drugs having neutral effects on metabolism is an important factor in the treatment of hypertension related to the renal disease in order to decrease renal progression 5. Statin treatment beside the diet could decrease renal progression not only by decreasing dyslipidaemia, but also by other pleitropic beneficial effects, for example by reducing the proteinuria

Question 37

INT - 10.39
Which of the following needs to be addressed in the conservative therapy of chronic renal failure?
1) anaemia

2) metabolic acidosis

3) hyperkalaemia

4) hyponatraemia

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers arecorrect

Answer 37

ANSWER
A) answers 1., 2. and 3. are correct

EXPLANATION
See explanation for question 10.27.

Question 38

INT - 10.40
Which antidiabetic can be given to patients with declined kidney function (eGFR<30 ml/min/1,73m2), including patients receiving dialysis therapy?
1) gliquidone

2) metformin

3) insulin

4) glimepiride

A) answers 1., 2. and 3. are correct

B) answers 1. and 3. are correct

C) answers 2. and 4. are correct

D) only answer 4. is correct

E) all 4 answers are correct

Answer 38

ANSWER
B) answers 1. and 3. are correct

EXPLANATION
See explanation for question 10.2.

Question 39

INT - 10.41
Which of the following can be used in the conservative treatment of hyperkalaemia?
1) insulin + glucose infusion

2) iv. calcium

3) furosemide and physiological saline infusion

4) ion-exchange resin

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 39

ANSWER
E) all 4 answers are correct

EXPLANATION
Hyperkalaemia may develop from iatrogenic causes or as a consequence of certain disease states, leading to possibly life-threatening condition. Intravenously administered calcium may be used to prevent cardiac arrhythmias. During acute treatment, higher potassium level could be primarily lowered by using insulin + glucose infusion, furosemide, and physiological saline infusion, and inhaled beta receptor agonists. In chronic therapy, dietary potassium restriction and potassium-binding resins could be applied. If these conservative methods are ineffective, dialysis may be necessary.

Question 40

INT - 10.42
It is important to know the patient’s kidney function when ordering a new medication, as the pharmacokinetics of several medications and thereby, the dosage depends on the kidney function.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 40

ANSWER
A) both are correct, there is a causal relationship between the two,

EXPLANATION
Before prescribing medication, it is important to know the patient’s kidney function, because the pharmacokinetics and dosage of several medications (e.g. antibiotics, antidiabetics, digoxin) depend on kidney function. In patients with severely declined kidney function where thiazide-like diuretics are ineffective, loop diuretics could be used to decrease hypervolaemia.

Question 41

INT - 10.43
Haematuria is the most common symptom in minimal change nephropathy, therefore the patient has to be protected from physical exercise/burden.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 41

ANSWER
E) both are incorrect

EXPLANATION
The term of minimal change nephropathy arises from its histological features. Electronmicroscopic analysis of the kidney biopsy sample shows effacement of the podocyte foot processes; whereas with light microscopic and immunfluorescent examinations histological abnormalities cannot be found. The precise aetiology and pathomechanism of the disease is still unknown, although it has been shown to more likely occur with atopy, NSAIDs abuse, and Hodgkin lymphoma. It predominantly affects children. Steroid therapy (glucocorticoids) induces remission in 90% of children. The urine finding typically includes nephrotic range, selective proteinuria. Pyuria is not characteristic at all.

Question 42

INT - 10.44
In the case of non-dialysed patients with declined kidney function thiazide-type diuretics should be given for diuretic therapy, becauseat this stage loop-diuretics are ineffective.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 42

ANSWER
E) both are incorrect

EXPLANATION
See explanation for question 10.42.

Question 43

INT - 10.45
In patients over 50 suffering from membranous glomerulonephritis cancer screening is necessary, since in older age tumour antigen-containing immune complexes more frequently cause membranous glomerulonephritis.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 43

ANSWER
A) both are correct, there is a causal relationship between the two,

EXPLANATION
In membranous glomerulonephritis, nephrotic range, usually non-selective proteinuria could be detected in more than 80% of cases. The onset of haematuria could not be observed characteristically. It usually develops secondary to immunological diseases (e.g. SLE), tumours (e.g. lung carcinoma), and infections (e.g. hepatitis B and C), or it may be drug-induced (e.g. captopril, NSAID) as well. In young patients, therefore, tests toward immunological disorders, while in elderly patients tumour screening tests should be conducted.

Question 44

INT - 10.46
Acute diffuse poststreptococcal glomerulonephritis is characterised by fever and inflammatory symptoms, therefore the patient has to be treated with antipyretics.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 44

ANSWER
E) both are incorrect

EXPLANATION
See explanation for question 10.21.

Question 45

INT - 10.47
The main symptom of patients with nephrotic syndrome is pyuria, therefore, changes causing obstruction to the urinary flow have to be looked for.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 45

ANSWER
E) both are incorrect

EXPLANATION
See explanation for question 10.12.

Question 46

INT - 10.50
In the case of diabetic kidney disease, RAAS-inhibitor therapy is given due to abnormal albuminuria, as RAAS-inhibitors decrease the intraglomerular pressure.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 46

ANSWER
A) both are correct, there is a causal relationship between the two,

EXPLANATION
See explanation for question 10.3.

Question 47

INT - 10.51
Stages of the renal alterations are similar in Type1 and Type 2 diabetes mellitus, as both types of diabetes mellitus develop as the result of severely damaged insulin production of the pancreas.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 47

ANSWER
C) the first is correct, the second is incorrect

EXPLANATION
See explanation for question 10.3.

Question 48

INT - 10.52
Nephropathy may be present at the time of the diagnosis in Type 2 diabetes, as diabetic nephropathy belongs to the so-called macroangiopathies.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 48

ANSWER
C) the first is correct, the second is incorrect

EXPLANATION
See explanation for question 10.3.

Question 49

INT - 10.53
In general practice, CKD-epi equation is used for estimating the kidney function, as its determination requires the collection of 24-hour urine sample.
A) both are correct, there is a causal relationship between the two,

B) both are correct, there is no causal relationship between the two,

C) the first is correct, the second is incorrect

D) the first is incorrect , the second is correct

E) both are incorrect

Answer 49

ANSWER
C) the first is correct, the second is incorrect

EXPLANATION
See explanation for question 10.34.

Question 50

INT-10.59-10.62
Link the symptoms indicated by numbers with the most matching pathological clinical pictures (with capital letters).
A) renal anaemia

B) nephrotic syndrome

C) nephritic syndrome

D) uroinfection

INT - 10.59 - proteinuria above 3.5 g/day

INT - 10.60 - glomerular type haematuria

INT - 10.61 - pyuria + bacteriuria

INT - 10.62 - erythropoietin therapy

Answer 50

ANSWER

INT - 10.59 - proteinuria above 3.5 g/day- B)

INT - 10.60 - glomerular type haematuria- C)

INT - 10.61 - pyuria + bacteriuria - D)

INT - 10.62 - erythropoietin therapy - A)

Question 51

INT-10.63-10.66
Link the symptoms indicated by numbers with the most matching pathological clinical pictures (with capital letters)!
A) acute kidney injury

B) chronic renal insufficiency

C) both of the above

D) none of the above

INT - 10.63 - low glomerular filtration rate

INT - 10.64 - kidneys are of normal size or enlarged

INT - 10.65 - it develops unnoticeably, almost symptomless

INT - 10.66 - the kidneys’ concentrating ability is not disturbed

Answer 51

ANSWER
INT - 10.63 - low glomerular filtration rate- B)

INT - 10.64 - kidneys are of normal size or enlarged -A)

INT - 10.65 - it develops unnoticeably, almost symptomless - B)

INT - 10.66 - the kidneys’ concentrating ability is not disturbed - D)

Question 52

INT-10.67-10.70
Match the therapeutic possibilities marked by numbers with the clinical picture marked by capital letters in the treatment of which the given therapeutic possibility is the most appropriate treatment of choice.
A) renal anaemia

B) pre-renal acute kidney injury

C) severe acute kidney injury

D) nephrotic syndrome

INT - 10.67 - management of homeostatic/volume balance

INT - 10.68 - potassium-sparing diuretic

INT - 10.69 - erythropoietin

INT - 10.70 - dialysis

Answer 52

ANSWER
INT - 10.67 - management of homeostatic/volume balance - B)

INT - 10.68 - potassium-sparing diuretic- D)

INT - 10.69 - erythropoietin - A)

INT - 10.70 - dialysis - C)

Question 53

INT-10.71-10.74
Match conditions marked by numbers with the most appropriate concept!
A) cardiovascular progression

B) cardiovascular regression

C) early screening for cardiovascular disease

D) no increase in cardiovascular risk

INT - 10.71 - screening of albuminuria

INT - 10.72 - acute post-streptococcal glomerulonephritis

INT - 10.73 - decrease in GFR

INT - 10.74 - decreased proteinuria

Answer 53

ANSWER
INT - 10.71 - screening of albuminuria- C)

INT - 10.72 - acute post-streptococcal glomerulonephritis - D)

INT - 10.73 - decrease in GFR - A)

INT - 10.74 - decreased proteinuria - B)

Question 54

INT - 10.28
Out of the following, which ultrasound result indicates chronic kidney disease in an average-sized adult?
1) the length of kidneys is 80 mm

2) hyperreflective parenchyma

3) wave-like appearance of the surface

4) 12–14 mm thick parenchyma

A) answers 1, 2 and 3 are correct

B) answers 1 and 3 are correct

C) answers 2 and 4 are correct

D) only answer 4 is correct

E) all 4 answers are correct

Answer 54

ANSWER
A) answers 1, 2 and 3 are correct

EXPLANATION
Alterations in chronic kidney failure described by ultrasound are as follows: the length of the kidney is usually < 10 cm; the parenchyma is hyperreflective; the parenchyma thickness is < 10 mm; the surface of the kidneys is finely roughened, while in certain diseases it shows deeper incisions (e.g. chronic pyelonephritis, analgesic nephropathy). In acute kidney injury normal or enlarged kidney size could be found.