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216 Cards in this Set

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A 24-year-old male is diagnosed with urolithiasis after passing a small radiopaque stone. He has no underlying illnesses and has been healthy all his life. Afebrile, BP 110/70. Na 142, K 4, Cl 96, C02 25, glucose 74, creatinine 1.1, calcium 9.1, phosphorus 2.9. Urinalysis shows a pH of 7, specific gravity 1.020, and no protein, glucose, ketones, or nitrite. He is advised to drink more water. He likes iced tea, and he consumes large quantities over the course of a hot summer. However, he continues to have urinary tract calculi. What type of calculi is he most likely to have on stone analysis?
Calcium oxalate. About 75% of all renal stones are made up of calcium oxalate crystals. Patients with these stones tend to have hypercalciuria without hypercalcemia.
What two types of kidney stones are radiolucent and tend to form in acidic urine
Uric acid stones and cystine stones
What type of kidney stones tend to occur in association with urinary tract infections, particulary those caused by urease-positive bacteria such as Proteus
Triple phosphate stones
47 year old man has had decreased urine output over the past 10 days. Afebrile. Urinalysis 1+ proteinuria, 4+ hematuria, urobilinogen, and no glucose or ketones. Microscope shows few WBCs and some RBCs with RBC casts. A renal biopsy is performed, and the light microscopic appearance of a PAS-stained specimen is shown in the following figure. What is the most likely clinical course of this patient
Rapidly progressive renal failure accompanied by hemoptysis. The figure shows glomeruli with epithelial crescents that are the morphologic correlates of rapidly progressive glomerulonephritis. Patients with this condition rapidly develop renal failure. One cause of rapidly progressive renal failure is Goodpasture syndrome, in which anti-glomerular basement membrane antibodies damage both the glomeruli and the pulmonary alveoli. Damage to the alveoli results in hemoptysis.
Is acute tubular necrosis potentially reversible
Yes
Is focal segmental glomerulosclerosis typically responsive to corticosteroids
No, it is typically nonresponsive to corticosteroids
Acute pyelonephritis is accompanied by what systemic symptoms
Fever and leukocytosis
Can IgA nephropathy have intermittent hematuria
Yes
A 3 year old previously healthy boy has become increasingly lethargic for the past 3 weeks. 36.9C, pulse 80, resp 15, BP 140/90. Periorbital edema present. Urinalysis 4+ proteinuria, no blood, ketones, or glucose. What should the parents be told
Corticosteroid therapy should alleviate the problem. The most likely cause of nephrotic syndrome in a child is minimal change disease. For this reason, a course of corticosteroids is indicated, and 90% of patients respond. If there is no response, further workup, including a renal biopsy, can be performed. Few cases progress to chronic renal failure requiring dialysis or transplantation. The cause of minimal change disease is unknown. Children with minimal change disease do not develop rapid renal failure, and there is no genetic tendency associated with the disease
58 year old woman dies from a cerebral infarction. Lab findings before death included serum urea nitrogen 110, creatinine 9.8. Kidneys are small and have a coarsely granular surface appearance. Sclerotic glomeruli, fibrotic interstitium, tubular atrophy, arterial thickening, scattered lymphocytic infiltrates. What clinical finding was most likely reported on the patient's medical history
Hypertension. These findings describe end-stage renal disease, the appearance of which is similar regardless of the cause (eg. vascular disease or glomerular disease). With advanced renal destruction, hypertension almost always supervenes, even if it was absent at the onset of renal disease. Many such cases are referred to as "chronic glomerulonephritis" for want of a better term.
In a patient with kidney problems and hemoptysis, what should be suspected
Goodpasture syndrome
Lens dislocation is a feature of what disease
Alport syndrome
For the past 6 months, a 72 year old woman has noticed a slowly enlarging mass on the urethra. The mass causes local pain and irritation and is now bleeding. 2.5cm warty, ulcerated mass protruding from the external urethral meatus. There are no lesions of the labia or vagina. A biopsy specimen will most likely lead to what diagnosis
Squamous cell carcinoma. Carcinoma of the urethra is uncommon. It tends to occur in older women and is locally aggressive
An embryonal rhabdomyosarcoma (sarcoma botryoides) is a rare tumor that occurs in what age group
Children
What types of tumors are typically well circumscribed and do not ulcerate
Benign tumors, such as a leiomyoma or papilloma
What infectious disease produces indurated, painless lesions in the genito-rectal region
Syphilis
72 year old man with Alzheimer disease succumbs to pneumonia. The gross appearance of the right kidney at autopsy is shown above. The left kidney is normal in size, with a smooth cortical surface and a single 0.6cm fluid-filled cyst. The appearance of the right kidney was most likely caused by what
Ureteral obstruction. The ureteral, pelvic, and calyceal dilation results from long-standing obstruction leading to hydroureter and hydronephrosis.
With what disease do the kidneys become smaller and develop granular surfaces, but there is no dilation
Benign nephrosclerosis
The scarring that accompanies what two kidney diseases can be marked, and is associated with significant loss of parenchyma but not with pelvic dilation
Analgesic nephropathy or chronic pyelonephritis
25 year old man has a 5 year history of celiac sprue. Several days after a mild upper respiratory infection, he begins passing dark red-brown urine. The dark urine persists for the next three days and then becomes clear and yellow, only to become red-brown again 1 month later. No physical findings. Urinalysis pH 6.5, specific gravity 1.018, 3+ hematuria, 1+ proteinuria, no glucose or ketones. Urine RBCs but no WBCs, casts, or crystals. 24hr urine protein level 200mg. Renal biopsy specimen from the glomeruli of this patient will show what alteration
Mesangial IgA staining by immunofluorescence. IgA nephropathy, also known as Berger disease, can explain the presence of recurrent hematuria in a young adult. Nephrotic syndrome is not present, and mesangial IgA deposition is characteristic. The initial episode of hematuria usually follows an upper respiratory infection. IgA nephropathy occurs with increased frequency in patients with celiac disease.
Granular staining of basement membrane with IgG antibodies denotes immune complex deposition, which may occur in what disease
Postinfectious glomerulonephritis. The subepithelial deposits are seen on electron microscopy. Patients with these changes have nephritic syndrome
Diffuse cellular proliferation and basement membrane thickening denote what renal disease?
Membranoproliferative glomerulonephritis. In this condition, IgG and C3 are deposited in the glomeruli.
Glomerular capillary thrombosis is typical of what disease
Hemolytic-uremic syndrome
7 year old boy is recovering from impetigo. Physical exam shows a few honey-colored crusts on his face. The crusts are removed, and a culture of the lesions grows group A Streptococcus pyogenes. He is treated with a course of antibiotics. One week later, he develops malaise with nausea and a slight fever and passes dark brown urine. Lab studies show a serum anti-streptolysin O (ASO) of 1:1024. What is the most likely outcome for this boy
Complete recovery without treatment. These findings are characteristic of poststreptococcal glomerulonephritis. The strains of group A streptococci that cause poststreptococcal glomerulonephritis are different from those that give rise to rheumatic fever. Most children with poststreptococcal glomerulonephritis recover, although perhaps 1% develop a rapidly progressive glomerulonephritis. Progression to chronic renal failure may occur in 10-15% of affected adults. A urinary tract infection is not likely to accompany poststreptococcal glomerulonephritis, because the organisms that caused the immunologic reaction are no longer present when symptoms of glomerulonephritis appear
28 year old previously healthy man suddenly develops severe abdominal pain and begins passing red-colored urine. There are no abnormalities on physical examination. Urinalysis pH7, specific gravity 1.015, 1+ hematuria, no protein, glucose, or ketones. The patient is given a device to use in straining the urine for calculi. The next day, the patients recovers a 0.3cm stone that is sent for analysis. The chemical composition is found to be calcium oxalate. What underlying condition is most likely to be present
Idiopathic hypercalciuria. Calcium oxalate stones are the most common type of urinary tract stone. Approximately 50% of patients with calcium oxalate stones have increased excretion of calcium without hypercalcemia. The basis of hypercalciuria is not clear.
What type of kidney stones are formed in acidic urine and are not necessarily related to gout
Uric acid stones. At low pH, uric acid is insoluble, and stones form
Infections can predispose to the formation of what type of kidney stones
Magnesium ammonium phosphate stones
Hyperparathyroidism predisposes affected persons to form kidney stones containing what
Calcium, however, few patients with urinary tract stones have hyperparathyroidism
56 year old man has had back pain and has passed dark-colored urine for the past month. Right costovertebral angle tenderness. Urinalysis pH 6, specific gravity 1.015, 2+ hematuria, no protein, glucose, or ketones. Urine has numerous RBCs, few WBCs, no casts or crystals. Renal lesion shown above. What abnormal lab value is this patient likely to also have
Increased hematocrit. The figure shows a renal cell carcinoma. About 5-10% of these tumors secrete erythropoietin, giving rise to polycythemia. Other substances can be secreted--among them corticotropin (adrenocorticotropic hormone), resulting in hypercortisolism in Cushing syndrome--but these cases are encountered less frequently than polycythemia.
What are some characteristics of renal cell carcinomas
They are usually unilateral, and typically they do not destroy all of a kidney. There is no significant loss of renal function, and the serum nitrogen and creatinine levels are not elevated
A 15-year-old boy has been passing dark-colored urine for the past month. On physical examination, he has bilateral sensorineural hearing loss and corneal erosions. Urinalysis shows pH 6.5, specific gravity 1.015, 1+ hematuria, 1+ protein, no ketones, no glucose, and no leukocytes. A renal biopsy reveals tubular epithelial foam cells by light microscopy. By electron microscopy, the glomerular basement membrane shows areas of attenuation, with splitting and lamination of lamina densa in other thickened areas. Diagnosis?
Alport syndrome. Alport syndrome is a form of hereditary nephritis. Hematuria is the most common presenting feature, but proteinuria is often present and may be in the nephrotic range. Patients progress to chronic renal failure in adulthood. Most patients have an X-linked dominant pattern of inheritance, but autosomal dominant and autosomal recessive pedigrees also exist. The foamy change in the tubular epithelial cells and ultrastructural alterations of the basement membrane are characteristic features. The genetic defect results from mutation in the gene for the alpha5 chain of type IV collagen
Acute tubular necrosis follows what
Ischemic or toxic injuries to the kidney. It does not involve the glomeruli
What generally produces a nephrotic syndrome and deposition of immune complexes in glomerular basement membrane
Membranous glomerulonephritis
Nodular and diffuse glomerulosclerosis are typical changes seen in what disease
Diabetic nephropathy
What is Berger disease, or IgA nephropathy
A form of glomerulonephritis that does not produce tubular changes
32 year old man has developed a fever and skin rash over the past 3 days. Five days later, he has increasing malaise and visits his physician. Maculopapular erythematous rash on his trunk has nearly faded away. 37.1C, BP 135/85. Creatinine 2.8, BUN 29. Urinalysis 2+ proteinuria, 1+ hematuria, no glucose, ketones, or nitrite. Leukocyte esterase positive. Microscope urine shows RBCs and WBCs, some of which are eosinophils. What most likely caused this patient's condition
Antibiotic use. These findings are typical of drug-induced interstitial nephritis. A variety of drugs can cause this condition, including sulfonamides, penicillins, cephalosporins, the fluoroquinolone antibiotics ciprofloxacin and norfloxacine, and the antituberculous drugs isoniazid and rifampin. Acute tubulointerstitial nephritis can also occur with use of thizide and loop diuretics, cimetidine, ranitidine, omeprazole, and nonsteroidal antiinflammatory drugs. The disease appears about 2 weeks after the patient begins to use the drug. Elements of type I (increased IgE) and type IV (skin test positivity to drug haptens) hypersensitivity are present
What type of WBC will not be seen in the urine of a patient with a urinary tract infection
Eosinophils
When does glomerulonephritis develop in patients infected with group A Beta-hemolytic streptococci that cause skin infection
Glomerulonephritis develops weeks after the skin infection
What syndrome can occur after ingestion of strains of E coli that may be present in ground beef
Hemolytic uremic syndrome
After eating a cheeseburger, French fries, and ice cream for dinner one night, a 6 year old girl develops nausea, mild abdominal cramping, and a slight fever. Three days later, her parents notice that she is passing dark stools and dark urine and appears fatigued and weak. 37.9C, pulse 88, resp 18, BP 140/90. Scattered petechiae are present on the extremities. Serum creatinine level 2.2, urea nitro 20. Urinalysis pH6, specific gravity 1.016, 2+ hematuria, no protein or glucose. Renal biopsy shows small thrombi within glomerular capillary loops. Diagnosis?
Hemolytic uremic syndrome, one of the most common causes of acute renal failure in children. It most commonly occurs after ingestion of meat infected with verocytotoxin-producing E.coli, most often O157:H7. The toxin damages endothelium, reducing nitric oxide, promoting vasoconstriction and necrosis, and promoting thrombosis. With supportive therapy, most patients recover in a few weeks, although perhaps one fourth progress to chronic renal failure
When does postinfectious glomerulonephritis usually occur
Several weeks after an infection, usually with group A Beta-hemolytic streptococci
In what age group does the vasculitis Wegener granulomatosis occur
Most often in adults
Hereditary nephritis usually occurs in what age group
Childhood; it is progressive and is not related to vascular disease
Is an IgA nephropathy accompanied by vascular changes
No. It most often occurs in young adults
The parents of a 6 year old girl notice that she has become increasingly lethargic over the past 2 weeks. Puffiness around the eyes. 36.9C, BP 100/60. Serum creatinine 0.7, urea nitro 12. Urinalysis pH 6.5, specific gravity 1.011, 4+ proteinuria, no blood or glucose. 24 hour urine protein level is 3.8g. The child's condition improves after a course of glucocorticoid therapy. EM will most likely show what process in the kidneys
Effacement of podocyte foot processes. A child with nephrotic syndrome and no other clinical findings is most likely to have lipoid nephrosis, also called minimal change disease. The term "minimal change disease' reflects the paucity of pathologic findings. There is fusion of foot processes, which can be seen only by electron microscopy
In kidney EM, what do subepithelial electron-dense humps represent
Immune complexes, which are seen with postinfectious glomerulonephritis
In kidney EM, variability of basement membrane thickening may be seen in what disease
Alport syndrome
The mesangial matrix is expanded in some forms of what kidney disease
Glomerulonephritis (eg IgA nephropathy) and other diseases, such as diabetes mellitus. It will not be expanded in minimal change disease
25 year old woman experiences sudden onset of fever, malaise, and nausea. 38.2C, pulse 85, resp 18, BP 140/90. Urinalysis 1+ proteinuria, 4+ hematuria, no ketones or glucose. RBC casts are seen on microscopic exam of the urine. Renal biopsy shows marked glomerular hypercellularity with neutrophils in glomerular capillary loops. Immunofluorescence microscopy shows granular deposition of IgG and C3 in glomerular capillary basement membranes. EM shows electron-dense subepithelial "humps." Diagnosis?
Postinfectious glomerulonephritis, one of many causes of a nephritic syndrome characterized by hematuria and RBC casts. Most children recover completely, but one in six adults may progress to chronic renal failure. Some cases may occur after a streptococcal pharyngitis (poststreptococcal glomerulonephritis). In other cases such as this one, the preceding infection is so mild that patients give no history.
Nodular and diffuse glomerulosclerosis are characteristic of what diease
Diabetic nephropathy
77 year old man has had increasing difficulties with urination for the past 2 years. He has difficulty starting and stopping the urine stream. 37C, BP 130/85. The gross appearance of his bladder is shown. What laboratory finding is most likely to be reported in this patient
Prostate-specific antigen level of 5ng/mL. This patient has bladder hypertrophy resulting from outlet obstruction. In an older man, this type of obstruction is most often caused by prostatic enlargement resulting from hyperplasia or carcinoma. Mild elevations in the prostate-specific antigen level may occur in patients with prostatic hyperplasia, and greater increases in PSA suggest carcinoma
Why would a positive ANA test not be expected in a patient with bladder neck obstruction
Autoimmune conditions may be associated with interstitial cystitis, but cystitis does not cause bladder neck obstruction
Schistosomiases leads to what bladder morphology
Chronic inflammation and scarring
50 year old woman sees her physician because she has had flank pain for the past 2 days. Bilateral costovertebral angle tenderness. Urinalysis pH 7, specific gravity 1.010, 2+ hematuria, no protein, glucose, or ketones. US shows bilaterally enlarged kidneys that have been replaced completely by 0.5-3cm cysts. What complication is most likely to develop in this patient
Hypertension. This woman has an autosomal dominant form of polycystic kidney disease. Hypertension and infection are the most frequent complications of this disorder.
What disease is at increased risk in persons with dialysis-acquired cysts but not in those with polycystic kidney disease
Renal cell carcinoma
Is nephrotic syndrome common in polycystic kidney disease
Although some proteinuria is present in many forms of chronic renal disease, nephrotic syndrome is not common in polycystic kidney disease
A microangiopathic hemolytic anemia may be seen in what disease that typically affects the kidney
Hemolytic-uremic syndrome
Are vascular changes with resultant infarction seen in polycystic kidney disease
No
Is Cushing syndrome a complication of polycystic kidney disease
Cushing syndrome may complicate renal cell carcinoma, but it is not a complication of polycystic kidney disease
26 year old man is involved in a motor vehicle accident and sustains acute blood loss. Hypotensive for several hours before help arrives. Receives a transfusion of 3 units of packed RBCs. Over the next week, serum nitro increases to 48, serum creatinine increases to 5, urine output decreases. He undergoes hemodialysis for the next 2 weeks and then develops marked polyuria, with urine output of 2-3 L per day. Recovery is complicated by bronchopneumonia, but renal function gradually returns to normal. The patient's transient renal disease is best characterized by what histologic feature
Rupture of the tubular basement membrane. This patient's history is typical of ischemic acute tubular necrosis, which is often accompanied by rupture of the basement membrane (tubulorrhexis). An initiating phase that lasts approximately 1 day is followed by a maintenance phase during which progressive oliguria and rising blood urea nitrogen levels occur, with salt and water overload. This is followed by a recovery phase during which there is a steady increase in urinary output and hypokalemia. Eventually, tubular function is restored. Treatment of this acute renal failure results in recovery of nearly all patients
Glomerular crescents in Bowman's space suggest what
A rapidly progressing glomerulonephritis that is unlikely to resolve
Interstitial lymphocytic infiltrates in the kidneys suggests what
A chronic tubulointerstitial process
Fibrinoid necrosis in arterioles of the kidney is a feature of what
Malignant nephrosclerosis, a serious condition that produces significant renal damage.
Nodular glomerulosclerosis is a feature of what disease
Diabetic nephropathy. It is a progressive condition that leads to chronic renal failure
60 year old previously health man feels feverish and weak. Reports passing dark-colored urine on several occasions during the past month but has no urinary frequency, dysuria, or nocturia. 37.8C, BP 125/85. Urinalysis 4+ hematuria, 1+ proteinuria, no glucose or ketones. What procedure should be done on this patient
Abdominal CT scan for renal mass. Painless hematuria in an older adult suggest a renal neoplasm. The additional presence of constitutional symptoms, such as fever and weakness, should raise the suspicion of a renal cell carcinoma.
What symptoms accompany urinary tract calculi when passed
Severe, colicky pain
What urinalysis value is typically manifest with nephrotic syndrome
Proteinuria
Why is a renal biopsy not recommened in a patient with suspect renal cell carcinoma
A renal biopsy has a low yield in a patient without an acute-onset renal disease, and it is an ineffective way of diagnosing tumors
40 year old man has experienced increasing lower extremity edema for the past 3 weeks. Afebrile and BP 135/90 with pitting edema to the knees. Serum creatinine 1.2, urea nitro 16, 24 hour urine protein level is 7. Urinalysis 4+ protein but no blood or glucose. Serologic test results for ANA, anti-streptolysin O, HIV, and ANCA are all negative. Serum complement levels are normal. A renal biopsy is performed; light micro shows normal appearing glomeruli except for diffuse, uniform thickening of the glomerular capillary basement membranes. Immunofluorescence shows granular peripheral staining of basement membrane for IgG and C3. Given the clinical and histopathologic findings, electron microscopy of the biopsy specimen is most likely to show what findings?
Subepithelial electron-dense deposits. This patient with nephrotic syndrome has clinical and histologic features of membranous glomerulonephritis. In most cases, this is an idiopathic disease caused by immune complex deposition on the glomerular basement membranes. Granular immunofluorescence with IgG and C3 supports this diagnosis. Under the electron microscope, electron-dense immune complexes are seen on the epithelial side of the basement membrane
An EM of the kidney showing subendothelial electron-dense deposits with duplication of the basement membrane is a feature of what
Type I membranoproliferative glomerulonephritis
An EM of the kidney showing electron-dense deposits limited to the mesangium are seen in what disease
IgA nephropathy
An EM of the kidney showing podocyte foot process fusion without any other abnormalities occurs in what disease
Lipoid nephrosis (minimal change disease)
50 year old woman has had fever and flank pain for the past 2 days. 38.2C, pulse 81, resp 16, BP 130/80. Urinalysis no protein, glucose, or ketones. Leukocyte esterase test is positive. Micro exam of urine shows numerous polymorphonuclear leukocytes and occasional WBC casts. What organism will likely be found in the urine culture
Escherichia coli. The clinical features in this patient are typical of urinary tract infection, and Eschericia coli is the most common cause. The WBCs are characteristic of an acute inflammatory process. The presence of WBC casts indicates that the infection must have occured in the kidney, because casts are formed in renal tubules. Most infections of the urinary tract begin in the lower urinary tract and ascend to the kidneys. Hematogenous spread is less common
58 year old man who is relatively healthy sees his physician for a routine health maintenance exam. Mild hypertension. Serum creatinine 2.2, urea nitro 25. Microalbuminuria is present, with excretion of 250mg/day of albumin. Two years later, he returns for a followup visit. He is now hypertensive and has a serum creatinine level of 3.8, urea nitro 38, 24hr urine protein 2.8. Renal biopsy is performed, and the light microscopic appearance of a PAS-stained specimen is shown above. What lab finding is most likely to be abnormal in this patient
Hemoglobin A1c. The figure shows nodular and diffuse glomerulosclerosis, a classis lesion in diabetes mellitus. Patients with diabetes mellitus have an elevated level of glycosylated hemoblobin A1C. Patients with type 1 diabetes mellitus may initially have microalbuminuria, which predicts development of future overt diabetic nephropathy. There is progressive loss of renal function. These patients are often hypertensive and have hyaline arteriolosclerosis. The presence of overt proteinuria suggest progression to end-stage renal disease within 5 years
The ANCA test is postitive in what forms of kidney disease
Some forms of vasculitis, such as Wegener granulomatosis, which can involve the kidneys
The anti-streptolysin O (ASO) titer is elevated following what
Streptococcal infections, which may cause glomerulonephritis
The C3 nephritic factor may be present in what kidney disease
Type II membranoproliferative glomerulonephritis (dense deposit disease).
Some patients with membranous glomerulonephritis have a positive serologic test result for what viral antigen
HBsAg
A 20 year old woman, G1P0, who is in the third trimester, has felt minimal fetal movement. An ultrasound shows markedly decreased amniotic fluid index characteristic of oligohydramnios. She gives birth to a stillborn male fetus at 33 weeks gestation. At autopsy, there are deformations resulting from marked oligohydramnios, including flattening of the facies, varus deformities of the feet, and marked pulmonary hypoplasia. Microscopic exam of the liver shows multiple epithelium-lined cysts and a proliferation of bile ducts. What will the kidneys look like?
Symmetrically enlarged kidneys composed of small, radially arranged cysts. This fetus has features of autosomal recessive polycystic kidney disease (RPKD) involving the liver. RPKD is a disease that occurs in children; by contrast, autosomal dominant polycystic kidney disease (DPKD) leads to presentation with renal failure in adults. Some less common forms of RPKD are accompanied by survival beyond infancy, and these patients develop congenital hepatic fibrosis.
Enlarged kidneys with 1-4cm cysts are characteristic of what disease
Autosomal dominant polycystic kidney disease in adults.
What is the most common renal cystic disease seen in fetuses and infants, in which the cysts and kidneys are variably sized
Multicystic renal dysplasia (multicystic dysplastic kidney). This disease can be focal, unilateral, or bilateral; however, congenital hepatic fibrosis is not present
Small, shrunken, granular kidneys typify what disease
End-stage renal disease in adults
In the kidneys, irregular cortical scars with pelviceal dilation may represent what
Hydronephrosis complicated by infection in chronic pyelonephritis, a process that occurs in adults
In a fetus, kidney dilation with calyceal thinning can occur how
With obstructions in utero, such as posterior urethral valves in males or urethral atresia in either males or females; liver lesions will not be present
65 year old woman has experienced increasing malaise with nocturia and polyuria for the past year. BP 170/95. Urinalysis pH 7.5, specific gravity 1.010, 1+ proteinuria, no glucose, blood, or ketones. The tests for leukocyte esterase and nitrite yield positive results, and levels of serum urea nitro and serum creatinine are both elevated. Her clinical course is characterized by worsening renal failure, and she dies of bronchopneumonia. At autopsy, the kidneys are shrunken but unequal in size and have deep, irregular surface scars. On sectioning, the calyces underlying the cortical scars are blunted and deformed. What is the most likely cause of renal failure in this patient
Reflux nephropathy. This description of the gross appearance of the kidney is characteristic of chronic pyelonephritis, caused most often by reflux nephropathy. Typical features include coarse and irregular scarring resulting from ascending infection, blunting and deformity of calyces, and asymmetric involvement of the kidneys. The loss of tubules from scarring gives rise to reduced renal concentrating ability; hence, the patient had polyuria with a low specific gravity in the urine
Essential hypertension is a risk factor for what kidney disease
Benign nephrosclerosis
How will the kidneys appear in chronic glomerulonephritis, benign nephrosclerosis (caused by essential hypertension), or systemic lupus erythematosus.
Bilateral symmetric kidney involvement, and the affected kidneys will be shrunked and finely granular
What disease is characterized by large cysts that replace the renal parenchyma and greatly increase the size of the kidneys bilaterally
Autosomal dominant polycystic kidney disease
29 year old woman has had fever and sore throat for the past 3 days. Temp 38C. Pharynx is erythematous, with yellowish tonsillar exudate. Group A Streptococcus pyogenes is cultured. She is treated with ampicillin and recovers fully in 7 days. Two weeks later, she develops fever and a rash and notices a slight decrease in urinary output. 37.7C, diffuse erythematous rash on the trunk and extremities. Urinalysis shows pH 6, specific gravity 1.022, 1+ proteinuria, 1+ hematuria, no glucose or ketones. Microscopic exam of urine shows RBCs and WBCs, including eosinophils, but no casts or crystals. What is the most likely cause of her disease
Hypersensitivity reaction to ampicillin. These findings point to an acute drug-induced interstitial nephritis caused by ampicillin. This is an immunologic reaction, probably caused by a drug acting as a hapten.
Deposition in the kidney of immune complexes with streptococcal antigens will lead to what disease
Poststreptococcal glomerulonephritis. It is unlikely to be accompanied by a rash or by eosinophils in the urine
Where does the infection originate in acute pyelonephritis
It is an ascending infection; only uncommonly is it caused by hematogenous spread of bacteria from other sites.
Acute tubular necrosis, which can lead to acute renal failure, is caused by what
Hypoxia resulting from shock or from toxic injury caused by chemicals such as mercury, and only rarely if ever by bacterial toxins
4 year old girl has complained of abdominal pain for the past month. Febrile, and palpation of the ab shows tender mass on the right. Bowel sounds present. Lab studies show hematuria without proteinuria. Ab CT shows 12cm circumscribed, solid mass in the right kidney. A right nephrectomy is performed. Diagnosis?
Wilms Tumor. Wilms tumor is the most common renal neoplasm in children, and one of the most common childhood neoplasms. A complex staging, grading, and molecular analysis formula, as well as surgery, chemotherapy, and radiation, result in a high cure rate. The microscopic pattern of Wilms tumor (nephroblastoma) resembles the fetal kidney nephrogenic zone.
What type of renal tumors may be sporadic or part of the genetic syndrome of tuberous sclerosis. They may be multiple and bilateral and have well-differentiated muscle, adipose tissue, and vascular components
Angiomyolipomas
What type of renal tumors are generally less than 1cm and are incidental findings
Renomedullary interstitial cell tumors (medullary fibromas)
What type of renal tumor is rare in children, and the most common patterns are clear cell, papillary, and chromophobe
Renal cell carcinoma
What type of tumors arise in the urothelium in adults and microscopically resemble urothelium
Transitional cell carcinomas
One week after a mild flulike illness, a 9 year old boy has an episode of hematuria that subsides within 2 days. One month later, he tells his parents that his urine is red again. On physical exam there are no findings. Urinalysis pH7, specific gravity 1.015, 1+ proteinuria, 1+ hematuria, no ketones, glucose, or urobilinogen. Serum urea nitro 36, creatinine 3.2. Renal biopsy specimen shows diffuse mesangial proliferation and electron-dense deposits in the mesangium. What mechansim is most likely to produce these findings
Deposition of immune complexes containing IgA. Development of recurrent hematuria following a viral illness in a child or young adult is typically associated with IgA nephropathy. In these patients, some defect in immune regulation causes excessive mucosal IgA synthesis in response to viral or other environmental antigens. IgA complexes are deposited in the mesangium and initiate glomerular injury.
Antibodies against type IV collagen are formed in what disease
Goodpasture syndrome.
Cytokine-mediated injury to the glomerular capillaries can occur when
In transplant rejection
Defects in the structure of glomerular basement membrane are a feature of what disease
Hereditary nephritis
A 35 year old man is awakened at night because of severe lower abdominal pain that radiates to the groin. The pain is very intense and comes in waves. The next morning, he notices blood in his urine. On exam, there are no remarkable findings. Diagnosis?
Ureteral lithiasis. This patient has ureteral colic from the passage of a stone down the ureter.
What type of pain usually accompanies renal cell carcinoma
Dull pain
7 year old boy is brought to the physician by his mother, who is concerned because he has become less active over the past 10 days. Facial puffiness present. Urinalysis no blood, glucose, or ketones, and micro exam shows no casts or crystals. Serum creatinine normal. 24hr urine yields 3.8g of protein. He improves after a course of corticosteroid therapy. He has two more episodes of proteinuria over the next few years, both of which respond to corticosteroid therapy. Renal biopsy is performed. What is the most likely mechanism causing his disease
Cytokine-mediated visceral epithelial cell injury. Steroid-responsive proteinuria in a child is typical of minimal change disease in which the kidney looks normal by light micro but there is foot process fusion by EM. The most likely cause of foot process fusion is a primary injury to visceral epithelial cells caused by T-cell derived cytokines
Immune complex deposition in membranous glomerulopathy can give rise to what disease
Nephrotic syndrome. It is less common in children than adults and is not steroid-responsive
Certain verotoxin-producing E. coli strains can cause hemolytic-uremic syndrome by injury to what tissue
Capillary endothelium
What kidney disease is mediated by T cell injury with tubulitis
Acute cellular renal transplant rejection
IgA nephropathy with mesangial IgA deposition and consequent glomerular injury gives rise to what finding on urinalysis
Recurrent gross or microscopic hematuria and far less commonly to nephrotic syndrome
49 year old man saw his physician because he had increased swelling in the extremities for 2 months. Generalized edema. 24hr urine collected 4.1g of protein as well as albumin and globulins. Extensive testing did not indicate the presence of a systemic disease, such as diabetes mellitus or systemic lupus erythematosus. He did not respond to a course of corticosteroid therapy. A renal biopsy showed diffused thickening of the basement membrane. Immunofluorescence staining with antibody to the C3 component of complement was positive in a granular pattern in the glomerular capillary loops. Two years later, he experiences increasing malaise. Serum creatinine 4.5, urea nitro 44. What immunologic mechanism is most likely responsible for the glomerular changes observed in the biopsy specimen
Deposition of immune complexes on the basement membrane. This patient has idiopathic membranous glomerulopathy, producing nephrotic syndrome. Diffuse basement membrane thickening, in the absence of proliferation changes, and granular deposits of IgG and C3 are typical of this condition. It is caused by deposition of immune complexes on the basement membrane, which activates complement.
Antibodies that react with basement membrane, as in Goodpasture syndrome, give rise to what type of immunofluorescence pattern
A linear pattern
What are the causes of membranous glomerulopathy
In 85% of patients with membranous glomerulopathy, the cause of immune complex deposition is unknown. In the remaining 15%, an associated disease (eg systemic lupus erythematosus) or some known cause of immune complex formation (eg drug reaction) exists. Membranous glomerulopathy has no association with streptococcal infections, and there is no evidence of cytokine or T-cell mediated damage in this disease
31 year old woman experiences a bout of abdominal pain and sees her physician 1 week after noticing blood in her urine. She has had three episodes of urinary tract infection during the past year. There are no remarkable findings on physical examination. Urinalysis shows 2+ hematuria, 1+ proteinuria, hypercalciuria, and no glucose or ketones. Microscopic exam of urine shows numerous RBCs and oxalate crystals. An intravenous pyelogram shows linear striations radiating into the renal papillae, along with small cystic collections of contrast in dilated collecting ducts. She is advised to increase her daily intake of fluids, and her condition improves. Diagnosis?
Medullary sponge kidney. The congenital disorder known as MSK is present to some degree in up to 1% of adults. In MSK, cystic dilation of 1-5mm is present in the inner medullary and papillary ducts. MSK is bilateral in 70% of cases. Not all papillae are equally affected, although calculi are often present in dilated collecting ducts. Patients usually develop kidney stone, infection, or recurrent hematuria in the third or fourth decade. More than 50% of patients have stones.
What type of crystals are present in gout
Uric acid crystals
What disease may occur sporadically or as part of various genetic syndromes, such as Meckel-Gruber syndrome, in fetuses and newborns
Multicystic renal dysplasia
What disease can lead to hydroureter, hydronephrosis, and an increased risk of infection
Vesicoureteral reflux
42 year old man has had right flank pain for the past 2 days. 37.4C, pulse 70, resp 14, BP 130/85. Serum creat 1.1. Urinalysis no blood, protein, glucose. No WBCs or RBCs in urine. CT shows 7cm eccentric lesion of the upper pole of the right kidney. The lesion is well-circumscribed and cystic with a thin wall and focal hemorrhage. Diagnosis?
Simple renal cyst. Simple cysts are common in adults, and multiple cysts also may occur. The cysts are not as numerous as those occuring in autosomal dominant polycystic kidney disease, and there is no evidence of renal failure. Simple cysts may be as large as 10cm, and hemorrhage sometimes occurs into a cyst. Multiple cysts sometimes develop in patients receiving long-term hemodialysis.
Acute pyelonephritis is usually accompanied by what signs and symptoms
Fever, and WBCs in the urine
Acute tubular necrosis follows what
Ischemic or toxic injury, and there is evidence of renal failure
51 year old woman has had recurrent urinary tract infections for the past 15 years. Proteus mirabilis was cultured from her urine. For the past 4 days, she has had burning pain on urination and urinary frequency. On physical exam, 37.9C, pulse 70, resp 15, BP 135/85. Marked tenderness on deep pressure over the right costovertebral angle and on deep palpation. Urinalysis pH 7.5, specific gravity 1.020, 1+ hematuria, no protein, glucose, or ketones. Many RBCs, WBCs, and triple-phosphate crystals. What renal lesion is most likely to be present?
Staghorn calculus. Recurrent urinary tract infections with urea-splitting organisms such as Proteus can lead to formation of magnesium ammonium phosphate stones. These stones are large, and they fill the dilated calyceal system. Because of their large size and projections into the calyces, such stones are sometimes called "staghorn calculi."
Cases of acute tubular necrosis typically occur from what types of injuries
Toxic or ischemic renal injuries
Malignant nephrosclerosis primarily affects what tissue
It is primarily a vascular process that is not associated with infection
53 year old woman has had dysuria and frequency of urination for the past week. 38C, pain on palpation over the left costovertebral angle. Glucose 177, HgbA1C 9.8%, Hgb 13.1, platelets 232,200, WBC 11,320. Urinalysis pH 6.5, specific gravity 1.016, 2+ glucosuria, no blood, protein, or ketones. Numerous neutrophils in the urine, and a urine culture is positive for E. coli. What complication is likely to develop in this patient
Necrotizing papillitis. This patient has laboratory findings consistent with diabetes mellitus and clinical features of acute pyelonephritis caused by Escherichia coli infection. Necrotizing papillitis with papillary necrosis is a complication of acute pyelonephritis, and diabetic patients are particularly prone to this development. In the absence of diabetes mellitus, papillary necrosis develops when acute pyelonephritis occurs in combination with urinary tract obstruction. Papillary necrosis also can occur with chronic use of analgesics
What complication does Crescentic glomerulonephritis cause
Rapidly progressive renal failure
42 year old man has experience increasing malaise for the past month. He is bothered by increasing swelling in both hands and legs. Generalized edema present. Afebrile, BP 140/90. Urinalysis pH 6.5, specific gravity 1.017, 4+ proteinuria, no blood, glucose, or ketones. Exam of urine shows no casts or RBCs and 2 WBCs per high-power field. 24hr urine protein level is 4.2g. Renal biopsy obtained, and the immunofluorescence staining with antibody to the C3 component of complement produces the pattern shown on the left picture. What is a likely underlying disease process that may be present
Chronic Hepatitis B. One of the most common causes of nephrotic syndrome in adults is membranous glomerulopathy, caused by immune complex deposition, shown on the left as granular deposits with C3. About 85% of cases are idiopathic, but some cases follow infections (eg hepatitis or malaria) or are associated with causes such as malignancies or autoimmune diseases
Recurrent urinary tract infection can cause what kidney disease
Chronic pyelonephritis
58 year old man is in stable condition after an acute myocardial infarction. Two days later, his urine output decreases, and the serum nitro increases to 3.3. Oliguria persists for 5 days, followed by polyuria for 2 days. He is then discharged from the hospital. What renal lesion best explains these renal abnormalities
Acute tubular necrosis. The most common cause of acute tubular necrosis is ichemic injury. The hyptotension that develops after myocardial infarction causes decreased renal blood flow.
What renal disease takes years to develop and is associated with benign essential hypertension
Benign nephrosclerosis
Several members of a family developed chronic renal failure by the age of 50 years. Most are males. The affected persons also developed visual problems. Some younger family members have proteinuria and hematuria on urinalysis. A renal biopsy specimen from a 20 year old man shows prominent tubular foam cells and glomerular basement membrane thickening and thinning. Family members with this disease are most likely to have what additional manifestation
Nerve deafness. These findings are characteristic of Alport syndrome, a form of hereditary nephritis. Most cases are inherited in an X-linked dominant pattern, but autosomal dominant and autosomal recessive patterns of inheritance also are seen. Most commonly, males are severly affected. Vision, hearing, and renal function are affected, but other organ systems are not affected
65 year old man recently retired after many years in a job that involved exposure to aniline dyes, including Beta-naphthylamine. One month ago, he had an episode of hematuria that was not accompanied by abdominal pain. On physical exam, there are no abnormal findings. Urinalysis shows 4+ hematuria and no ketones, glucose, or protein. Micro exam of urine reveals RBCs that are too numerous to count, 5-10 WBCs per high-power field, and no crystals or casts. The result of a urine culture is negative. Diagnosis?
Urothelial carcinoma. Exposure to arylamines markely increases the risk of bladder cancer, which can occur decades after the initial exposure. After absorption, aromatic amines are hydroxylated into an active form, which is detoxified by conjugation with glucuronic acid and then excreted. Urinary glucuronidase then splits the nontoxic conjugated form into the active carcinogenic form. Renal cell carcinomas also may present as painless hematuria, but exposure to aniline dyes is not a risk factor.
When is hemorrhagic cystitis likely to occur
After radiation injury or treatment with cytotoxic drugs such as cyclophosphamide
Tubercular cystitis is typically a complication of what disease
Renal tuberculosis
55 year old woman has had poorly controlled hyperglycemia for many years. Now has burning pain on urination for 3 days. 2cm ulceration on the skin of the heel and reduced sensation in the lower extremities. Visual 20/100 bilaterally. Urinalysis 1+ proteinuria, 2+ glucosuria, no blood, ketones, or urobilinogen. Urine culture contains more than 100,000 CFUs of Klebsiella pneumoniae. What pathologic finding is most likely to be present in both kidneys?
Nodular hyaline mesangial masses. This patient has diabetes mellitus. Nodular and diffuse glomerulosclerosis often occur in patients with long-standing diabetes mellitus. Infections with bacterial organisms also occur more frequently in patients with diabetes mellitus
Deposition of what proteins onto the glomerular basement membrane occurs with forms of glomerulonephritis caused by immune complex deposition, including lupus nephritis and membranous glomerulonephritis
IgG and C3
What is the only abnormality observed in minimal change disease
Effacement of podocyte foot processes, but this change is not specific for MCD and may be seen in other disorders that produce proteinuria
In what disease is there IgA deposition in the mesangium
Berger disease (IgA nephropathy)
A necrotizing granulomatous vasculitis can be present in the kidneys of patients with what disease
Wegener granulomatosis
Thickening and thinning of glomerular basement membranes occurs in what disease
Alport syndrome
A 17 year old girl has had arthralgias and myalgias for several months. During the past week, she has noticed a decreased output of urine, which is reddish brown. BP 160/100, and she has an erythematous malar skin rash. ANA and anti-double-stranded DNA test are both positive. Serum urea nitro is 52. What abnormal urinalysis finding is expected in this patient
RBC casts. This patient has findings of systemic lupus erythematosus, an autoimmune disease that often manifests with renal involvement. There are several forms of lupus nephritis, and they tend to produce a nephritic pattern of involvement. Because these patients have leakage of RBCs from damaged glomeruli, as well as proteinuria, RBC casts are found in the urine.
When will eosinophils be found in the urine
As a result of drug-induced interstitial nephritis
Myoglobinuria results most often from what
Rhabdomyolysis, which can occur after severe crush injuries
What are oval fat bodies in the urine
Sloughed tubular cells containing abundant lipid that are characteristic of nephrotic syndromes
Triple phosphate crystals in the urine are found in what circumstance
Patients with infections caused by urease-positive bacteria, such as Proteus.
Where do waxy casts found in the urine form
Dilated, damaged tubules
A 28 year old woman has had dysuria, frequency, and urgency for the past 2 days. 37.6C. Urine culture grows >100,000 colonies of E. coli. She is treated with antibiotics. If the problem continues to recur, that patient is likely to be at greatest risk for development of what renal disease
Chronic pyelonephritis. Most cases of pyelonephritis result from ascending bacterial infections, which are more common in women. Recurrent urinary tract infections complicated by vesicoureteral reflux cause progressive interstitial damage and scarring, which can lead to chronic pyelonephritis with renal failure. Glomerular injury is not the major consequence of renal infections
Diffuse glomerulosclerosis is a feature of what disease
Diabetes mellitus
A sexually active 26 year old man has had pain on urination for the past 4 days. No lesions on the penis. Afebrile. Urinalysis shows no blood, ketones, protein, or glucose. Urine exam shows few WBCs and no casts or crystals. What infectious agent is most likely to produce these findings
Chlamydia trachomatis. This patient has urethritis. The most common cause of nongonococcal urethritis in males is Chlamydia trachomatis. The condition is a nuisance; however, the behavior that led to the infection can place the patient at risk of other sexually transmitted diseases
61 year old woman sees the physician because she has experienced increasing malaise for the past 5 years. No physical abnormalities except BP 150/95. One week later she dies suddenly and unexpectedly. At autopsy, both kidneys appear as above. What was the most probably cause of death
Ruptured berry aneurysm. These findings are characteristic of autosomal dominant polycystic kidney disease. As seen in the pictures, several large cysts have completely replaced the kidney. In autosomal recessive polycystic kidney disease, which typically presents in fetal and neonatal life, the kidneys have a smooth external appearance. On cut section, many small cysts give the kidney a spongelike appearance. About 10-30% of affected patients with DPKD have an intracranial berry aneurysm, and some of these can rupture without warning
For the past 20 years, a 69 year old man with chronic arthritis has taken more than 3g of analgesics per day, including phenacetin, aspirin, and acetaminophen. He sees his physician because of increasing malaise, nausea, and diminished mentation. BP 156/92. Serum urea nitro 68, creatinine 7.1. CBC shows hgb 11.7, hct 35.1%, platelets 188,500, WBC 5385. What renal disease is this patient most likely to develop
Renal papillary necrosis. This patient has analgesic nephropathy, which damages the renal interstitium and can give rise to papillary necrosis. The toxic injury that occurs with analgesic use is slowly progressive and not acute, in contrast to the course of acute tubular necrosis
58 year old woman sees her physician for a routine health maintenance exam. The only abnormality on exam is BP 168/109. Urinalysis pH7, specific gravity 1.020, 1+ proteinuria, no blood, glucose, or ketones. Ab ultrasound scan shows bilaterally and symmetrically small kidneys with no masses. ANA negative, serum urea nitro 51, creatinine level 4.7. Hgb A1C normal. Diagnosis?
Chronic glomerulonephritis. Chronic glomerulonephritis may follow specific forms of acute glomerulonephritis. In many cases, however, it develops insidiously with no known cause. With progressive glomerular injury and sclerosis, both kidneys become smaller, and their surfaces become granular. Hypertension often develops because of renal ischemia. Regardless of the initiating cause, the end-stage kidneys appear morphologically identical. They have sclerotic glomeruli, thickened arteries, and chronic inflammation of the interstitium
58 year old woman sees her physician for a routine health maintenance exam. The only abnormality on exam is BP 168/109. Urinalysis pH7, specific gravity 1.020, 1+ proteinuria, no blood, glucose, or ketones. Ab ultrasound scan shows bilaterally and symmetrically small kidneys with no masses. ANA negative, serum urea nitro 51, creatinine level 4.7. Hgb A1C normal. Diagnosis?
Chronic glomerulonephritis. Chronic glomerulonephritis may follow specific forms of acute glomerulonephritis. In many cases, however, it develops insidiously with no known cause. With progressive glomerular injury and sclerosis, both kidneys become smaller, and their surfaces become granular. Hypertension often develops because of renal ischemia. Regardless of the initiating cause, the end-stage kidneys appear morphologically identical. They have sclerotic glomeruli, thickened arteries, and chronic inflammation of the interstitium
Previously healthy 21 year old man sees his physician because he notices blood in his urine. No dysuria, frequency, or hesitancy of urination. No abnormal physical findings. Serum urea nitro 39, creatinine 4.1. Renal biopsy immunofluorescence pattern of staining with antibody against human IgG is shown on the right. What serum lab study is most likely to be positive in this patient
Anti-glomerular basement membrane antibody. The linear pattern of staining shown in the right figure indicates the presence of anti-glomerular basement membrane antibodies. Such antibodies are typically seen in Goodpasture syndrome.
Poststreptococcal glomerulonephritis typically has what pattern of immune complex deposition
Granular
HIV infection can lead to a nephropathy that resembles focal segmental glomerulosclerosis, in which IgM and C3 are deposited where
The mesangial areas of affected glomeruli
The C3 nephritic factor can be a marker for what
Type II membranoproliferative glomerulonephritis
33 year old woman has had fever and increasing fatigue for the past 2 months. Over the past year, she has noticed soreness of her muscles and joints and has had a 4kg weight loss. 37.5C, pulse 80, resp 15, BP 145/95. Pain on deep inspiration, friction rub is heard on auscultation of the chest. Glucose 73, total cholesterol 160, total protein 5.2, albumin 2.9, total bilirubin 0.9, creatinine 2.4. Serum complement levels are decreased. CBC shows hbg 9.7, platelets 85,000, WBC 3560. Renal biopsy shows diffuse proliferative glomerulonephritis with extentensive granular immune deposits of IgG and C1q in capillary loops and mesangium. After being treated with immunosuppressive therapy consisting of prednisone and cyclophosphamide, her condition improves. What serolic study is most likely to be positive in this patient
Anti-double stranded DNA antibody. This patient has findings characteristic of systemic lupus erythematosus with lupus nephritis. Systemic problems include fever, arthralgias, myalgias, pancytopenia, and serositis with pericarditis and pleuritis. Renal disease is common in SLE, and a renal biopsy helps to determine the severity of involvement and the appropriate therapy.
Antihistone antibody may be present in what disease
Drug-induced lupus
ANCAs can be seen when
Some forms of vasculitis, such as Wegener granulomatosis or microscopic polyangiitis
66 year old woman died of an acute myocardial infarction. At autopsy, both kidneys were decreased in size (about 120g each) with a finely granular cortical surface. High mag of kidney shown above. What clinical abnormality most likely accompanied this lesion
Benign hypertension. This figure shows hyaline arteriolosclerosis, which typically occurs in patients with benign hypertension. Similar changes also can be seen with aging in the absence of hypertension.
Malignant hypertension causes distinctive renal vascular lesions that include...
Fibrinoid necrosis and hyperplastic arteriosclerosis
Flank pain is a symptom of what diseases
Acute pyelonephritis and some renal neoplasms
79 year old man has had increasing back pain and fatigue for the past 6 months. No remarkable physical findings. Hgb 9.6, platelet 241,600, WBC 7160, serum protein 9.8, albumin 3.6, glucose 72, creatinine 3.3, urea nitro 30. Urinalysis pH 7, specific gravity 1.011, no blood, protein, or glucose. One month later he develops a cough with fever, and S. pneumoniae is cultured from his sputum. Despite antibiotics he develops sepsis and dies. At autopsy, kidneys are normal size, but micro exam shows dilated tubules filled with amorphous blue to pink casts and occasional multinucleated giant cells. What was the most likely underlying cause of his death
Multiple myeloma. This patient has a high serum globulin level from the presence of a monoclonal protein, and the back pain is probably caused by lytic lesions in the spine. Patients with myeloma often have Bence-Jones proteinuria (not detected by the standard dipstick urinalysis), and some have cast nephropathy, which can cause acute or, more commonly, chronic renal failure.
Cystinuria leads to stones with what appearance
The distinctive crystals look like stop signs
30 year old woman with a history of recurrent urinary tract infections has had a high fever for the past 3 days. 38.4C. Marked tenderness on deep palpation. A renal sonogram shows an enlarged right kidney with pelvic and calyceal enlargement and cortical thinning; the left kidney appears normal. A right nephrectomy is performed, and microscopic examination shows inflammatory infiltrates extending from the medulla to the cortex, with tubular destruction and extensive interstitial fibrosis. Lymphocytes, plasma cells, and neutrophils are abundant. What is the most likely to produce these findings
Vesicoureteral reflux. These changes are characteristic of chronic pyelonephritis. Urinary tract obstruction favors recurrent urinary tract infection. Vesicoureteral reflux propels infected urine from the urinary bladder to the ureters and renal pelvis and predisposes to infection.
32 year old man with a history of intravenous drug use comes to the ER because he has had a high fever for the past 2 days. 38.4C. Palpable spleen tip, bilateral costovertebral tenderness, diastolic cardiac murmur. Serum urea nitro 15. Urinalysis 2+ hematuria, no glucose, protein, or ketones. Blood culture positive for S. aureus. What will his kidneys look like
Wedge-shaped regions of yellow-white cortical necrosis involving both kidneys. This patient is septic, and the heart murmur strongly suggests infective endocarditis. Cardiac lesions are the source of emboli (from valvular vegetations or mural thrombi) that can lodge in renal artery branches, producing areas of coagulative necrosis. These areas of acute infarction typically are wedge-shaped on cut section because of the vascular flow pattern.
Small, shrunked kidneys represent what?
An end stage of many chronic renal diseases
Irregular cortical scars in asymmetrically shrunken kidneys with calyceal dilation may represent what
Hydronephrosis complicated by infection with chronic pyelonephritis.
In the kidney, what does marked bilateral renal pelvic and calyceal dilation with thinning of the cortices point to?
Obstructive uropathy, such as occurs with nodular prostatic hyperplasia
What do scattered petechial hemorrhages in slightly swollen kidneys represent
Hyperplastic arteriolosclerosis associated with malignant hypertension
Three years ago, a 47 year old woman had a mastectomy of the right breast to remove an infiltrating ductal carcinoma. She now has bone pain, and a radionuclide scan shows multiple areas of increased uptake in the vertebrae, ribs, pelvis, and right femur. Urinalysis shows a specific gravity of 1.010, which remains unchanged after water deprivation for 12 hours. She undergoes several courses of chemotherapy over the next year. During this time, the serum urea nitrogen level progressively increases. What abnormal lab finding is most likely to be reported in this patient
Hypercalcemia. This patient has findings characteristic of nephrocalcinosis resulting from hypercalcemia. One of the most common causes of hypercalcemia in adults is metastatic disease. The hypercalcemia produces a chronic tubulointerstitial disease of the kidneys that is initially manifested by loss of concentrating ability. With continued hypercalcemia, there is progressive loss of renal function. Urinary tract stones formed of calcium oxalate may also be present
Hypercholesterolemia may be seen in some cases of what kidney disease
Minimal change disease, which can occur in Hodgkin disease and other lymphoproliferative malignancies
Some patients with what kidney disease may have a positive serologic test result for Hepatitis B surface antigen
Membranous glomerulonephritis
45 year old man has experienced increasing malaise, nausea, and reduced urine output for the past 3 days. Afebrile and normotensive. Serum creatinine 2.5. Urinalysis shows hematuria but no pyuria or glucosuria. A renal biopsy is performed and shown above. Immunofluorescence with anti-fibrinogen shows a similar pattern. What additional study will be most useful for classification and treatment of this disease?
Antiglomerular basement membrane antibody test. The renal biopsy specimen shows glomerular crescents, indicative of rapidly progressive glomerulonephritis. Crescentic glomerulonephritis is divided into three groups on the basis of immunofluorescence: type I (antiglomerular basement membrane [GBM] disease); type II (immune-complex disease); and type III (characterized by absence of anti-GBM antibodies or immune complexes). Each type has a different cause and treatment. The presence of anti-GBM antibodies suggests Goodpasture syndrome; patients with this disorder require plasmapheresis. Type II crescentic glomerulonephritis can occur in systemic lupus erythematosus, in Henoch-Schonlein purpura, and after infections. Causes of type III crescentic glomerulonephritis include Wegener granulomatosis and microscopic polyangitis. Immunofluorescence studies are critical for the classification and treatment of crescentic glomerulonephritis
28 year old man is diagnosed with acute myelogenous leukemia (M2). After induction with a multiagent chemotherapy protocol, he has an episode of lower abdominal pain accompanied by passage of red-colored urine. He has no fever, dysuria, or urinary frequency. On physical examination, there are no remarkable findings. Urinalysis shows a pH of 5.5, specific gravity 1.021, 2+ hematuria, and no protein, ketones, or glucose. There are no remarkable findings on an abdominal radiograph. What additional urinalysis finding is most likely in this patient
Uric acid crystals. The rapid cell turnover in acute leukemias, and cell death from treatment, causes the release of purines from the cellular DNA breakdown. The resulting hyperuricemia can predispose to the formation of uric acid stones. Renal stones can produce colicky pain when they pass down the ureter and through the urethra, and the local trauma to the urothelium can produce hematuria. Uric acid stones form in acidic urine. Unlike stones containing calcium, uric acid stones are radiolucent and are not visible on a plain radiograph
When may eosinophils appear in the urine
Drug induced interstitial nephritis
Oval fat bodies, which are sloughed tubular cells containing abundant lipid, are characteristic of what kidney disease
Nephrotic syndromes
Where in the kidney do waxy casts in the urine form
They form in dilated, damaged tubules
44 year old man has developed fever, nonproductive cough, and decreased urine output over the past 3 days. 37.7C and BP 145/95. He has sinusitis. Crackles are heard over all lung fields. CXR bilateral patchy infiltrates and nodules. Serum creatinine 4.1, urea nitro 43. Negative ANA but positive C-ANCA. Renal biopsy shows glomerular crescents and granulomatous vasculitis. The result of immunofluorescence staining with anti-IgG and anti-C3 antibodies is negative. Diagnosis?
Wegener granulomatosis. Wegener causes rapidly progressive glomerulonephritis characterized by epithelial crescents in Bowman's space. Several features differentiate Wegener granulomatosis from other forms of crescentic glomerulonephritis (eg Goodpastures syndrome). These are the presence of granulomatous vasculitis, the absence of immune complexes or anti-glomerular basement membrane-(GBM) antibodies, and the presence of C-ANCA.
65 year old woman has recently experienced several transient ischemic attacks. BP 150/95. Urinalysis 1+ proteinuria and no glucose, blood, or ketones. Micro exam of urine shows no RBCs or WBCs and few oxalate crystals. Ultrasound shows kidneys are slightly decreased in size. What renal lesion is most likely to be present in this patient
Hyaline arteriolosclerosis. Hyaline arteriolosclerosis, characterized by thickening and hyalinization of small arteries and arterioles, is typically seen in patients with long-standing benign hypertension. Such a change also occurs with aging. Vascular narrowing causes ischemic changes that are slow and progressive. There is diffuse scarring and shrinkage of the kidneys.
When will fibrinoid necrosis in arterioles of the kidney be seen
Malignant hypertension
Over the past 72 hours, a 44 year old man has experienced worsening headache, nausea, and vomiting. BP 276/158, and there is bilateral papilledema. Urinalysis 2+ proteinuria, 1+ hematuria, and no glucose or ketones. What renal lesion is most likely to be present in this patient
Necrotizing arteriolitis. This patient has malignant hypertension. Necrotizing arteriolitis and hyperplastic arteriolosclerosis are the distinctive vascular lesions of malignant hypertension.
Papillary necrosis is more likely to complicate what forms of nephropathy
Diabetic nephropathy or analgesic nephropathy.
35 year old previously healthy man is found dead in his home. At autopsy, the medical examiner notices bilaterally enlarged kidneys that contain multiple, irregularly arranged cysts of different shapes and sizes. There is a 0.5 cm nonruptured intracerebral berry aneurysm of the anterior communicating artery. There are scattered 1-2cm fluid-filled, liver cysts involving 10% of the parenchymal volume. Postmortem laboratory testing of the urine and blood shows markedly elevated levels of cocaine and its metabolite, benzoylecgonine. What conclusions can be drawn from these findings
The patient has autosomal dominant polycystic kidney disease, but died of a cocaine overdose. The combination of cysts in the kidney and berry aneruysms in the brain is characteristic of DPKD. The cysts also may appear in the liver and pancreas. Because of the autosomal dominant pattern of inheritance, with high penetrance of the gene, first-degree relatives are at risk of having the same disorder and should be evaluated by ultrasound or other imaging techniques. This is particulary important, because many patients remain asymptomatic until the onset of renal failure in adults.
12 year old girl has experienced increasing malaise for the past 2 weeks. There is periorbital edema on physical examination. The child is afebrile. Proteinuria on dipstick urinalysis but no hematuria or glucosuria. Exam of urine shows numerous oval fat bodies. Serum creatinine 2.3. She receives a course of corticosteroid therapy but does not improve. Renal biopsy is performed, and the biopsy specimen shows that approximately 50% of the glomeruli in the specimen are affected by the lesion shown. Diagnosis?
Focal segmental glomerulosclerosis. The biopsy specimen shows sclerosis of only a segment of the glomerulus (segmental lesion), and because only 50% of the glomeruli are affected, this is focal disease. Focal segmental glomerulosclerosis manifests clinically with nephrotic syndrome that does not respond to corticosteroid therapy. In contrast, corticosteroid-responsive nephrotic syndrome in children is typically caused by minimal change disease (lipoid nephrosis), which is not associated with any glomerular change seen under the light microscope.
Nephrotic syndrome with nodular glomerulosclerosis or diffuse thickening of the basement membrane is likely caused by what disease
Diabetes
19 year old woman has had fever and chills accompanied by right flank pain for the past 3 days. 38.3C, BP 150/90, right costovertebral angle tenderness. Serum glucose 77, creatinine 1.0. Urinalysis pH 6.5, specific gravity 1.018, no protein, blood, glucose, or ketones. Urine exam shows many WBCs and WBC casts. What factor is most important in the pathogenesis of the renal disease affecting this patient
Vesicoureteral reflux. This patient has acute pyelonephritis. Vesicoureteral reflux, acquired or congenital, is extremely important in the pathogenesis of ascending urinary tract infections, because it allows bacteria to ascend from the urinary bladder into the ureter and the pelvis. In general, urinary tract infections are more common in females because of their shorter urethra, but in the abscence of vesicoureteral reflux, the infections tend to remain localized in the urinary bladder. Older women and sexually active women are at increased risk of urinary tract infections.
Several days after eating a hamburger, chili, and ice cream at a home barbeque, a 5 year old girl develops cramping abdominal pain and diarrhea. The next day, she has decreased urine output. Petechial hemorrhages on the skin. 37C, pulse 90, resp 18, BP 90/50. Stool sample is positive for occult blood. Hgb 10.8, hct 32.4%, platelets 64,300, WBC 6480. Peripheral blood smear shows schistocytes, and the serum D dimer level is elevated. What organism caused this
E. coli. This girl has hemolytic-uremic syndrome. Some strains of E coli, which can contaminate ground beef products, may elaborate a toxin that damages endothelium, causing this syndrome. Hemolytic-uremic syndrome most often occurs in children and is one of the most important causes of acute renal failure in children.
A 17 year old boy is involved in a motor vehicle accident in which he sustains severe blunt trauma to the extremities and abdomen. Over the next 3 days, he develops oliguria and dark-brown colored urine. The urine dipstick analysis is positive for myoglobin and for blood, but microscopic exam of the urine shows no RBCs. His serum urea nitro rises to 38, and he undergoes hemodialysis for 3 weeks. His condition improves, but the urine output remains in excess of 3L/day for 1 week before the urea nitro returns to normal. What renal lesion is present in this patient
Acute tubular necrosis. This patient suffered from muscle injury that resulted in myoglobinemia and myoglobinuria. The large amount of excreted myoglobin produces a toxic acute tubular necrosis. With supportive care, the tubular epithelium can regenerate, and renal function can be restored. During the recovery phase of acute tubular necrosis, patients excrete large volumes of urine, because the glomerular filtrate cannot be adequately reabsorbed by the damaged tubular epithelium.
A 45 year old man has had headaches, nausea, and vomiting that have worsened over the past 5 days. He has started "seeing spots" before his eyes. BP 268/150. Urinalysis 1+ proteinuria 2+ hematuria, no glucose, ketones, or leukocytes. Serum urea nitro and creatinine level are both elevated. What histologic finding is most likely to be seen in this patient's kidneys?
Hyperplastic arteriolosclerosis. This patient has malignant hypertension, which may follow long-standing benign hypertension. Two types of vascular lesions are found in malignant hypertension. Fibrinoid necrosis of the arterioles may be present; in addition, there is intimal thickening in interlobular arteries and arterioles, caused by proliferation of smooth muscle cells and collagen deposition. The proliferating smooth muscle cells are concentrically arranged, and these lesions, called hyperplastic arteriolosclerosis, cause severe narrowing of the lumen. The resultant ischemia elevates the renin level, which further promotes vasoconstriction to potentiate the injury.
62 year old man has had several episodes of hematuria over the past week. He has not experienced increased urinary frequency or dysuria. No remarkable physical findings. Urinalysis shows 4+ hematuria. Urine culture is negative. Cytoscopy is performed and a 2cm sessile, friable mass is seen on the right bladder wall. A biopsy shows that it is a transitional cell carcinoma. What risk factor is most important in the pathogenesis of this bladder lesion
Smoking cigarettes. Cigarette smoking is the greatest risk factor in half of all men with such cancers. Schistosomiasis is also a risk factor for bladder cancer, although typically for squamous cell carcinoma
38 year old woman has been feeling tired and lethargic for several months. Afebrile, BP 140/90. Hgb 10.3, hct 30.9%, platelets 310,000, WBC 5585. Serum creatinine 5.8. C3 nephritic factor is present in serum, and the ANA test result is negative. Urinalysis shows 2+ proteinuria. Renal biopsy shows hypercellular glomeruli and prominent electron-dense deposits along the lamina densa of the glomerular basement membrane. What form of glomerulonephritis is most likely to be seen in this patient
Membranoproliferative glomerulonephritis. This patient has type II membranoproliferative glomerulonephritis, or dense-deposit disease, which usually leads to chronic renal failure
How is postinfectious glomerulonephritis often characterized morphologically
Hypercellular glomerulus with infiltration of polymorphonuclear leukocytes but no basement membrane thickening
A rapidly progressive glomerulonephritis is marked by what
Crescents
When is the term "chronic glomerulonephritis" used
When sclerosis of many glomeruli is present with no clear cause
60 year old man presents with a feeling of fullness in has abdomen and a 5kg weight loss over the past 6 months. Physical exam normal. Hgb 8.2, hct 24%, MCV 70. Urinalysis 3+ hematuria but no protein, glucose, or leukocytes. Ab CT shows 11cm mass in the upper pole of the right kidney. A right nephrectomy shows that the mass invades the renal vein. Cells have abundant clear cytoplasm. What molecular abnormality is most likely to be found in tumor cell DNA
Homozygous loss of the von Hippel Lindau (VHL) gene. Clear cell carcinoma, the most common form of kidney cancer, often presents with painless hematuria, most often in persons in the 6th or 7th decade. Approximately 80% of sporadic clear cell carcinomas show loss of both alleles of the VHL gene. Germ-line inheritance of the VHL mutation can give rise to von Hippel Lindau syndrome, with peak incidence of renal cell carcinoma in the 4th decade, and they may have other tumors including cerebellar and retinal hemangiomas and adrenal pheochromocytomas
Mutation of the MET gene on chromosome 7 is associated with what type of cancer
Papillary variant of renal cell carcinoma
45 year old Hispanic man has had increasing malaise with headaches and easy fatigability for the past 3 months. Physical exam reveals his blood pressure is 200/100. There are no palpable abdominal masses and no costovertebral tenderness. Hgb 9.5, hct 28.3%, MCV 92, creatinine 4.5, urea nitro 42. Urinalysis reveals 3+ hematuria and 3+ proteinuria but no glucose or leukocytes. A renal biopsy is performed and shows that approximately 50% of the glomeruli appear normal, but the rest show that a portion of the capillary tuft is sclerotic. Immunofluorescence staining shows IgM and C3 deposition in these sclerotic areas. Past history is significant for repeated episodes of passing dark brown urine, which failed to respond to corticosteroid therapy. What mechanism is most likely responsible for his disease
Dysfunction of the podocyte slit diaphragm apparatus. Corticosteroid-resistant hematuria and proteinuria in a Hispanic male leading to hypertension and renal failure is typical for focal segmental glomerulosclerosis (FSGS). FSGS is now the most common cause of nephrotic syndrome in adults in the US. Specialized extracellular areas overlying the glomerular basement membrane between adjacent foot processes of podocytes are slit diaphragms, and these exert control over glomerular permeability. Mutations in genes affecting several proteins including nephrin and podocin have been found in inherited cases of FSGS, and their dysfunction, possibly caused by cytokines or unknown toxic factors, is believed to be responsible for the acquired cases of FSGS. FSGS is also seen in patients with HIV-associated nephropathy
What is nephrotic syndrome characterized by
Increased basement membrane permeability, permitting the urinary loss of plasma proteins, particulary low-weight proteins, such as albumin
What nephrotic syndrome is characterized by no visible membrane changes; fused epithelial foot processes; lipid accumulation in renal tubular cells
Minimal change disease (lipoid nephrosis)
What nephrotic syndrome is characterized by no visible basement membrane changes; segmental sclerosis of scattered juxtamedulary glomeruli
Focal segmental glomerulosclerosis
What nephrotic syndrome is characterized by basement membrane markedly thickened by intramembranous and epimembranous (subepithelial) immune complex deposits; granular immunofluorescence; "spike and dome" apearance
Membranous glomerulonephritis
What nephrotic syndrome is characterized by basement membrane thickened; diffuse or nodular mesangial accumulations of basement membrane-like material
Diabetic nephropathy
What nephrotic syndrome is characterized by amyloid protein identified by special stains (Congo red), birefringence under polarized light, or electron microscopic criss-cross fibrillary pattern
Renal amyloidosis
What nephrotic syndrome is characterized by immune complex deposition in subendothelial location that may manifest as membranous glomerulonephritis
Lupus nephropathy
How is nephritic syndrome characterized
Inflammatory rupture of the glomerular capillaries, with resultant bleeding into the urinary space; proteinuria and edema may be present but usually are mild
What nephritic syndrome is characterized by subepithelial electron-dense "humps" and "lumpy-bumpy" immunofluorescence
Poststreptococcal glomerulonephritis
What nephritic syndrome is characterized by crescents, ANCA-negative forms with immune complexes or antiglomerular basement membrane antibodies; ANCA positive form with Wegener granulomatosis
Rapidly progressive (crescentic) glomerulonephritis
What type of nephritic syndrome is characterized by linear immunofluorescence caused by antiglomerular basement membrane antibodies
Goodpasture syndrome
What type of nephritic syndrome is characterized by split basement membranes
Alport syndrome
What glomerular disorder is characterized by mesangial IgA deposits
IgA nephropathy (Berger disease)
What glomerular disorder is characterized by tram-track appearance; deposits of C3, and dense deposits in one variant
Membranoproliferative glomerulonephritis
Define glomerulonephritis
Renal disease characterized by inflammatory changes in glomeruli which are not the result of infection of the kidneys
Define glomerulosclerosis
Hyaline deposits or scarring within the renal glomeruli, a degenerative process occuring in association with renal arteriosclerosis or diabetes
Define nephritis
Inflammation of the kidneys
Define pyelonephritis
Inflammation of the renal parenchyma, calices, and pelvis, particularly due to local bacterial infection
Define interstitial nephritis
A form of nephritis in which the interstitial connective tissue is chiefly affected
Define tubulointerstitial nephritis
Nephritis affecting renal tubules and interstitial tissue, with infiltration by plasma cells and mononuclear cells; seen in lupus nephritis, allograft rejection, and methicillin sensitization.