Nephrology Practice Questions

Q: 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?

Hemolytic uremic syndrome. ***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.

Q: 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?

Congenital urinary obstruction. ***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].

Q: 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?

Corticosteroids. ***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.

Q: A 5-year-old boy presents with abdominal pain, bloody diarrhea, and lethargy. Laboratory findings reveal microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. What is the most likely diagnosis?

Hemolytic uremic syndrome. ***Hemolytic uremic syndrome (HUS)*** - The classic triad of **microangiopathic hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury** is pathognomonic for **hemolytic uremic syndrome (HUS)**, especially in a child with bloody diarrhea. - This condition is most commonly triggered by **Shiga toxin-producing E. coli (STEC)** infection, which causes widespread endothelial damage and microvascular thrombosis. - The typical presentation includes a prodrome of bloody diarrhea (often from contaminated food), followed by the development of the triad within days. *Henoch-Schönlein purpura* - Characterized by palpable **purpura**, **arthralgia**, **abdominal pain**, and **renal involvement** (often IgA-mediated glomerulonephritis). - Importantly, **platelet counts are typically normal or elevated** in HSP, which distinguishes it from HUS. - While it can cause bloody diarrhea due to GI vasculitis, the microangiopathic hemolytic anemia and thrombocytopenia seen in HUS are absent. *Intussusception* - Presents with sudden onset, intermittent, severe **abdominal pain** (often described as colicky), **vomiting**, and **currant jelly stools** (blood and mucus). - Peak incidence is 6-36 months of age, typically in well-appearing infants between episodes. - Does not cause **microangiopathic hemolytic anemia**, **thrombocytopenia**, or **acute kidney injury** as seen in this case. *Crohn's disease* - A chronic inflammatory bowel disease presenting with **abdominal pain**, **diarrhea** (sometimes bloody), **weight loss**, and **fatigue**, often with a more insidious onset. - Does not cause the acute triad of **microangiopathic hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury** that defines HUS. - Would be unusual to present acutely at age 5 without preceding chronic symptoms.

Q: 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?

High-dose corticosteroids. ***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.

Q: A 4-year-old girl with Henoch-Schönlein purpura presents with abdominal pain, palpable purpura, hematuria, and nephrotic-range proteinuria. Renal biopsy shows mesangial proliferative glomerulonephritis with IgA deposits. What is the most appropriate treatment plan for this patient?

High-dose corticosteroids + ACE inhibitors. ***High-dose corticosteroids + ACE inhibitors*** * **High-dose corticosteroids** are indicated for **severe Henoch-Schönlein purpura nephritis** characterized by nephrotic-range proteinuria and significant renal involvement, as they help reduce inflammation and proteinuria. * **ACE inhibitors** are crucial for mitigating **proteinuria** and providing **renoprotection**, especially in the presence of significant proteinuria, by reducing intraglomerular pressure. *Plasmapheresis + cyclophosphamide* * **Plasmapheresis** is generally reserved for rapidly progressive glomerulonephritis, severe cryoglobulinemic vasculitis, or anti-glomerular basement membrane disease, which is not described here. * **Cyclophosphamide** is a potent immunosuppressant typically used in severe, refractory cases or for specific types of vasculitis and lupus nephritis; it is not a first-line treatment for HSP nephritis. *Observation and supportive care* * **Observation and supportive care** are appropriate for mild cases of HSP, typically those with only skin symptoms or mild abdominal pain without significant renal involvement or proteinuria. * Given the presence of **nephrotic-range proteinuria and mesangial proliferative glomerulonephritis**, this patient requires more aggressive intervention to prevent long-term renal damage. *Rituximab + antihypertensive therapy* * **Rituximab**, a B-cell depleting agent, is used for certain autoimmune conditions like ANCA-associated vasculitis or refractory nephrotic syndrome, but it is not a standard first-line treatment for HSP nephritis. * While **antihypertensive therapy** is often necessary in renal disease, it is primarily for blood pressure control and does not address the underlying inflammatory process or nephrotic-range proteinuria as effectively as corticosteroids and ACE inhibitors.

Q: A 5-year-old boy presents with a history of nocturnal enuresis and recurrent urinary tract infections. What is the most appropriate initial investigation?

Renal ultrasound. ***Renal ultrasound*** - A **renal ultrasound** is the most appropriate initial investigation as it is non-invasive and can assess for structural abnormalities of the **kidneys** and **bladder**, such as hydronephrosis, renal scarring, or bladder wall thickening, which may contribute to **nocturnal enuresis** and **recurrent UTIs**. - It helps rule out conditions like **vesicoureteral reflux (VUR)** indirectly by showing **dilated ureters** or **renal pelvis**, guiding further, more invasive tests if needed. *Voiding cystourethrogram* - A **voiding cystourethrogram (VCUG)** is primarily used to diagnose and grade **vesicoureteral reflux (VUR)**, which is often associated with recurrent UTIs. - While important, it is typically performed *after* an ultrasound has identified potential abnormalities or if the clinical suspicion for VUR is high due to persistent UTIs despite antibiotic prophylaxis. *Intravenous pyelogram* - An **intravenous pyelogram (IVP)** uses contrast dye and X-rays to visualize the urinary tract, providing detailed anatomical and functional information. - However, it is an **invasive procedure** involving radiation and contrast exposure, and is generally reserved for more complex cases or when other less invasive imaging (like ultrasound) has not provided sufficient diagnostic information. *Urodynamic studies* - **Urodynamic studies** assess bladder function, including storage, emptying, and sphincteric control. - These are usually reserved for cases where **neuropathic bladder dysfunction** or complex functional voiding issues are suspected, especially after initial anatomical assessments have been completed.

Q: A 3-year-old child presents with a history of recurrent urinary tract infections, poor growth, and hypertension. What is the most likely diagnosis?

Vesicoureteral reflux. ***Vesicoureteral reflux (VUR)*** - **Vesicoureteral reflux** is a common cause of recurrent **urinary tract infections (UTIs)** in children, leading to potential **renal scarring** and subsequent **hypertension** and **poor growth**. - The reflux of urine from the bladder back into the ureters can introduce bacteria into the kidneys, causing pyelonephritis and long-term renal damage. *Nephrotic syndrome* - Characterized by **massive proteinuria**, **hypoalbuminemia**, **edema**, and **hyperlipidemia**, which are not mentioned in the child's presentation. - While it can lead to complications such as acute kidney injury, **recurrent UTIs** and hypertension are not primary features of nephrotic syndrome. *Acute glomerulonephritis* - Typically presents with **hematuria**, **proteinuria**, **edema**, and **hypertension**, often following a streptococcal infection. - **Recurrent UTIs** and **poor growth** are not characteristic presenting symptoms of acute glomerulonephritis. *Polycystic kidney disease* - This is a genetic disorder characterized by the growth of numerous cysts in the kidneys, leading to **enlarged kidneys**, **hypertension**, and eventual kidney failure. - While it can manifest with hypertension, **recurrent UTIs** and **poor growth** are less specific primary indicators compared to VUR.

Question 1

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?

Accepted Answer

Voiding cystourethrogram

Answer

Renal ultrasound

Answer

Urodynamic studies

Answer

Start behavioral therapy

Question 2

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?

Accepted Answer

Hemolytic uremic syndrome

Answer

Severe malaria

Answer

Immune thrombocytopenic purpura

Answer

Acute kidney injury due to nephrotoxic agents

Question 3

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?

Accepted Answer

Congenital urinary obstruction

Answer

Vesicoureteral reflux (VUR)

Answer

Bladder dysfunction due to neurological causes

Answer

Inherited renal cystic disease

Question 4

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?

Accepted Answer

Corticosteroids

Answer

ACE inhibitors

Answer

Diuretics

Answer

Immunosuppressants

Question 5

A 5-year-old boy presents with abdominal pain, bloody diarrhea, and lethargy. Laboratory findings reveal microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. What is the most likely diagnosis?

Accepted Answer

Hemolytic uremic syndrome

Answer

Henoch-Schönlein purpura

Answer

Intussusception

Answer

Crohn's disease

Question 6

A 5-year-old child presents with edema, proteinuria, and hypoalbuminemia. What is the most likely diagnosis?

Accepted Answer

Nephrotic syndrome

Answer

Acute glomerulonephritis

Answer

Henoch-Schönlein purpura

Answer

Urinary tract infection

Question 7

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?

Accepted Answer

High-dose corticosteroids

Answer

Immunosuppressants + biopsy

Answer

Plasmapheresis

Answer

Supportive care + hydration

Question 8

A 4-year-old girl with Henoch-Schönlein purpura presents with abdominal pain, palpable purpura, hematuria, and nephrotic-range proteinuria. Renal biopsy shows mesangial proliferative glomerulonephritis with IgA deposits. What is the most appropriate treatment plan for this patient?

Accepted Answer

High-dose corticosteroids + ACE inhibitors

Answer

Plasmapheresis + cyclophosphamide

Answer

Observation and supportive care

Answer

Rituximab + antihypertensive therapy

Question 9

A 5-year-old boy presents with a history of nocturnal enuresis and recurrent urinary tract infections. What is the most appropriate initial investigation?

Accepted Answer

Renal ultrasound

Answer

Voiding cystourethrogram

Answer

Intravenous pyelogram

Answer

Urodynamic studies

Question 10

A 3-year-old child presents with a history of recurrent urinary tract infections, poor growth, and hypertension. What is the most likely diagnosis?

Accepted Answer

Vesicoureteral reflux

Answer

Nephrotic syndrome

Answer

Acute glomerulonephritis

Answer

Polycystic kidney disease

Nephrology — MCQs

Nephrology — MCQs

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