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228 Cards in this Set

  • Front
  • Back
What does it tell you if there are casts in the urine?
Hematuria / pyuria is of renal origin (vs bladder if there are no casts)
What are the types of casts that can be present in the urine?
- RBC casts
- WBC casts
- Fatty casts ("oval fat bodies")
- Granular ("muddy brown") casts
- Waxy casts
- Hyaline casts
What can RBC casts in the urine indicate?
- Glomerulonephritis
- Ischemia
- Malignant hypertension
What can WBC casts in the urine indicate?
- Tubulointerstitial inflammation
- Acute pyelonephritis
- Transplant rejection
What can fatty casts ("oval fat bodies") in the urine indicate?
Nephrotic syndrome
What can granular ("muddy brown") casts in the urine indicate?
Acute Tubular Necrosis
What can waxy casts in the urine indicate?
Advanced renal disease / chronic renal failure
What can hyaline casts in the urine indicate?
Non-specific, can be a normal finding, often seen in concentrated urine samples
What can hematuria without casts in the urine indicate?
- Bladder cancer
- Kidney stones
What can pyuria (pus) with no casts in the urine indicate?
Acute Cystitis
What terms can be used to describe glomerular disorders?
- Focal vs Diffuse
- Proliferative
- Membranous
- 1° Glomerular disease
- 2° Glomerular disease
What does the term "focal" mean when naming a glomerular disorder? Example?
<50% of glomeruli are involved
- Eg: focal segmental glomerulosclerosis
What does the term "diffuse" mean when naming a glomerular disorder? Example?
>50% of glomeruli are involved
- Eg: diffuse proliferative glomerulonephritis
What does the term "proliferative" mean when naming a glomerular disorder? Example?
Hypercellular glomeruli
- Eg: Mesangial Proliferative
What does the term "membranous" mean when naming a glomerular disorder? Example?
Thickening of the glomerular basement membrane
- Eg: Membranous Nephropathy
What does the term "1° Glomerular Disease" tell you about the glomerular disorder? Example?
Involves only glomeruli, thus a 1° disease of the kidney
- Eg: minimal change disease
What does the term "2° Glomerular Disease" tell you about the glomerular disorder? Example?
Involves glomeruli and other organs, thus a disease of another organ system, or a systemic disease that has impact on the kidney
- Eg: SLE and diabetic nephropathy
What are the types of glomerular diseases?
- Nephritic Syndrome
- Nephrotic Syndrome
- Both
What are the types of Nephritic Syndromes?
- Acute Post-Streptococcal Glomerulonephritis
- Rapidly Progressive Glomerulonephritis
- Berger Disease (IgA Glomerulonephropathy)
- Alport Syndrome

*Note that the classic nephritic disorders can exhibit some nephrotic features
What are the types of Nephrotic Syndromes?
- Focal Segmental Glomerulosclerosis
- Membranous Nephropathy
- Minimal Change Disease
- Amyloidosis
- Diabetic Glomerulonephropathy
What are the types of glomerular diseases that are characterized as both Nephritic and Nephrotic Syndromes?
- Diffuse Proliferative Glomerulonephritis
- Membranoproliferative Glomerulonephritis
What makes a renal disease a "Nephrotic syndrome"?
- Massive Pr"O"teinuria (>3.5 g/day, frothy urine)
- Hyperlipidemia
- Fatty casts
- Edema
What are Nephrotic Syndromes associated with? Why?
- Thromboembolism (hypercoagulable state d/t AT III loss in urine)
- Increased risk of infection (due to loss of immunoglobulins)
Which type of nephrotic syndrome is associated with the following LM findings: segmental sclerosis and hyalinosis?
Focal Segmental Glomerulosclerosis
Focal Segmental Glomerulosclerosis
Which type of nephrotic syndrome is associated with the following LM findings: diffuse capillary and GBM thickening?
Membranous Nephropathy
Membranous Nephropathy
Which type of nephrotic syndrome is associated with the following LM findings: normal glomeruli (lipid may be seen in PCT cells)?
Minimal Change Disease (Lipoid Nephrosis)
Which type of nephrotic syndrome is associated with the following LM findings: congo red stain shows apple-green birefringence under polarized light?
Amyloidosis
Which type of nephrotic syndrome is associated with the following LM findings: mesangial expansion, GBM thickening, and eosinophilic nodular glomerulosclerosis (Kimmelstiel-Wilson lesion)?
Diabetic Glomerulonephropathy
Diabetic Glomerulonephropathy
Which type of nephrotic syndrome is associated with the following LM findings: thickened "tram tracks"?
Membrano-Proliferative Glomerulonephritis (Type 1)
- Left: PAS stain
- Right: H&E stain
Membrano-Proliferative Glomerulonephritis (Type 1)
- Left: PAS stain
- Right: H&E stain
Which type of nephrotic syndrome is associated with the following EM findings: effacement of foot processes?
- Focal Segmental Glomerulosclerosis
- Minimal Change Disease (Lipoid Nephrosis) = picture
- Focal Segmental Glomerulosclerosis
- Minimal Change Disease (Lipoid Nephrosis) = picture
Which type of nephrotic syndrome is associated with the following EM findings: "spike-and-dome" appearance with subepithelial deposits?
Membranous Nephropathy
Which type of nephrotic syndrome is associated with the following immunofluorescence findings: granular as a result of immune complex deposition?
Membranous Nephropathy
What is the most common cause of nephrotic syndrome in African Americans and Hispanics?
Focal Segmental Glomerulosclerosis
What is the most common cause of nephrotic syndrome in Caucasian adults?
Membranous Nephropathy
What is the most common cause of nephrotic syndrome in children?
Minimal Change Disease (Lipoid Nephrosis)
Which type of nephrotic syndrome is associated with HIV infection?
Focal Segmental Glomerulosclerosis
Which type of nephrotic syndrome is associated with sickle cell disease?
Focal Segmental Glomerulosclerosis
Which type of nephrotic syndrome is associated with heroin abuse?
Focal Segmental Glomerulosclerosis
Which type of nephrotic syndrome is associated with massive obesity?
Focal Segmental Glomerulosclerosis
Which type of nephrotic syndrome is associated with interferon treatment?
Focal Segmental Glomerulosclerosis
Which type of nephrotic syndrome is associated with chronic kidney disease due to congenital absence or surgical removal?
Focal Segmental Glomerulosclerosis
How do you treat Focal Segmental Glomerulosclerosis? Efficacy? Prognosis?
- Inconsistent response to steroid therapy
- May progress to chronic renal disease
What type of disease is Focal Segmental Glomerulosclerosis? What changes occur in this disease?
Nephrotic Syndrome:
- Segmental sclerosis and hyalinosis
- Effacement of foot processes similar to in minimal change disease
Nephrotic Syndrome:
- Segmental sclerosis and hyalinosis
- Effacement of foot processes similar to in minimal change disease
Which type of nephrotic syndrome is associated with antibody to phospholipase A2 receptor?
Membranous Nephropathy
Which type of nephrotic syndrome is associated with drugs like NSAIDs and penicillamine?
Membranous Nephropathy
Which type of nephrotic syndrome is associated with infections like HBV and HCV?
Membranous Nephropathy
Which type of nephrotic syndrome is associated with Systemic Lupus Erythematosus?
Membranous Nephropathy
Which type of nephrotic syndrome is associated with solid tumors?
Membranous Nephropathy
How do you treat Membranous Nephropathy? Efficacy? Prognosis?
- Poor response to steroid therapy
- May progress to chronic renal disease
What type of disease is Membranous Nephropathy? What changes occur in this disease?
Nephrotic Syndrome
- Diffuse capillary and GBM thickening
- Granular immunofluorescence as a result of immune complex deposition
- "Spike and dome" appearance on EM with subepithelial deposits
Nephrotic Syndrome
- Diffuse capillary and GBM thickening
- Granular immunofluorescence as a result of immune complex deposition
- "Spike and dome" appearance on EM with subepithelial deposits
Which type of nephrotic syndrome may be triggered by a recent infection, immunization, or other immune stimulus?
Minimal Change Disease (Lipoid Nephrosis)
Which type of nephrotic syndrome is associated with Hodgkin Lymphoma (eg, cytokine-mediated damage)?
Minimal Change Disease (Lipoid Nephrosis)
How do you treat Minimal Change Disease (Lipoid Nephrosis)? Efficacy? Prognosis?
Excellent response to corticosteroids
What type of disease is Minimal Change Disease (Lipoid Nephrosis)? What changes occur in this disease?
Nephrotic Syndrome:
- Normal glomeruli (lipid may be seen in PCT cells)
- Effacement of foot processes
Nephrotic Syndrome:
- Normal glomeruli (lipid may be seen in PCT cells)
- Effacement of foot processes
Which type of nephrotic syndrome is associated with chronic conditions like multiple myeloma, TB, or Rheumatoid arthritis?
Amyloidosis
Amyloidosis most commonly affects what organ?
Kidney is the most common organ involved in systemic amyloidosis
What type of disease is Amyloidosis that affects the kidney? How do you make diagnosis?
Nephrotic Syndrome
- Congo red stain shows apple-green birefringence under polarized light
What are the types of membrano-proliferative glomerulonephritis?
- Type I: subendothelial immune complex (IC) deposits with granular immunofluorescence - "tram-track" appearance
- Type II: intramembranous IC deposits - "dense deposits"
Which type of nephrotic syndrome is associated with HBV and HCV? What type of deposits? Appearance?
Type I Membrano-Proliferative Glomerulonephritis
- Subendothelial immune complex (IC) deposits
- Granular IF
- "Tram-track" appearance due to GBM splitting caused by mesangial ingrowth
Type I Membrano-Proliferative Glomerulonephritis
- Subendothelial immune complex (IC) deposits
- Granular IF
- "Tram-track" appearance due to GBM splitting caused by mesangial ingrowth
Which type of nephrotic syndrome is associated with C3 nephritic factor? Function? What type of deposits are seen in this type of nephrotic syndrome?
Type II Membrano-Proliferative Glomerulonephritis
- C3 nephritic factor stabilizes C3 convertase → ↓ serum C3 levels
- Intramembranous immune complex (IC) deposits
- "Dense deposits"
What type of renal disease is Membrano-Proliferative Glomerulonephritis?
Nephritic syndrome that can also present with nephrotic syndrome
What causes the renal damage in Diabetic Glomerulonephropathy?
- Non-enzmatic glycosylation of GBM → ↑ permeability, thickening
- Non-enzymatic glycosylation of efferent arterioles → ↑ GFR → mesangial expansion
What type of disease is Diabetic Nephropathy? What changes occur in this disease?
Nephrotic Syndrome
- Mesangial expansion
- GBM thickening
- Eosinophilic nodular glomerulosclerosis (Kimmelstiel-Wilson lesion)
Nephrotic Syndrome
- Mesangial expansion
- GBM thickening
- Eosinophilic nodular glomerulosclerosis (Kimmelstiel-Wilson lesion)
What makes a renal disease a "Nephritic syndrome"?
"I"nflammatory process
- When it involves glomeruli, it leads to hematuria and RBC casts in the urine
- Associated with azotemia (abnormally high levels of nitrogen-containing compounds in blood), oliguria, hypertension (d/t salt retention), and proteinuria (<3.5 g/day)
How do Nephrotic Syndromes and Nephritic Syndromes compare in terms of the proteinuria?
- Nephrotic Syndrome: >3.5 g/day
- Nephritic Syndrome: <3.5 g/day
How do Nephrotic Syndromes and Nephritic Syndromes compare in terms of the urine casts?
- Nephrotic Syndrome: fatty casts
- Nephritic Syndrome: RBC casts
Which type of nephritic syndrome is associated with the following LM findings: glomeruli enlarged and hypercellular?
Acute Post-Streptococcal Glomerulonephritis
Which type of nephritic syndrome is associated with the following LM findings: crescent-moon-shape consisting of fibrin and plasma proteins (eg, C3b) with glomerular parietal cells, monocytes, and macrophages?
Rapidly Progressive (Crescentic) Glomerulonephritis (RPGN)
Rapidly Progressive (Crescentic) Glomerulonephritis (RPGN)
Which type of nephritic syndrome is associated with the following LM findings: wire looping of capillaries?
Diffuse Proliferative Glomerulonephritis (DPGN)
Which type of nephritic syndrome is associated with the following LM findings: mesangial proliferation?
IgA Nephropathy (Berger Disease)
Which type of nephritic syndrome is associated with the following EM findings: subepithelial immune complex (IC) humps?
Acute Post-Streptococcal Glomerulonephritis
Which type of nephritic syndrome is associated with the following EM findings: subendothelial and sometimes intramembranous IgG based immune complexes often with C3 deposition?
Diffuse Proliferative Glomerulonephritis (DPGN)
Which type of nephritic syndrome is associated with the following EM findings: mesangial immune complex deposits?
IgA Nephropathy (Berger Disease)
Which type of nephritic syndrome is associated with the following immunofluorescence findings: "starry sky" granular appearance ("lumpy-bumpy) due to IgG, IgM, and C3 deposition along GBM and mesangium?
Acute Post-Streptococcal Glomerulonephritis
Which type of nephritic syndrome is associated with the following immunofluorescence findings: crescent-moon-shape consisting of fibrin and plasma proteins (eg, C3b) with glomerular parietal cells, monocytes, and macrophages?
Rapidly Progressive (Crescentic) Glomerulonephritis (RPGN)
Which type of nephritic syndrome is associated with the following immunofluorescence findings: granular?
Diffuse Proliferative Glomerulonephritis (DPGN)
Which type of nephritic syndrome is associated with the following immunofluorescence findings: IgA based immune complex deposits in mesangium?
IgA Nephropathy (Berger Disease)
What type of renal pathology is Acute Post-Streptococcal Glomerulonephritis? Who is more likely to have this kind of damage? Cause?
Nephritic Syndrome
- Most frequently in children
- Occurs ~2 weeks after group A streptococcal infection of pharynx or skin; type III hypersensitivity reaction
- Resolves spontaneously
What type of reaction mediates Acute Post-Streptococcal Glomerulonephritis?
Type III Hypersensitivity reaction (antigen-antibody complexes) to group A streptococcal infection of pharynx or skin
What renal pathology presents with peripheral and periorbital edema, dark urine (cola-colored), and hypertension? What lab values would you check?
Acute Post-Streptococcal Glomerulonephritis:
- ↑ Anti-DNase B titers
- ↓ Complement levels
What type of renal pathology is Rapidly Progressive Glomerulonephritis (RPGN)? What disease processes may result in this pattern?
Nephritic Syndrome:
- Goodpasture Syndrome
- Granulomatosis with Polyangiitis (Wegener)
- Microscopic Polyangiitis
What type of renal pathology is caused by Goodpasture Syndrome? What findings are associated with this syndrome?
Rapidly Progressive Glomerulonephritis (RPGN)
- Type II hypersensitivity (antibodies produced by the immune response bind to antigens on the patient's own cells)
- Abs to GBM and alveolar basement membrane → linear immunofluorescence
- Presents with hematuria and hemoptysis
What type of renal pathology is caused by Granulomatosis with Polyangiitis (Wegener)? What findings are associated with this syndrome?
Rapidly Progressive Glomerulonephritis (RPGN)
- PR3-ANCA / c-ANCA
What type of renal pathology is caused by Microscopic Polyangiitis? What findings are associated with this syndrome?
Rapidly Progressive Glomerulonephritis (RPGN)
- MPO-ANCA / p-ANCA
What is the prognosis for Rapidly Progressive Glomerulonephritis (RPGN)?
- Poor prognosis
- Rapidly deteriorating renal function (days to weeks)
What is the most common cause of death in patient with SLE? What type of pathology is this?
Diffuse Proliferative Glomerulonephritis (DPGN)
- Can present as nephrotic syndrome and nephritic syndrome concurrently
Which type of renal pathology often presents or flares with a URI or acute gastroenteritis? Signs?
IgA Nephropathy (Berger Disease) = Nephritic Syndrome
- Episodic hematuria with RBC casts
Which type of renal pathology is caused by a mutation in type IV collagen? Implications?
Alport Syndrome = Nephritic Syndrome
- Thinning and splitting of glomerular BM
- Presents with glomerulonephritis, deafness, and less commonly, eye problems
What is the cause of Alport Syndrome?
- Mutation in type IV collagen → thinning and splitting of glomerular BM
- Most commonly X-linked
Which type of renal pathology presents with glomerulonephritis, deafness, and less commonly eye problems?
Alport Syndrome
What type of disease is Acute Post-Streptococcal Glomerulonephritis? What changes occur in this disease?
Nephritic Syndrome
- Glomeruli enlarge and become hypercellular
- IgG, IgM, and C3 deposition along GBM and mesangium leads to "Starry sky" granular appearance ("lumpy-bumpy) on immunofluorescence
- Subepithelial immune complex (IC) humps
What type of disease is Rapidly Progressive Glomerulonephritis? What changes occur in this disease?
Nephritic Syndrome
- Crescent-moon shape consists of fibrin and plasma proteins (eg, C3b) with glomerular parietal cells, monocytes, and macrophages
Nephritic Syndrome
- Crescent-moon shape consists of fibrin and plasma proteins (eg, C3b) with glomerular parietal cells, monocytes, and macrophages
What type of disease is Diffuse Proliferative Glomerulonephritis (DPGN)? What changes occur in this disease?
Nephritic Syndrome
- "Wire looping" of capillaries
- Subendothelial and sometimes intramembranous IgG-based immune complexes, often with C3 deposition
- Granular appearance on immunofluorescence
What type of disease is IgA Nephropathy? What changes occur in this disease?
Nephritic Syndrome
- Mesangial proliferation
- Mesangial immune complex deposits
- IgA based immune complex deposits in mesangium
- Seen with Henoch-Schönlein purpura
What type of disease is Alport syndrome? What changes occur in this disease?
Nephritic Syndrome
- Glomerulonephritis - thinning and splitting of glomerular BM
- Deafness
- Eye problems (less commonly)
What diagnosis should you consider in a patient presenting with unilateral flank tenderness, colicky pain radiating to groin, and hematuria? Treatment/Prevention?
Kidney Stones
- Treat and prevent by encouraging fluid intake
What are the potential complications of kidney stones?
- Hydronephrosis
- Pyelonephritis
What are the types of kidney stones based on content? How common?
- Calcium (80%)
- Ammonium magnesium phosphate (15%)
- Uric acid (5%)
- Cystine (1%)
What kind of kidney stones precipitate with ↑ pH?
- Calcium phosphate
- Ammonium magnesium phosphate
What kind of kidney stones precipitate with ↓ pH?
- Calcium oxalate
- Uric acid
- Cystine
What kind of kidney stones appear radiopaque on x-ray?
- Calcium phosphate and calcium oxalate
- Ammonium magnesium phosphate
- Cystine
What kind of kidney stones appear radiolucent on x-ray?
Uric Acid (think radiol"U"cent for "U"ric acid)
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
Calcium kidney stones
- This is the "envelope" type of calcium urine crystal
- There is also a dumbbell shaped urine crystal
Calcium kidney stones
- This is the "envelope" type of calcium urine crystal
- There is also a dumbbell shaped urine crystal
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
Ammonium magnesium phosphate kidney stones
- This is the "coffin lid" type of urine crystal
Ammonium magnesium phosphate kidney stones
- This is the "coffin lid" type of urine crystal
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
Uric Acid kidney stones
- Rhomboid or rosettes appearing urine crystals
Uric Acid kidney stones
- Rhomboid or rosettes appearing urine crystals
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
If your patient presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria, and the following urine crystals are identified, what should you diagnose?
Cystine kidney stones
- Hexagonal appearing urine crystals
Cystine kidney stones
- Hexagonal appearing urine crystals
What is the most common kidney stone presentation?
Calcium oxalate stone in a patient with hypercalciuria and normalcalcemia
Calcium kidney stones can be composed of what? What promotes their formation?
- Content: calcium oxalate, calcium phosphate, or both
- Promoted by hypercalciuria: idiopathic or 2° to conditions that cause hypercalcemia such as cancer or ↑ PTH)
What can cause calcium oxalate crystals to form?
- Ethylene glycol (anti-freeze)
- Vitamin C abuse
- Crohn disease
How do you treat patients with recurrent calcium kidney stones?
- Thiazide diuretics
- Citrate
What type of renal pathology is also known as "struvite"?
Ammonium Magnesium Phosphate kidney stones
What causes Ammonium Magnesium Phosphate kidney stones / Struvite?
Infection with urease (+) bugs:
- Proteus mirabilis
- Staphylococcus
- Klebsiella

These bugs hydrolyze urea to ammonia → urine alkalinization
What are potential complications of Ammonium Magnesium Phosphate kidney stones / Struvite?
Staghorn calculi (picture) → can be a nidus for UTIs
Staghorn calculi (picture) → can be a nidus for UTIs
How do you treat Ammonium Magnesium Phosphate kidney stones / Struvite?
- Eradicate underlying infection (Proteus mirabilis, Staphylococcus, or Klebsiella)
- Surgical removal of stone
What type of kidney stone is likely to form in a patient with ↓ urine volume, acidic pH, and arid climate?
Uric Acid
How can you identify a Uric Acid kidney stone?
- Visible on CT and Ultrasound, but not on x-ray (radiolucent)
- Strongly associated with hyperuricemia (eg, gout)
What are Uric Acid kidney stones associated with?
- Hyperuricemia (eg, Gout)
- Diseaes with ↑ cell turnover, such as leukemia
How do you treat patients with Uric Acid kidney stones?
Alkalinization of urine
Who is more likely to get Cystine kidney stones? What is the most common cause?
- Mostly seen in children
- Secondary to cystinuria
How can you diagnose a patient with having Cystine kidney stones?
- Sodium nitroprusside test is positive 
- Look at crystals (hexagonal)
- Sodium nitroprusside test is positive
- Look at crystals (hexagonal)
What are the potential complications of Cystine kidney stones?
Can form staghorn calculi
Can form staghorn calculi
How do you treat a patient with Cystine kidney stones?
- Alkalinization of urine
- Hydration
What is the term for the distention / dilation of the renal pelvis and calyces?
Hydronephrosis
Hydronephrosis
What are the most common causes of Hydronephrosis?
- Urinary tract obstruction: eg, renal stones, BPH, cervical cancer, injury to ureter
- Retroperitoneal fibrosis
- Vesicoureteral reflux
What findings occur in Hydronephrosis? Complications?
- Distention / dilation of renal pelvis and calyces proximal to site of pathology
- Only impairs renal function if bilateral or patient only has one kidney
- Leads to compression atrophy of renal cortex and medulla
- Distention / dilation of renal pelvis and calyces proximal to site of pathology
- Only impairs renal function if bilateral or patient only has one kidney
- Leads to compression atrophy of renal cortex and medulla
What is the most common primary renal malignancy? Origin?
Renal Cell Carcinoma
- Originates from proximal tubule cells → polygonal clear cells (picture) filled with lipids and carbohydrates
Renal Cell Carcinoma
- Originates from proximal tubule cells → polygonal clear cells (picture) filled with lipids and carbohydrates
In whom is Renal Cell Carcinoma most common?
- Most common in men 50-70 years old
- ↑ incidence in patients who smoke and are obese
What diagnosis should you consider in a patient with hematuria, a palpable mass, 2° polycythemia, flank pain, fever, and weight loss?
Renal Cell Carcinoma
Renal Cell Carcinoma
What are the most common locations for Renal Cell Carcinoma to spread to? Significance?
- Invades renal vein then IVC to spread hematogenously
- Metastasizes to lung and bone
- "Silent" cancer because it commonly presents as a metastatic neoplasm
What genetic change is associated with Renal Cell Carcinoma?
Gene deletion on chromosome 3 (sporadic or inherited as von Hippel-Lindau syndrome)

RCC = 3 letters = chromosome 3
What is Renal Cell Carcinoma associated with?
Paraneoplastic syndromes:
- Ectopic EPO
- Ectopic ACTH
- Ectopic PTHrP
How do you treat Renal Cell Carcinoma?
- Resection if localized disease
- Immunotherapy or targeted therapy for advanced / metastatic disease
- Resistant to chemotherapy and radiation therapy
What is the typical presentation of Renal Cell Carcinoma?
- Commonly silent because it often only presents once it has metastasized
- Hematuria
- Palpable mass
- 2° polycythemia
- Flank pain
- Fever
- Weight loss
Which type of renal tumor presents as a well-circumscribed mass with a central scar? Benign or malignant? Source?
Which type of renal tumor presents as a well-circumscribed mass with a central scar? Benign or malignant? Source?
Renal oncocytoma
- Benign epithelial cell tumor
Renal oncocytoma
- Benign epithelial cell tumor
What is the histologic appearance of a Renal Oncocytoma?
Large eosinophilic cells with abundant mitochondria without perinuclear clearing
Large eosinophilic cells with abundant mitochondria without perinuclear clearing
What diagnosois should you consider in a patient who presents with painless hematuria, flank pain, and an abdominal mass? How should you treat?
Renal Oncocytoma
- Treat with nephrectomy
Renal Oncocytoma
- Treat with nephrectomy
What is the most common renal malignancy of early childhood (ages 2-4)?
Wilms Tumor (Nephroblastoma)
What kind of structures are in a Wilms Tumor (Nephroblastoma)?
Embryonic glomerular structures
What is the typical presentation of a Wilms Tumor (Nephroblastoma)?
- Child aged 2-4
- Huge, palpable flank mass
- Hematuria
What genetic change is associated with Wilms Tumor (Nephroblastoma)?
Loss of function mutations of tumor suppressor genes WT1 and WT2 on chromosome 11
If your patient with a Wilms tumor also has Aniridia (absence or iris), a genitourinary malformation, and mental retardation / intellectual disability, what diagnosis should you consider?
Beckwith-Wiedemann Syndrome or WAGR complex:
- Wilms tumor
- Aniridia
- Genitourinary malformation
- mental Retardation (intellectual disability)
What are the findings in the Beckwith-Wiedemann Syndrome?
WAGR complex:
- Wilms tumor
- Aniridia
- Genitourinary malformation
- mental Retardation (intellectual disability)
What is the most common tumor of the urinary tract system? Where can it occur specifically?
Transitional Cell Carcinoma
- Renal calyces
- Renal pelvis
- Ureters
- Bladder
A patient presents with painless hematuria without casts, what is the most likely diagnosis?
Bladder cancer (Transitional Cell Carcinoma)
What are the associated exposures in patients with Transitional Cell Carcinoma?
Problems in your Pee SAC:
- Phenacetin (pain-relieving and fever-reducing drug, banned in 80s)
- Smoking
- Aniline dyes
- Cyclophosphamide
What is the histologic appearance of Transitional Cell Carcinoma?
Papillary growth lined by transitional epithelium with mild nuclear atypica and pleomorphism
Papillary growth lined by transitional epithelium with mild nuclear atypica and pleomorphism
What types of cancer can occur in the bladder?
- Transitional cell carcinoma
- Squamous cell carcinoma of the bladder
What causes squamous cell carcinoma of the bladder?
Chronic irritation of urinary bladder → squamous metaplasia → dysplasia and squamous cell carcinoma
What are the risk factors for squamous cell carcinoma of the bladder?
- Schistosoma haematobium infection (Middle East)
- Chronic cystitis
- Smoking
- Chronic nephrolithiasis
If your patient from the Middle East presents with painless hematuria what diagnosis / cause should you consider?
Schistosoma haemotobium infection → chronic irritation of urinary bladder → squamous metaplasia → dysplasia and Squamous Cell Carcinoma of bladder
What diagnosis should you consider in a patient presenting with suprapubic pain, dysuria, urinary frequency, and urgency?
Acute infectious cystitis (bladder infection)
What are the risk factors for acute infectious cystitis?
- Female gender (short urethra)
- Sexual intercourse ("honeymoon cystitis")
- Indwelling catheters
What are the most common causes of acute infectious cystitis?
- E. coli (most common)
- Staphylococcus saprophyticus (sexually active young women - although E. coli still more common)
- Klebsiella
- Proteus mirabilis (urine has ammonia scent)
- Adenovirus (hemorrhagic cystitis)
What are the most common causes of acute infectious cystitis in young sexually active women?
- E. coli (most common)
- Staphylococcus saprophyticus
Which cause of acute infectious cystitis is associated with an ammonia scent to the urine?
Proteus mirabilis
What infection causes hemorrhagic cystitis?
Adenovirus
What are the typical lab findings in acute infectious cystitis?
- Leukocyte esterase (+)
- Nitrites appear for G- organisms (especially E. coli)
- Sterile pyruia with (-) urine cultures suggests urethritis (N. gonorrhoeae or Chlamydia trachomatis)
What diagnosis should you consider in a patient with sterile pyuria and negative urine cultures?
Urethritis by Neisseria gonorrhoeae or Chlamydia trachomatis
What diagnosis should you consider in a patient presenting with dysuria, fever, costovertebral angle tenderness, nausea, and vomiting?
Acute Pyelonephritis
What are the most common causes of Acute Pyelonephritis?
- Ascending UTI (E. coli most common)
- Vesicoureteral reflux
- Hematogenous spread of infection to kidney
What lab / imaging findings are associated with Acute Pyelonephritis?
- White cell casts in urine
- CT: striated parenchymal enhancement
- White cell casts in urine
- CT: striated parenchymal enhancement
What are the risk factors for Acute Pyelonephritis?
- Indwelling urinary catheter
- Urinary tract obstruction
- Diabetes mellitus (sugar in urine = food for infection)
- Pregnancy
What are the possible complications of Acute Pyelonephritis?
- Chronic pyelonephritis
- Renal papillary necrosis
- Perinephric abscess
What is the histologic appearance of Acute Pyelonephritis?
Neutrophilic infiltration (arrows) into renal interstitium
Neutrophilic infiltration (arrows) into renal interstitium
How do you treat Acute Pyelonephritis?
Antibiotics appropriate for cause
What is the cause of Chronic Pyelonephritis?
- Recurrent episodes of acute pyelonephritis
- Typically requires predisposition to infection such as vesicoureteral reflux or chronically obstructing kidney stones
What is the histologic appearance of Chronic Pyelonephritis?
- Coarse, asymmetric corticomedullary scarring
- Blunted calyx
- Tubules can contain eosinophilic casts that resemble thyroid tissue (thyroidization of kidney) = picture
- Coarse, asymmetric corticomedullary scarring
- Blunted calyx
- Tubules can contain eosinophilic casts that resemble thyroid tissue (thyroidization of kidney) = picture
In what renal pathology is there "thyroidization of the kidney"?
Chronic Pyelonephritis
- Tubules can contain eosinophilic casts that resemble thyroid tissue
Chronic Pyelonephritis
- Tubules can contain eosinophilic casts that resemble thyroid tissue
What diagnosis should you consider in a patient with fever, rash, hematuria, and costovertebral angle tenderness in a patient who has been taking a new drug for 1-2 weeks? What drugs are most likely to cause this?
Drug-Induced Interstitial Nephritis (Tubulointerstitial Nephritis)
- Diuretics
- Penicillin derivatives
- Sulfonamides
- Rifampin
- Can occur months after taking NSAIDs
What changes occur in Drug-Induced Interstitial Nephritis (Tubulointerstitial Nephritis)?
- Acute interstitial renal inflammation
- Pyuria (classically eosinophils)
- Azotemia (abnormally high levels of nitrogen-containing compounds in blood)
How do drugs cause Drug-Induced Interstitial Nephritis (Tubulointerstitial Nephritis)?
Drugs act as "haptens" (elicit an immune response only when attached to a large carrier such as a protein), inducing hypersensitivity
What renal pathology is associated with obstetric catastrophes (eg, abruptio placentae)? Cause?
Diffuse Cortical Necrosis
- Acute generalized cortical infarction of both kidneys
- Likely due to a combination of vasospasm and DIC
What renal pathology is associated with septic shock? Cause?
Diffuse Cortical Necrosis
- Acute generalized cortical infarction of both kidneys
- Likely due to a combination of vasospasm and DIC
What causes Diffuse Cortical Necrosis?
- Acute generalized cortical infarction of both kidneys
- Likely due to a combination of vasospasm and DIC
- Associated with obstetric catastrophes (eg, abruptio placentae) and septic shock
What is the most common cause of intrinsic renal failure?
Acute Tubular Necrosis
What is the prognosis for Acute Tubular Necrosis?
- Self-reversible in some cases
- Can be fatal if left untreated
- Death most often occurs during the initial "oliguric" phase
What is the key identifying feature of Acute Tubular Necrosis?
Granular "muddy brown" casts
Granular "muddy brown" casts
What are the three stages of Acute Tubular Necrosis?
1. Inciting event
2. Maintenance phase - oliguric (small production of urine)
3. Recovery phase - polyuric (increased production of dilute urine)
What is the first stage of Acute Tubular Necrosis?
Inciting event
- Ischemic injury
- Nephrotoxic injury
What is the second stage of Acute Tubular Necrosis, after the inciting event? Length? Characteristics?
Maintenance phase
- Oliguria (production of a small amount of urine)
- Lasts 1-3 weeks
- Risk of hyperkalemia and metabolic acidosis
What is the third stage of Acute Tubular Necrosis, after the maintenance phase / oliguria? Characteristics?
Recovery phase
- Polyuria (production of large amounts of dilute urine)
- BUN and serum creatinine fall
- Risk of hypokalemia
What can cause Acute Tubular Necrosis?
- Ischemic injury
- Nephrotoxic injury
What can be responsible for an ischemic injury leading to Acute Tubular Necrosis? What does this lead to?
- 2° to ↓ renal blood flow (eg, hypotension, shock, sepsis, hemorrhage, CHF)
- Results in death of tubular cells that may slough into tubular lumen (proximal tubule and thick ascending limb are highly susceptible to injury)
- 2° to ↓ renal blood flow (eg, hypotension, shock, sepsis, hemorrhage, CHF)
- Results in death of tubular cells that may slough into tubular lumen (proximal tubule and thick ascending limb are highly susceptible to injury)
Which parts of the kidney are particularly susceptible to injury by ischemia?
- Proximal tubule
- Thick ascending limb of loop of Henle
- Proximal tubule
- Thick ascending limb of loop of Henle
What can be responsible for a nephrotoxic injury leading to Acute Tubular Necrosis? What does this lead to?
- 2° to injury resulting from toxic substances (eg, aminoglycosides, radiocontrast agents, lead, cisplatin)
- Or 2° to crush injury (myoglobinuria) or hemoglobinuria
- Proximal tubule is particularly susceptible to injury
Which toxic substances can cause a nephrotoxic injury leading to Acute Tubular Necrosis?
- Aminoglycosides
- Radiocontrast agents
- Lead
- Cisplatin
Which part of the kidney is particularly susceptible to nephrotoxic injury?
Proximal Tubule
What can cause gross hematuria and proteinuria?
Renal Papillary Necrosis
- Sloughing of renal papillae
- May be triggered by a recent infection or immune stimulus
What is Renal Papillary Necrosis associated with?
- Diabetes Mellitus
- Acute pyelonephritis
- Chronic phenacetin use (acetaminophen is a phenacetin derivative)
- Sickle cell anemia and trait
What is the definition of Acute Kidney Injury (acute renal failure)?
- Abrupt decline in renal function
- ↑ Creatinine and ↑ BUN
- Occurs over a period of several days
What happens to BUN and creatinine in a normal nephron? Why?
- BUN is reabsorbed for countercurrent multiplication
- Creatinine is not reabsorbed
What are the forms of acute kidney injury / acute renal failure?
- Pre-renal Azotemia
- Intrinsic Renal Failure
- Post-renal Azotemia
What happens to the kidney in Pre-Renal Azotemia? Why?
- ↓ GFR due to ↓ RBF (eg, hypotension)
- Na+, H2O, and urea are retained by the kidney in an attempt to conserve volume
- ↑ BUN/creatinine ratio
What happens to the kidney in Intrinsic Renal Failure? Why?
- Generally due to acute tubular necrosis or ischemia / toxins
- Less commonly due to acute glomerulonephritis (eg, RPGN)
- Patchy necrosis leads to debris obstructing tubule and fluid backflow across necrotic tubule → ↓ GFR
- Urine has epithelial / granular casts
- BUN reabsorption is impaired → ↓ BUN/creatinine ratio
What happens to the kidney in Post-Renal Azotemia? Why?
- Due to outflow obstruction (eg, stones, BPH, neoplasia, congenital anomalies)
- Develops only with bilateral obstruction
Which type of acute kidney injury causes:
- Urine osmolality: >500 mOsm/kg
- Urine Na+: <20 mEq/L
- FENa: <1% (fractional Na+ excretion)
- Serum BUN/Cr ratio: >20

Causes?
Pre-Renal Azotemia
- As a result of ↓ RBF, eg, hypotension
Which type of acute kidney injury causes:
- Urine osmolality: <350 mOsm/kg
- Urine Na+: >40 mEq/L
- FENa: >2% (fractional Na+ excretion)
- Serum BUN/Cr ratio: <15

Causes?
Intrinsic Renal Failure
- Generally due to acute tubular necrosis or ischemia/toxins
- Less commonly due to glomerulonephritis (eg, RPGN)
Which type of acute kidney injury causes:
- Urine osmolality: <350 mOsm/kg
- Urine Na+: >40 mEq/L
- FENa: >1% if mild, >2% if severe (fractional Na+ excretion)
- Serum BUN/Cr ratio: >15

Causes?
Post-Renal Azotemia
- Due to outflow obstruction (eg, stones, BPH, neoplasia, congenital anomalies
What is the urine osmolality in Pre-Renal Azotemia vs Intrinsic Renal Failure vs Post-Renal Azotemia?
- Pre-Renal Azotemia: >500
- Intrinsic Renal Failure: <350
- Post-Renal Azotemia: <350

(in mOsm/kg)
What is the urine Na+ in Pre-Renal Azotemia vs Intrinsic Renal Failure vs Post-Renal Azotemia?
- Pre-Renal Azotemia: <20
- Intrinsic Renal Failure: >40
- Post-Renal Azotemia: >40

(in mEq/L)
What is the FENa (fractional sodium excretion) in Pre-Renal Azotemia vs Intrinsic Renal Failure vs Post-Renal Azotemia?
- Pre-Renal Azotemia: <1%
- Intrinsic Renal Failure: >2%
- Post-Renal Azotemia: >1% (mild), >2% (severe)
What is the serum BUN/creatinine ratio in Pre-Renal Azotemia vs Intrinsic Renal Failure vs Post-Renal Azotemia?
- Pre-Renal Azotemia: >20
- Intrinsic Renal Failure: <15
- Post-Renal Azotemia: >15
What are the consequences of renal failure?
MAD HUNGER:
- Metabolic Acidosis
- Dyslipidemia (esp. ↑ TGs)

- Hyperkalemia
- Uremia
- Na+/H2O retention
- Growth retardation and developmental delay
- Erythropoietin failure (anemia)
- Renal osteodystrophy
What are the two forms of renal failure? Causes?
- Acute: pre-renal azotemia, acute tubular necrosis, post-renal azotemia
- Chronic: hypertension, diabetes, congenital anomalies
What is there an inability to do in renal failure?
Inability to:
- Make urine
- Excrete nitrogenous wastes
What acid/base disturbance is associated with renal failure?
Metabolic Acidosis

MAd hunger
What lipid disturbance is associated with renal failure?
Dyslipidemia: especially ↑ TGs

maD hunger
What electrolyte disturbance is associated with renal failure?
- Hyperkalemia
- Uremia
- Na+/H2O retention

mad HUNger
What disturbances are there in children with with renal failure?
Growth retardation and developmental delay

mad hunGer
What blood disturbance is associated with renal failure?
anemia due to Erythropoietin failure

(and platelet dysfunction due to uremia)

mad hungEr
What bone disturbance is associated with renal failure?
Renal osteodystrophy - causes subperiosteal thinning of bones

mad hungeR
What are the characteristics of Uremia in renal failure?
↑ BUN and ↑ Creatinine, leads to:
- Nausea and anorexia
- Pericarditis
- Asterixis
- Encephalopathy
- Platelet dysfunction
What causes renal osteodystrophy?
- Failure of vitamin D hydroxylation → ↓ 1,25-(OH)2-Vitamin D → ↓ intestinal Ca2+ absorption
- Hypocalcemia
- Hyperphosphatemia also independently ↓ serum Ca2+ by causing tissue calcifications
What happens in renal osteodystrophy due to the failure of vitamin D hydroxylation, hypocalcemia, and hyperphosphatemia?
- Subperiosteal thinning of bones
- 2° Hyperparathyroidism
What are the types of renal cyst disorders?
- Autosomal Dominant Polycystic Kidney Disease (ADPKD)
- Autosomal Recessive Polycystic Kidney Disease (ARPKD)
- Medullary Cystic Disease
- Simple vs Complex Renal Cysts
Which type of renal cyst disorder occurs more often in adults? Appearance of kidneys?
Autosomal Dominant Polycystic Kidney Disease (ADPKD)
- Innumerable cysts
- Bilateral enlarged kidneys
- Destroys kidney parenchyma
Autosomal Dominant Polycystic Kidney Disease (ADPKD)
- Innumerable cysts
- Bilateral enlarged kidneys
- Destroys kidney parenchyma
What are the symptoms of a patient with Autosomal Dominant Polycystic Kidney Disease (ADPKD)?
- Flank pain
- Hematuria
- Hypertension
- Urinary infection
- Progressive renal failure
What is the cause of Autosomal Dominant Polycystic Kidney Disease (ADPKD)?
- 85% of cases: mutation in PKD1 on chromosome 16
- 15% of cases: mutation in PKD2 on chromosome 4

Autosomal dominant inheritance
What are the complications and prognosis in patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD)?
- Death from complications of chronic kidney disease or hypertension (caused by ↑ renin production)
- Associated with Berry aneurysms, mitral valve prolapse, and benign hepatic cysts
Which type of renal cyst disorder occurs more often in infants? Appearance of kidneys?
Autosomal Recessive Polycystic Kidney Disease (ARPKD)
- Cysts in parenchyma
What is Autosomal Recessive Polycystic Kidney Disease (ARPKD) associated with?
- Congenital hepatic fibrosis
- Potter sequence (if significant renal failure in utero)
- Beyond neonatal period: hypertension, portal hypertension, progressive renal insufficiency
What is the appearance of the kidneys in Medullary Cystic Disease?
- Medullary cysts usually not visualized
- Kidneys appear shrunken on ultrasound
- Medullary cysts usually not visualized
- Kidneys appear shrunken on ultrasound
What damage occurs in Medullary Cystic Disease? Prognosis?
- Tubulointerstitial fibrosis
- Progressive renal insufficiency
- Inability to concentrate urine
- Poor prognosis
- Tubulointerstitial fibrosis
- Progressive renal insufficiency
- Inability to concentrate urine
- Poor prognosis
What diagnosis should you consider in a patient with difficulty concentrating urine and shrunken kidneys on ultrasound?
Medullary Cystic Disease
Medullary Cystic Disease
What is responsible for the majority of all renal masses? Location?
Simple Renal Cysts - found in outer cortex
Simple Renal Cysts - found in outer cortex
What are the findings of simple renal cysts?
- Found in outer cortex
- Filled with ultrafiltrate
- Found incidentally and typically asymptomatic
- Found in outer cortex
- Filled with ultrafiltrate
- Found incidentally and typically asymptomatic
What kind of renal cyst increases the risk of renal cell carcinoma?
Complex Renal Cysts
Complex Renal Cysts
What is the appearance of Complex Renal Cysts? How should they be treated?
- Can be septated, enhanced, or have solid components, as seen on CT
- Require follow-up or removal due to risk of renal cell carcinoma
- Can be septated, enhanced, or have solid components, as seen on CT
- Require follow-up or removal due to risk of renal cell carcinoma