Nephrotic Syndrome — 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 an indication for renal biopsy in a child with nephrotic syndrome?
All are features of nephrotic syndrome in children except –
A 7-year-old child has steroid dependent Nephrotic syndrome. His weight is 30 kg and height is 106 cm. He is having truncal obesity with sub-capsular bilateral cataracts. Which is the best drug for this patient?
Which of the following organisms is commonly implicated in spontaneous bacterial peritonitis in patients of Nephrotic syndrome?
Child with proteinuria, generalized edema, hypoproteinemia, and hyperlipidemia - most common cause is?
What is the best method to estimate the amount of proteinuria in a 2-year-old child with nephrotic syndrome?
A 5 year old child presented with periorbital swelling and oliguria. Nephrotic syndrome is suspected. Which of the following is the commonest type of nephrotic syndrome in this child?
A 40-year-old woman presents with facial swelling, periorbital edema, and proteinuria. Which condition is most likely responsible for her symptoms?
Screening for nephropathy in prepubertal children with type 1 DM should be initiated after how many years of disease onset?
Nephrotic Syndrome 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 an indication for renal biopsy in a child with nephrotic syndrome?
- A. High selective proteinuria
- B. Serum albumin less than 1g/dL
- C. Age at onset 2-6 years
- D. Low blood C3 levels (Correct Answer)
Explanation: ***Low blood C3 levels*** - A persistently **low C3** level in a child with nephrotic syndrome suggests **membranoproliferative glomerulonephritis (MPGN)** or **lupus nephritis**, which require histological diagnosis and specific treatment. - This finding indicates immune complex-mediated disease or complement dysregulation, necessitating a renal biopsy to identify the underlying pathology and guide therapy. *High selective proteinuria* - **Selective proteinuria** (primarily albuminuria) is a common feature of **minimal change disease**, which is the most frequent cause of nephrotic syndrome in children and typically responds well to corticosteroids without the need for biopsy. - The selectivity of proteinuria alone does not usually warrant a biopsy unless atypical features or non-response to steroids are present. *Serum albumin less than 1g/dL* - A very low **serum albumin** indicates severe hypoalbuminemia, which is a common and expected feature of severe nephrotic syndrome, reflecting significant protein loss. - While it reflects the severity of the syndrome, it does not, by itself, serve as an indication for renal biopsy as it's a consequence rather than a specific diagnostic marker for a distinct underlying pathology. *Age at onset 2-6 years* - The age range of **2-6 years** is the most common age for the onset of **minimal change disease** (MCD), which is corticosteroid-sensitive. - This typical presentation argues against an immediate biopsy, as most children in this age group will respond to empirical steroid therapy.
Question 3: All are features of nephrotic syndrome in children except –
- A. Hyperalbuminemia (Correct Answer)
- B. Hyperlipidemia
- C. Proteinuria
- D. Lipiduria
Explanation: ***Hyperalbuminemia*** - Nephrotic syndrome is characterized by significant protein loss in the urine, leading to **hypoalbuminemia** (low serum albumin), not hyperalbuminemia. - **Hyperalbuminemia** would suggest excessive albumin in the blood, which is contrary to the pathophysiology of nephrotic syndrome. *Hyperlipidemia* - This is a common feature of nephrotic syndrome, resulting from increased hepatic synthesis of lipoproteins in response to low plasma oncotic pressure and impaired lipid catabolism. - Patients often present with elevated **total cholesterol**, **LDL**, and **triglycerides**. *Proteinuria* - This is a hallmark of nephrotic syndrome, defined by massive urinary protein excretion, typically >3.5 g/day in adults or >40 mg/m²/hour in children. - The proteinuria is primarily due to increased glomerular permeability to proteins, especially **albumin**. *Lipiduria* - This is the presence of lipids in the urine, often seen as **fatty casts** or **oval fat bodies**, and is a characteristic finding in nephrotic syndrome. - It results from the excretion of lipoproteins that have passed through the damaged glomerular filter.
Question 4: A 7-year-old child has steroid dependent Nephrotic syndrome. His weight is 30 kg and height is 106 cm. He is having truncal obesity with sub-capsular bilateral cataracts. Which is the best drug for this patient?
- A. Azathioprine
- B. Levamisole (Correct Answer)
- C. Cyclophosphamide
- D. Mycophenolate
Explanation: ***Levamisole*** - Levamisole is an effective **steroid-sparing agent** for **steroid-dependent nephrotic syndrome** in children. - It helps reduce the frequency of relapses and allows for **reduction in steroid dosage**, thereby mitigating steroid-related adverse effects like **truncal obesity and cataracts**. - It has a **favorable safety profile** compared to alkylating agents, with main side effects being neutropenia (reversible) and rare vasculitis. - Given as **2.5 mg/kg on alternate days**, it is well-tolerated and effective in maintaining remission while minimizing steroid exposure. - Recent guidelines increasingly favor levamisole as an initial steroid-sparing agent due to its safety and efficacy. *Cyclophosphamide* - Cyclophosphamide is a potent immunosuppressant that can induce sustained remission in steroid-dependent nephrotic syndrome. - However, it carries significant risks including **gonadotoxicity** (infertility risk), **hemorrhagic cystitis**, **bone marrow suppression**, and **malignancy risk**. - Due to these serious adverse effects, it is now typically reserved for **cases resistant to other steroid-sparing agents** or when calcineurin inhibitors are not available/tolerated. - While effective, it is not the first-line steroid-sparing agent in current practice. *Azathioprine* - Azathioprine has **limited efficacy** in steroid-dependent nephrotic syndrome. - It is generally less effective than other immunosuppressants like cyclophosphamide, levamisole, or calcineurin inhibitors. - Not considered a preferred steroid-sparing agent for this condition. *Mycophenolate* - Mycophenolate Mofetil (MMF) is an alternative steroid-sparing agent with emerging evidence of efficacy in steroid-dependent nephrotic syndrome. - Studies show variable results, with some suggesting efficacy comparable to cyclophosphamide but with better safety profile. - While a reasonable option, **levamisole is typically preferred** as initial steroid-sparing therapy due to established efficacy, ease of administration, and safety profile.
Question 5: Which of the following organisms is commonly implicated in spontaneous bacterial peritonitis in patients of Nephrotic syndrome?
- A. Streptococcus pneumoniae (Correct Answer)
- B. Salmonella
- C. Hemophilus influenza
- D. Staphylococcus
Explanation: ***Streptococcus pneumoniae*** - This organism is a common cause of **spontaneous bacterial peritonitis (SBP)** in patients with **nephrotic syndrome**, particularly in children. - Patients with nephrotic syndrome are prone to infections due to impaired immunity (e.g., loss of immunoglobulins in urine) and **ascites**, providing a favorable environment for bacterial growth. *Salmonella* - While Salmonella can cause opportunistic infections, it is **not commonly implicated** in spontaneous bacterial peritonitis in nephrotic syndrome. - Salmonella typically causes **gastroenteritis** and can lead to bacteremia, but peritoneal infection is less common without direct bowel perforation. *Hemophilus influenza* - *Haemophilus influenzae* is a significant pathogen, but it is **not typically a cause** of spontaneous bacterial peritonitis in nephrotic syndrome. - It is more commonly associated with **respiratory infections**, meningitis, and epiglottitis. *Staphylococcus* - **Staphylococcal species** are generally not the primary cause of spontaneous bacterial peritonitis in uncomplicated nephrotic syndrome. - While *Staphylococcus aureus* can cause peritonitis, particularly in patients on **peritoneal dialysis** or with other predisposing factors, it is less common in SBP associated with nephrotic syndrome compared to *Streptococcus pneumoniae*.
Question 6: Child with proteinuria, generalized edema, hypoproteinemia, and hyperlipidemia - most common cause is?
- A. Mesangial glomerulonephritis
- B. FSGS
- C. IgA nephropathy
- D. Minimal change nephrotic syndrome (Correct Answer)
Explanation: **Minimal change nephrotic syndrome** - This is the most common cause of **nephrotic syndrome** in children, characterized by the classic tetrad of **proteinuria**, **hypoalbuminemia**, **edema**, and **hyperlipidemia**. - The disease involves **effacement of podocyte foot processes**, visible on electron microscopy, but the glomeruli appear normal on light microscopy. *Mesangial glomerulonephritis* - This condition involves immune complex deposition in the **mesangium**, often presenting with **hematuria** and proteinuria, but not typically the full nephrotic picture in children. - It's a form of **glomerulonephritis**, distinct from the podocytopathy seen in minimal change disease. *FSGN* - **Focal segmental glomerulosclerosis (FSGS)** is a common cause of nephrotic syndrome, but it's less common than minimal change disease as the initial presentation in young children. - It is characterized by **segmental scarring of glomeruli**, which can be seen on light microscopy. *IgA nephropathy* - This is a common cause of **glomerular hematuria**, often presenting after an upper respiratory infection. - While proteinuria can occur, it's typically not severe enough to cause the full-blown **nephrotic syndrome** with generalized edema, hypoproteinemia, and hyperlipidemia in children.
Question 7: What is the best method to estimate the amount of proteinuria in a 2-year-old child with nephrotic syndrome?
- A. Single morning spot urine sample for protein/creatinine ratio (Correct Answer)
- B. 24 hr urine protein
- C. Dipstick testing
- D. Microalbuminuria
Explanation: ***Single morning spot urine sample for protein/creatinine ratio*** - The **protein/creatinine ratio** in a single morning spot urine sample correlates well with 24-hour urine protein excretion and is more convenient, especially in children. - This method avoids the difficulties associated with **24-hour urine collection** in young children, such as incomplete or inaccurate collection. *24 hr urine protein* - While considered the gold standard, **24-hour urine collection** is often impractical and unreliable in a 2-year-old due to challenges in complete collection. - Incomplete collections can lead to **underestimation** of proteinuria, making the result inaccurate for diagnosis and monitoring. *Dipstick testing* - **Dipstick testing** provides a qualitative or semi-quantitative estimate of proteinuria but can be affected by urine concentration and pH. - It lacks the precision needed to accurately quantify proteinuria for monitoring treatment response or assessing disease severity in **nephrotic syndrome**. *Microalbuminuria* - **Microalbuminuria** refers specifically to the excretion of albumin in amounts too small to be detected by standard dipstick tests but higher than normal. - This test is primarily used for early detection of **diabetic nephropathy** and is not the primary method for quantifying overt proteinuria in nephrotic syndrome.
Question 8: A 5 year old child presented with periorbital swelling and oliguria. Nephrotic syndrome is suspected. Which of the following is the commonest type of nephrotic syndrome in this child?
- A. Focal segmental glomerulosclerosis (FSGS)
- B. Chronic glomerulonephritis
- C. Minimal change disease (Correct Answer)
- D. Congenital nephrotic syndrome
Explanation: ***Minimal change disease*** - This is the **most common cause of nephrotic syndrome** in children, accounting for approximately 80% of cases. - It presents with sudden onset of **periorbital edema**, **generalized edema**, and often **oliguria** due to severe proteinuria. *Focal segmental glomerulosclerosis (FSGS)* - While a significant cause of nephrotic syndrome in children, it ranks second to minimal change disease in frequency. - FSGS tends to have a **poorer response to steroids** and a higher risk of progression to **end-stage renal disease**. *Chronic glomerulonephritis* - This is a broad category of glomerular diseases, typically having a **more insidious onset** and often associated with hematuria and hypertension, which are not mentioned in this acute presentation. - It usually presents with features that suggest **nephritic syndrome** (e.g., hematuria, hypertension) rather than primarily nephrotic syndrome features. *Congenital nephrotic syndrome* - This is a **rare genetic condition** that presents within the first 3 months of life, which is much earlier than the 5-year-old age of this patient. - It is characterized by severe proteinuria from birth and is typically part of inherited syndromes.
Question 9: A 40-year-old woman presents with facial swelling, periorbital edema, and proteinuria. Which condition is most likely responsible for her symptoms?
- A. Congestive heart failure
- B. Liver cirrhosis
- C. Hypothyroidism
- D. Nephrotic syndrome (Correct Answer)
Explanation: ***Nephrotic syndrome*** - The combination of **facial swelling**, **periorbital edema**, and **proteinuria** is the classic triad of symptoms defining nephrotic syndrome [1]. - This syndrome is characterized by **massive proteinuria** (>3.5g/day), leading to **hypoalbuminemia**, which in turn causes reduced plasma oncotic pressure and fluid extravasation into interstitial spaces [1]. *Congestive heart failure* - While it can cause **edema**, it typically presents with **dependent edema** (e.g., in legs), **dyspnea**, and signs of fluid overload, not prominent facial or periorbital edema as a primary symptom with proteinuria. - **Proteinuria** can occur in chronic heart failure due to reduced renal perfusion, but it is usually not the massive proteinuria characteristic of nephrotic syndrome. *Liver cirrhosis* - Can cause **peripheral edema** and **ascites** due to portal hypertension and hypoalbuminemia, but **facial and periorbital edema** are less common as primary presenting symptoms. - While some **proteinuria** can be seen in chronic liver disease, it's typically milder and not the massive proteinuria seen in nephrotic syndrome. *Hypothyroidism* - Can cause **non-pitting edema** (myxedema), often described as puffy facial features and periorbital swelling, due to the accumulation of **hyaluronic acid** in the interstitial space. - However, **significant proteinuria** is not a characteristic feature of hypothyroidism; hence, it's less likely to explain the full constellation of symptoms.
Question 10: Screening for nephropathy in prepubertal children with type 1 DM should be initiated after how many years of disease onset?
- A. 3 years
- B. 4 years
- C. 2 years
- D. 5 years (Correct Answer)
Explanation: ***5 years*** - The **American Diabetes Association (ADA)** recommends initiating screening for **diabetic nephropathy** in type 1 DM patients starting at **5 years after diagnosis**, provided the patient has reached **puberty (Tanner stage 2-3) or age ≥11 years**. - In prepubertal children, even with 5+ years of disease duration, screening is typically **deferred until puberty** because microvascular complications are exceedingly rare before pubertal onset. - The **5-year duration threshold** is the standard timeframe, but it is coupled with pubertal status as a key criterion. *3 years* - This duration is too early according to current **ADA guidelines**, which recommend screening after **5 years** of disease duration. - The risk of **nephropathy** developing within 3 years in type 1 DM patients, especially prepubertal children, is very low. *4 years* - While closer to the guideline, **4 years** is still premature compared to the evidence-based **5-year threshold** recommended by major diabetes organizations. - Early screening before 5 years would increase false positives and unnecessary interventions. *2 years* - Initiating screening after only **2 years** is far too early and not supported by current evidence. - **Microvascular complications** including nephropathy require longer disease duration to develop, making 2-year screening inefficient and not cost-effective.
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