Nephrology Practice Questions

Q: A 5-year-old boy is brought to the office by his mother with complaints of facial puffiness and “frothy” urine for 4 days. The puffiness first started in his eyes and then spread to the face. His mother does not provide any history of similar symptoms in the past. Past medical history is non-significant. His birth history is uneventful and all his vaccinations are up to date. The vital signs include: blood pressure 100/62 mm Hg, pulse 110/min, temperature 36.7°C (98.0°F), and respiratory rate 16/min. On examination, there is pitting edema of the upper and lower extremities bilaterally. Urinalysis results are as follows: pH 6.2 Color light yellow RBC none WBC 3–4/HPF Protein 4+ Cast Fat globules Glucose absent Crystal none Ketone absent Nitrite absent 24-hour urine protein excretion 4.1 g A renal biopsy is sent which shows normal glomeruli on light microscopy. Which of the following is the most likely diagnosis?

Lipoid nephrosis. ***Lipoid nephrosis*** - The classic presentation in a young child with **facial puffiness**, **edema**, **frothy urine**, **heavy proteinuria** (>3.5 g/24h), and **fat globules** in the urine (suggesting **lipoid nephrosis** or minimal change disease). - Normal glomeruli on **light microscopy** is a hallmark finding of **minimal change disease** (lipoid nephrosis), as the pathology is primarily at the podocyte level, which is only visible on electron microscopy showing **effacement of foot processes**. *Incorrect Option: Post-infectious glomerulonephritis* - Often follows a **streptococcal infection** and presents with **hematuria**, **hypertension**, and **mild proteinuria**, which are not seen here. - Light microscopy would typically show **hypercellular glomeruli** with immune deposits, contrasting with the normal findings in this case. *Incorrect Option: Focal segmental glomerulosclerosis* - While it can cause nephrotic syndrome, this condition typically presents with **hypertension** and **microscopic hematuria**, which are absent in this patient. - Light microscopy would reveal **segmental scarring** and **sclerosis** of some glomeruli, which is not consistent with the "normal glomeruli" described. *Incorrect Option: Membranoproliferative glomerulonephritis* - This condition is characterized by **thickened glomerular basement membranes** and **mesangial cell proliferation**, leading to a "tram track" appearance on microscopy. - It often presents with mixed nephritic-nephrotic features, including **hematuria** and **hypertension**, which are not observed in this child.

Q: Treatment of choice used in nocturnal enuresis is:

Bed alarms. ***Bed alarms*** - **Bed alarms** are the **first-line, non-pharmacological treatment (TOC)** for nocturnal enuresis, working through classical conditioning to train the child to wake up when urination begins. - They have a high success rate and durable response once treatment is completed. *Trazodone* - **Trazodone** is an antidepressant primarily used for **insomnia** and depression; it is not indicated for the treatment of nocturnal enuresis. - It works by modulating serotonin reuptake and blocking alpha-1 adrenergic receptors, with a different mechanism of action than treatments for enuresis. *Fluoxetine* - **Fluoxetine** is a Selective Serotonin Reuptake Inhibitor (SSRI) primarily used to treat **depression, anxiety disorders**, and OCD. - It is not a recommended treatment for nocturnal enuresis and does not address the underlying physiological mechanisms. *Imipramine* - **Imipramine** is a tricyclic antidepressant that has been used for nocturnal enuresis, but it is **not the treatment of choice** due to potential side effects and the availability of safer, more effective options. - It works by anticholinergic and alpha-adrenergic effects to increase bladder capacity and arousal, but its use is often limited by its adverse effect profile.

Q: A child presents with complaints of bed wetting. What is the first line of treatment?

Bed alarm technique. ***Bed alarm technique*** - The **bed alarm technique** is considered the most effective first-line treatment for **nocturnal enuresis** in children. - It works through **classical conditioning**, training the child to wake up in response to bladder fullness. *Motivational therapy* - **Motivational therapy** can be a useful adjunct to other treatments, but it is not typically the sole **first-line therapy** due to varying effectiveness. - It focuses on building the child's confidence and encouraging dryness but does not directly address the physiological aspects of bedwetting. *Oxybutynin* - **Oxybutynin** is an anticholinergic medication that can reduce bladder contractions and increase bladder capacity. - It is usually reserved for cases where **bedwetting alarms** and **desmopressin** have been ineffective, or when there is an identifiable **overactive bladder component**. *Desmopressin* - **Desmopressin** is an antidiuretic hormone analogue that reduces urine production during the night. - While effective, it is often considered a **second-line treatment** after behavioral interventions like the bed alarm, or when rapid but temporary improvement is desired.

Q: The most common underlying anomaly in a child with recurrent urinary tract infections is:

Vesicoureteric reflux. ***Vesicoureteric reflux*** - **Vesicoureteric reflux (VUR)** is the most common anatomic anomaly contributing to recurrent UTIs in children, allowing urine to flow backward from the bladder to the kidneys. - This retrograde flow can carry bacteria from the bladder to the upper urinary tract, leading to **pyelonephritis** and kidney damage. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are a cause of severe urinary obstruction almost exclusively in newborn males, leading to bladder and kidney damage, but are less common than VUR for recurrent UTIs in childhood generally. - While PUV can cause recurrent UTIs due to stasis and obstruction, its incidence is lower than VUR, and it typically presents with more severe obstructive symptoms early in life. *Neurogenic bladder* - **Neurogenic bladder** results from nerve damage (e.g., spina bifida) affecting bladder control, leading to incomplete emptying, stasis, and recurrent UTIs. - While a significant cause of UTIs in affected children, it is a specific neurological condition and not the *most common underlying anomaly* overall for recurrent UTIs. *Renal calculi* - **Renal calculi (kidney stones)** can cause urinary obstruction and provide a nidus for bacterial growth, leading to recurrent UTIs. - However, kidney stones are less common in children than adults and are not the primary underlying anatomical anomaly; they are often secondary to other metabolic or structural issues.

Q: The following are causes of hematuria in childhood except

Alpha thalassemia. ***Alpha thalassemia*** - **Alpha thalassemia** primarily affects **hemoglobin production**, leading to anemia. It does not directly cause hematuria. - While severe anemia can sometimes lead to organ dysfunction, hematuria is not a characteristic or direct symptom of alpha thalassemia itself. *Alport syndrome* - **Alport syndrome** is a genetic disorder affecting the **glomerular basement membrane**, leading to microscopic or macroscopic hematuria, proteinuria, and progressive renal failure. - It classically presents with **hematuria in childhood**, often accompanied by hearing loss and ocular abnormalities. *Factor V Leiden mutation* - The **Factor V Leiden mutation** increases the risk for **thrombophilia** and **venous thromboembolism**. - While it can lead to clots in renal veins, causing hematuria, its primary manifestation is not direct hematuria but rather a predisposition to thrombosis that can secondarily cause it. *E. coli O157* - **_E. coli_ O157 infection** can cause **hemolytic uremic syndrome (HUS)**, particularly in children. - HUS is characterized by a **microangiopathic hemolytic anemia**, thrombocytopenia, and acute kidney injury, which often manifests with hematuria due to glomerular damage.

Q: A 2-year-old child with severe dehydration has sudden-onset gross hematuria with a unilateral flank mass. The most likely diagnosis is

Renal vein thrombosis. ***Renal vein thrombosis*** - Severe dehydration in infants can lead to a **hypercoagulable state**, predisposing to **renal vein thrombosis**. - This condition presents with sudden-onset **gross hematuria** and a unilateral **flank mass** due to swelling of the affected kidney. *Hemolytic syndrome* - This term is broad; if referring to **Hemolytic Uremic Syndrome (HUS)**, it typically involves a prodrome of **diarrhea** and presents with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. - While it causes kidney injury and hematuria, it generally presents with systemic symptoms and a different clinical progression than described. *Wilms tumor* - This is a common pediatric renal malignancy presenting as an **abdominal mass**, but hematuria is often microscopic and less sudden in onset. - While it is a differential for a flank mass in a child, the acute presentation with severe dehydration and gross hematuria points away from a primary tumor. *Hydronephrosis* - This is the **swelling of the kidney** due to urine backup, often caused by an obstruction in the urinary tract. - While it can present with a flank mass and sometimes hematuria (especially if there's an associated infection or stone), severe dehydration leading to acute gross hematuria is not its typical presentation.

Q: A 10-year-old child develops hematuria after 2 days of diarrhea. Blood film shows fragmented RBCs & thrombocytopenia. Ultrasound shows marked enlargement of both kidneys. The likely diagnosis is:

Hemolytic uremic syndrome. ***Hemolytic uremic syndrome*** - The combination of preceding **diarrhea** (often *E. coli* O157:H7 related), **hematuria**, **fragmented RBCs** (**microangiopathic hemolytic anemia**), and **thrombocytopenia** is the classic triad of **hemolytic uremic syndrome (HUS)**. - Renal enlargement is also consistent with the acute kidney injury and associated inflammation seen in HUS. *Acute pyelonephritis* - This condition presents with **fever**, **flank pain**, and urinary symptoms like **dysuria** and **frequency**, often without significant hematuria. - It does not typically cause **fragmented RBCs** or **thrombocytopenia**. *Renal vein thrombosis* - While it can cause **hematuria**, renal enlargement, and acute kidney injury, it is not typically preceded by **diarrhea**. - It does not commonly present with **fragmented RBCs** or **thrombocytopenia** as primary features. *Disseminated intravascular coagulopathy* - This involves widespread activation of coagulation, leading to both **clotting** and **bleeding**, often with **thrombocytopenia** and **fragmented RBCs**. - However, it isn't typically triggered by **diarrhea** as a primary cause and usually has a much more severe and systemic presentation, often in critically ill patients.

Q: The renal biopsy of a 6–year–old boy with recurrent gross hematuria shows IgA nephropathy. The urinary protein excretion is 130 mg/day. Which of the following is the most appropriate next step in the management –

Regular monitoring with supportive care. ***Regular monitoring with supportive care*** - The patient presents with **IgA nephropathy**, **recurrent gross hematuria**, and **minimal proteinuria** (130 mg/day, just above normal <100 mg/day) - For children with IgA nephropathy without significant proteinuria (typically <500 mg/day) and preserved renal function, **supportive care with regular monitoring** of blood pressure, urine protein, creatinine, and GFR is the most appropriate management - This represents a **mild course** with excellent prognosis *Give Azathioprine* - **Azathioprine** is an immunosuppressant reserved for severe IgA nephropathy: rapidly progressive glomerulonephritis, crescentic disease, or significant proteinuria with declining renal function - **Not indicated** in mild cases due to potential side effects (bone marrow suppression, infection risk) and lack of evidence for benefit - Would expose the child to unnecessary immunosuppressive risks *Dietary protein restriction* - **Dietary protein restriction** is considered in advanced chronic kidney disease (CKD stages 3-5) to slow progression - **Not appropriate** for a child with mild disease and normal renal function - Can lead to **malnutrition and growth impairment** in children, which is a critical concern in pediatric practice *Start ACE inhibitor therapy* - **ACE inhibitors** (or ARBs) are indicated in IgA nephropathy when there is **significant proteinuria** (>500-1000 mg/day) or **hypertension** - Help reduce proteinuria and provide renoprotection by decreasing intraglomerular pressure - In this case, with **minimal proteinuria of 130 mg/day** and no mention of hypertension, the threshold for ACE inhibitor therapy is **not met**

Q: A 3 week old child presents with an abdominal mass. What is the most common congenital renal cystic abnormality causing this presentation?

Multicystic dysplastic kidney. ***Multicystic dysplastic kidney*** - This is the **most common cause of an abdominal mass detected in the neonatal period** due to its congenital nature. - It results from abnormal renal development in utero, leading to multiple non-communicating cysts and virtually no functioning renal tissue. *Distended bladder* - While a distended bladder can present as an abdominal mass in an infant, especially with **posterior urethral valves**, it is typically symptomatic with difficulty urinating or urinary tract infections. - It is not the most common overall cause of an abdominal mass at this age. *Wilms tumor* - **Wilms tumor**, originating from the kidney, is the **most common renal malignancy in children**, but it typically presents in toddlers (2-5 years of age) rather than at 3 weeks old. - Presentation at 3 weeks would be exceptionally rare, as it is an embryonal tumor that grows over time. *Neuroblastoma* - **Neuroblastoma** is a common extracranial solid tumor in infancy, often originating in the adrenal gland or sympathetic chain. - However, it is generally outranked by multicystic dysplastic kidney as the *most common* cause of an abdominal mass this early in life, and it can present with various systemic symptoms depending on tumor location and metastasis.

Question 1

A 5-year-old boy is brought to the office by his mother with complaints of facial puffiness and “frothy” urine for 4 days. The puffiness first started in his eyes and then spread to the face. His mother does not provide any history of similar symptoms in the past. Past medical history is non-significant. His birth history is uneventful and all his vaccinations are up to date. The vital signs include: blood pressure 100/62 mm Hg, pulse 110/min, temperature 36.7°C (98.0°F), and respiratory rate 16/min. On examination, there is pitting edema of the upper and lower extremities bilaterally.
Urinalysis results are as follows:
pH 6.2
Color light yellow
RBC none
WBC 3–4/HPF
Protein 4+
Cast Fat globules
Glucose absent
Crystal none
Ketone absent
Nitrite absent
24-hour urine protein excretion 4.1 g
A renal biopsy is sent which shows normal glomeruli on light microscopy. Which of the following is the most likely diagnosis?

Accepted Answer

Lipoid nephrosis

Answer

Post-infectious glomerulonephritis

Answer

Focal segmental glomerulosclerosis

Answer

Membranoproliferative glomerulonephritis

Question 2

Treatment of choice used in nocturnal enuresis is:

Accepted Answer

Bed alarms

Answer

Trazodone

Answer

Fluoxetine

Answer

Imipramine

Question 3

A child presents with complaints of bed wetting. What is the first line of treatment?

Accepted Answer

Bed alarm technique

Answer

Motivational therapy

Answer

Oxybutynin

Answer

Desmopressin

Question 4

The most common underlying anomaly in a child with recurrent urinary tract infections is:

Accepted Answer

Vesicoureteric reflux

Answer

Posterior urethral valves

Answer

Neurogenic bladder

Answer

Renal calculi

Question 5

The following are causes of hematuria in childhood except

Accepted Answer

Alpha thalassemia

Answer

Alport syndrome

Answer

Factor V Leiden mutation

Answer

E. coli O157

Question 6

A 2-year-old child with severe dehydration has sudden-onset gross hematuria with a unilateral flank mass. The most likely diagnosis is

Accepted Answer

Renal vein thrombosis

Answer

Hemolytic syndrome

Answer

Wilms tumor

Answer

Hydronephrosis

Question 7

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?

Accepted Answer

Levamisole

Answer

Azathioprine

Answer

Cyclophosphamide

Answer

Mycophenolate

Question 8

A 10-year-old child develops hematuria after 2 days of diarrhea. Blood film shows fragmented RBCs & thrombocytopenia. Ultrasound shows marked enlargement of both kidneys. The likely diagnosis is:

Accepted Answer

Hemolytic uremic syndrome

Answer

Acute pyelonephritis

Answer

Renal vein thrombosis

Answer

Disseminated intravascular coagulopathy

Question 9

The renal biopsy of a 6–year–old boy with recurrent gross hematuria shows IgA nephropathy. The urinary protein excretion is 130 mg/day. Which of the following is the most appropriate next step in the management –

Accepted Answer

Regular monitoring with supportive care

Answer

Give Azathioprine

Answer

Dietary protein restriction

Answer

Start ACE inhibitor therapy

Question 10

A 3 week old child presents with an abdominal mass. What is the most common congenital renal cystic abnormality causing this presentation?

Accepted Answer

Multicystic dysplastic kidney

Answer

Distended bladder

Answer

Wilms tumor

Answer

Neuroblastoma

Nephrology — MCQs

Nephrology — MCQs

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