Nephrology Practice Questions

Q: What is the diagnosis ?

Ureterocele. ***Ureterocele*** - A ureterocele is a **congenital cystic dilation** of the distal intravesical portion of the ureter, often presenting as a **"cobra-head" sign** on intravenous pyelography or a round, thin-walled cyst within the bladder on ultrasound. - It frequently results from an obstruction at the **ureterovesical junction** and is commonly associated with a **duplex collecting system** (ureter duplex), particularly following the Weigert-Meyer rule. *Bladder diverticula* - A bladder diverticulum appears as an **outpouching** of the bladder wall rather than an intravesical cystic structure originating from the ureter. - They are typically associated with **bladder outlet obstruction** or chronic neurogenic bladder, rather than being a primary developmental anomaly of the distal ureter. *Pseudoureteroceles* - Pseudoureteroceles are extrinsic processes, such as an **impacted distal ureteral stone** or focal bladder tumor, that mimic the appearance of a ureterocele. - Unlike true ureteroceles, the imaging appearance is caused by **edema** or mass effect around the ureteral orifice rather than intrinsic cystic dilation of the ureter. *Gartner's duct cysts* - Gartner's duct cysts represent remnants of the **mesonephric (Wolffian) duct** located in the lateral wall of the vagina, not the bladder lumen. - They are **gynecological findings** found in females and do not involve the ureterovesical junction or produce imaging findings mimicking a bladder ureterocele.

Q: A patient with congenital nephrotic syndrome requires which of the following procedures?

Renal biopsy. **Explanation:** **Congenital Nephrotic Syndrome (CNS)** is defined as the onset of nephrotic-range proteinuria, edema, and hypoalbuminemia within the first three months of life. **Why Renal Biopsy is the Correct Answer:** In CNS, a renal biopsy is a critical diagnostic step to differentiate between various underlying etiologies. While the most common cause is the **Finnish type (NPHS1 mutation)**, a biopsy helps rule out other structural or syndromic causes like Diffuse Mesangial Sclerosis (DMS) or secondary causes like congenital syphilis or CMV. Histopathology in the Finnish type typically shows characteristic microcystic dilatation of the proximal tubules. **Analysis of Incorrect Options:** * **Live Attenuated Vaccines:** These are generally **contraindicated** in patients with nephrotic syndrome who are on immunosuppressive therapy or are severely edematous/malnourished due to the risk of disseminated infection. * **High-dose Steroids:** Unlike Minimal Change Disease (MCD) in older children, CNS is **steroid-resistant**. The condition is caused by genetic mutations in podocyte proteins (e.g., Nephrin, Podocin), making steroid therapy ineffective and potentially toxic. * **Low-protein Diet:** Patients with CNS lose massive amounts of albumin in the urine. A low-protein diet would worsen the malnutrition and growth failure. Instead, these infants require a **high-protein, high-calorie diet** to compensate for urinary losses. **High-Yield Clinical Pearls for NEET-PG:** * **Finnish Type (NPHS1):** Most common cause; inherited as autosomal recessive; mutation in the **Nephrin** gene (chromosome 19q13). * **Antenatal Diagnosis:** Elevated **Alpha-fetoprotein (AFP)** levels in amniotic fluid or maternal serum. * **Management:** Definitive treatment is **bilateral nephrectomy** (to stop protein loss) followed by peritoneal dialysis and eventual **renal transplantation**.

Q: A 1-year-old girl presents after her first febrile urinary tract infection (UTI). She has no bladder-bowel dysfunction and renal ultrasound shows no hydronephrosis or renal scarring. A voiding cystourethrogram (VCUG) is performed and the findings are shown below, demonstrating Grade III vesicoureteral reflux (VUR) with contrast filling the ureter and renal pelvis with mild ureteral and calyceal dilation but without tortuosity. Which of the following is the most appropriate management option?

Low-dose daily antibiotics. ***Low-dose daily antibiotics*** - **Prophylactic antibiotics** are the first-line conservative management for **Grade III vesicoureteral reflux (VUR)** in a young child with a febrile UTI, no bladder-bowel dysfunction, and no renal scarring, to prevent recurrent UTIs and potential **renal scarring**. - This approach allows time for potential **spontaneous resolution** of VUR as the child grows, which commonly occurs in low-to-moderate grade reflux (Grades I–III). *Immediate surgical reimplantation of the ureters* - **Ureteral reimplantation** is reserved for **high-grade VUR (Grade IV-V)** or cases with breakthrough infections despite prophylactic antibiotics, or progressive renal scarring. - **Grade III VUR** without renal abnormalities or bladder-bowel dysfunction often resolves spontaneously with conservative management, making immediate surgery unnecessarily aggressive. *Weekly urinalyses and culture* - **Monitoring alone** without prophylaxis increases the risk of **recurrent febrile UTIs** and potential **renal scarring** in a young child with Grade III VUR. - This approach fails to provide **active protection** against ascending infections that VUR predisposes the patient to, particularly given the febrile nature of the initial UTI. *Diet low in protein* - **Protein restriction** is indicated for **chronic kidney disease** with significant **renal impairment**, not for VUR management. - VUR with normal renal function does not require **dietary modifications**, and protein is essential for normal growth in children.

Q: Which of the following is NOT a characteristic of nephrotic syndrome in children?

Low complement levels are typically observed. **Explanation:** The hallmark of **Minimal Change Disease (MCD)**, the most common cause of Nephrotic Syndrome in children, is that it is a **"pauci-immune"** condition. In typical childhood nephrotic syndrome, the complement system is not consumed; therefore, **serum complement levels (C3 and C4) remain normal.** Low complement levels should instead raise suspicion for nephritic conditions like Post-Streptococcal Glomerulonephritis (PSGN), Lupus Nephritis, or Membranoproliferative Glomerulonephritis (MPGN). **Analysis of Options:** * **Option A:** Hypertension is generally **not associated** with pure nephrotic syndrome (MCD). Its presence, along with hematuria, often suggests a "nephritic" component or a different pathology like FSGS. * **Option B:** **Minimal Change Disease** accounts for approximately 80-90% of cases in children under 10 years of age, making it the most common histological subtype in this demographic. * **Option C:** **Massive proteinuria** is the defining feature. In pediatric terms, this is defined as >40 mg/m²/hr or a spot protein:creatinine ratio >2. In adults, the threshold is >3.5 g/24 hours. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Nephrotic Syndrome (Children):** Minimal Change Disease (MCD). * **Most common cause of Nephrotic Syndrome (Adults):** Membranous Nephropathy (globally) or FSGS (increasingly common). * **MCD Morphology:** Light microscopy is normal; Electron microscopy shows **effacement of podocyte foot processes.** * **Treatment:** Corticosteroids (Prednisolone) are the first-line treatment. * **Indications for Renal Biopsy:** Age 12 years, persistent hypertension, gross hematuria, or **low complement levels.**

Q: A 9-year-old boy presents with decreased urine output, cola-colored urine, and swelling of the face and hands for 2 days. He is hypertensive, has a puffy face, and pitting edema of the lower limbs. He had a history of skin lesions 4 weeks prior. A diagnosis of post-streptococcal glomerulonephritis is made. At what point are C3 levels likely to return to normal?

8 weeks. **Explanation:** **1. Why Option C (8 weeks) is correct:** Post-streptococcal glomerulonephritis (PSGN) is an immune-complex-mediated disease (Type III hypersensitivity). The activation of the **alternative complement pathway** leads to the consumption of C3, resulting in low serum C3 levels in >90% of patients during the acute phase. A hallmark of PSGN is that these levels are **transient**. In a typical case, C3 levels begin to rise after the first week and return to the normal range within **6 to 8 weeks**. If C3 remains low beyond 8–12 weeks, alternative diagnoses like Membranoproliferative Glomerulonephritis (MPGN) or Systemic Lupus Erythematosus (SLE) must be considered. **2. Why other options are incorrect:** * **Options A & B (2 and 4 weeks):** While C3 levels start rising early, they usually remain below the normal reference range during the first month of the illness. * **Option D (6 weeks):** Although some patients may normalize by 6 weeks, **8 weeks** is the standard clinical benchmark used in textbooks (like Nelson Pediatrics) and exams to differentiate PSGN from chronic nephritic conditions. **3. High-Yield Clinical Pearls for NEET-PG:** * **Latent Period:** PSGN occurs 1–3 weeks after pharyngitis and 3–6 weeks after pyoderma (skin lesions). * **Sequence of Recovery:** 1. **Diuresis:** First sign of improvement (usually within 1 week). 2. **C3 Normalization:** Within 8 weeks. 3. **Hematuria:** Can persist for 6 months to 1 year. 4. **Proteinuria:** Usually disappears within 6 months. * **Gold Standard Diagnosis:** Renal biopsy (though rarely needed) shows "lumpy-bumpy" appearance on immunofluorescence and "subepithelial humps" on electron microscopy. * **C4 Levels:** Typically remain **normal** in PSGN (unlike SLE where both C3 and C4 are low).

Q: A 10-year-old girl presents with polyuria and polydipsia, along with hypokalemia, hypercalciuria, and metabolic alkalosis. What is the probable diagnosis?

Bartter syndrome. ### Explanation **Bartter Syndrome** is the correct diagnosis because it typically presents in early childhood with the triad of **hypokalemia, metabolic alkalosis, and hypercalciuria**. It is caused by a defect in the thick ascending limb (TAL) of the Loop of Henle (specifically the NKCC2 transporter, ROMK, or ClC-Kb channels). This mimics the effect of **Loop diuretics** (Furosemide), leading to salt wasting, activation of the RAAS system, and increased urinary calcium excretion. #### Why the other options are incorrect: * **Gitelman Syndrome:** Often presents later (adolescence/adulthood). While it also features hypokalemia and metabolic alkalosis, it is characterized by **hypocalciuria** (low urinary calcium), mimicking **Thiazide diuretics**. * **Liddle Syndrome:** This is a "pseudoaldosteronism" caused by overactivity of ENaC channels. While it causes hypokalemia and alkalosis, it presents with **hypertension** and low renin/aldosterone levels. Bartter syndrome patients are typically normotensive. * **Alport’s Syndrome:** This is a collagen IV defect presenting with **hereditary nephritis (hematuria)**, sensorineural deafness, and ocular defects. It does not cause the electrolyte disturbances described. #### High-Yield Clinical Pearls for NEET-PG: * **Bartter vs. Gitelman:** The "Gold Standard" differentiator is urinary calcium. **Bartter = High/Normal Calcium**; **Gitelman = Low Calcium**. * **Mnemonic:** **B**artter is like a **B**oop (Loop) diuretic; **G**itelman is like a **G**iazide (Thiazide) diuretic. * **Antenatal Bartter:** Can present with polyhydramnios and severe salt wasting in the neonatal period. * **Treatment:** NSAIDs (to inhibit prostaglandins) and potassium-sparing diuretics/potassium supplements.

Q: All the following are used in the treatment of enuresis except?

Spironolactone. **Explanation:** Enuresis (specifically nocturnal enuresis) is defined as involuntary voiding of urine during sleep in children aged 5 years or older. The management involves behavioral therapy (enuresis alarms) and pharmacological interventions aimed at reducing urine production or increasing bladder capacity. **Why Spironolactone is the correct answer:** **Spironolactone** is a potassium-sparing diuretic that inhibits aldosterone receptors in the distal tubule. Its primary effect is to **increase diuresis** (urine production). Using a diuretic would exacerbate bedwetting rather than treat it; therefore, it has no role in the management of enuresis. **Why the other options are used:** * **Desmopressin (Option A):** This is an analog of Antidiuretic Hormone (ADH). It is the first-line pharmacological treatment. It works by decreasing urine production overnight, thereby preventing the bladder from overfilling during sleep. * **Imipramine & Nortriptyline (Options B & C):** These are Tricyclic Antidepressants (TCAs). They are used as second-line agents. Their mechanism in enuresis is multifactorial: they possess anticholinergic effects (increasing bladder capacity), antispasmodic effects on the detrusor muscle, and alter sleep-arousal patterns. **High-Yield Clinical Pearls for NEET-PG:** * **First-line management:** Behavioral modification (fluid restriction, lifting) and **Enuresis Alarms** (highest long-term cure rate). * **First-line drug:** Desmopressin (nasal spray is avoided due to hyponatremia risk; oral melts are preferred). * **TCA Caution:** Imipramine is effective but carries a risk of cardiotoxicity in overdose; it is generally reserved for resistant cases. * **Rule of Thumb:** Always rule out secondary causes (UTI, Diabetes Mellitus, Constipation) before starting therapy.

Q: Which type of glomerulonephritis should not be treated with prednisolone?

Post-streptococcal GN. ### Explanation The correct answer is **Post-streptococcal Glomerulonephritis (PSGN)**. **1. Why PSGN is the correct answer:** PSGN is an **immune-complex mediated** disease that occurs following a skin or throat infection with Group A Beta-hemolytic Streptococcus. Unlike many other glomerular diseases, PSGN is a **self-limiting condition**. The management is strictly **supportive**, focusing on controlling hypertension and edema (using diuretics and salt restriction) and treating the underlying infection if still present. Steroids like prednisolone have no role in the treatment of uncomplicated PSGN as they do not hasten recovery or improve the prognosis. **2. Why the other options are incorrect:** * **Minimal Change Disease (MCD) & Lipoid Nephrosis:** These terms are often used interchangeably. MCD is the most common cause of nephrotic syndrome in children. It is highly **steroid-sensitive**, and oral Prednisolone is the first-line, standard-of-care treatment. * **Congenital Nephrotic Syndrome (CNS):** While CNS (specifically the Finnish type) is notoriously resistant to steroids, the question asks which *should not* be treated with them. In clinical practice, a trial of steroids is often avoided in CNS once the genetic diagnosis is confirmed, but the definitive "contraindication" or lack of indication in a standard pediatric board context always points toward the self-limiting nature of PSGN. **Clinical Pearls for NEET-PG:** * **Classic Triad of PSGN:** Hematuria (Cola-colored urine), Hypertension, and Edema. * **Serology:** Low **C3 levels** are characteristic (normalize within 6–8 weeks). If C3 remains low after 8 weeks, consider Membranoproliferative GN (MPGN). * **Indication for Biopsy in PSGN:** Persistent low C3, rapidly declining renal function (RPGN), or persistent gross hematuria. * **Most common cause of Nephrotic Syndrome in children:** Minimal Change Disease (MCD).

Question 1

What is the diagnosis ?

Accepted Answer

Ureterocele

Answer

Bladder diverticula

Answer

Pseudoureteroceles

Answer

Gartner's duct cysts

Question 2

A 28-week preterm male neonate, born via emergency caesarean section, develops grunting, nasal flaring, and subcostal retractions within 30 minutes of birth. Oxygen saturation on room air is 78%. The neonatologist orders an urgent chest X-ray (Image 1). Which of the following is the most appropriate immediate pharmacological intervention?

Accepted Answer

A. Intratracheal natural surfactant (poractant alfa) via endotracheal tube

Answer

B. Intravenous dexamethasone to reduce pulmonary inflammation

Answer

C. Nebulised salbutamol to relieve bronchospasm

Answer

D. Intravenous caffeine citrate to stimulate respiratory drive

Question 3

A patient with congenital nephrotic syndrome requires which of the following procedures?

Accepted Answer

Renal biopsy

Answer

Live attenuated vaccines

Answer

High-dose steroids

Answer

Low-protein diet

Question 4

A 1-year-old girl presents after her first febrile urinary tract infection (UTI). She has no bladder-bowel dysfunction and renal ultrasound shows no hydronephrosis or renal scarring. A voiding cystourethrogram (VCUG) is performed and the findings are shown below, demonstrating Grade III vesicoureteral reflux (VUR) with contrast filling the ureter and renal pelvis with mild ureteral and calyceal dilation but without tortuosity. Which of the following is the most appropriate management option?

Accepted Answer

Low-dose daily antibiotics

Answer

Immediate surgical reimplantation of the ureters

Answer

Weekly urinalyses and culture

Answer

Diet low in protein

Question 5

Which of the following is NOT a characteristic of nephrotic syndrome in children?

Accepted Answer

Low complement levels are typically observed

Answer

Hypertension is not associated

Answer

Minimal change disease is common in children less than 10 years

Answer

Massive proteinuria is greater than 3.5 grams per 24 hours

Question 6

A 9-year-old boy presents with decreased urine output, cola-colored urine, and swelling of the face and hands for 2 days. He is hypertensive, has a puffy face, and pitting edema of the lower limbs. He had a history of skin lesions 4 weeks prior. A diagnosis of post-streptococcal glomerulonephritis is made. At what point are C3 levels likely to return to normal?

Accepted Answer

8 weeks

Answer

2 weeks

Answer

4 weeks

Answer

6 weeks

Question 7

A 10-year-old girl presents with polyuria and polydipsia, along with hypokalemia, hypercalciuria, and metabolic alkalosis. What is the probable diagnosis?

Accepted Answer

Bartter syndrome

Answer

Gitelmann syndrome

Answer

Liddle syndrome

Answer

Alport's syndrome

Question 8

All the following are used in the treatment of enuresis except?

Accepted Answer

Spironolactone

Answer

Desmopressin

Answer

Imipramine

Answer

Nortriptyline

Question 9

Which type of glomerulonephritis should not be treated with prednisolone?

Accepted Answer

Post-streptococcal GN

Answer

Minimal change disease

Answer

Lipoid nephrosis

Answer

Congenital Nephrotic Syndrome

Question 10

A 3-year-old boy presented with significant dehydration, irritability, weakness, and severe lethargy. His mother reported a history of bloody diarrhea, fever, and abdominal pain 8 days prior. Laboratory findings included anemia, deranged renal function tests, thrombocytopenia, severe hyponatremia, and leukocytosis. PT and aPTT were normal, and the Coombs test was negative. Urine analysis revealed microscopic hematuria and low-grade proteinuria. Peripheral blood smear was also performed. If there had been no history of diarrhea in this patient, which of the following drugs could have been administered?

Accepted Answer

Eculizumab

Answer

Omalizumab

Answer

Caplacizumab

Answer

Mepolizumab

Nephrology — MCQs

Nephrology — MCQs

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