Renal Replacement Therapy in Children — MCQs

10 questions

What is the investigation of choice for blunt abdominal trauma in an unstable patient?

Most common acute complication of dialysis is

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?

In the oliguric phase of renal failure, which of the following statements is false?

Most common cause of persistent hypertension in a child with intrinsic renal disease is -

In a child, non-functioning kidney is best diagnosed by:

In SCHWARTZ formula for calculation of creatinine clearance in a child, the constant depends on the following except –

A 7-year-old girl is brought with complaints of generalized swelling of the body. Urinary examination reveals Grade 3 proteinuria and the presence of hyaline and fatty casts. She has no history of Hematuria. Which of the following statements about her condition is true:

A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

Q10

Commonest cause of sustained severe hypertension in children

Renal Replacement Therapy in Children Indian Medical PG Practice Questions and MCQs

Question 1: What is the investigation of choice for blunt abdominal trauma in an unstable patient?

A. X-ray abdomen
B. MRI
C. USG (Correct Answer)
D. Diagnostic Peritoneal Lavage (DPL)

Explanation: ***USG (FAST Exam)*** - In an **unstable patient** with blunt abdominal trauma, **Focused Assessment with Sonography for Trauma (FAST) exam** is the investigation of choice. - It is **rapid, non-invasive, and bedside**, allowing immediate detection of **free fluid** (blood) in the peritoneal cavity, pericardium, and pleural spaces without transporting the patient. - Guides immediate decision for **laparotomy** in hemodynamically unstable patients. - **Note:** In **stable patients**, **CT abdomen** is the gold standard as it provides detailed anatomical information, but it requires patient transport and time. *X-ray abdomen* - Provides limited information in blunt trauma, primarily showing **free air** (bowel perforation) or **bony fractures**. - **Not sensitive** for detecting intraperitoneal bleeding, which is the primary concern in unstable patients. *MRI* - Offers excellent soft tissue detail but is **time-consuming** and requires the patient to be **hemodynamically stable**. - **Impractical** for unstable trauma patients requiring rapid assessment and intervention. *Diagnostic Peritoneal Lavage (DPL)* - An **invasive procedure** that is sensitive for detecting intra-abdominal hemorrhage. - Has largely been **replaced by FAST exam** in most trauma centers due to FAST being non-invasive, rapid, and repeatable. - DPL has a **higher false-positive rate** and cannot identify the source of bleeding.

Question 2: Most common acute complication of dialysis is

A. Hypotension (Correct Answer)
B. Bleeding
C. Dementia
D. Muscle cramps

Explanation: ***Hypotension*** - **Intradialytic hypotension** is the most common acute complication, occurring in 15-30% of dialysis sessions. - It is often caused by rapid removal of fluid (ultrafiltration), leading to a significant drop in blood pressure [1]. *Bleeding* - While bleeding can occur due to **anticoagulation** used during dialysis or as a complication of vascular access, it is less common than hypotension. - It is not considered the most frequent acute complication of the dialysis procedure itself. *Dementia* - **Dementia** is a chronic neurological condition that is not an acute complication directly attributable to a single dialysis session. - It can be a long-term comorbidity in patients with end-stage renal disease (ESRD), but not an immediate side effect. *Muscle cramps* - **Muscle cramps** are a relatively common acute complication during or immediately after dialysis, affecting about 5-20% of patients. - However, their frequency is generally lower than that of intradialytic hypotension [1].

Question 3: 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?

A. 3D MCU (Correct Answer)
B. MR UROGRAM
C. 3D CT UROGRAM
D. IVP

Explanation: ***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

Question 4: In the oliguric phase of renal failure, which of the following statements is false?

A. Anaemia
B. Hyperkalemia
C. Hyponatremia
D. Hypercalcemia (Correct Answer)

Explanation: ### Hypercalcemia - In the oliguric phase of renal failure, **hypercalcemia** is typically *not* seen; rather, **hypocalcemia** is common due to impaired vitamin D activation and phosphate retention [1]. - The kidneys are crucial for activating vitamin D, which helps regulate **calcium absorption**. With renal failure, this activation is impaired [1]. *Hyponatremia* - **Hyponatremia** is common in the oliguric phase due to fluid overload and the kidneys' inability to excrete excess water, diluting serum sodium concentrations. - Patients accumulate fluid, leading to **dilutional hyponatremia**. *Anaemia* - **Anemia** is a frequent complication of renal failure, primarily due to decreased production of **erythropoietin** by the damaged kidneys [1]. - Reduced erythropoietin production impairs red blood cell formation in the bone marrow [1]. *Hyperkalemia* - **Hyperkalemia** is a significant concern in the oliguric phase because the kidneys are unable to adequately excrete potassium [1]. - Potassium accumulation can lead to life-threatening **cardiac arrhythmias**.

Question 5: Most common cause of persistent hypertension in a child with intrinsic renal disease is -

A. CGN (Correct Answer)
B. Obstructive uropathy
C. Renal tumor
D. Chronic Pyelonephritis

Explanation: ***CGN*** - **Chronic glomerulonephritis (CGN)** is a leading cause of persistent hypertension in children with intrinsic renal disease due to widespread glomerular damage leading to **renin-angiotensin-aldosterone system** activation and fluid retention. - The damaged kidneys are unable to filter waste and regulate blood pressure effectively, contributing to sustained hypertension. *Chronic Pyelonephritis* - While chronic pyelonephritis can cause hypertension, it is typically due to **scarring and inflammation** affecting renal function. - However, it is not as common a cause of persistent hypertension as CGN in children with intrinsic renal disease. *Obstructive uropathy* - **Obstructive uropathy** is classified as a **post-renal (obstructive) disorder** rather than intrinsic renal disease, though it can lead to secondary renal parenchymal damage. - It can cause hypertension through renal parenchymal damage and **renin release** due to increased pressure, but it is not a primary intrinsic renal disease. *Renal tumor* - **Renal tumors**, such as Wilms' tumor, can cause hypertension through **compression of renal arteries** or increased renin production. - While a significant cause of hypertension, it is generally less common than CGN as a cause of persistent hypertension in children with *intrinsic renal disease* overall.

Question 6: In a child, non-functioning kidney is best diagnosed by:

A. Ultrasonography
B. IVU
C. Creatinine clearance
D. DTPA renogram (Correct Answer)

Explanation: ***DTPA renogram*** - A **DTPA (diethylenetriamine pentaacetic acid) renogram** is a nuclear medicine study that assesses **renal blood flow**, **glomerular filtration**, and urinary drainage. It directly measures the function of each kidney by quantifying tracer uptake and excretion, making it ideal for diagnosing a non-functioning kidney in a child. - The test provides information on the **relative function** of each kidney and outflow obstruction, which is crucial for determining if a kidney is truly non-functioning rather than just poorly visualized. *Ultrasonography* - While ultrasound can visualize the **anatomy** of the kidney (size, shape, presence of hydronephrosis), it does not directly assess renal function. - It may show a small, atrophic, or poorly developed kidney, but cannot definitively determine if it is non-functioning without functional studies. *IVU (Intravenous Urogram)* - An **IVU** relies on the kidneys' ability to excrete contrast material, which is visualized by X-ray. If a kidney is non-functioning, it will not excrete the contrast, leading to non-visualization. - However, IVU exposes the child to **radiation** and **iodinated contrast**, and newer, safer, and more precise functional studies like renograms are preferred, especially in pediatric cases where radiation exposure should be minimized. *Creatinine clearance* - **Creatinine clearance** is a measure of overall **glomerular filtration rate (GFR)** for both kidneys combined. - It does not provide information on the individual function of each kidney, so it cannot diagnose a non-functioning unilateral kidney.

Question 7: In SCHWARTZ formula for calculation of creatinine clearance in a child, the constant depends on the following except –

A. Age
B. Mass
C. Severity of renal failure (Correct Answer)
D. Method of estimation of creatinine

Explanation: ***Severity of renal failure*** - The constant in the **Schwartz formula** primarily accounts for factors like muscle mass and maturation, not the severity of renal failure itself. - The formula is designed to estimate glomerular filtration rate (GFR) over a range of renal function, with the creatinine value reflecting the severity, not the constant. *Age* - The original Schwartz formula uses an age-dependent constant, with different values for infants, children, and adolescents, reflecting changes in **muscle mass** and **creatinine generation** with age. - Specifically, constants like 0.33, 0.45, 0.55, and 0.65 are used depending on the patient's age group. *Mass* - The constant implicitly accounts for differences in **muscle mass** and body composition, which are related to age and sex, influencing creatinine production. - The formula itself includes **height** in cm as a direct variable, which is a proxy for lean body mass. *Method of estimation of creatinine* - The constant is adjusted based on the method used to measure **serum creatinine**, specifically whether it's an **enzymatic** method or a **Jaffe reaction-based** method. - Different constants are necessary because Jaffe assays can overestimate true creatinine levels due to interference from non-creatinine chromogens.

Question 8: A 7-year-old girl is brought with complaints of generalized swelling of the body. Urinary examination reveals Grade 3 proteinuria and the presence of hyaline and fatty casts. She has no history of Hematuria. Which of the following statements about her condition is true:

A. IgA Nephropathy is the likely diagnosis
B. No IgG deposits or C3 deposition on Renal biopsy (Correct Answer)
C. Alport syndrome is the likely diagnosis
D. Her C3 levels will be low

Explanation: ***No IgG deposits or C3 deposition on Renal biopsy*** - The presentation of **generalized swelling**, **grade 3 proteinuria**, and the absence of **hematuria** in a 7-year-old girl is highly suggestive of **minimal change disease** (MCD). - In MCD, the renal biopsy characteristically shows **no immune complex deposition** (IgG, IgA, IgM, C3) on immunofluorescence. The glomeruli appear normal on light microscopy, with only effacement of podocyte foot processes visible on electron microscopy. *IgA Nephropathy is the likely diagnosis* - **IgA nephropathy** typically presents with **hematuria** (often macroscopic and recurrent, especially after infections), which is absent in this patient. - While proteinuria can occur, the primary hallmark of IgA nephropathy is the presence of **IgA immune complex deposits** in the mesangium, which contradicts the expected findings for this clinical picture. *Alport syndrome is the likely diagnosis* - **Alport syndrome** is characterized by **hematuria**, progressive renal failure, **sensorineural hearing loss**, and ocular abnormalities. None of these distinguishing features are mentioned as primary complaints. - While proteinuria can occur, it's the association with **hematuria** and **extra-renal manifestations** that define Alport syndrome, differentiating it from the presented case. *Her C3 levels will be low* - Low C3 levels are typically seen in conditions involving significant **complement activation**, such as **post-streptococcal glomerulonephritis** or membranoproliferative glomerulonephritis. - In **minimal change disease**, which is the most likely diagnosis given the clinical picture, **complement levels (including C3) are typically normal**, as it is not an immune-complex mediated disease that consumes complement.

Question 9: A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

A. Reflux nephropathy
B. Polycystic kidney disease
C. Chronic glomerulonephritis (Correct Answer)
D. All of the options

Explanation: ***Chronic glomerulonephritis*** - The combination of **microscopic hematuria, proteinuria, and RBC casts** is pathognomonic for **glomerular disease**. - **RBC casts** specifically indicate glomerular bleeding and are highly specific for **glomerulonephritis**. - **Hypertension** in chronic glomerulonephritis results from sodium retention, fluid overload, and activation of the renin-angiotensin-aldosterone system. - The absence of acute features suggests a **chronic** process rather than acute post-streptococcal glomerulonephritis. *Reflux nephropathy* - While reflux nephropathy can cause hypertension and proteinuria, it typically presents with a history of **recurrent urinary tract infections**, which is explicitly absent in this case. - **RBC casts are NOT a feature** of reflux nephropathy; urinalysis may show proteinuria and occasionally WBCs/bacteria if infection is present. - Diagnosis requires imaging (VCUG, DMSA scan) showing vesicoureteral reflux and renal scarring. *Polycystic kidney disease* - **Autosomal dominant PKD** rarely presents with symptoms in childhood; it typically manifests in the 3rd-4th decade. - **Autosomal recessive PKD** presents in infancy/early childhood with enlarged kidneys and renal failure. - While PKD can cause hematuria (from cyst rupture), **RBC casts are not characteristic** as the pathology is cystic, not glomerular. - Diagnosis is made by ultrasound showing multiple bilateral renal cysts. *All of the options* - This is incorrect because the **specific urinalysis findings** (particularly **RBC casts**) point definitively to **glomerular pathology**. - RBC casts are the hallmark of glomerulonephritis and are not seen in reflux nephropathy or polycystic kidney disease. - The clinical presentation with specific laboratory findings allows differentiation between these conditions.

Question 10: Commonest cause of sustained severe hypertension in children

A. Pheochromocytoma
B. Endocrine causes
C. Renal parenchyma disease (Correct Answer)
D. Coarctation of aorta

Explanation: ***Renal parenchyma disease*** - **Renal parenchymal diseases** such as **glomerulonephritis**, **pyelonephritis**, and **polycystic kidney disease** are the most frequent causes of sustained severe hypertension in children. - These conditions lead to **impaired renal function**, affecting fluid and electrolyte balance and activating the **renin-angiotensin-aldosterone system**, thereby increasing blood pressure. *Pheochromocytoma* - While a **pheochromocytoma** can cause severe hypertension, it is an extremely rare cause in children, typically presenting with paroxysmal episodes of high blood pressure, palpitations, and sweating. - This condition arises from **catecholamine-producing tumors** of the adrenal medulla, leading to distinct and episodic hypertension rather than sustained. *Endocrine causes* - **Endocrine causes** like **Cushing's syndrome** or **thyrotoxicosis** can lead to hypertension, but they are less common causes of sustained severe hypertension in children compared to renal pathologies. - These conditions are also associated with other systemic symptoms specific to the hormonal imbalance, which would typically be evident. *Coarctation of aorta* - **Coarctation of the aorta** is a congenital narrowing of the aorta that can cause hypertension, particularly in the upper extremities. - While significant, it is less common than renal parenchymal disease as a cause of *sustained severe hypertension* across the board in children and presents with characteristic differences in blood pressure between upper and lower limbs.

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