MCQ NO 1: Nephrotic syndrome/ Renal system MCQ
A 5-year-old boy with steroid-sensitive nephrotic syndrome (SSNS) presents with generalized edema and abdominal pain. He has been receiving prednisolone 2 mg/kg/day for the last 7 days following a relapse. On examination, he is afebrile, pulse 118/min, blood pressure 88/56 mmHg, and has tense ascites with marked pedal edema. Urinalysis shows 4+ proteinuria. Laboratory investigations reveal: serum albumin 1.6 g/dL, serum creatinine 0.5 mg/dL, hematocrit 45%, and urine protein/creatinine ratio 8 mg/mg. He has passed only 0.4 mL/kg/hour of urine over the past 12 hours despite adequate fluid intake.
What is the most appropriate next step in management?
A. Administer 20% albumin infusion followed by intravenous furosemide
B. Increase the dose of oral prednisolone to 4 mg/kg/day
C. Initiate continuous intravenous furosemide infusion alone
D. Restrict oral fluids to 50% of maintenance and observe
E. Start intravenous normal saline bolus (20 mL/kg)
Correct answer:
Correct Answer: A. Administer 20% albumin infusion followed by intravenous furosemide
Explanation:
This child has intravascular volume depletion (hypovolemia) despite severe edema, suggested by:
Hypotension
Oliguria
Hemoconcentration (hematocrit 45%)
Severe hypoalbuminemia
Preserved renal function
In hypovolemic nephrotic syndrome, the recommended treatment is 20% albumin (0.5–1 g/kg over 2–4 hours) followed by intravenous furosemide (1–2 mg/kg) near the end of the infusion to mobilize edema while restoring intravascular volume.
Why the other options are incorrect
B. Increasing steroid dose does not correct acute hypovolemia and is not indicated.
C. Diuretics alone may worsen hypovolemia and precipitate acute kidney injury.
D. Fluid restriction alone is inadequate and may further compromise renal perfusion.
E. Normal saline alone provides only transient intravascular expansion and is generally less effective than albumin in severe hypoalbuminemia unless albumin is unavailable.
Learning Point:
Before prescribing diuretics in nephrotic syndrome, always assess intravascular volume status. Children with edema may still be hypovolemic, and treating them with diuretics alone can worsen renal perfusion and precipitate acute kidney injury.
MCQ NO 2: Nephrotic syndrome/ Renal system MCQ
An 8-year-old boy presents with generalized edema and heavy proteinuria. He was diagnosed with idiopathic nephrotic syndrome 6 weeks ago and has received prednisolone 2 mg/kg/day (maximum 60 mg/day) for 6 weeks with good compliance. Despite treatment, he continues to have 4+ proteinuria on urine dipstick, serum albumin is 1.8 g/dL, and urine protein/creatinine ratio is 9 mg/mg. His serum creatinine is normal, complement levels (C3 and C4) are normal, and there is no evidence of secondary causes of nephrotic syndrome. A renal biopsy reveals minimal change disease.
What is the most appropriate next-line treatment?
A. Cyclophosphamide
B. Cyclosporine
C. Mycophenolate mofetil
D. Rituximab
E. Tacrolimus
Correct Answer
Correct Answer: B. Cyclosporine
Explanation:
This child has steroid-resistant nephrotic syndrome (SRNS), defined as failure to achieve remission after 6 weeks of daily corticosteroid therapy. According to current KDIGO and IPNA recommendations, a calcineurin inhibitor (CNI) is the first-line immunosuppressive therapy for primary SRNS. Cyclosporine (or tacrolimus) is recommended together with low-dose corticosteroids.
Why the other options are incorrect
A. Cyclophosphamide: Effective mainly in frequently relapsing or steroid-dependent nephrotic syndrome; not recommended for SRNS.
C. Mycophenolate mofetil: Less effective than calcineurin inhibitors as initial therapy for SRNS.
D. Rituximab: Generally reserved for selected refractory cases or steroid-dependent/frequently relapsing disease, not first-line treatment for SRNS.
E. Tacrolimus: Also an acceptable first-line calcineurin inhibitor. However, if a single best answer is required, cyclosporine is the classic guideline-supported choice and has the strongest historical evidence.
Learning Point:
The cornerstone of treatment for primary steroid-resistant nephrotic syndrome is a calcineurin inhibitor (cyclosporine or tacrolimus) administered for at least 6 months while monitoring drug levels and renal function. Before initiating therapy, secondary causes should be excluded, and a kidney biopsy should be performed.
MCQ NO 3: Nephrotic syndrome/Renal system MCQ
A 7-year-old boy with steroid-dependent nephrotic syndrome has been receiving oral cyclophosphamide for 8 weeks. He is in remission and is asymptomatic. Routine investigations show:
-
Total leukocyte count: 2.1 × 10⁹/L
-
Absolute neutrophil count (ANC): 700/µL
What is the most appropriate management?
A. Continue cyclophosphamide
B. Stop cyclophosphamide
C. Increase prednisolone dose
D. Start G-CSF and continue cyclophosphamide
E. Switch to tacrolimus immediately
Correct Answer:
B. Stop cyclophosphamide
Explanation:
Cyclophosphamide-induced neutropenia requires immediate discontinuation of the drug. Blood counts should be monitored until recovery, and the patient should be advised to seek urgent care if fever develops. Routine G-CSF is not indicated in an asymptomatic child, and alternative immunosuppressive therapy should be considered only after recovery.
This style is more appropriate for postgraduate examinations, where the clinical scenario is detailed but the options are brief and focused.
MCQ NO 4: Nephrotic syndrome/Renal system MCQ
A 6-year-old boy with steroid-sensitive nephrotic syndrome has experienced four relapses in the past 12 months despite responding completely to prednisolone each time. He is currently in remission but has developed cushingoid facies, excessive weight gain, and hypertension due to repeated steroid courses.
What is the most appropriate long-term management?
A. Cyclophosphamide
B. Levamisole
C. Mycophenolate mofetil
D. Prednisolone only during relapses
E. Rituximab
Correct answer:
A. cyclophosphamide
Explanation:
The child has frequently relapsing steroid-sensitive nephrotic syndrome (FRNS) with significant steroid toxicity. In such patients, a steroid-sparing agent is indicated. For a frequently relapsing child who is not steroid-dependent, cyclophosphamide is an appropriate first-line steroid-sparing agent because it can induce prolonged remission.
Learning Point:
Frequently relapsing nephrotic syndrome (FRNS): ≥2 relapses in 6 months or ≥4 relapses in 12 months.
Steroid-sparing agents include cyclophosphamide, levamisole, mycophenolate mofetil, calcineurin inhibitors, and rituximab, with the choice depending on relapse pattern, steroid dependence, and prior therapy.
MCQ NO 5: Vaccination in nephrotic syndrome/Renal system MCQ
A 5-year-old boy with steroid-dependent nephrotic syndrome is receiving prednisolone (1 mg/kg alternate days) and tacrolimus. He has completed all vaccinations according to the Pakistan EPI schedule. He has never had chickenpox. His parents ask whether he should receive the varicella vaccine.
What is the most appropriate advice?
A. Give varicella vaccine
B. Give VZIG
C. Defer vaccination
D. Stop tacrolimus
E. Repeat MR vaccine
Correct Answer:
Correct Answer: C. Defer vaccination
Explanation:
Explanation
Varicella vaccine is a live attenuated vaccine and should not be administered to children receiving significant immunosuppressive therapy such as tacrolimus. Vaccination should be deferred until immunosuppressive therapy has been discontinued for the recommended interval and immune function has recovered.
MCQ NO 6: Chronic kidney disease/ Renal system
A 10-year-old boy with stage 4 chronic kidney disease presents with increasing fatigue, poor exercise tolerance, and reduced school performance. On examination, he is pale, with a blood pressure of 130/85 mmHg. Laboratory investigations reveal:
- Hemoglobin: 7.8 g/dL
- MCV: 88 fL
- Serum ferritin: 180 ng/mL
- Transferrin saturation: 28%
There is no evidence of active bleeding or hemolysis.
What is the most appropriate treatment for his anemia?
A. Blood transfusion
B. Erythropoietin
C. Folic acid
D. Oral iron
E. Vitamin B12
Correct answer & Explanation:
Correct Answer: B. Erythropoietin
Explanation
Anemia in chronic kidney disease is primarily due to decreased renal production of erythropoietin. This child has normocytic normochromic anemia with adequate iron stores (normal ferritin and transferrin saturation), making erythropoiesis-stimulating agents (ESAs), such as erythropoietin, the treatment of choice.
Learning Point
Before initiating erythropoietin therapy in children with CKD, iron deficiency should be excluded or corrected, as adequate iron stores are necessary for an optimal response to treatment. Blood transfusions should be reserved for severe symptomatic anemia or emergency situations.
MCQ NO 7: Chronic kidney disease/ Renal system MCQ
A 12-year-old boy with stage 5 chronic kidney disease presents with worsening bone pain and difficulty walking. Examination reveals short stature and bony tenderness over the lower limbs. Laboratory investigations show:
- Serum calcium: 7.6 mg/dL
- Serum phosphate: 7.2 mg/dL
- Serum alkaline phosphatase: 680 IU/L
- Parathyroid hormone (PTH): Markedly elevated
What is the most likely cause of his bone disease?
A. Hyperparathyroidism
B. Osteogenesis imperfecta
C. Vitamin C deficiency
D. Vitamin D intoxication
E. Wilson disease
Correct answer & Explanation:
Correct Answer: A. Hyperparathyroidism
Explanation
Children with advanced CKD develop CKD-mineral and bone disorder (CKD-MBD) due to phosphate retention, reduced activation of vitamin D, hypocalcemia, and secondary hyperparathyroidism. Elevated PTH causes increased bone turnover, leading to renal osteodystrophy, bone pain, fractures, and growth failure.
Learning Point:
Secondary hyperparathyroidism is a common complication of advanced CKD and is managed with dietary phosphate restriction, phosphate binders, active vitamin D (calcitriol), and optimization of dialysis when indicated.
MCQ NO 8: Chronic kidney disaese/ Renal system mCQ
A 9-year-old boy with stage 5 chronic kidney disease presents with progressive bone pain, difficulty walking, and poor height gain. On examination, he has genu valgum and tenderness over the long bones. Laboratory investigations reveal:
- Serum calcium: 7.8 mg/dL
- Serum phosphate: 7.0 mg/dL
- Alkaline phosphatase: 750 IU/L
- Parathyroid hormone: Markedly elevated
What is the most appropriate treatment for this child?
A. Calcitriol
B. Iron therapy
C. Prednisolone
D. Sodium bicarbonate
E. Vitamin C
Correct answer & Explanation
Correct Answer: A. Calcitriol
Explanation
This child has renal osteodystrophy (CKD-mineral and bone disorder) due to advanced chronic kidney disease. Impaired renal conversion of vitamin D to its active form leads to hypocalcemia, secondary hyperparathyroidism, and defective bone mineralization. Calcitriol (active vitamin D) suppresses parathyroid hormone secretion and improves calcium absorption, making it a cornerstone of treatment. Hyperphosphatemia should also be managed with dietary phosphate restriction and phosphate binders.
Learning Point:
Renal osteodystrophy is characterized by hypocalcemia, hyperphosphatemia, elevated alkaline phosphatase, and secondary hyperparathyroidism. Treatment includes calcitriol, phosphate binders, dietary phosphate restriction, and optimization of CKD management.
MCQ NO 9: Chronic kidney disaese/ Renal system MCQ
A 13-year-old boy with stage 5 chronic kidney disease presents with progressive shortness of breath and chest pain that is relieved by sitting forward. On examination, he has a pericardial friction rub. ECG shows diffuse ST-segment elevation. Echocardiography confirms a moderate pericardial effusion.
What is the most appropriate management?
A. Broad-spectrum antibiotics
B. Emergency dialysis
C. High-dose corticosteroids
D. Intravenous furosemide
E. Pericardiocentesis
Correct answer & Explanation:
Correct Answer: B. Emergency dialysis
Explanation
The child has uremic pericarditis, a life-threatening complication of advanced chronic kidney disease caused by accumulation of uremic toxins. The treatment of choice is urgent initiation or intensification of dialysis, which usually leads to resolution of pericarditis. Pericardiocentesis is reserved for patients who develop cardiac tamponade or have a large symptomatic effusion that does not respond to dialysis.
Learning Point:
Uremic pericarditis is an absolute indication for urgent dialysis in patients with advanced CKD.
MCQ NO 10: Chronic kidney disease/Renal system MCQ
A 14-year-old boy undergoing regular follow-up for chronic kidney disease complains of increasing numbness around the mouth and painful muscle spasms over the last two days. On examination, Chvostek’s sign is positive. Laboratory investigations show:
- Serum calcium: 6.9 mg/dL
- Serum phosphate: 7.4 mg/dL
- Serum creatinine: 5.2 mg/dL
Which complication of chronic kidney disease is the most likely cause of these findings?
A. Hyperkalemia
B. Metabolic acidosis
C. Renal osteodystrophy
D. Uremic encephalopathy
E. Volume overload
Correct answer & Explanation:
correct Answer: C. Renal osteodystrophy
Explanation: Chronic kidney disease causes phosphate retention and reduced calcitriol production, resulting in hypocalcemia and secondary hyperparathyroidism. Symptomatic hypocalcemia with tetany is a manifestation of renal osteodystrophy (CKD-MBD).