Pediatric Nephrology (Nephrotic, Nephritic, UTI, Congenital) MCQs

Pediatrics · 40 free questions with answers & explanations.

1. A 4-year-old boy presents with bilateral periorbital puffiness, frothy urine, and abdominal distension. Investigations show: urine protein 4+ (>3.5 g/day), serum albumin 1.8 g/dL, serum cholesterol 420 mg/dL, and normal blood pressure. Renal biopsy shows effacement of foot processes on electron microscopy with no deposits on immunofluorescence. What is the TREATMENT of CHOICE?
2. A 7-year-old girl presents with gross hematuria, oliguria, periorbital edema, and hypertension following a sore throat 2 weeks ago. Investigations show C3 complement decreased, elevated ASO titer, and RBC casts in urine. What is the MOST likely diagnosis?
3. An 8-year-old child with steroid-sensitive nephrotic syndrome has relapsed 4 times in the past 18 months and is currently on alternate-day prednisolone 0.5 mg/kg. The child develops Cushingoid features and poor growth. The MOST appropriate addition to minimize steroid toxicity while maintaining remission is:
4. A 2-year-old girl presents with her second culture-proven UTI (E. coli >10^5 CFU/mL). Renal ultrasound shows bilateral hydroureteronephrosis. VCUG demonstrates bilateral grade IV vesicoureteric reflux. After treatment of acute infection, what is the MOST important next step in long-term management?
5. A 4-year-old boy presents with periorbital puffiness, heavy proteinuria (>40 mg/m²/hr), hypoalbuminemia (1.8 g/dL), hyperlipidemia, and normal blood pressure. Renal biopsy (if performed) would most likely show minimal change on light microscopy with diffuse effacement of podocyte foot processes on electron microscopy. After 4 weeks of prednisolone (2 mg/kg/day), the child shows no response. Which of the following best describes 'steroid-resistant nephrotic syndrome' in children?
6. A 7-year-old girl presents with her second febrile UTI confirmed with mid-stream urine culture showing >10⁵ CFU/mL of E. coli. DMSA scan reveals bilateral renal scarring. MCUG reveals bilateral vesicoureteric reflux grade III. Which of the following is the current recommended management approach for VUR with renal scarring in a child of this age?
7. A 4-year-old child with steroid-sensitive nephrotic syndrome has relapsed twice in the past year (frequent relapser). He has been on prednisolone for 8 months total. Which of the following is the most appropriate next step to reduce steroid toxicity and maintain remission?
8. An 8-year-old boy presents with haematuria, oliguria, periorbital oedema, and blood pressure of 148/96 mmHg. Serum complement C3 is markedly low; C4 is normal. Anti-streptolysin O (ASO) titre is 600 IU/mL. Renal biopsy shows 'lumpy bumpy' IgG and C3 deposits on immunofluorescence. The single most reliable marker of recovery in this condition is:
9. A 5-year-old boy presents with periorbital puffiness, massive proteinuria (4+ on dipstick), hypoalbuminemia (1.8 g/dL), and hypercholesterolemia. He has no hematuria and blood pressure is normal. He is started on prednisolone. After 8 weeks of adequate corticosteroid therapy, proteinuria persists. What is the NEXT step?
10. A 3-year-old girl presents with her third episode of UTI in 6 months. Urine culture grows E. coli >10^5 CFU/mL. After treatment, DMSA scan shows bilateral cortical scarring in the upper poles. MCUG reveals Grade III vesicoureteral reflux (VUR) on the right. What is the MOST appropriate long-term management?
11. A 5-year-old boy presents with his third relapse of nephrotic syndrome within 6 months. He has been responding to corticosteroids each time (proteinuria clears within 4 weeks). He is currently on alternate-day prednisolone for maintenance. This pattern is classified as:
12. A 1-year-old girl is diagnosed with her first febrile UTI. Urine culture grows E. coli >10^5 CFU/mL. Renal ultrasound shows no abnormality. According to current IAP/NICE guidelines, which imaging study should be performed to evaluate for vesicoureteral reflux and renal scarring after treatment?
13. A 5-year-old boy has his second episode of nephrotic syndrome (massive proteinuria, hypoalbuminaemia, oedema). He responded well to steroids (8-week course) during the first episode 6 months ago. Which statement about subsequent management is CORRECT according to standard paediatric nephrology practice?
14. A 2-year-old girl has her first febrile UTI confirmed with a catheter specimen showing E. coli >10^5 CFU/mL, 100 WBCs/hpf, and positive leucocyte esterase. She has no antenatal history of hydronephrosis. After completing appropriate antibiotic treatment, what imaging investigation is MOST indicated as per current evidence-based guidelines?
15. An 8-year-old boy with steroid-sensitive nephrotic syndrome (SSNS) has had 4 relapses in the past 18 months. He is currently on alternate-day prednisolone. His mother is concerned about steroid toxicity — height velocity has declined, and he has developed cataracts. Which agent should be considered to induce and maintain remission while reducing cumulative steroid dose?
16. A 3-week-old male infant presents with poor feeding, irritability, and fever of 38.5°C. Urine dipstick shows leucocytes 3+ and nitrites positive. The urine culture grows >10^5 CFU/mL E. coli. After antibiotic treatment, DMSA renal scintigraphy at 4–6 months shows a cortical scar in the left kidney. What is the MOST important investigation to be done acutely and why?
17. A 4-year-old child with idiopathic nephrotic syndrome (INS) is started on prednisolone 60 mg/m²/day. After 6 weeks of full-dose steroids, the child remains nephrotic (urine protein 4+ on dipstick, albumin 1.8 g/dL). The MOST appropriate next management step is:
18. A 3-year-old girl presents with her second episode of febrile UTI in 8 months. Culture grows >10⁵ CFU/mL E. coli sensitive to trimethoprim-sulfamethoxazole. What investigation is indicated after completing this acute treatment, according to evidence-based guidelines?
19. An 8-year-old boy presents with gross hematuria, mild proteinuria, and bilateral flank pain. His maternal uncle has chronic kidney disease on dialysis. Audiometry shows bilateral sensorineural hearing loss. Renal biopsy electron microscopy shows thinning, splitting, and lamellation of the glomerular basement membrane (GBM). The mode of inheritance and causative gene is most likely:
20. A 4-year-old boy presents with generalized edema, urine protein 3+ on dipstick, serum albumin 1.6 g/dL, serum cholesterol 380 mg/dL, and normal blood pressure. Serum C3 is normal. He is started on prednisolone and achieves remission within 4 weeks. He has 3 more relapses within 12 months, each requiring prednisolone. He now develops significant cushingoid features. What is the MOST APPROPRIATE next pharmacological step?
21. A 6-year-old child presents with gross hematuria (cola-colored urine), periorbital edema, and hypertension 1 week after a throat infection. Serum C3 is 52 mg/dL (low). ASOT is 800 IU/mL. Urine shows RBC casts. What is the MOST IMPORTANT prognostic indicator of long-term outcome in this condition?
22. A 5-year-old boy has massive proteinuria (urinary protein:creatinine ratio 8), hypoalbuminaemia (2.0 g/dL), oedema, and hyperlipidaemia. There is no haematuria and BP is normal. He is started on prednisolone 60 mg/m²/day. After 4 weeks of full-dose steroid therapy there is no remission. What defines 'steroid resistance' in nephrotic syndrome?
23. A 3-year-old girl presents with high fever, dysuria, and a positive urine culture showing ≥10⁵ CFU/mL of E. coli. Micturating cystourethrogram (MCU/VCUG) reveals bilateral grade III vesicoureteral reflux. What is the most important long-term risk of untreated VUR with recurrent UTIs?
24. A 4-year-old boy has had 5 relapses of nephrotic syndrome in 18 months, each requiring oral corticosteroids. He is currently on prednisolone and has cushingoid features. The BEST strategy to achieve steroid-free remission and prevent further relapses in a frequently-relapsing steroid-sensitive nephrotic syndrome is:
25. A 2-year-old girl has her first febrile UTI confirmed by suprapubic aspiration (E. coli >10^3 CFU/mL). Post-treatment DMSA scan at 6 months shows bilateral upper pole cortical defects. MCUG shows Grade III bilateral VUR. Long-term management decision should be based on the principle that:
26. A 5-year-old boy with nephrotic syndrome is started on prednisolone 60 mg/m2/day. He achieves complete remission (urine protein trace/nil) at week 4. He then develops two relapses within a 6-month period. The term for this relapse pattern and the most appropriate next step is:
27. A 3-year-old girl presents with high-grade fever, dysuria and vomiting. Urine dipstick shows leucocyte esterase positive and nitrite positive. Urine culture grows >100,000 CFU/mL of E. coli. DMSA scan at 6 months follow-up shows permanent cortical scar. This finding indicates:
28. An 8-year-old child with idiopathic nephrotic syndrome (minimal change disease) has been on prednisolone for 8 weeks with complete remission. He is now in his third relapse within 12 months and has been on steroids for 6 of the last 12 months. Which of the following best defines his condition and guides alternative therapy?
29. A 2-year-old girl presents with dysuria, fever, and a urine culture showing >10^5 CFU/mL of E. coli. Renal ultrasound shows a dilated right ureter and renal pelvis. VCUG demonstrates grade III vesicoureteric reflux on the right. What is the MOST appropriate initial management?
30. An 8-year-old girl presents with facial puffiness, frothy urine, ascites, and bilateral leg edema for 2 weeks. Urinalysis shows 4+ proteinuria with no hematuria. Serum albumin is 1.6 g/dL, cholesterol 420 mg/dL. She is started on prednisolone 2 mg/kg/day. After 4 weeks of full-dose steroids, proteinuria persists 3+. What defines STEROID-RESISTANT nephrotic syndrome (SRNS)?
31. A 4-year-old boy presents with sudden onset severe cola-colored urine, periorbital puffiness, and reduced urine output 3 weeks after a sore throat. Blood pressure is 140/95 mmHg. Urinalysis shows RBC casts, proteinuria 2+. Serum C3 is markedly reduced; C4 is normal. ASO titre is elevated. What does the selectively reduced C3 with normal C4 indicate about complement pathway activation in this disease?
32. A 5-year-old boy presents with periorbital edema, heavy proteinuria (protein:creatinine ratio 8), hypoalbuminemia (serum albumin 1.8 g/dL), and hypercholesterolemia. His blood pressure is normal. He is started on prednisolone 60 mg/m²/day (maximum 60 mg/day). After 4 weeks of daily prednisolone, the urine protein remains negative for 3 consecutive days. What is the correct next step per ISKDC guidelines?
33. A 3-year-old girl is evaluated for her second febrile UTI. Urine culture grows E. coli >100,000 CFU/mL. Renal ultrasound shows left-sided hydronephrosis. DMSA scan performed 3 months after the infection shows a cortical scar in the upper pole of the left kidney. What is the most likely underlying structural abnormality?
34. A 4-year-old presents with bilateral eyelid puffiness, massive ascites, and frothy urine. Urinalysis shows 4+ protein (urine protein:creatinine ratio 4.2). Serum albumin is 1.8 g/dL. This is his first episode. The FIRST-LINE treatment is:
35. A 7-year-old child presents with gross hematuria (tea-colored urine), periorbital edema, hypertension (BP 148/96 mmHg), and oliguria 2 weeks after a streptococcal sore throat. Urinalysis shows red cell casts. The pathological lesion MOST likely to be found on renal biopsy is:
36. A 2-year-old girl presents with her second febrile UTI. DMSA scan shows a focal cortical defect in the upper pole of the left kidney consistent with scarring. Which congenital anatomical abnormality is the MOST important risk factor for recurrent UTI and renal scarring in children?
37. A 5-year-old boy presents with periorbital edema, massive proteinuria (urine protein:creatinine ratio 9), hypoalbuminemia (serum albumin 1.8 g/dL), and hypercholesterolemia. He responds completely to prednisolone. Two years later he relapses for the sixth time in 12 months while being tapered. Which agent is MOST appropriate for steroid-sparing in frequently relapsing nephrotic syndrome?
38. A 10-year-old boy presents 10 days after an episode of impetigo with cola-colored urine, facial edema, and hypertension. Urine microscopy shows RBC casts and dysmorphic RBCs. Complement C3 is low, C4 is normal. ASOT is elevated. Which finding differentiates Post-Streptococcal Glomerulonephritis (PSGN) from Lupus Nephritis?
39. An 8-year-old child presents with periorbital edema, heavy proteinuria (5 g/day), hypoalbuminemia (1.8 g/dL), and hyperlipidemia. He is started on oral prednisolone. After 8 weeks of standard doses, he still has nephrotic-range proteinuria. This child is now classified as:
40. A 4-year-old girl has her first febrile UTI. DMSA scan shows an area of reduced uptake in the right upper pole. What does this finding represent acutely, and what is its clinical significance?