Nephrology — MCQs
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A 6-year-old child with hematuria and presence of RBC cast in urine with a history of URTI and edema. What is the diagnosis?
A 4-year-old child presents with hematuria following an upper respiratory tract infection. Urinalysis shows red blood cell casts. What is the most likely diagnosis?
A 7-year-old boy presents with generalized edema, frothy urine, and significant proteinuria. On examination, there is no hematuria. What is the most likely diagnosis?
A 6-year-old boy presents with periorbital edema, frothy urine, and persistent proteinuria. What is the most likely diagnosis?
A 4-year-old child presents with decreased urine output for the last 20 hours and petechial spots over the body. There is a history of diarrhea 2 weeks prior. Blood investigations reveal hemoglobin of 7 g/dL, total leukocyte count of 11,800/mm³, and a platelet count of 35,000/mm³. What is the diagnosis?
A 6-year-old child with diurnal and nocturnal enuresis and a history of recurrent urinary tract infections presents for evaluation. What is the next best step in the evaluation?
A 7-year-old girl presents with a history of recurrent urinary tract infections and failure to thrive. On examination, a palpable abdominal mass is noted. An ultrasound reveals hydronephrosis. What is the most likely diagnosis?
A 4-year-old with periorbital edema, frothy urine, and recurrent upper respiratory infections presents with laboratory findings of hypoalbuminemia, hyperlipidemia, and proteinuria. A biopsy shows minimal change disease. What is the most appropriate initial treatment?
A 5-year-old child presents with edema, proteinuria, and hypoalbuminemia. What is the most likely diagnosis?
A 3-year-old child presents with abdominal pain, palpable purpura on the legs, and hematuria. Laboratory results show increased creatinine and proteinuria. What is the most appropriate management for this condition?
Nephrology Indian Medical PG Practice Questions and MCQs
Question 241: A 6-year-old child with hematuria and presence of RBC cast in urine with a history of URTI and edema. What is the diagnosis?
- A. MCD
- B. PSGN (Correct Answer)
- C. MGN
- D. FSGS
Explanation: ***PSGN*** - The classic presentation of a child with **hematuria**, **RBC casts**, **edema**, and a history of a recent **upper respiratory tract infection (URTI)** strongly indicates **Post-Streptococcal Glomerulonephritis (PSGN)**. - PSGN typically occurs 1-3 weeks after a **streptococcal infection**, leading to immune complex deposition in the glomeruli. *MCD* - **Minimal Change Disease (MCD)** presents as **nephrotic syndrome** (heavy proteinuria, edema, hyperlipidemia, hypoalbuminemia) without significant hematuria or RBC casts. - While MCD causes edema, the presence of **hematuria** and **RBC casts** points away from this diagnosis. *FSGS* - **Focal Segmental Glomerulosclerosis (FSGS)** is another cause of **nephrotic syndrome** and can sometimes present with hematuria, but the presence of **RBC casts** and a clear history of a preceding **URTI** points more towards PSGN. - FSGS typically has a more insidious onset and is not directly linked to a recent infectious event in this manner. *MGN* - **Membranous Glomerulonephritis (MGN)** is commonly associated with **nephrotic syndrome** in adults, and can present with hematuria, but **RBC casts** are less common. - MGN is rare in children and does not typically follow an acute URTI with this constellation of symptoms.
Question 242: A 4-year-old child presents with hematuria following an upper respiratory tract infection. Urinalysis shows red blood cell casts. What is the most likely diagnosis?
- A. Urinary Tract Infection
- B. Nephrotic Syndrome
- C. Post-Streptococcal Glomerulonephritis (Correct Answer)
- D. IgA Nephropathy
Explanation: ***Post-Streptococcal Glomerulonephritis*** - This condition is characterized by **hematuria** and **red blood cell casts** that typically appear 1-2 weeks after an **upper respiratory tract infection**, common in children. - The presence of **red blood cell casts** specifically indicates **glomerular inflammation**, distinguishing it from other causes of hematuria. *Urinary Tract Infection* - While UTIs can cause **hematuria**, they are typically associated with **dysuria**, **frequency**, and **pyuria**, and do not usually present with **red blood cell casts**. - Urinalysis in UTIs often shows **leukocyte esterase** and **nitrites**, with bacteria, rather than casts. *Nephrotic Syndrome* - This syndrome is defined by **massive proteinuria**, **hypoalbuminemia**, **edema**, and **hyperlipidemia**, not primarily hematuria. - While some forms of nephrotic syndrome can have microscopic hematuria, **red blood cell casts** are not a defining feature, and the primary presentation is not typically post-infection hematuria. *IgA Nephropathy* - **IgA nephropathy** also presents with **hematuria** following an upper respiratory infection, but it typically occurs **concurrently with or within 1-2 days** of the infection, not 1-2 weeks later. - Although it can present with **red blood cell casts**, the timing relative to the infection is a key differentiating factor.
Question 243: A 7-year-old boy presents with generalized edema, frothy urine, and significant proteinuria. On examination, there is no hematuria. What is the most likely diagnosis?
- A. Acute Glomerulonephritis
- B. Nephrotic Syndrome (Correct Answer)
- C. Henoch-Schönlein Purpura
- D. Urinary Tract Infection
Explanation: ***Nephrotic Syndrome*** - The classic presentation of generalized **edema**, severe **proteinuria** (>40 mg/m²/hr or urine protein:creatinine ratio >2), and **frothy urine** (due to proteinuria) is characteristic of nephrotic syndrome. - In children, minimal change disease is the most common cause of nephrotic syndrome, presenting with **hypoalbuminemia**, **hyperlipidemia**, and edema. - The **absence of hematuria** helps distinguish this from nephritic syndrome. *Acute Glomerulonephritis* - Typically presents with **hematuria** (cola-colored urine), periorbital edema, **hypertension**, and oliguria, often following a streptococcal infection. - While edema and proteinuria can occur, the **absence of gross hematuria** and **absence of hypertension** in this case, along with the severity of proteinuria and generalized edema, point away from acute glomerulonephritis. *Henoch-Schönlein Purpura* - Characterized by palpable **purpura** (typically on lower extremities and buttocks), **arthralgia**, abdominal pain, and sometimes renal involvement with IgA nephropathy. - The presenting symptoms do not include purpura or joint pain, making this diagnosis less likely. *Urinary Tract Infection* - Typically presents with dysuria, frequency, urgency, and fever, sometimes with flank pain. - The symptoms of generalized edema, significant proteinuria, and frothy urine are not typical for a UTI.
Question 244: A 6-year-old boy presents with periorbital edema, frothy urine, and persistent proteinuria. What is the most likely diagnosis?
- A. Nephrotic syndrome (Correct Answer)
- B. Glomerulonephritis
- C. Diabetes mellitus
- D. Urinary tract infection
Explanation: ***Nephrotic syndrome*** - **Periorbital edema** is a classic early sign of nephrotic syndrome due to hypoalbuminemia and fluid retention. - **Frothy urine** indicates significant proteinuria (lipiduria creating foam). - **Persistent proteinuria** is the hallmark of nephrotic syndrome, with protein loss >40 mg/m²/hour or urine protein:creatinine ratio >2. - In children 2-10 years old, **minimal change disease** is the most common cause (80-90% of cases). *Glomerulonephritis* - While it causes proteinuria, it typically presents with **hematuria** (tea-colored urine), **hypertension**, and **oliguria**. - The nephritic syndrome pattern shows active urinary sediment with RBC casts, which differs from the nephrotic picture. - Edema in glomerulonephritis is due to salt and water retention, not primarily hypoalbuminemia. *Diabetes mellitus* - Can cause polyuria and polydipsia, but the key findings would be **hyperglycemia** and **glycosuria**, not isolated proteinuria. - **Diabetic nephropathy** develops after years of poor glucose control and would not be the initial presentation in a 6-year-old. - Type 1 diabetes in children typically presents with weight loss, not edema. *Urinary tract infection* - Presents acutely with **dysuria**, **frequency**, **urgency**, and possibly fever. - Urinalysis shows **pyuria** (WBCs), **bacteriuria**, and **positive nitrites**, not primarily proteinuria. - While UTI can cause mild transient proteinuria, it does not cause persistent heavy proteinuria or edema.
Question 245: A 4-year-old child presents with decreased urine output for the last 20 hours and petechial spots over the body. There is a history of diarrhea 2 weeks prior. Blood investigations reveal hemoglobin of 7 g/dL, total leukocyte count of 11,800/mm³, and a platelet count of 35,000/mm³. What is the diagnosis?
- A. Hemolytic uremic syndrome (Correct Answer)
- B. Severe malaria
- C. Immune thrombocytopenic purpura
- D. Acute kidney injury due to nephrotoxic agents
Explanation: ***Hemolytic uremic syndrome*** - The triad of **microangiopathic hemolytic anemia** (hemoglobin 7 g/dL), **thrombocytopenia** (platelet count 35,000/mm³), and **acute kidney injury** (decreased urine output) following a diarrheal illness is characteristic of HUS. - **Petechial spots** are due to thrombocytopenia, and the prior **diarrhea** often caused by Shiga toxin-producing E. coli is a common precursor. *Severe malaria* - While severe malaria can cause anemia and thrombocytopenia, it is typically associated with **fever**, **splenomegaly**, and parasitic findings on blood smear, which are not mentioned. - **Acute kidney injury** can occur in severe malaria, but the specific triad of microangiopathic anemia, thrombocytopenia, and AKI following diarrhea is more indicative of HUS. *Immune thrombocytopenic purpura* - ITP primarily causes isolated **thrombocytopenia** and petechiae, often without significant anemia or kidney involvement unless secondary complications arise. - It typically does not involve preceding **diarrhea** or the development of **acute kidney injury** as a defining feature. *Acute kidney injury due to nephrotoxic agents* - This diagnosis would primarily present with **decreased urine output** and elevated renal markers, but it would not explain the severe **anemia** and **thrombocytopenia** or the preceding diarrheal illness. - There is no mention of exposure to specific **nephrotoxic agents** in the patient's history.
Question 246: A 6-year-old child with diurnal and nocturnal enuresis and a history of recurrent urinary tract infections presents for evaluation. What is the next best step in the evaluation?
- A. Renal ultrasound
- B. Urodynamic studies
- C. Voiding cystourethrogram (Correct Answer)
- D. Start behavioral therapy
Explanation: ***Voiding cystourethrogram*** - A **voiding cystourethrogram (VCUG)** is the most appropriate next step given the history of **recurrent UTIs** combined with **both diurnal and nocturnal enuresis**, which strongly suggests **vesicoureteral reflux (VUR)** or significant voiding dysfunction. - The presence of **diurnal enuresis** (abnormal at age 6) along with recurrent UTIs is a **red flag** that warrants definitive evaluation for VUR and anatomical abnormalities. - VUR is a common cause of recurrent UTIs and can lead to **renal scarring** and chronic kidney disease if not identified and managed promptly. *Renal ultrasound* - While a **renal ultrasound** is typically the **first-line imaging** for initial UTI evaluation and is useful for assessing kidney size, detecting **hydronephrosis**, and identifying **structural anomalies**, it **cannot diagnose VUR**. - In this case, given the **severity of presentation** (both types of enuresis + recurrent UTIs), a more definitive study like VCUG is warranted, though ultrasound may be done concurrently. - Ultrasound alone would miss VUR, which is the most likely diagnosis here. *Urodynamic studies* - **Urodynamic studies** are reserved for **complex voiding dysfunction** that persists despite initial evaluation and standard therapies, or when neurogenic bladder is suspected. - They provide detailed information about bladder and sphincter function but are **not first-line** for recurrent UTIs in children. - VCUG should be performed first to rule out anatomical causes before proceeding to functional studies. *Start behavioral therapy* - **Behavioral therapy** is important for managing enuresis, but it should **never be initiated** before ruling out underlying **organic causes** like VUR, especially with a history of recurrent UTIs. - Treating empirically without investigation could lead to **missed diagnosis** of VUR and subsequent **renal damage**. - Addressing potential anatomical abnormalities is crucial before attributing symptoms to behavioral causes alone.
Question 247: A 7-year-old girl presents with a history of recurrent urinary tract infections and failure to thrive. On examination, a palpable abdominal mass is noted. An ultrasound reveals hydronephrosis. What is the most likely diagnosis?
- A. Vesicoureteral reflux (VUR)
- B. Bladder dysfunction due to neurological causes
- C. Inherited renal cystic disease
- D. Congenital urinary obstruction (Correct Answer)
Explanation: ***Congenital urinary obstruction*** - **Recurrent UTIs**, **failure to thrive**, **palpable abdominal mass**, and **hydronephrosis** in a 7-year-old girl are highly suggestive of congenital urinary obstruction [1]. - This combination of symptoms points to a chronic issue hindering normal renal function and growth, with a potential buildup of urine explaining the palpable mass and hydronephrosis [1]. *Vesicoureteral reflux (VUR)* - While VUR can cause **recurrent UTIs** and **hydronephrosis**, it typically does not present with a **palpable abdominal mass** unless there is severe, bilateral hydronephrosis or an underlying obstruction exacerbating it [1]. - VUR is a condition where urine flows backward from the bladder to the kidneys, often associated with kidney scarring rather than a distinct abdominal mass from chronic obstruction [2]. *Bladder dysfunction due to neurological causes* - Neurological bladder dysfunction can lead to **recurrent UTIs** and sometimes hydronephrosis due to incomplete bladder emptying [1]. - However, it's less likely to cause a **palpable abdominal mass** directly from urinary obstruction, and **failure to thrive** would be a secondary, rather than primary, presentation. *Inherited renal cystic disease* - Inherited renal cystic diseases can cause **enlarged kidneys** (potentially palpable) and sometimes lead to **renal failure** and failure to thrive. - However, **recurrent UTIs** and **hydronephrosis** are not the primary features of most renal cystic diseases, which are more commonly associated with cyst development and progressive renal impairment [1].
Question 248: A 4-year-old with periorbital edema, frothy urine, and recurrent upper respiratory infections presents with laboratory findings of hypoalbuminemia, hyperlipidemia, and proteinuria. A biopsy shows minimal change disease. What is the most appropriate initial treatment?
- A. ACE inhibitors
- B. Diuretics
- C. Corticosteroids (Correct Answer)
- D. Immunosuppressants
Explanation: ***Corticosteroids*** - **Corticosteroids** are the first-line and most effective treatment for **minimal change disease (MCD)** in children, inducing remission in over 90% of cases. - The disease is highly responsive to steroids due to their potent **anti-inflammatory** and **immunosuppressive** effects, which stabilize the glomerular basement membrane. *ACE inhibitors* - **ACE inhibitors** primarily reduce **proteinuria** by decreasing intraglomerular pressure, but they do not address the underlying immunological mechanism of MCD. - While they might be used as an adjunct to manage persistent proteinuria or hypertension, they are not the initial treatment for inducing remission in MCD. *Diuretics* - **Diuretics** are used to manage **edema** in nephrotic syndrome but do not treat the underlying disease process or induce remission. - While they can relieve symptoms like periorbital edema, they are supportive therapy and not the primary treatment to stop protein loss. *Immunosuppressants* - Other **immunosuppressants** (e.g., cyclophosphamide, cyclosporine) are typically reserved for patients with **steroid-resistant** or **steroid-dependent MCD**, or those with frequent relapses. - They are considered second-line agents after failure or intolerance to corticosteroids, not initial therapy.
Question 249: A 5-year-old child presents with edema, proteinuria, and hypoalbuminemia. What is the most likely diagnosis?
- A. Nephrotic syndrome (Correct Answer)
- B. Acute glomerulonephritis
- C. Henoch-Schönlein purpura
- D. Urinary tract infection
Explanation: ***Nephrotic syndrome (Correct Answer)*** - This syndrome is characterized by the triad of **edema**, **proteinuria** (>3.5g/24h in adults or >40mg/m²/hr in children), and **hypoalbuminemia** (serum albumin <3.0 g/dL), which perfectly matches the child's presentation. - The underlying pathophysiology involves glomerular damage leading to increased permeability to proteins, resulting in their excessive loss in urine and subsequent reduced oncotic pressure. - In children, **Minimal Change Disease** is the most common cause of nephrotic syndrome, typically presenting between ages 2-6 years. *Acute glomerulonephritis (Incorrect)* - This condition typically presents with **hematuria** (often macroscopic), hypertension, and renal impairment (elevated creatinine), along with edema. - While proteinuria can occur, it is usually less severe than in nephrotic syndrome, and marked hypoalbuminemia is less common. - The clinical picture emphasizes the "nephritic" features rather than the massive proteinuria seen in this case. *Henoch-Schönlein purpura (Incorrect)* - This is a systemic vasculitis characterized by a classic tetrad of **palpable purpura** (often on the lower extremities and buttocks), **arthritis/arthralgia**, **abdominal pain**, and sometimes renal involvement. - While renal involvement can cause hematuria and proteinuria, the predominant features for diagnosis involve skin lesions and gastrointestinal/joint symptoms, which are not mentioned in this case. - The absence of characteristic purpuric rash makes this diagnosis unlikely. *Urinary tract infection (Incorrect)* - A UTI typically presents with symptoms such as **dysuria**, frequency, urgency, and fever, often with positive urine cultures and pyuria. - While severe pyelonephritis can rarely cause transient proteinuria, it does not typically lead to the profound proteinuria, hypoalbuminemia, and generalized edema characteristic of nephrotic syndrome. - UTIs do not cause the nephrotic triad presented in this case.
Question 250: A 3-year-old child presents with abdominal pain, palpable purpura on the legs, and hematuria. Laboratory results show increased creatinine and proteinuria. What is the most appropriate management for this condition?
- A. Immunosuppressants + biopsy
- B. Plasmapheresis
- C. Supportive care + hydration
- D. High-dose corticosteroids (Correct Answer)
Explanation: ***High-dose corticosteroids*** - The constellation of **palpable purpura**, abdominal pain, and hematuria with **significant kidney involvement** (increased creatinine, proteinuria) is classic for **Henoch-Schönlein Purpura (HSP)** with nephritis. - In HSP with **significant renal involvement** (elevated creatinine indicating renal insufficiency), **corticosteroids** are indicated to reduce inflammation, treat severe symptoms, and potentially prevent progression of renal disease. - While evidence is evolving, corticosteroids remain standard treatment for **moderate-to-severe HSP nephritis** in pediatric practice. *Supportive care + hydration* - **Supportive care** (pain management, hydration, monitoring) is the mainstay for **uncomplicated HSP** or mild cases without significant renal impairment. - However, in this case with **elevated creatinine** (indicating renal insufficiency beyond simple hematuria/proteinuria), supportive care alone is insufficient and risks progression of renal damage. - Supportive care should be provided **in addition to** corticosteroids, not as sole therapy in significant renal involvement. *Immunosuppressants + biopsy* - **Renal biopsy** and additional immunosuppressants (cyclophosphamide, azathioprine, mycophenolate) are reserved for **severe or rapidly progressive** HSP nephritis not responding to corticosteroids. - Initial management of HSP nephritis typically begins with **corticosteroids** before escalating to more aggressive immunosuppression. - Biopsy may be considered if diagnosis is unclear or if considering escalation of therapy. *Plasmapheresis* - **Plasmapheresis** is reserved for severe, rapidly progressive glomerulonephritis or severe ANCA-associated vasculitis. - It is **not standard treatment** for HSP nephritis and would not be first-line before trying corticosteroids.
Practice by Chapter
Urinary Tract Infections
Practice Questions
Vesicoureteral Reflux
Practice Questions
Glomerulonephritis
Practice Questions
Nephrotic Syndrome
Practice Questions
Acute Kidney Injury
Practice Questions
Chronic Kidney Disease
Practice Questions
Renal Tubular Disorders
Practice Questions
Congenital Anomalies of the Kidney
Practice Questions
Hydronephrosis
Practice Questions
Hypertension in Children
Practice Questions
Hemolytic Uremic Syndrome
Practice Questions
Renal Replacement Therapy in Children
Practice Questions
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