Nephrology Practice Questions

Q: 2 year old child with length 85cm and weight of 11kg was found to have serum urea of 49mg/dl, serum creatinine 2mg/dl What is the estimated GFR of this child, as per Schwartz formula?

19. ***19*** - The **Schwartz formula** for estimating GFR in children is: **GFR = k × (length in cm / serum creatinine in mg/dL)**. - For a 2-year-old child, the constant **k is typically 0.45**. Therefore, GFR = 0.45 × (85 cm / 2 mg/dL) = 0.45 × 42.5 = 19.125, which rounds to **19 mL/min/1.73m²**. - This GFR value indicates **moderate to severe chronic kidney disease** in a child. *48* - This value is likely obtained if an incorrect **k constant** was used (such as k = 0.55 for older children) or if there was a calculation error. - A GFR of 48 mL/min/1.73m² would indicate **moderate chronic kidney disease (Stage 3)**, but the calculation using the appropriate k value does not support this. *9* - This value would result from using an incorrect k value (possibly dividing 0.45 by 2) or making an **arithmetic error** in the calculation. - A GFR of 9 mL/min/1.73m² would suggest **severe kidney failure (Stage 5 CKD)**, which is inconsistent with the provided parameters when calculated correctly. *90* - A GFR of 90 mL/min/1.73m² or higher generally indicates **normal kidney function**. - This value is significantly higher than what would be calculated using the Schwartz formula with the given creatinine level of 2 mg/dL, which indicates significant kidney impairment in a child.

Q: Most common cause of nephrotic syndrome in paediatric age group is

Minimal change disease. ***Minimal change disease*** - **Minimal change disease (MCD)** is the most frequent cause of **nephrotic syndrome** in children, accounting for 70-90% of cases in the paediatric age group. - It is characterized by normal kidney appearance on light microscopy, with **effacement of foot processes** visible only on electron microscopy. *Mesangioproliferative glomerulonephritis* - While various forms of mesangioproliferative glomerulonephritis can cause nephrotic syndrome, they are **not the most common cause** in paediatric patients. - This diagnosis often involves **cellular proliferation within the mesangium**, which is distinct from the characteristic findings of MCD. *Malarial infection* - **Malarial infection**, particularly *Plasmodium malariae*, can cause **malaria-associated nephropathy**, which may present as nephrotic syndrome. - However, this is typically seen in **endemic malarial regions** and is not the most common global cause of paediatric nephrotic syndrome. *Membranous glomerulonephritis* - **Membranous glomerulonephritis** is a common cause of nephrotic syndrome in **adults**, especially in those over 40 years of age. - It is **rare in children** and is characterized by subepithelial immune deposits and thickening of the glomerular basement membrane.

Q: A child with 22-25 stool/day, 3 day old pneumonitis, no passage of urine from 36 hours. low B.P. Blood pH – 7.21. Urine Na+–18 meq/L, S. Urea 120, serum Creatinine 1.2 indicate –

Pre–renal Azotemia. ***Pre–renal Azotemia*** - Pre-renal azotemia is characterized by **reduced renal perfusion**, leading to decreased glomerular filtration rate and increased reabsorption of water and urea due to activation of the renin-angiotensin-aldosterone system. - The combination of **low blood pressure**, no urine output for 36 hours, metabolic acidosis (pH 7.21), elevated urea (120) and creatinine (1.2), and a relatively normal urine sodium (18 meq/L) despite severe dehydration (22-25 stools/day) is highly indicative of pre-renal azotemia as the kidneys are attempting to conserve sodium and water in response to hypovolemia. *Acute tubular necrosis* - **Acute tubular necrosis (ATN)** typically presents with a **high urine sodium** (>40 meq/L) due to damaged tubules failing to reabsorb sodium effectively, which contradicts the given urine sodium of 18 meq/L. - Although it can cause acute kidney injury with elevated BUN/creatinine and acidosis, the clinical picture here is more consistent with pre-renal causes due to the preserved tubular function indicated by low urine Na+ and oliguria in the setting of severe hypovolemia. *Acute cortical necrosis* - **Acute cortical necrosis** is a rare and severe form of acute kidney injury involving widespread necrosis of the renal cortex, often leading to **irreversible renal failure** and anuria. - While it can present with anuria, it is less common in children with gastroenteritis and hypovolemia, and the initial presentation of preserved tubular function (low urine sodium) points away from significant intrinsic damage. *Acute medullary necrosis* - **Acute medullary necrosis**, also known as **renal papillary necrosis**, primarily affects the renal medulla and papillae, often associated with conditions like sickle cell disease, diabetes, or NSAID abuse. - This condition is unlikely in a child presenting with severe dehydration and hypovolemia from gastroenteritis.

Q: A characteristic feature of nephritic syndrome in children is:

RBC casts in urine. ***RBC casts in urine*** - The presence of **red blood cell (RBC) casts** in urine is a **pathognomonic sign** of **glomerulonephritis**, which is the underlying pathology in nephritic syndrome. - This indicates **glomerular inflammation** and bleeding, where RBCs leak through damaged glomeruli and are molded into casts within the renal tubules. *WBC casts in urine* - **White blood cell (WBC) casts** are characteristic of **pyelonephritis** (kidney infection) or other severe interstitial nephritis, indicating inflammation within the renal tubules. - While infection can sometimes accompany nephritic syndrome, WBC casts are not a primary diagnostic feature of the syndrome itself. *Lipid casts in urine* - **Lipid casts** and **fatty oval bodies** are typically associated with **nephrotic syndrome**, resulting from significant proteinuria and hyperlipidemia. - They signify severe disruption of glomerular filtration leading to lipid excretion, which is not the defining feature of nephritic syndrome. *Albumin in urine* - While **proteinuria (albumin in urine)** is present in nephritic syndrome, it is a non-specific finding and is also a hallmark of **nephrotic syndrome**, where it is much more severe. - The *quality* of the proteinuria (e.g., whether it contains RBCs) is more indicative for differentiating nephritic from nephrotic syndrome.

Q: Which of the following is NOT commonly associated with pediatric nephrotic syndrome?

Thrombocytopenia. ***Thrombocytopenia*** - **Thrombocytopenia**, or low platelet count, is generally **not associated** with pediatric nephrotic syndrome and is even less common than thrombocytosis. - While thrombotic and thromboembolic events can occur due to **hypercoagulability**, these are typically related to **increased clotting factors** and rarely involve low platelet counts. *Proteinuria* - **Proteinuria** (specifically **nephrotic range proteinuria** >40 mg/m2/hr or urine protein-to-creatinine ratio >2 mg/mg) is a **hallmark** feature of nephrotic syndrome. - It results from increased **glomerular permeability** leading to excessive leakage of protein into the urine. *Hyperlipidemia* - **Hyperlipidemia** is a common compensatory mechanism in nephrotic syndrome, as the liver increases lipoprotein synthesis to counteract the decreased **oncotic pressure** from albumin loss. - This often leads to elevated levels of **cholesterol** and **triglycerides**. *Hypoalbuminemia* - **Hypoalbuminemia** (<2.5 g/dL) is a **defining characteristic** of nephrotic syndrome, resulting from the significant urinary loss of albumin. - This low serum albumin contributes to **generalized edema** due to decreased plasma oncotic pressure.

Q: A 5 year child is brought with brown coloured urine and oliguria since 3 days with mild facial puffiness and pedal edema with 3+ proteinuria, BP 126/90. Urine examination shows RBCs 100/hpf and granular casts. Which of the following doesn't present with this finding?

Minimal change disease. ***Minimal change disease*** - This condition is the most common cause of **nephrotic syndrome** in children, characterized by **marked proteinuria**, **edema**, and **normal renal function**. - It typically does **NOT** present with **hematuria**, **hypertension**, or **red blood cell casts** in the urine, which are prominent features in this case. - MCD presents with **pure nephrotic syndrome** without nephritic features, making it the condition that doesn't match this clinical presentation. *FSGS* - **Focal segmental glomerulosclerosis (FSGS)** can present with a **mixed nephrotic-nephritic picture**, including significant **proteinuria**, **hematuria**, and **hypertension**. - The presence of **RBC casts** and **hypertension** is consistent with FSGS, which can show inflammatory glomerular changes. *Membranous glomerulonephritis* - **Membranous glomerulonephritis (MGN)** primarily causes **nephrotic syndrome** in adults but can occur in children. - While MGN predominantly presents with **proteinuria** and **edema**, it can occasionally have **microscopic hematuria** and mild **hypertension**. - The prominent **nephritic features** (marked hematuria, RBC casts, oliguria) make MGN less likely but not impossible in this case. *IgA nephropathy* - **IgA nephropathy** is the **best match** for this presentation with **brown-colored urine** (gross hematuria), **proteinuria**, **hypertension**, and **edema**. - Classically presents with **episodic gross hematuria** following upper respiratory tract infections. - The presence of **RBCs**, **granular casts**, and **acute nephritic features** (oliguria, facial puffiness, hypertension) are highly consistent with IgA nephropathy.

Q: 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?

PSGN. ***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.

Q: 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?

Post-Streptococcal Glomerulonephritis. ***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.

Q: 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?

Nephrotic Syndrome. ***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.

Q: A 6-year-old boy presents with periorbital edema, frothy urine, and persistent proteinuria. What is the most likely diagnosis?

Nephrotic syndrome. ***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 1

2 year old child with length 85cm and weight of 11kg was found to have serum urea of 49mg/dl, serum creatinine 2mg/dl What is the estimated GFR of this child, as per Schwartz formula?

Accepted Answer

19

Answer

48

Answer

9

Answer

90

Question 2

Most common cause of nephrotic syndrome in paediatric age group is

Accepted Answer

Minimal change disease

Answer

Mesangioproliferative glomerulonephritis

Answer

Malarial infection

Answer

Membranous glomerulonephritis

Question 3

A child with 22-25 stool/day, 3 day old pneumonitis, no passage of urine from 36 hours. low B.P. Blood pH – 7.21. Urine Na+–18 meq/L, S. Urea 120, serum Creatinine 1.2 indicate –

Accepted Answer

Pre–renal Azotemia

Answer

Acute tubular necrosis

Answer

Acute cortical necrosis

Answer

Acute medullary necrosis

Question 4

A characteristic feature of nephritic syndrome in children is:

Accepted Answer

RBC casts in urine

Answer

WBC casts in urine

Answer

Albumin in urine

Answer

Lipid casts in urine

Question 5

Which of the following is NOT commonly associated with pediatric nephrotic syndrome?

Accepted Answer

Thrombocytopenia

Answer

Proteinuria

Answer

Hyperlipidemia

Answer

Hypoalbuminemia

Question 6

A 5 year child is brought with brown coloured urine and oliguria since 3 days with mild facial puffiness and pedal edema with 3+ proteinuria, BP 126/90. Urine examination shows RBCs 100/hpf and granular casts. Which of the following doesn't present with this finding?

Accepted Answer

Minimal change disease

Answer

FSGS

Answer

Membranous glomerulonephritis

Answer

IgA nephropathy

Question 7

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?

Accepted Answer

PSGN

Answer

MCD

Answer

MGN

Answer

FSGS

Question 8

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?

Accepted Answer

Post-Streptococcal Glomerulonephritis

Answer

Urinary Tract Infection

Answer

Nephrotic Syndrome

Answer

IgA Nephropathy

Question 9

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?

Accepted Answer

Nephrotic Syndrome

Answer

Acute Glomerulonephritis

Answer

Henoch-Schönlein Purpura

Answer

Urinary Tract Infection

Question 10

A 6-year-old boy presents with periorbital edema, frothy urine, and persistent proteinuria. What is the most likely diagnosis?

Accepted Answer

Nephrotic syndrome

Answer

Glomerulonephritis

Answer

Diabetes mellitus

Answer

Urinary tract infection

Nephrology — MCQs

Nephrology — MCQs

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