Nephrology Practice Questions

Q: A 4-year-old male child presents with fever, anemia and azotemia after an episode of dysentery 9 days earlier. The commonest organism responsible for this condition is?

E. coli. ***E. coli*** - **Enterohemorrhagic E. coli** (EHEC), particularly O157:H7, is the most common cause of **hemolytic uremic syndrome (HUS)**, which presents with the triad of **fever, anemia (hemolytic)**, and **azotemia (acute kidney injury)** following bloody diarrhea (dysentery). - The incubation period of about 7-10 days between the diarrheal episode and the onset of HUS symptoms is consistent with the timeline described. *Meningococcus* - **Neisseria meningitidis** typically causes **meningitis** and **meningococcemia**, characterized by fever, headache, neck stiffness, and a petechial rash. - It is not associated with dysentery or the subsequent development of hemolytic uremic syndrome. *E. histolytica* - **Entamoeba histolytica** causes **amebic dysentery** and can lead to complications such as **liver abscesses**. - While it causes dysentery, it does not typically lead to the systemic complications of hemolytic anemia and azotemia characteristic of HUS. *Staphylococcus* - **Staphylococcus aureus** can cause a wide range of infections, including **skin infections**, **food poisoning**, and **sepsis**, but it is primarily a gram-positive coccus. - It is not a common cause of dysentery leading to HUS; EHEC, a gram-negative rod, is the usual culprit in this clinical scenario.

Q: In Potter syndrome - primary pathology is:

Renal agenesis. ***Renal agenesis*** - **Potter syndrome** is characterized by the absence of kidney development, known as **renal agenesis**, which is the primary underlying pathological event. - This congenital anomaly leads to a cascade of secondary problems due to the kidneys' role in producing amniotic fluid. *Oligohydramnios* - **Oligohydramnios** (low amniotic fluid) is a **consequence** of renal agenesis, not the primary pathology itself. - The fetal kidneys normally produce most of the amniotic fluid after the first trimester, so their absence leads to insufficient fluid. *Dysmorphism* - **Dysmorphic facial features** (such as flattened nose, recessed chin, epicanthic folds) are part of the **Potter sequence**, which refers to a set of features resulting from oligohydramnios. - These features are **secondary effects** caused by the compression of the fetus in the uterus due to reduced amniotic fluid, rather than the primary defect. *Limb defects* - **Limb defects**, such as club feet or contractures, are also **secondary manifestations** of the Potter sequence. - They arise from the **compression** of the fetus in the cramped uterine environment due to severe oligohydramnios, restricting fetal movement and development.

Q: Acute urinary retention in a male child may be due to:

Meatal ulcer with scabbing. ***Meatal ulcer with scabbing*** - A **meatal ulcer** in a male child, often caused by ammonia dermatitis or balanitis, can lead to **scabbing** that physically obstructs the urethral meatus. - This physical obstruction prevents the outflow of urine, causing acute urinary retention. - This is one of the **most common causes** of acute urinary retention in male children. *Psychogenic urinary retention* - **Psychogenic urinary retention** (previously termed 'hysterical retention') is rare in male children and is a diagnosis of exclusion. - While psychological factors can influence micturition, a physical obstruction is a more common and direct cause in children with acute retention. - Requires psychiatric evaluation and management. *Prostatic radiotherapy* - **Prostatic radiotherapy** is a treatment for **prostatic cancer**, a condition that primarily affects older adult males. - Prostate cancer and its treatments are virtually nonexistent in male children, making this an irrelevant option. *Urethral stricture* - While a **urethral stricture** can cause urinary retention, particularly in adult males, it is a less common cause of **acute urinary retention** in male children compared to meatal obstruction. - Congenital strictures are possible, but an acute presentation due to meatal scabbing is a more typical scenario in the pediatric population.

Q: A child presented with cola-colored urine, proteinuria (2+), and history of rash 2 weeks ago. The most probable diagnosis is

HSP. ***HSP*** - **Henoch-Schönlein Purpura (HSP)** often presents with a characteristic **rash**, abdominal pain, and arthritis, followed by renal involvement manifested as **cola-colored urine** and **proteinuria**. - The rash (palpable purpura) appearing two weeks prior to the renal symptoms is a classic timeline for **HSP nephritis**. *HUS* - **Hemolytic Uremic Syndrome (HUS)** is characterized by a triad of **hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury**, often preceded by a diarrheal illness (e.g., E. coli O157:H7 infection). - While it causes acute kidney injury, the primary presentation in the question (rash followed by cola-colored urine) is not typical for HUS. *IgA nephropathy* - **IgA nephropathy** often presents with **recurrent macroscopic hematuria** (cola-colored urine) usually occurring concurrently with or shortly after an upper respiratory or gastrointestinal infection. - However, the history of a preceding generalized rash two weeks ago is not a classic feature of IgA nephropathy. *Wegener Granulomatosis* - **Wegener Granulomatosis** (now known as **Granulomatosis with Polyangiitis**) is a systemic vasculitis affecting small to medium-sized vessels, typically involving the **upper and lower respiratory tracts** and **kidneys**. - Its presentation usually includes symptoms like chronic sinusitis, pulmonary infiltrates, and rapidly progressive glomerulonephritis, without the characteristic preceding rash described.

Q: A three-year-old boy presents with a poor urinary stream. Most likely cause is -

Posterior urethral valve. ***Posterior urethral valve*** - **Posterior urethral valve (PUV)** is the most common cause of **urethral obstruction** in male neonates and infants, leading to a poor urinary stream. - The obstruction is caused by abnormal folds of tissue in the **posterior urethra**, which impede urine flow from the bladder. *Stricture urethra* - While urethral strictures can cause a poor urinary stream, they are more commonly acquired through **trauma, infection, or instrumentation** and are less common in a 3-year-old boy as an initial presentation. - **Congenital urethral strictures** are rare and typically found more distally than PUV. *Neurogenic bladder* - **Neurogenic bladder** results from impaired neurological control over bladder function, leading to issues like poor stream, incontinence, or retention. - Although it can cause a poor stream, it is usually associated with other neurological signs or a history of **spinal cord anomalies** (e.g., myelomeningocele), which are not mentioned. *Urethral calculus* - **Urethral calculi** (stones) can obstruct urine flow and cause a poor stream, but they are relatively rare in a 3-year-old child without predisposing factors like metabolic abnormalities or recurrent urinary tract infections. - The presentation would typically include sudden onset of pain, hematuria, and potentially a history of prior stones.

Q: A 3-year-old boy presents with fever, dysuria and gross hematuria. Physical examination shows a prominent suprapubic area which is dull on percussion. Urinalysis reveals red blood cells but no proteinuria. Which of the following is the most likely diagnosis -

Posterior urethral valves. ***Posterior urethral valves*** - The combination of **fever**, **dysuria**, **gross hematuria**, and a **prominent, dull suprapubic area** (suggesting a distended bladder) in a young male child points to an obstructive uropathy. - **Posterior urethral valves** are the most common cause of lower urinary tract obstruction in male infants and young children, leading to bladder outlet obstruction, urinary retention, and potential hydronephrosis. *Acute glomerulonephritis* - While it can cause hematuria, it typically presents with **proteinuria**, **edema**, and **hypertension**, which are not present in this case. - The prominent, dull suprapubic area is not a characteristic finding for acute glomerulonephritis. *Urinary tract infection* - A **UTI** can cause fever and dysuria, but significant **gross hematuria** and a **prominent suprapubic area** (indicating bladder distention) are less typical initial presentations. - While possible, the strong evidence of obstruction makes another diagnosis more likely. *Teratoma* - A **teratoma** is a tumor, which might present with a mass, but the constellation of acute symptoms including fever, dysuria, and a distended bladder points away from a primary diagnosis of teratoma. - Teratomas in the urinary tract are rare and usually present with non-specific symptoms or a palpable mass rather than acute obstructive signs.

Q: A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?

3D MCU. ***3D MCU (Micturating Cystourethrogram)*** - **Gold standard** for diagnosing **vesicoureteral reflux (VUR)**, the most common cause of recurrent UTIs in children - In a child with **2-year history of recurrent UTIs** (fever + frequent micturition), VUR is the primary concern that needs to be ruled out - MCU provides **dynamic imaging** during bladder filling and voiding, allowing direct visualization of **reflux** and assessment of **bladder and urethral anatomy** - **Standard of care** recommended by IAP (Indian Academy of Pediatrics) and major pediatric nephrology guidelines - Though it involves ionizing radiation, the **diagnostic benefit far outweighs risks** in this clinical scenario - Cost-effective and widely available in Indian healthcare settings *MR Urogram* - Provides excellent anatomical detail of the **upper urinary tract** (kidneys, ureters) without radiation - However, it is **NOT the first-line investigation** for recurrent UTI workup in children - Does not adequately assess **dynamic VUR** like MCU does - More expensive, requires sedation in many children, and less accessible - Reserved for specific indications like suspected anatomical anomalies after initial screening *3D CT Urogram* - Excellent for detailed anatomical evaluation but involves **high radiation dose** - Not appropriate as first-line investigation in a **chronic, non-acute pediatric case** - Reserved for complex cases where MR is contraindicated or for acute complications *IVP (Intravenous Pyelogram)* - **Obsolete modality** that has been replaced by ultrasound, MCU, and modern cross-sectional imaging - Provides limited functional and anatomical information - Higher radiation exposure with inferior image quality compared to modern techniques - Not used in current pediatric practice

Q: 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?

Glomerulonephritis. ***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 1

A 4-year-old male child presents with fever, anemia and azotemia after an episode of dysentery 9 days earlier. The commonest organism responsible for this condition is?

Accepted Answer

E. coli

Answer

Meningococcus

Answer

E. histolytica

Answer

Staphylococcus

Question 2

In Potter syndrome - primary pathology is:

Accepted Answer

Renal agenesis

Answer

Oligohydramnios

Answer

Dysmorphism

Answer

Limb defects

Question 3

An otherwise asymptomatic child was found to have hypertension. On further evaluation, his urine analysis revealed 2-3 pus cells/HPF and 2-4 RBCs. Which of the following would be the most likely diagnosis?

Accepted Answer

Chronic Reflux-Associated Pyelonephritis (Reflux Nephropathy)

Answer

Idiopathic RPGN

Answer

Post-Streptococal GN

Answer

IgA nephropathy

Question 4

Acute urinary retention in a male child may be due to:

Accepted Answer

Meatal ulcer with scabbing

Answer

Psychogenic urinary retention

Answer

Prostatic radiotherapy

Answer

Urethral stricture

Question 5

A child presented with cola-colored urine, proteinuria (2+), and history of rash 2 weeks ago. The most probable diagnosis is

Accepted Answer

HSP

Answer

HUS

Answer

IgA nephropathy

Answer

Wegener Granulomatosis

Question 6

A three-year-old boy presents with a poor urinary stream. Most likely cause is -

Accepted Answer

Posterior urethral valve

Answer

Stricture urethra

Answer

Neurogenic bladder

Answer

Urethral calculus

Question 7

A 3-year-old boy presents with fever, dysuria and gross hematuria. Physical examination shows a prominent suprapubic area which is dull on percussion. Urinalysis reveals red blood cells but no proteinuria. Which of the following is the most likely diagnosis -

Accepted Answer

Posterior urethral valves

Answer

Acute glomerulonephritis

Answer

Urinary tract infection

Answer

Teratoma

Question 8

A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?

Accepted Answer

3D MCU

Answer

MR UROGRAM

Answer

3D CT UROGRAM

Answer

IVP

Question 9

A 5-year old child of severe nephrotic syndrome on treatment with tacrolimus, frusemide and prednisolone developed seizures. The investigations revealed:
Serum Na+ = 136 mEq/L
Blood urea = 78 mg/dL
Serum creatinine = 0.5 mg/dL
Serum albumin = 1.5 g/dL
Serum total Ca = 7.5 mg/dL
Urine albumin = 2g
What is the likely cause of symptoms in this child?

Accepted Answer

Hypocalcemia

Answer

Tacrolimus toxicity

Answer

Uremia

Answer

Hyponatremia

Question 10

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?

Accepted Answer

Glomerulonephritis

Answer

Renal artery stenosis

Answer

Essential hypertension

Answer

Coarctation of Aorta

Nephrology — MCQs

Nephrology — MCQs

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