Glomerulonephritis — MCQs
An 8-year-old child presents with hematuria 5 days after a throat infection. What is the most likely diagnosis?
Which of the following is not a feature of Poststreptococcal Glomerulonephritis (PSGN)?
Which of the following is associated with pauci-immune glomerulonephritis?
A child presents with brown colored urine and oliguria for last 3 days. He has mild facial and pedal edema. His blood pressure is 126/90. He has +3 proteinuria with 100 red cell and a few granular casts. His creatinine is 0.9, urea is 56. What is his diagnosis?
Proteoglycan present in the glomerular basement membrane is?
Which of the following is NOT a feature of nephrotic syndrome?
A patient presents with cutaneous vasculitis, glomerulonephritis and peripheral neuropathy. What investigation is to be performed next for work up?
2 year old child presented with sudden onset of altered sensorium. On examination, BP was 200/100. What is the most likely diagnosis?
A 2-year-old child presents with sudden onset of altered sensorium. On examination, blood pressure is 200/100 mmHg. What is the most likely diagnosis?
Which of the following is not a hallmark of nephrotic syndrome in children?
Glomerulonephritis Indian Medical PG Practice Questions and MCQs
Question 1: An 8-year-old child presents with hematuria 5 days after a throat infection. What is the most likely diagnosis?
- A. Nephrotic syndrome
- B. Ig A nephropathy (Correct Answer)
- C. Post streptococcal nephropathy
- D. Hereditary nephritis (Alport syndrome)
Explanation: ***Ig A nephropathy*** - This condition is characterized by **hematuria** that typically occurs within days (1-5 days) of an **upper respiratory tract infection**. - The rapid onset of symptoms after infection is a key differentiator from post-streptococcal glomerulonephritis. *Nephrotic syndrome* - This syndrome is defined by **massive proteinuria**, **hypoalbuminemia**, **edema**, and **hyperlipidemia**, not primarily by gross hematuria following an infection. - While some forms of nephrotic syndrome can cause hematuria, the prominent feature here is the timing after a throat infection and gross hematuria. *Post streptococcal nephropathy* - This condition typically presents with **hematuria** 7-21 days after a Streptococcus infection, a longer latency period than described here. - It often involves a decline in renal function, hypertension, and edema, which are not the primary focus of the vignette's timing. *Hereditary nephritis (Alport syndrome)* - This is a genetic disorder causing progressive renal failure, **sensorineural hearing loss**, and ocular abnormalities. - While it causes hematuria, it is typically chronic and not acutely triggered by a throat infection in a specific timeframe as described.
Question 2: Which of the following is not a feature of Poststreptococcal Glomerulonephritis (PSGN)?
- A. HTN
- B. Increased urea
- C. Increased creatinine
- D. Normal C3 level (Correct Answer)
Explanation: ***Normal C3 level*** - In Post-streptococcal glomerulonephritis (PSGN), **C3 levels are typically decreased** due to complement consumption during the inflammatory process. [1] - A **normal C3 level** would not be consistent with PSGN, as it suggests no significant complement activation. *Increased urea* - Increased urea can occur due to **impaired renal function**, which is common in PSGN due to glomerular inflammation. [1] - It's a typical finding reflecting the kidneys' inability to excrete waste products properly. *HTN* - Hypertension is frequently associated with PSGN due to **volume overload** and activation of the renin-angiotensin system. [1] [2] - It is a common clinical feature that results from increased fluid retention. *Increased creatinine* - Increased creatinine levels indicate **renal impairment**, which is characteristic of PSGN as kidney function is affected during this condition. [1] - This finding highlights the reduction in glomerular filtration rate (GFR), typical in glomerulonephritis. [2]
Question 3: Which of the following is associated with pauci-immune glomerulonephritis?
- A. Anti-GBM glomerulonephritis
- B. SLE nephritis
- C. IgA nephropathy
- D. Granulomatosis with polyangiitis (GPA) (Correct Answer)
Explanation: ***Granulomatosis with polyangiitis (GPA)*** - **Pauci-immune glomerulonephritis** is characterized by the absence or scarcity of immune complex deposits in the glomeruli. - This is typical of **ANCA-associated vasculitides**, such as GPA (formerly Wegener's granulomatosis), which cause severe necrotising glomerulonephritis with few immune deposits [1]. *Anti-GBM glomerulonephritis* - This condition is characterized by **linear deposition of anti-GBM antibodies** along the glomerular basement membrane, making it an **immune complex-mediated disease**, not pauci-immune [1]. - It involves autoantibodies attacking the **collagen type IV** in the GBM. *SLE nephritis* - Systemic lupus erythematosus (SLE) nephritis is a classic example of **immune complex-mediated glomerulonephritis**, with abundant immune deposits containing immunoglobulins and complement [1]. - The pathology often shows **full-house immunofluorescence** with IgG, IgA, IgM, C3, and C1q. *IgA nephropathy* - This is characterized by prominent **mesangial deposition of IgA immune complexes**, which is clearly an immune complex-mediated process [1]. - While it can present with different histological patterns, the presence of **IgA deposition** means it is not pauci-immune [1].
Question 4: A child presents with brown colored urine and oliguria for last 3 days. He has mild facial and pedal edema. His blood pressure is 126/90. He has +3 proteinuria with 100 red cell and a few granular casts. His creatinine is 0.9, urea is 56. What is his diagnosis?
- A. PSGN (Correct Answer)
- B. FSGS
- C. IgA Nephropathy
- D. Nephrolithiasis
Explanation: ***PSGN*** - The presentation with **brown urine**, **oliguria**, **edema**, **hypertension**, and **hematuria with red cell casts** is classic for an acute nephritic syndrome. - Given the patient is a child, and the constellation of symptoms including **sudden onset**, **significant hypertension**, and **granular casts**, **Post-Streptococcal Glomerulonephritis (PSGN)** is the most likely diagnosis. - PSGN typically follows streptococcal pharyngitis or skin infection by 1-3 weeks and presents with acute nephritic syndrome. *FSGS* - **Focal Segmental Glomerulosclerosis (FSGS)** typically presents with **nephrotic syndrome** (heavy proteinuria, hypoalbuminemia, severe edema), not primarily with nephritic features. - While it can cause proteinuria, the presence of **red cell casts** and significant hematuria with acute hypertension points to an inflammatory glomerulonephritis, not FSGS. *IgA Nephropathy* - **IgA Nephropathy (Berger's disease)** can also cause nephritic syndrome in children with hematuria and RBC casts. - However, it typically presents with **recurrent episodes of gross hematuria** occurring **during or immediately after** upper respiratory infections (synpharyngitic hematuria), rather than the delayed presentation seen here. - It usually has a more chronic course with less prominent edema and hypertension compared to PSGN. *Nephrolithiasis* - **Nephrolithiasis (kidney stones)** would typically present with **colicky flank pain** and hematuria. - It would not explain the prominent **edema**, **hypertension**, **significant proteinuria**, or presence of **red cell casts** seen in this patient.
Question 5: Proteoglycan present in the glomerular basement membrane is?
- A. Keratan sulfate 1
- B. Keratan sulfate 2
- C. Heparan sulfate (Correct Answer)
- D. Chondroitin sulfate
Explanation: ***Heparan sulphate*** - Heparan sulphate is a key component of the **glomerular basement membrane** (GBM), crucial for its **negative charge and filtration function** [1][2]. - It plays a significant role in **filtration barrier** properties and affects the permeability of the GBM to proteins [1]. *Keratan sulphate 1* - Predominantly found in **cartilage** and **corneal tissue**, not associated with the glomerular basement membrane. - It contributes to **mechanical support** but lacks the essential role in renal filtration. *Keratan sulphate 2* - Similar to Keratan sulphate 1, this variant is involved in **cartilage** but not in the structure of the glomerular basement membrane. - Has distinct functions related to **tissue hydration** rather than the filtration dynamics of the GBM. *Chondroitin sulphate* - Commonly located in **cartilage** and connective tissues, it does not play a significant role in the structure of the glomerular basement membrane. - While it assists in **cell signaling** and regeneration, it does not influence the GBM permeability like heparan sulphate. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 905-907. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. With Illustrations By, pp. 34-35.
Question 6: Which of the following is NOT a feature of nephrotic syndrome?
- A. Hematuria (Correct Answer)
- B. Edema
- C. Hypoalbuminemia
- D. Proteinuria
Explanation: ### Original Explanation ***Hematuria*** - **Hematuria** is a characteristic feature of **nephritic syndrome**, which involves glomerular inflammation and damage leading to blood in the urine [1]. - In contrast, **nephrotic syndrome** is primarily characterized by increased glomerular permeability to protein, not red blood cells, resulting in significant **proteinuria** [1]. *Edema* - **Edema** is a hallmark of nephrotic syndrome, resulting from severe **hypoalbuminemia** that reduces plasma oncotic pressure [2]. - This leads to fluid extravasation into the interstitial spaces, causing generalized swelling. *Hypoalbuminemia* - **Hypoalbuminemia** is a defining feature of nephrotic syndrome, caused by excessive urinary loss of albumin due to widespread glomerular damage [2]. - Reduced serum albumin levels contribute to the characteristic edema and increased lipid synthesis by the liver. *Proteinuria* - **Proteinuria**, specifically *massive proteinuria* (>3.5 g/day in adults), is the cardinal feature of nephrotic syndrome [1], [2]. - It signifies significant damage to the glomerular filtration barrier, allowing large amounts of protein to leak into the urine.
Question 7: A patient presents with cutaneous vasculitis, glomerulonephritis and peripheral neuropathy. What investigation is to be performed next for work up?
- A. HBsAg
- B. RA factor
- C. CRP
- D. ANCA (Correct Answer)
Explanation: **ANCA** - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points strongly towards a Systemic Vasculitis [1]. **ANCA** (anti-neutrophil cytoplasmic antibodies) are crucial for diagnosing and classifying **ANCA-associated vasculitides**, such as **Granulomatosis with Polyangiitis (GPA)**, **Microscopic Polyangiitis (MPA)**, and **Eosinophilic Granulomatosis with Polyangiitis (EGPA)**, which perfectly fit this clinical picture [1]. - Identification of specific ANCA patterns (p-ANCA or c-ANCA) and their corresponding target antigens (e.g., **MPO** or **PR3**) is essential for confirming the diagnosis and guiding treatment. *HBsAg* - While **Hepatitis B virus (HBV) infection** can cause **polyarteritis nodosa (PAN)**, which may present with vasculitis and neuropathy, it typically does not involve **glomerulonephritis** as a primary feature [1]. - Testing for HBsAg would be relevant if PAN was strongly suspected or if other risk factors for HBV were present, but ANCA testing is more direct for the given clinical triad. *RA factor* - **Rheumatoid factor (RF)** is primarily associated with **Rheumatoid Arthritis**, which is an inflammatory joint disease and does not typically present with this triad of **vasculitis**, **glomerulonephritis**, and **neuropathy** [2]. - Although some connective tissue diseases can have vasculitic manifestations, RF itself is not a primary diagnostic marker for systemic vasculitis. *CRP* - **C-reactive protein (CRP)** is a general **marker of inflammation**, which would undoubtedly be elevated in a patient with systemic vasculitis [1]. - However, CRP is **non-specific** and would not help in narrowing down the diagnosis or determining the etiology of the vasculitis, making it less useful for specific workup compared to ANCA.
Question 8: 2 year old child presented with sudden onset of altered sensorium. On examination, BP was 200/100. What is the most likely diagnosis?
- A. Essential hypertension
- B. Glomerulonephritis (Correct Answer)
- C. Renal artery stenosis
- D. Coarctation of the aorta
Explanation: ***Glomerulonephritis*** - **Sudden onset of altered sensorium** in a child with severe **hypertension (BP 200/100)** is highly suggestive of hypertensive encephalopathy, a common complication of acute glomerulonephritis. - **Acute glomerulonephritis** often presents with hypertension, edema, and hematuria, which can lead to neurological symptoms due to rapid and severe blood pressure elevation. *Essential hypertension* - **Essential hypertension** is extremely rare in a 2-year-old child; hypertension in this age group is typically secondary to an underlying condition. - The sudden onset of severe hypertension with neurological symptoms points away from primary hypertension, which usually develops gradually. *Renal artery stenosis* - While **renal artery stenosis** can cause hypertension, it usually presents as sustained hypertension and is less likely to cause a sudden, acute presentation with altered sensorium in a 2-year-old compared to acute glomerulonephritis. - Renal artery stenosis often causes **renovascular hypertension**, which may be indicated by abdominal bruits, but the acute neurological crisis is more characteristic of the rapid blood pressure rise seen in glomerulonephritis. *Coarctation of the aorta* - **Coarctation of the aorta** causes hypertension, but it typically presents with a **difference in blood pressure between the upper and lower extremities** or absent/diminished femoral pulses. - While it can lead to severe hypertension, the sudden onset of altered sensorium as the primary presenting feature is less typical; other signs related to the anatomical defect would usually be present.
Question 9: A 2-year-old child presents with sudden onset of altered sensorium. On examination, blood pressure is 200/100 mmHg. What is the most likely diagnosis?
- A. Renal artery stenosis
- B. Essential hypertension
- C. Glomerulonephritis (Correct Answer)
- D. Coarctation of Aorta
Explanation: ***Glomerulonephritis*** - The sudden onset of **altered sensorium** in a 2-year-old with severe **hypertension** (200/100 mmHg) is highly suggestive of **hypertensive encephalopathy**, a serious complication often seen in acute glomerulonephritis. - **Acute glomerulonephritis**, particularly post-streptococcal glomerulonephritis, frequently presents with sudden onset of hypertension, fluid retention, and neurological symptoms such as altered sensorium in young children. *Renal artery stenosis* - While renal artery stenosis can cause severe hypertension, it typically does not present with such an acute and dramatic onset of altered sensorium in a 2-year-old, unless there's a thrombotic event. - Hypertensive encephalopathy secondary to renal artery stenosis is possible but less common as the initial presentation in this age group compared to acute glomerulonephritis. *Essential hypertension* - **Essential hypertension** is extremely rare in a 2-year-old and would not typically present with such a severe, sudden onset of hypertension leading to altered sensorium. - When hypertension is diagnosed in young children, an underlying **secondary cause** is almost always present and must be aggressively investigated. *Coarctation of Aorta* - **Coarctation of the aorta** causes hypertension, but the hypertension is usually present from birth or early infancy and would typically manifest with a **difference in blood pressure** between the upper and lower extremities and specific murmur. - While it can lead to high blood pressure, an acute presentation with sudden altered sensorium due to extremely high pressure is less characteristic compared to the acute inflammatory process of glomerulonephritis.
Question 10: Which of the following is not a hallmark of nephrotic syndrome in children?
- A. Hypoalbuminemia < 2.5 g/dL
- B. Edema
- C. Severe proteinuria >2 gm/m2/day
- D. Gross hematuria (Correct Answer)
Explanation: ***Gross hematuria*** - While some glomerular disorders that cause nephrotic syndrome can also present with microscopic hematuria, **gross hematuria** is a hallmark feature of **nephritic syndrome**, not nephrotic syndrome. - Nephritic syndrome typically involves significant inflammation and damage to the glomeruli, leading to blood in the urine, often accompanied by hypertension and acute kidney injury. *Severe proteinuria >2 gm/m2/day* - **Severe proteinuria** (typically defined as >40 mg/m2/hr or >50 mg/kg/day, or >3.5 g/day in adults, which translates to high values in children) is a **defining characteristic** of nephrotic syndrome, resulting from increased glomerular permeability. - The excessive loss of protein in the urine is responsible for many of the other clinical manifestations of the syndrome. *Hypoalbuminemia < 2.5 g/dL* - **Hypoalbuminemia** is a direct consequence of the massive proteinuria, as the liver cannot synthesize albumin quickly enough to compensate for its loss. - A serum albumin level of less than 2.5 g/dL is a key diagnostic criterion for nephrotic syndrome. *Edema* - **Edema**, particularly periorbital, scrotal, and lower extremity swelling, is a prominent clinical feature of nephrotic syndrome. - It results from the reduced plasma oncotic pressure due to hypoalbuminemia, leading to fluid shifts from the intravascular space to the interstitial space.
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