MCQs. The following statements are true / false

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1 HK J Paediatr (new series) 2004;9:89-95 MCQs Instruction: 1. Please use pencil to shade the box for the correct answer (see loose leaf page). 2. Send back the answer sheet to the Hong Kong College of Paediatricians for the award of 4 CME points for those with >50% correct answers. The following statements are true / false (A) What's New in Childhood Hypertension? 1. Which of the following statements are correct? Systolic hypertension:- a. Is less common in children than diastolic hypertension. b. Is, in adults, a cardiovascular risk factor. c. Is more closely related to left ventricular mass than diastolic hypertension in childhood. d. If treated, in adults, is not beneficial compared to placebo in terms of myocardial infarct or stroke. 2. Which of the following statements are incorrect? Primary hypertension:- a. Is not associated with obesity. b. Has its origins in foetal life and is linked to low birthweight and rapid postnatal growth. c. Is influenced by social conditions in childhood. d. Is a monogenic disorder. 3. Which of the following statements do you agree with? Secondary hypertension in childhood:- a. If due to renovascular disease can accurately be diagnosed using Doppler ultrasonography and ACE inhibitor renography. b. Associated with marked hypokalaemia and a high plasma renin is suggestive of Liddle's syndrome. c. Is commonly due to reflux nephropathy. d. If considered to be due to phaeochromocytoma could be helpfully investigated using MIBG scanning technology. 4. Which of the following statements do you not agree with? Ambulatory blood pressure monitoring:- a. Is a helpful means of identifying white coat hypertension. b. Identifies abnormal blood pressure by means of demonstrating nocturnal dipping. c. Normal blood pressure ranges are interchangeable with ranges derived using mercury sphygmomanometry. d. Utilising devices validated for adult use can be safely used in children. 5. Which of the following statements are correct? In relation to blood pressure monitoring:- a. Mercury sphygmomanometry can be safely phased out in favour of alternative blood pressure measuring devices. b. Mercury is a considerable health hazard and constitutes a greater risk than environmental exposure. c. Aneroid manometers are the best alternative to mercury on the basis of accuracy and reliability. d. Oscillometric devices record diastolic blood pressure by a sudden decrease in arterial wall oscillation. (B) Infant Dialysis 1. The following statement about the incidence of infants with ESRF is true: a. It represents more than 20% of paediatric ESRF b. It represents about 15-20% of paediatric ESRF c. It represents about 10-15% of paediatric ESRF d. It represents about 5-10% of paediatric ESRF e. It represents <5% of paediatric ESRF 2. The commonest cause of ESRF in infants is: a. Focal segmental glomerulosclerosis. b. Posterior urethral valve. c. Congenital nephrotic syndrome. d. Renal dysplasia. e. Pelvic-ureteral junction obstruction.

2 90 3. Which of the following on the decision to initiate infant dialysis is false: a. "wait and see" policy. b. The decision is reversible. c. A joint decision should be arrived with the involvement of the parents. d. Co-morbid conditions of the infant should be taken into account. e. Emotional and financial burden to the family should not affect the decision. 4. Which of the following is often not required in the management of infants on dialysis: a. Erythropoietin. b. Phosphate binders. c. Activated vitamin D. d. Potassium supplements. e. Recombinant human growth hormone. 5. Regarding outcome, which of the following is not true for infant dialysis: a. It is often related to co-morbid conditions. b. Peritonitis is common and dialysis inadequacy often a problem. c. Normal growth and development can hardly be achieved. d. Because of encouraging outcome, infant dialysis should now be considered the standard of care. e. Survival in otherwise normal infants is similar to older children. (C) Management Options for Henoch-Schönlein Nephritis: Evidence-based Approach 1. The long-term prognosis for Henoch-Schönlein purpura depends on: a. Severity of purpuric rash. b. Number of relapses. c. Degree of renal involvement. d. Identification of an infective organism. e. Number of joints involvement. 2. Which of the followings best describe the long-term outcome of renal function in patients with Henoch- Schönlein nephritis: a. Degree of hypertension. b. Serum creatinine at presentation. c. Degree of hypoalbuminemia. d. Degree of proteinuria. e. Presenting renal histology. 3. In which of the following circumstances, corticosteroid has been used to treat patients with Henoch-Schönlein purpura: a. To prevent the onset of Henoch-Schönlein nephritis. b. To treat Henoch-Schönlein nephritis with nephrotic syndrome. c. To treat Henoch-Schönlein nephritis with rapidly deteriorated renal function. d. To treat severe abdominal pain in Henoch-Schönlein purpura. e. All of the above. 4. Which of the following agents is used in the treatment of rapidly progressive Henoch-Schönlein nephritis: a. Cyclophoshamide. b. Angiotensin II inhibitor. c. Methotrexate. d. Cyclosporin A. e. FK Patients recovered from Henoch-Schönlein nephritis may develop renal complication: a. One month from the onset of the disease. b. Ten years later after an apparent normality. c. During pregnancy. d. None of the above. e. All of the above. (D) Lessons from a Limited Paediatric Renal Registry The following statements about childhood nephrotic syndrome are true: a. From 1998 to 2000, there were 2 new cases of congenital nephrotic syndrome in Hong Kong. b. Most cases of secondary nephrotic syndrome in Hong Kong children were due to systemic lupus erythematosus and Henoch-Schönlein purpura. c. Children with nephrotic syndrome were subjected to renal biopsy only if they were resistant to steroid treatment. d. If they were steroid sensitive but dependent, renal biopsy most likely yielded minimal change disease, diffuse mesangial proliferation, or IgM nephropathy. e. There were controversy whether to perform renal biopsy if children showed steroid response but steroid dependence.

3 91 2. From the renal registry in 1998 to 2000 in the public hospital in Hong Kong, the following statements are true: a. There were about 7 new cases of chronic renal failure in children below 15 years old each year. b. About 4-5 patients entered the stage of endstage renal disease each year in children below 15 years old. c. The approximate number of new cases of childhood nephrotic syndrome was 57 per year. d. About 66 children underwent renal biopsies for evaluation of their renal diseases each year. e. There were about 10 new cases of childhood lupus nephritis each year. (E) Symptomatic Urinary Tract Infection in Children: Experience in a Regional Hospital in Hong Kong 1. Urinary tract infection (UTI) is more common in: a. Girls. b. Adolescent. c. Infants. d. Black. 2. Escherichia coli: a. Accounts for 80% of UTI in children. b. Causes significant renal scarring. c. Associated with grading of VUR. d. Is the commonest microorganism in recurrent UTI. 3. Vesicoureteric reflux: a. Is common in male. b. Is positively related to renal scarring. c. Is a risk factor of recurrent UTI. d. About 80% will be resolved spontaneously. 4. Renal scarring: a. Is associated with VUR. b. Is more in female. c. Is more on the left side. d. Is common in E. coli UTI. 5. Young children with first UTI: a. Should perform circumcision in boys. b. Should undergo ultrasound scan and voiding cystourethrogram. c. Napkin use is a risk factor. d. Fever is the commonest presentation. (F) Haemofiltration: Experience in a Local Paediatric Intensive Care Unit 1. The advantages of haemofiltration over the other means of renal replacement therapy: a. Technique simplicity. b. Haemodynamic stability. c. Better urea clearance. d. Less effect on respiration. 2. The choice of haemofilters was guided by: a. Patient's age. b. Patient's primary disease. c. Patient's size and body surface area. d. Patient's renal function before haemofiltration. 3. When heparin is used for anticoagulation during haemofiltration, the activated partial thrombin time (aptt) should be kept at: a X of normal. b X of normal. c X of normal. d X of normal. 4. In the QEH observational study, what was the major complication in haemofiltration?: a. Infection. b. Shock. c. Blockage of circuit. d. Haemorrhage. 5. The mortality of patients receiving haemofiltration was mostly related to: a. Urea and creatinine level. b. Complications of procedure. c. Underlying diseases. d. Electrolyte disturbances. (G) Automated Peritoneal Dialysis: Clinical Experience in 32 Children 1. Which of the following statements is / are correct?: a. A cycler machine is required for continuous ambulatory peritoneal dialysis (CAPD). b. A cycler machine is required for automated peritoneal dialysis (APD). c. The children will have uninterrupted daytime activities while on APD. d. APD can deliver higher dialysis dose than CAPD. e. CAPD is more suitable for paediatric patients with end stage renal disease than APD.

4 92 2. The followings are the different treatment modalities of automated peritoneal dialysis except: a. Nightly intermittent peritoneal dialysis (NIPD). b. Continuous ambulatory peritoneal dialysis (CAPD). c. Continuous cyclic peritoneal dialysis (CCPD). d. High dose CCPD. e. Tidal peritoneal dialysis (TPD). 3. Which of the following concerning peritoneal equilibration test is / are correct?: a. The peritoneal equilibration test can characterise the peritoneal membrane transport rate. b. The peritoneal membrane transport rate can be classified into high, high average, low average and low transporters. c. High and high average transporters are more suitable for CAPD than APD. d. In peritoneal equilibration test, a peritoneal dialysate of 1.5% is used. e. The peritoneal equilibration test was done only in the initiation of peritoneal dialysis. 4. Which of the following statements about peritonitis in children on peritoneal dialysis is / are correct: a. Peritonitis is defined as cloudy peritoneal effluent with dialysate white blood cell >100 cells/ul, with >50% neutrophil. b. A positive peritoneal fluid culture is required for diagnosis of peritonitis. c. Recent studies have shown that the peritonitis rate is higher in APD than in CAPD. d. Peritonitis is associated with complications such as catheter replacement and technique failure. e. The low peritonitis rate is important for children on peritoneal dialysis as it can preserve the peritoneal membrane function longer. 5. The adequacy of peritoneal dialysis is associated with the followings: a. Presence or abscence of uraemic symptoms. b. Nutritional state. c. Growth. d. Duration on dialysis. e. Weekly Kt/V urea and total weekly creatinine clearance. (H) Is Early Morning Urine Osmolality a Good Predictor of Response to Oral Desmopressin in Children with Primary Monosymptomatic Nocturnal Enuresis? 1. According to the DSM IV and ICD-10, the socially accepted age for achieving bladder control during sleep is: a. 3 years old. b. 4 years old. c. 5 years old. d. 6 years old. e. 7 years old. 2. The spontaneous remission rate of nocturnal enuresis per year is: a. 8%. b. 10%. c. 12%. d. 15%. e. 18%. 3. Which of the following is not an etiology of primary nocturnal enuresis?: a. Genetic factors. b. Nocturnal oliguria. c. Ingestion of caffeine. d. Abnormal bladder function. e. Delayed development. 4. The natural occurring anti-diuretic hormone in our body is called: a. Desmopressin. b. Somatostatin. c. Angiotensin. d. Aldosterone. e. Vasopressin. 5. Which of the following is not a good predictor for children with primary nocturnal enuresis under desmopressin treatment? a. Young age. b. Frequency of wet nights per week. c. Frequency of bedwetting once per night. d. Timing of bedwetting at night. e. Early morning urine osmolality.

5 93 (I) Primary Nocturnal Enuresis: Patient Attitudes and Parental Perceptions 1. The following statements about childhood nocturnal enuresis are true: a. Primary nocturnal enuresis is commoner in girls than boys. b. The prevalence of nocturnal enuresis is about 15% in boys aged 5 years. c. In late adolescents and early adults, nocturnal enuresis is still present in 5% of the d. Children with nocturnal enuresis always have low selfesteem. e. Children with nocturnal enuresis may have poor school performance. 2. From the questionnaire survey, the following findings are true: a. Children with nocturnal enuresis were observed to be deep sleepers. b. A positive family history of enuresis was found in two-thirds of children with nocturnal enuresis. c. The majority of the siblings of children with nocturnal enuresis also had bedwetting. d. Most children with nocturnal enuresis sleep in single rooms so they would not disturb other family members. e. Most children did not get up to toilet even if they are awakened by the bedwetting. 3. From the questionnaire survey, the following statements are true: a. Children with enuresis avoid talking about the bedwetting. b. A large proportion of children with enuresis still wear nappy at sleep. c. 50% of the children with nocturnal enuresis will not sleep out of home. d. Most parents thought that their children with nocturnal enuresis had neurological diseases. e. About half of the parents thought that enuresis in their children was caused by kidney or bladder diseases. 4. From the questionnaire survey, the parents attitudes in response to their enuretic children were: a. Most were worried about organic diseases in their children. b. Most felt that their children were troublesome to look after. c. A positive family history did not significantly change parental beliefs about the cause of enuresis. d. Most were angry toward their children for having the bedwetting. e. Punishment were commonly used to stop the bedwetting. 5. From the questionnaire survey, common methods tried by parents to prevent enuresis were: a. Limiting fluid intake at night. b. Waking children up in the middle of night to go to toilet. c. Taking herbal medicines. d. Encouragement and reward to children when they are dry at night. e. Giving their children a cup of hot milk before sleep. (J) Can We Prevent Chronic Renal Failure in Children? 1. The following are usual complications of chronic renal failure in children: a. Attention deficit and hyperactivity disorder. b. Fall in body height standard deviation score. c. Metabolic alkalosis. d. Severe anemia despite adequate dietary iron intake. e. Genu valgum deformity of knees. 2. The common causes of chronic renal failure in Hong Kong children are: a. Hypercalciuria. b. Focal segmental glomerulonephritis. c. Alport's syndrome. d. IgA nephropathy. e. Thin membrane disease. 3. The following statement about chronic glomerulonephritis in Hong Kong are true: a. Minimal change disease is the commonest histological diagnosis. b. IgA nephropathy always have good recovery of renal function. c. Some patients may present with isolated proteinuria or haematuria. d. Systemic lupus erythematosus with chronic glomerulonephritis is usually treated with steroid alone. e. Renal biopsy are usually needed to confirm the diagnosis when patient has both haematuria and proteinuria. 4. The following are accepted standard treatment for chronic renal failure in children: a. Growth hormone therapy. b. Sodium bicarbonate. c. Vitamin E tablets.

6 94 d. Anti-hypertensive drugs. e. Angiotensin converting enzyme inhibitors. 5. The following statements are true: a. Infants who are afebrile but have a bag urine culture yielding mixed growth are diagnosed as having urinary tract infection. b. All infants who had bilateral dilatation of renal pelves detected at birth are advised to undergo micturiting cystourethrogram. c. All children with chronic renal failure should have a restricted intake of protein to 0.6 g/kg/day. d. Lupus nephritis are now commonly treated with intravenous cyclophosphamide. e. The child with nephrotic syndrome and persistently low complement C3 should be referred to nephrologist assessment. (K) Laparoscopy In Paediatric Urology: Recent Advances 1. Indications for performing a laparoscopic varicocoelectomy include symptomatic patients, testicular growth retardation and subclinical varices. 2. Laparoscopy in intersex disorders may be both diagnostic and therapeutic. 3. Laparoscopy in the management of underscended testis emerged since none of the existing imaging modalities were able to accurately identify the presence and location of an undescended testis with certainty as compared with laparoscopy. 4. Endoscopic incision of ureterocoeles has eliminated the need for subsequent definitive surgery in extravesical ureterocoeles. 5. Cystoscopic subureteric injection (STING) is the treatment of choice in high grade vesicoureteral reflux. (L) An Update Overview on Paediatric Renal Transplantation 1. The best treatment option for ESRD in children: a. Peritoneal dialysis. b. Haemodialysis. c. Cadaver kidney transplant. d. Living kidney transplant. e. CVVH. 2. Which of the following immunosuppressants is not used in kidney transplant: a. Cyclosporin. b. MMF. c. Cyclophosphamide. d. Azathioprine. e. Sirolomus. 3. According to NAPRCTS, What is the 5- year living graft survival: a %. b %. c %. d %. e %. 4. According to UNOS, which of the following has the worst 7-year living graft survival Transplant done in: a. <2 yrs boys. b. <2 yrs girls. c. 2-5 yr. d yr. e yr. 5. What is the most common cause for overall graft loss: a. Vascular thrombosis. b. Acute rejection. c. Chronic rejection. d. Recurrence of original diseases. e. Non-compliance of medication. (M)A Tuberous Sclerosis Girl with Huge Nephromegaly 1. Which of the following is NOT the recommended screening test for monitoring progress of tuberous sclerosis patients? a. Ophthalmic examination. b. Renal USG. c. Chest CT. d. 24 hr Holter study. e. Cranial MRI. 2. Which of the following statement is TRUE? a. AML is always benign. b. Only 10% of tuberous sclerosis patient have AML by age of 10. c. AML occur in kidney only. d. HMB-45 is a useful maker for AML. e. It is safe to keep observe for AML >8 cm size.

7 95 3. Common presentation of AML include the following EXCEPT: a. Diffuse abdominal discomfort. b. Haematuria. c. Renal failure. d. Hypertension. e. Heart failure. 5. Which of the following is the first-line treatment of choice for AML? a. Radiotherapy. b. Selective arterial embolisation. c. Nephron-sparing nephrectomy. d. Chemotherapy. e. Total nephrectomy. 4. The following are complication of large AML EXCEPT: a. Metastsis. b. Spontaneous haemorrhage. c. Compression of other organs. d. Respiratory distress. e. Renal failure. CLINICAL QUIZ (p82) ANSWER 1. Figure 1 shows the left kidney was enlarged with mild hydronephrosis and multiple small cysts (measured 1-3 mm in size) replacing the renal parenchyma. The normal corticomedullary demoration was lost. Figure 2 showed the liver was grossly enlarged. Hepatic ductal ectasia was seen. Figure 3 showed a contrast nephrogram with striated pattern. The kidneys were enlarged. The striated nephrogram after contrast material administration represented the dilated collecting ducts in the kidneys 1 and was a typical radiological feature of ARPKD. The classical ultrasound findings of ARPKD in neonatal period are bilaterally enlarged echogenic kidneys with loss of corticomedullary differentiation. Cysts are usually very small and may not be detected easily in neonates and they are better characterised in older patients. 2. The diagnosis was autosomal recessive polycystic kidney disease (ARPKD). 1,2 ARPKD is a heritable but phenotypically variable disorder. It is characterised by varying degree of non-obstructive renal collecting duct ectasia, hepatic biliary duct ectasia and fibrosis of both liver and kidneys. In severe cases, the dilated collecting ducts and interstitial fibrosis may significantly impair renal function and result in renal failure whereas periportal fibrosis accompanies the malformed and dilated bile ducts may result in portal hypertension. 3 References 1. Lonergan GJ, Rice RR, Suarez ES. Autosomal Recessive Polycystic Kidney Disease: Radiologic-Pathologic Correlation. Radiographics 20: McDonald AR, Avner ED. Inherited Polycystic Kidney Disease in Children. Semin Nephrol 1991, 11: Dische F. Structure and Development of the Kidney and Cystic Disease. In: Renal Pathology, second edition. Oxford Medical Publication, 1995:7-21.