Nephrology — MCQs

A 5-year-old girl presents with the sudden onset of diffuse arthralgias and skin rash. Physical examination shows a violaceous maculopapular rash on the lower torso. Urinalysis discloses oliguria and 2+ hematuria. Urine cultures are negative. This child's clinical presentation is commonly associated with which of the following diseases?

Q157Easy

What is the most common nephrotic syndrome in children?

Q158Medium

Which of the following is true about Henoch-Schonlein Purpura?

Q159Medium

A 7-year-old boy presents with cramping abdominal pain and a rash primarily affecting the back of his legs and buttocks, as well as the extensor surfaces of his forearms. Laboratory analysis reveals proteinuria and micro-hematuria. In addition to his rash and abdominal pain, what other finding is he likely to have?

Q160Easy

True about nephrotic syndrome in a child?

Nephrology Indian Medical PG Practice Questions and MCQs

Question 151: A four-year-old child presents with mild fever, malaise, purpura, arthritis, abdominal pain, and microscopic hematuria. What is the most likely diagnosis?

A. Thrombasthenia
B. Idiopathic thrombocytopenic purpura
C. Systemic lupus erythematosus
D. Henoch-Schönlein purpura (Correct Answer)

Explanation: **Explanation:** The clinical presentation describes the classic tetrad of **Henoch-Schönlein Purpura (HSP)**, now commonly referred to as **IgA Vasculitis**. It is the most common systemic vasculitis in children, characterized by the deposition of IgA-containing immune complexes in small vessels. 1. **Why HSP is correct:** The diagnosis is clinical, based on the presence of **palpable purpura** (typically on the buttocks and lower extremities) plus at least one of the following: **Arthritis/Arthralgia** (large joints), **Abdominal pain** (due to bowel wall edema/intussusception), and **Renal involvement** (ranging from microscopic hematuria to nephritic syndrome). The mild fever and malaise often follow an upper respiratory tract infection. 2. **Why other options are incorrect:** * **Thrombasthenia (Glanzmann’s):** A platelet aggregation disorder characterized by mucosal bleeding and prolonged bleeding time, but it does not cause arthritis or abdominal pain. * **Idiopathic Thrombocytopenic Purpura (ITP):** Presents with petechiae and ecchymosis due to low platelet counts. Unlike HSP, the purpura in ITP is **non-palpable**, and there is no systemic involvement like joint pain or hematuria. * **Systemic Lupus Erythematosus (SLE):** While it can cause arthritis and nephritis, it is rare in a four-year-old and typically presents with a malar rash and positive ANA/anti-dsDNA markers. **High-Yield Clinical Pearls for NEET-PG:** * **Pathogenesis:** Leukocytoclastic vasculitis with **IgA deposition**. * **Renal biopsy:** Shows mesangial IgA deposits (identical to IgA Nephropathy/Berger’s disease). * **Platelet count:** Always **normal** in HSP (distinguishes it from ITP). * **Gastrointestinal complication:** The most common serious complication is **Intussusception** (typically ileo-ileal). * **Prognosis:** Generally excellent; renal involvement determines the long-term prognosis.

Question 152: Hypercalciuria is said to be present in children if daily calcium excretion in urine is more than:

A. 1 mg/kg
B. 2 mg/kg
C. 3 mg/kg
D. 4 mg/kg (Correct Answer)

Explanation: In pediatric nephrology, **Hypercalciuria** is a critical clinical finding often associated with hematuria, renal stones (nephrolithiasis), and voiding dysfunction. ### **Explanation of the Correct Answer** The standard definition of hypercalciuria in children (older than 2 years) is a 24-hour urinary calcium excretion exceeding **4 mg/kg/day** while on a normal diet. For screening purposes, a spot urine **Calcium:Creatinine (Ca:Cr) ratio** is often used; a ratio **>0.2** is considered suggestive of hypercalciuria in children over 2 years of age. ### **Analysis of Incorrect Options** * **Options A, B, and C (1, 2, and 3 mg/kg):** These values fall within the physiological range of calcium excretion. While calcium levels vary based on dietary intake (sodium and protein), they do not meet the diagnostic threshold for hypercalciuria in the pediatric population. ### **High-Yield Clinical Pearls for NEET-PG** * **Infant Variation:** In infants (0–6 months), the threshold is higher due to immature tubular reabsorption. A Ca:Cr ratio **>0.8** is considered normal in this age group. * **Clinical Presentation:** Idiopathic hypercalciuria is the most common cause of isolated hematuria in children without proteinuria or casts. * **Management:** The primary treatment involves **increased fluid intake** and **dietary sodium restriction** (as sodium and calcium are co-transported in the proximal tubule). Thiazide diuretics may be used in refractory cases to increase distal tubular calcium reabsorption. * **Association:** It is frequently linked to a family history of kidney stones.

Question 153: A 8-year-old boy presents with petechiae, azotemic oliguria, and altered sensorium in casualty. There is a history of diarrhea for the past 5 days. What is the most likely clinical diagnosis?

A. Acute porphyria (Correct Answer)
B. Idiopathic thrombocytopenic purpura
C. Henoch-Schonlein purpura
D. Hemolytic uremic syndrome

Explanation: **Explanation** The clinical presentation of an 8-year-old child with a prodrome of **diarrhea** followed by the triad of **microangiopathic hemolytic anemia (petechiae/purpura)**, **acute kidney injury (azotemic oliguria)**, and **neurological symptoms (altered sensorium)** is the classic hallmark of **Hemolytic Uremic Syndrome (HUS)**. *Note: There appears to be a discrepancy in the provided key. Based on standard medical literature and NEET-PG patterns, the correct clinical diagnosis for this presentation is **Hemolytic Uremic Syndrome (Option D)**.* **Why Hemolytic Uremic Syndrome (HUS) is the diagnosis:** HUS is most commonly caused by Shiga toxin-producing *E. coli* (STEC, O157:H7). The toxin causes endothelial damage, leading to platelet consumption (thrombocytopenia/petechiae) and microthrombi that obstruct renal vasculature (oliguria/azotemia) and cerebral vessels (altered sensorium). **Why other options are incorrect:** * **Acute Porphyria:** Presents with abdominal pain, neuropsychiatric symptoms, and dark urine, but is not typically preceded by infectious diarrhea or associated with acute renal failure and thrombocytopenia. * **Idiopathic Thrombocytopenic Purpura (ITP):** Presents with isolated thrombocytopenia (petechiae/bruising). It does **not** cause renal failure or altered sensorium. * **Henoch-Schonlein Purpura (HSP):** A small-vessel vasculitis presenting with palpable purpura (usually on buttocks/legs), joint pain, and abdominal pain. While it can involve the kidneys (hematuria), it rarely causes acute azotemic oliguria or follows a specific diarrheal prodrome like HUS. **NEET-PG High-Yield Pearls:** * **HUS Triad:** Microangiopathic hemolytic anemia (Schistocytes on smear), Thrombocytopenia, and Acute Renal Failure. * **Most common cause:** *E. coli* serotype O157:H7. * **Management:** Supportive care (fluids, dialysis). Antibiotics and anti-motility agents are generally **contraindicated** as they may worsen toxin release.

Question 154: Renal vein thrombosis in children is most commonly found in which of the following conditions?

A. Focal segmental glomerulosclerosis (FSGS)
B. Membranous glomerulopathy (Correct Answer)
C. Minimal change disease
D. Acute pyelonephritis

Explanation: **Explanation:** **Renal Vein Thrombosis (RVT)** is a known complication of **Nephrotic Syndrome** due to a hypercoagulable state caused by the loss of anticoagulant factors (like Antithrombin III) in urine and an increase in procoagulant factors. 1. **Why Membranous Glomerulopathy (MG) is correct:** Among all causes of nephrotic syndrome, MG has the strongest association with thromboembolic events, particularly RVT. While the exact reason is debated, it is attributed to a more profound activation of the coagulation cascade and higher rates of severe hypoalbuminemia seen in this pathology. In adults and older children, MG is the leading glomerular cause of RVT. 2. **Why other options are incorrect:** * **Minimal Change Disease (MCD):** Although the most common cause of nephrotic syndrome in children, the incidence of RVT is significantly lower compared to MG. * **FSGS:** While it can cause hypercoagulability, the statistical association with RVT is not as strong as it is with MG. * **Acute Pyelonephritis:** This is an inflammatory/infectious condition. While severe sepsis can lead to DIC, pyelonephritis itself is not a classic risk factor for isolated renal vein thrombosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of RVT in Neonates:** Dehydration and birth asphyxia (presents with a flank mass, hematuria, and thrombocytopenia). * **Most common cause of RVT in Adults:** Membranous Nephropathy. * **Clinical Triad of RVT:** Sudden onset of flank pain, hematuria, and an increase in kidney size (though often asymptomatic in chronic cases). * **Diagnosis:** Doppler Ultrasonography is the initial investigation of choice; CT angiography or MR angiography is more definitive.

Question 155: Which of the following is a feature of renal vasculitis in children?

A. Elevated IgA levels (Correct Answer)
B. Presence of antinuclear antibodies in serum
C. Low complement levels
D. Presence of cytoplasmic antinuclear antibodies

Explanation: **Explanation:** The question refers to **Henoch-Schönlein Purpura (HSP)**, now known as **IgA Vasculitis**, which is the most common systemic vasculitis in children. **1. Why Option A is Correct:** IgA Vasculitis is characterized by the deposition of **IgA-dominant immune complexes** in the walls of small vessels (capillaries, venules, or arterioles). In approximately 50-70% of affected children, serum **IgA levels are elevated** during the acute phase. The renal involvement (HSP Nephritis) is histologically indistinguishable from IgA Nephropathy (Berger’s disease), showing mesangial IgA deposits on immunofluorescence. **2. Why Other Options are Incorrect:** * **Option B (ANA):** Antinuclear antibodies are markers for systemic lupus erythematosus (SLE). While SLE can cause renal vasculitis (Lupus Nephritis), it is not a defining feature of the primary pediatric vasculitis (HSP). * **Option C (Low Complement):** HSP is a **normocomplementemic** condition. Low complement levels (C3, C4) are characteristic of Post-Streptococcal Glomerulonephritis (PSGN), Lupus Nephritis, or Membranoproliferative Glomerulonephritis (MPGN). * **Option D (c-ANCA):** Cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA/PR3-ANCA) are specific for Granulomatosis with Polyangiitis (Wegener’s), which is rare in children compared to HSP. **Clinical Pearls for NEET-PG:** * **Classic Tetrad of HSP:** Non-thrombocytopenic palpable purpura (lower limbs/buttocks), arthritis/arthralgia, abdominal pain (intussusception risk), and renal involvement. * **Renal Prognosis:** The long-term prognosis of HSP depends entirely on the severity of renal involvement. * **Biopsy Finding:** Mesangial proliferation with IgA and C3 deposition.

Question 156: A 5-year-old girl presents with the sudden onset of diffuse arthralgias and skin rash. Physical examination shows a violaceous maculopapular rash on the lower torso. Urinalysis discloses oliguria and 2+ hematuria. Urine cultures are negative. This child's clinical presentation is commonly associated with which of the following diseases?

A. Berger disease
B. Goodpasture syndrome
C. Hemolytic uremic syndrome
D. Henoch-Schonlein purpura (Correct Answer)

Explanation: **Explanation:** The clinical presentation of a **palpable purpuric rash** (violaceous maculopapular) localized to the lower extremities/buttocks, **arthralgia**, and **renal involvement** (hematuria/oliguria) in a young child is classic for **Henoch-Schönlein Purpura (HSP)**, now also known as IgA Vasculitis. **1. Why HSP is correct:** HSP is a small-vessel vasculitis characterized by the deposition of **IgA-dominant immune complexes**. The classic tetrad includes: * **Skin:** Palpable purpura (non-thrombocytopenic) on gravity-dependent areas. * **Joints:** Migratory arthralgia/arthritis (usually knees and ankles). * **GI Tract:** Abdominal pain, occult blood, or intussusception. * **Renal:** "HSP Nephritis," which is histologically identical to IgA Nephropathy (Berger disease), presenting with hematuria and proteinuria. **2. Why other options are incorrect:** * **Berger Disease (IgA Nephropathy):** While histologically similar to HSP, it is localized to the kidney and lacks systemic features like the characteristic purpuric rash and arthralgia. * **Goodpasture Syndrome:** Characterized by anti-GBM antibodies causing pulmonary hemorrhage (hemoptysis) and rapidly progressive glomerulonephritis. It is rare in young children and does not present with this specific rash. * **Hemolytic Uremic Syndrome (HUS):** Presents with the triad of Microangiopathic Hemolytic Anemia (MAHA), thrombocytopenia, and acute kidney injury, usually following bloody diarrhea (EHEC). It does not typically cause arthralgia or a maculopapular rash. **Clinical Pearls for NEET-PG:** * **Most common** systemic vasculitis in children. * **Preceding Event:** Often follows an Upper Respiratory Tract Infection (URTI). * **Diagnosis:** Primarily clinical; skin biopsy (if done) shows **leukocytoclastic vasculitis** with IgA deposits. * **Prognosis:** Generally excellent; renal involvement is the primary determinant of long-term morbidity.

Question 157: What is the most common nephrotic syndrome in children?

A. Minimal change disease (Correct Answer)
B. Membranoproliferative disease
C. Membranous glomerulonephritis
D. IgA nephropathy

Explanation: **Explanation:** **Minimal Change Disease (MCD)** is the most common cause of Nephrotic Syndrome in children, accounting for approximately **75–80%** of cases in the pediatric age group (typically between ages 2 and 6). * **Why it is correct:** MCD is characterized by massive proteinuria, hypoalbuminemia, and edema. On light microscopy, the glomeruli appear normal (hence "minimal change"), but electron microscopy reveals the hallmark feature: **effacement (fusion) of podocyte foot processes**. It is highly steroid-sensitive, which is a key clinical diagnostic marker. **Why the other options are incorrect:** * **Membranoproliferative Glomerulonephritis (MPGN):** This typically presents as a mixed nephritic-nephrotic picture and is more common in older children and young adults. It is associated with low complement levels (C3). * **Membranous Glomerulonephritis (MGN):** This is the most common cause of nephrotic syndrome in **non-diabetic adults**. In children, it is rare and often secondary to infections like Hepatitis B. * **IgA Nephropathy (Berger’s Disease):** This is the most common cause of **glomerulonephritis (nephritic syndrome)** worldwide, typically presenting with recurrent gross hematuria following an upper respiratory tract infection. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause in adults:** Focal Segmental Glomerulosclerosis (FSGS) is now cited as the most common primary cause in adults (surpassing MGN in some populations), while MCD remains the undisputed leader in children. * **Treatment:** Corticosteroids (Prednisolone) are the first-line treatment. * **Prognosis:** Excellent, though relapses are common. * **Immunofluorescence:** Typically negative (no immune deposits).

Question 158: Which of the following is true about Henoch-Schonlein Purpura?

A. It is a vasculitis affecting medium-sized vessels.
B. Renal symptoms typically begin late in the disease course.
C. There is IgA deposition in the mesangium. (Correct Answer)
D. It is characterized by a low platelet count.

Explanation: **Explanation:** Henoch-Schönlein Purpura (HSP), now commonly referred to as **IgA Vasculitis**, is the most common systemic vasculitis in children. It is an immune-complex-mediated disease characterized by the deposition of **IgA1-dominant immune complexes** in the walls of small vessels and the renal mesangium. **Why Option C is Correct:** The hallmark of HSP is the deposition of IgA in the **mesangium** of the kidneys, which is histologically indistinguishable from IgA Nephropathy (Berger’s disease). This deposition triggers an inflammatory response, leading to hematuria and proteinuria. **Analysis of Incorrect Options:** * **Option A:** HSP is a **small-vessel vasculitis** (affecting arterioles, capillaries, and venules), not medium-sized. Medium-vessel vasculitides include Kawasaki disease and Polyarteritis Nodosa. * **Option B:** While renal involvement can occur at any time, it typically manifests **within the first 4–6 weeks** of the onset of the rash. It is rarely a "late" complication and is the primary determinant of long-term prognosis. * **Option D:** HSP is a **non-thrombocytopenic purpura**. The platelet count is characteristically **normal or even elevated** (thrombocytosis). A low platelet count would suggest other diagnoses like ITP or HUS. **NEET-PG High-Yield Pearls:** * **Classic Tetrad:** Palpable purpura (without thrombocytopenia), arthritis/arthralgia, abdominal pain (colicky), and renal disease. * **Preceding Event:** Often follows an Upper Respiratory Tract Infection (URTI). * **Gastrointestinal Risk:** HSP is a leading trigger for **intussusception** (usually ileo-ileal) in older children. * **Diagnosis:** Primarily clinical; skin biopsy shows **leukocytoclastic vasculitis** with IgA deposits.

Question 159: A 7-year-old boy presents with cramping abdominal pain and a rash primarily affecting the back of his legs and buttocks, as well as the extensor surfaces of his forearms. Laboratory analysis reveals proteinuria and micro-hematuria. In addition to his rash and abdominal pain, what other finding is he likely to have?

A. Chronic renal failure
B. Arthritis or arthralgia (Correct Answer)
C. Seizures
D. Unilateral lymphadenopathy

Explanation: This clinical scenario describes a classic presentation of **Henoch-Schönlein Purpura (HSP)**, now commonly referred to as **IgA Vasculitis**. It is the most common systemic vasculitis in children. ### 1. Why the Correct Answer is Right HSP is characterized by a classic clinical tetrad: 1. **Palpable Purpura:** Typically distributed on gravity-dependent areas (buttocks and lower extremities). 2. **Arthritis/Arthralgia:** Occurs in approximately 75% of cases. It usually affects large joints (knees and ankles) and is transient and non-deforming. 3. **Abdominal Pain:** Due to submucosal hemorrhage and edema (vasculitis of the GI tract). 4. **Renal Involvement:** Presenting as hematuria and proteinuria (IgA nephropathy). The patient already exhibits three of these features; therefore, **arthritis or arthralgia** is the most likely additional finding. ### 2. Why Incorrect Options are Wrong * **A. Chronic Renal Failure:** While HSP can cause renal involvement (HSP nephritis), most children recover completely. Progression to chronic renal failure is rare (<1–5%) and would not be an acute finding. * **C. Seizures:** Neurological involvement in HSP is extremely rare. Seizures are not a characteristic feature of this vasculitis. * **D. Unilateral Lymphadenopathy:** This is a hallmark of **Kawasaki Disease**, not HSP. HSP does not typically present with significant lymphadenopathy. ### 3. High-Yield Clinical Pearls for NEET-PG * **Pathogenesis:** Small vessel vasculitis caused by **IgA1 immune complex deposition**. * **Trigger:** Often follows an **Upper Respiratory Tract Infection (URTI)**. * **GI Complication:** The most serious acute GI complication is **Intussusception** (typically ileo-ileal). * **Diagnosis:** Primarily clinical. Biopsy (if done) shows **leukocytoclastic vasculitis** with IgA deposits on immunofluorescence. * **Prognosis:** Generally excellent; the long-term prognosis depends entirely on the severity of **renal involvement**.

Question 160: True about nephrotic syndrome in a child?

A. Minimal change disease is the commonest cause. (Correct Answer)
B. Proteinuria of 4 gm/m2/hr is characteristic.
C. Cyclosporine and azathioprine are the mainstay of therapy.
D. Pretreatment biopsy is done in all cases.

Explanation: **Explanation:** **1. Why Option A is Correct:** Minimal Change Disease (MCD) is the most common cause of idiopathic nephrotic syndrome in children, accounting for approximately **80-85% of cases** in those aged 1 to 7 years. It is characterized by the effacement of podocyte foot processes on electron microscopy, while light microscopy appears normal. **2. Why the other options are Incorrect:** * **Option B:** The diagnostic threshold for nephrotic-range proteinuria is **>40 mg/m²/hr** (not 4 gm). Alternatively, it is defined as a urine protein/creatinine ratio >2 mg/mg or ≥3+ on dipstick. * **Option C:** **Corticosteroids (Prednisolone)** are the mainstay and first-line therapy for nephrotic syndrome. Cyclosporine and Azathioprine are "steroid-sparing agents" reserved for steroid-resistant or frequently relapsing cases. * **Option D:** Pretreatment biopsy is **not** indicated in all cases. Since MCD is so prevalent, children (1–10 years) are typically started on steroids empirically. Biopsy is reserved for atypical presentations (age <1 or >10 years, gross hematuria, hypertension, low C3 levels, or steroid resistance). **High-Yield Clinical Pearls for NEET-PG:** * **Definition Triad:** Proteinuria (>40 mg/m²/hr), Hypoalbuminemia (<2.5 g/dL), and Edema. Hyperlipidemia is a common associated finding. * **Most common complication:** Infections (specifically **Spontaneous Bacterial Peritonitis** caused by *Streptococcus pneumoniae*). * **Steroid Dosage:** 2 mg/kg/day (max 60 mg) for 6 weeks, followed by 1.5 mg/kg alternate days for 6 weeks. * **Hypercoagulability:** Occurs due to loss of Antithrombin III and Protein C/S in urine.

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Urinary Tract Infections

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Vesicoureteral Reflux

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Glomerulonephritis

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Nephrotic Syndrome

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Acute Kidney Injury

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Chronic Kidney Disease

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Renal Tubular Disorders

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Congenital Anomalies of the Kidney

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Hydronephrosis

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Hypertension in Children

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Hemolytic Uremic Syndrome

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Renal Replacement Therapy in Children

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Nephrology — MCQs

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