Pathology Chapter 20 Review Kidneys

Front 1

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?

Back 1

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.

Front 2

What two types of kidney stones are radiolucent and tend to form in acidic urine

Back 2

Uric acid stones and cystine stones

Front 3

What type of kidney stones tend to occur in association with urinary tract infections, particulary those caused by urease-positive bacteria such as Proteus

Back 3

Triple phosphate stones

Front 4

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

Back 4

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.

Front 5

Is acute tubular necrosis potentially reversible

Back 5

Yes

Front 6

Is focal segmental glomerulosclerosis typically responsive to corticosteroids

Back 6

No, it is typically nonresponsive to corticosteroids

Front 7

Acute pyelonephritis is accompanied by what systemic symptoms

Back 7

Fever and leukocytosis

Front 8

Can IgA nephropathy have intermittent hematuria

Back 8

Yes

Front 9

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

Back 9

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

Front 10

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

Back 10

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.

Front 11

In a patient with kidney problems and hemoptysis, what should be suspected

Back 11

Goodpasture syndrome

Front 12

Lens dislocation is a feature of what disease

Back 12

Alport syndrome

Front 13

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

Back 13

Squamous cell carcinoma. Carcinoma of the urethra is uncommon. It tends to occur in older women and is locally aggressive

Front 14

An embryonal rhabdomyosarcoma (sarcoma botryoides) is a rare tumor that occurs in what age group

Back 14

Children

Front 15

What types of tumors are typically well circumscribed and do not ulcerate

Back 15

Benign tumors, such as a leiomyoma or papilloma

Front 16

What infectious disease produces indurated, painless lesions in the genito-rectal region

Back 16

Syphilis

Front 17

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

Back 17

Ureteral obstruction. The ureteral, pelvic, and calyceal dilation results from long-standing obstruction leading to hydroureter and hydronephrosis.

Front 18

With what disease do the kidneys become smaller and develop granular surfaces, but there is no dilation

Back 18

Benign nephrosclerosis

Front 19

The scarring that accompanies what two kidney diseases can be marked, and is associated with significant loss of parenchyma but not with pelvic dilation

Back 19

Analgesic nephropathy or chronic pyelonephritis

Front 20

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

Back 20

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.

Front 21

Granular staining of basement membrane with IgG antibodies denotes immune complex deposition, which may occur in what disease

Back 21

Postinfectious glomerulonephritis. The subepithelial deposits are seen on electron microscopy. Patients with these changes have nephritic syndrome

Front 22

Diffuse cellular proliferation and basement membrane thickening denote what renal disease?

Back 22

Membranoproliferative glomerulonephritis. In this condition, IgG and C3 are deposited in the glomeruli.

Front 23

Glomerular capillary thrombosis is typical of what disease

Back 23

Hemolytic-uremic syndrome

Front 24

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

Back 24

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

Front 25

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

Back 25

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.

Front 26

What type of kidney stones are formed in acidic urine and are not necessarily related to gout

Back 26

Uric acid stones. At low pH, uric acid is insoluble, and stones form

Front 27

Infections can predispose to the formation of what type of kidney stones

Back 27

Magnesium ammonium phosphate stones

Front 28

Hyperparathyroidism predisposes affected persons to form kidney stones containing what

Back 28

Calcium, however, few patients with urinary tract stones have hyperparathyroidism

Front 29

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

Back 29

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.

Front 30

What are some characteristics of renal cell carcinomas

Back 30

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

Front 31

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?

Back 31

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

Front 32

Acute tubular necrosis follows what

Back 32

Ischemic or toxic injuries to the kidney. It does not involve the glomeruli

Front 33

What generally produces a nephrotic syndrome and deposition of immune complexes in glomerular basement membrane

Back 33

Membranous glomerulonephritis

Front 34

Nodular and diffuse glomerulosclerosis are typical changes seen in what disease

Back 34

Diabetic nephropathy

Front 35

What is Berger disease, or IgA nephropathy

Back 35

A form of glomerulonephritis that does not produce tubular changes

Front 36

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

Back 36

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

Front 37

What type of WBC will not be seen in the urine of a patient with a urinary tract infection

Back 37

Eosinophils

Front 38

When does glomerulonephritis develop in patients infected with group A Beta-hemolytic streptococci that cause skin infection

Back 38

Glomerulonephritis develops weeks after the skin infection

Front 39

What syndrome can occur after ingestion of strains of E coli that may be present in ground beef

Back 39

Hemolytic uremic syndrome

Front 40

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?

Back 40

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

Front 41

When does postinfectious glomerulonephritis usually occur

Back 41

Several weeks after an infection, usually with group A Beta-hemolytic streptococci

Front 42

In what age group does the vasculitis Wegener granulomatosis occur

Back 42

Most often in adults

Front 43

Hereditary nephritis usually occurs in what age group

Back 43

Childhood; it is progressive and is not related to vascular disease

Front 44

Is an IgA nephropathy accompanied by vascular changes

Back 44

No. It most often occurs in young adults

Front 45

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

Back 45

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

Front 46

In kidney EM, what do subepithelial electron-dense humps represent

Back 46

Immune complexes, which are seen with postinfectious glomerulonephritis

Front 47

In kidney EM, variability of basement membrane thickening may be seen in what disease

Back 47

Alport syndrome

Front 48

The mesangial matrix is expanded in some forms of what kidney disease

Back 48

Glomerulonephritis (eg IgA nephropathy) and other diseases, such as diabetes mellitus. It will not be expanded in minimal change disease

Front 49

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?

Back 49

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.

Front 50

Nodular and diffuse glomerulosclerosis are characteristic of what diease

Back 50

Diabetic nephropathy

Front 51

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

Back 51

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

Front 52

Why would a positive ANA test not be expected in a patient with bladder neck obstruction

Back 52

Autoimmune conditions may be associated with interstitial cystitis, but cystitis does not cause bladder neck obstruction

Front 53

Schistosomiases leads to what bladder morphology

Back 53

Chronic inflammation and scarring

Front 54

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

Back 54

Hypertension. This woman has an autosomal dominant form of polycystic kidney disease. Hypertension and infection are the most frequent complications of this disorder.

Front 55

What disease is at increased risk in persons with dialysis-acquired cysts but not in those with polycystic kidney disease

Back 55

Renal cell carcinoma

Front 56

Is nephrotic syndrome common in polycystic kidney disease

Back 56

Although some proteinuria is present in many forms of chronic renal disease, nephrotic syndrome is not common in polycystic kidney disease

Front 57

A microangiopathic hemolytic anemia may be seen in what disease that typically affects the kidney

Back 57

Hemolytic-uremic syndrome

Front 58

Are vascular changes with resultant infarction seen in polycystic kidney disease

Back 58

No

Front 59

Is Cushing syndrome a complication of polycystic kidney disease

Back 59

Cushing syndrome may complicate renal cell carcinoma, but it is not a complication of polycystic kidney disease

Front 60

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

Back 60

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

Front 61

Glomerular crescents in Bowman's space suggest what

Back 61

A rapidly progressing glomerulonephritis that is unlikely to resolve

Front 62

Interstitial lymphocytic infiltrates in the kidneys suggests what

Back 62

A chronic tubulointerstitial process

Front 63

Fibrinoid necrosis in arterioles of the kidney is a feature of what

Back 63

Malignant nephrosclerosis, a serious condition that produces significant renal damage.

Front 64

Nodular glomerulosclerosis is a feature of what disease

Back 64

Diabetic nephropathy. It is a progressive condition that leads to chronic renal failure

Front 65

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

Back 65

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.

Front 66

What symptoms accompany urinary tract calculi when passed

Back 66

Severe, colicky pain

Front 67

What urinalysis value is typically manifest with nephrotic syndrome

Back 67

Proteinuria

Front 68

Why is a renal biopsy not recommened in a patient with suspect renal cell carcinoma

Back 68

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

Front 69

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?

Back 69

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

Front 70

An EM of the kidney showing subendothelial electron-dense deposits with duplication of the basement membrane is a feature of what

Back 70

Type I membranoproliferative glomerulonephritis

Front 71

An EM of the kidney showing electron-dense deposits limited to the mesangium are seen in what disease

Back 71

IgA nephropathy

Front 72

An EM of the kidney showing podocyte foot process fusion without any other abnormalities occurs in what disease

Back 72

Lipoid nephrosis (minimal change disease)

Front 73

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

Back 73

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

Front 74

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

Back 74

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

Front 75

The ANCA test is postitive in what forms of kidney disease

Back 75

Some forms of vasculitis, such as Wegener granulomatosis, which can involve the kidneys

Front 76

The anti-streptolysin O (ASO) titer is elevated following what

Back 76

Streptococcal infections, which may cause glomerulonephritis

Front 77

The C3 nephritic factor may be present in what kidney disease

Back 77

Type II membranoproliferative glomerulonephritis (dense deposit disease).

Front 78

Some patients with membranous glomerulonephritis have a positive serologic test result for what viral antigen

Back 78

HBsAg

Front 79

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?

Back 79

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.

Front 80

Enlarged kidneys with 1-4cm cysts are characteristic of what disease

Back 80

Autosomal dominant polycystic kidney disease in adults.

Front 81

What is the most common renal cystic disease seen in fetuses and infants, in which the cysts and kidneys are variably sized

Back 81

Multicystic renal dysplasia (multicystic dysplastic kidney). This disease can be focal, unilateral, or bilateral; however, congenital hepatic fibrosis is not present

Front 82

Small, shrunken, granular kidneys typify what disease

Back 82

End-stage renal disease in adults

Front 83

In the kidneys, irregular cortical scars with pelviceal dilation may represent what

Back 83

Hydronephrosis complicated by infection in chronic pyelonephritis, a process that occurs in adults

Front 84

In a fetus, kidney dilation with calyceal thinning can occur how

Back 84

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

Front 85

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

Back 85

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

Front 86

Essential hypertension is a risk factor for what kidney disease

Back 86

Benign nephrosclerosis

Front 87

How will the kidneys appear in chronic glomerulonephritis, benign nephrosclerosis (caused by essential hypertension), or systemic lupus erythematosus.

Back 87

Bilateral symmetric kidney involvement, and the affected kidneys will be shrunked and finely granular

Front 88

What disease is characterized by large cysts that replace the renal parenchyma and greatly increase the size of the kidneys bilaterally

Back 88

Autosomal dominant polycystic kidney disease

Front 89

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

Back 89

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.

Front 90

Deposition in the kidney of immune complexes with streptococcal antigens will lead to what disease

Back 90

Poststreptococcal glomerulonephritis. It is unlikely to be accompanied by a rash or by eosinophils in the urine

Front 91

Where does the infection originate in acute pyelonephritis

Back 91

It is an ascending infection; only uncommonly is it caused by hematogenous spread of bacteria from other sites.

Front 92

Acute tubular necrosis, which can lead to acute renal failure, is caused by what

Back 92

Hypoxia resulting from shock or from toxic injury caused by chemicals such as mercury, and only rarely if ever by bacterial toxins

Front 93

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?

Back 93

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.

Front 94

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

Back 94

Angiomyolipomas

Front 95

What type of renal tumors are generally less than 1cm and are incidental findings

Back 95

Renomedullary interstitial cell tumors (medullary fibromas)

Front 96

What type of renal tumor is rare in children, and the most common patterns are clear cell, papillary, and chromophobe

Back 96

Renal cell carcinoma

Front 97

What type of tumors arise in the urothelium in adults and microscopically resemble urothelium

Back 97

Transitional cell carcinomas

Front 98

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

Back 98

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.

Front 99

Antibodies against type IV collagen are formed in what disease

Back 99

Goodpasture syndrome.

Front 100

Cytokine-mediated injury to the glomerular capillaries can occur when

Back 100

In transplant rejection

Front 101

Defects in the structure of glomerular basement membrane are a feature of what disease

Back 101

Hereditary nephritis

Front 102

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?

Back 102

Ureteral lithiasis. This patient has ureteral colic from the passage of a stone down the ureter.

Front 103

What type of pain usually accompanies renal cell carcinoma

Back 103

Dull pain

Front 104

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

Back 104

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

Front 105

Immune complex deposition in membranous glomerulopathy can give rise to what disease

Back 105

Nephrotic syndrome. It is less common in children than adults and is not steroid-responsive

Front 106

Certain verotoxin-producing E. coli strains can cause hemolytic-uremic syndrome by injury to what tissue

Back 106

Capillary endothelium

Front 107

What kidney disease is mediated by T cell injury with tubulitis

Back 107

Acute cellular renal transplant rejection

Front 108

IgA nephropathy with mesangial IgA deposition and consequent glomerular injury gives rise to what finding on urinalysis

Back 108

Recurrent gross or microscopic hematuria and far less commonly to nephrotic syndrome

Front 109

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

Back 109

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.

Front 110

Antibodies that react with basement membrane, as in Goodpasture syndrome, give rise to what type of immunofluorescence pattern

Back 110

A linear pattern

Front 111

What are the causes of membranous glomerulopathy

Back 111

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

Front 112

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?

Back 112

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.

Front 113

What type of crystals are present in gout

Back 113

Uric acid crystals

Front 114

What disease may occur sporadically or as part of various genetic syndromes, such as Meckel-Gruber syndrome, in fetuses and newborns

Back 114

Multicystic renal dysplasia

Front 115

What disease can lead to hydroureter, hydronephrosis, and an increased risk of infection

Back 115

Vesicoureteral reflux

Front 116

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?

Back 116

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.

Front 117

Acute pyelonephritis is usually accompanied by what signs and symptoms

Back 117

Fever, and WBCs in the urine

Front 118

Acute tubular necrosis follows what

Back 118

Ischemic or toxic injury, and there is evidence of renal failure

Front 119

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?

Back 119

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."

Front 120

Cases of acute tubular necrosis typically occur from what types of injuries

Back 120

Toxic or ischemic renal injuries

Front 121

Malignant nephrosclerosis primarily affects what tissue

Back 121

It is primarily a vascular process that is not associated with infection

Front 122

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

Back 122

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

Front 123

What complication does Crescentic glomerulonephritis cause

Back 123

Rapidly progressive renal failure

Front 124

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

Back 124

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

Front 125

Recurrent urinary tract infection can cause what kidney disease

Back 125

Chronic pyelonephritis

Front 126

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

Back 126

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.

Front 127

What renal disease takes years to develop and is associated with benign essential hypertension

Back 127

Benign nephrosclerosis

Front 128

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

Back 128

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

Front 129

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?

Back 129

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.

Front 130

When is hemorrhagic cystitis likely to occur

Back 130

After radiation injury or treatment with cytotoxic drugs such as cyclophosphamide

Front 131

Tubercular cystitis is typically a complication of what disease

Back 131

Renal tuberculosis

Front 132

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?

Back 132

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

Front 133

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

Back 133

IgG and C3

Front 134

What is the only abnormality observed in minimal change disease

Back 134

Effacement of podocyte foot processes, but this change is not specific for MCD and may be seen in other disorders that produce proteinuria

Front 135

In what disease is there IgA deposition in the mesangium

Back 135

Berger disease (IgA nephropathy)

Front 136

A necrotizing granulomatous vasculitis can be present in the kidneys of patients with what disease

Back 136

Wegener granulomatosis

Front 137

Thickening and thinning of glomerular basement membranes occurs in what disease

Back 137

Alport syndrome

Front 138

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

Back 138

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.

Front 139

When will eosinophils be found in the urine

Back 139

As a result of drug-induced interstitial nephritis

Front 140

Myoglobinuria results most often from what

Back 140

Rhabdomyolysis, which can occur after severe crush injuries

Front 141

What are oval fat bodies in the urine

Back 141

Sloughed tubular cells containing abundant lipid that are characteristic of nephrotic syndromes

Front 142

Triple phosphate crystals in the urine are found in what circumstance

Back 142

Patients with infections caused by urease-positive bacteria, such as Proteus.

Front 143

Where do waxy casts found in the urine form

Back 143

Dilated, damaged tubules

Front 144

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

Back 144

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

Front 145

Diffuse glomerulosclerosis is a feature of what disease

Back 145

Diabetes mellitus

Front 146

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

Back 146

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

Front 147

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

Back 147

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

Front 148

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

Back 148

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

Front 149

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?

Back 149

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

Front 150

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?

Back 150

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

Front 151

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

Back 151

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.

Front 152

Poststreptococcal glomerulonephritis typically has what pattern of immune complex deposition

Back 152

Granular

Front 153

HIV infection can lead to a nephropathy that resembles focal segmental glomerulosclerosis, in which IgM and C3 are deposited where

Back 153

The mesangial areas of affected glomeruli

Front 154

The C3 nephritic factor can be a marker for what

Back 154

Type II membranoproliferative glomerulonephritis

Front 155

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

Back 155

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.

Front 156

Antihistone antibody may be present in what disease

Back 156

Drug-induced lupus

Front 157

ANCAs can be seen when

Back 157

Some forms of vasculitis, such as Wegener granulomatosis or microscopic polyangiitis

Front 158

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

Back 158

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.

Front 159

Malignant hypertension causes distinctive renal vascular lesions that include...

Back 159

Fibrinoid necrosis and hyperplastic arteriosclerosis

Front 160

Flank pain is a symptom of what diseases

Back 160

Acute pyelonephritis and some renal neoplasms

Front 161

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

Back 161

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.

Front 162

Cystinuria leads to stones with what appearance

Back 162

The distinctive crystals look like stop signs

Front 163

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

Back 163

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.

Front 164

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

Back 164

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.

Front 165

Small, shrunked kidneys represent what?

Back 165

An end stage of many chronic renal diseases

Front 166

Irregular cortical scars in asymmetrically shrunken kidneys with calyceal dilation may represent what

Back 166

Hydronephrosis complicated by infection with chronic pyelonephritis.

Front 167

In the kidney, what does marked bilateral renal pelvic and calyceal dilation with thinning of the cortices point to?

Back 167

Obstructive uropathy, such as occurs with nodular prostatic hyperplasia

Front 168

What do scattered petechial hemorrhages in slightly swollen kidneys represent

Back 168

Hyperplastic arteriolosclerosis associated with malignant hypertension

Front 169

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

Back 169

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

Front 170

Hypercholesterolemia may be seen in some cases of what kidney disease

Back 170

Minimal change disease, which can occur in Hodgkin disease and other lymphoproliferative malignancies

Front 171

Some patients with what kidney disease may have a positive serologic test result for Hepatitis B surface antigen

Back 171

Membranous glomerulonephritis

Front 172

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?

Back 172

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

Front 173

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

Back 173

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

Front 174

When may eosinophils appear in the urine

Back 174

Drug induced interstitial nephritis

Front 175

Oval fat bodies, which are sloughed tubular cells containing abundant lipid, are characteristic of what kidney disease

Back 175

Nephrotic syndromes

Front 176

Where in the kidney do waxy casts in the urine form

Back 176

They form in dilated, damaged tubules

Front 177

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?

Back 177

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.

Front 178

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

Back 178

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.

Front 179

When will fibrinoid necrosis in arterioles of the kidney be seen

Back 179

Malignant hypertension

Front 180

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

Back 180

Necrotizing arteriolitis. This patient has malignant hypertension. Necrotizing arteriolitis and hyperplastic arteriolosclerosis are the distinctive vascular lesions of malignant hypertension.

Front 181

Papillary necrosis is more likely to complicate what forms of nephropathy

Back 181

Diabetic nephropathy or analgesic nephropathy.

Front 182

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

Back 182

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.

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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?

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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.

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Nephrotic syndrome with nodular glomerulosclerosis or diffuse thickening of the basement membrane is likely caused by what disease

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Diabetes

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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

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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.

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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

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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.

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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

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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.

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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?

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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.

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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

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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

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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

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Membranoproliferative glomerulonephritis. This patient has type II membranoproliferative glomerulonephritis, or dense-deposit disease, which usually leads to chronic renal failure

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How is postinfectious glomerulonephritis often characterized morphologically

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Hypercellular glomerulus with infiltration of polymorphonuclear leukocytes but no basement membrane thickening

Front 192

A rapidly progressive glomerulonephritis is marked by what

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Crescents

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When is the term "chronic glomerulonephritis" used

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When sclerosis of many glomeruli is present with no clear cause

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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

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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

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Mutation of the MET gene on chromosome 7 is associated with what type of cancer

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Papillary variant of renal cell carcinoma

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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

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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

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What is nephrotic syndrome characterized by

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Increased basement membrane permeability, permitting the urinary loss of plasma proteins, particulary low-weight proteins, such as albumin

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What nephrotic syndrome is characterized by no visible membrane changes; fused epithelial foot processes; lipid accumulation in renal tubular cells

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Minimal change disease (lipoid nephrosis)

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What nephrotic syndrome is characterized by no visible basement membrane changes; segmental sclerosis of scattered juxtamedulary glomeruli

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Focal segmental glomerulosclerosis

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What nephrotic syndrome is characterized by basement membrane markedly thickened by intramembranous and epimembranous (subepithelial) immune complex deposits; granular immunofluorescence; "spike and dome" apearance

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Membranous glomerulonephritis

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What nephrotic syndrome is characterized by basement membrane thickened; diffuse or nodular mesangial accumulations of basement membrane-like material

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Diabetic nephropathy

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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

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Renal amyloidosis

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What nephrotic syndrome is characterized by immune complex deposition in subendothelial location that may manifest as membranous glomerulonephritis

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Lupus nephropathy

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How is nephritic syndrome characterized

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Inflammatory rupture of the glomerular capillaries, with resultant bleeding into the urinary space; proteinuria and edema may be present but usually are mild

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What nephritic syndrome is characterized by subepithelial electron-dense "humps" and "lumpy-bumpy" immunofluorescence

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Poststreptococcal glomerulonephritis

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What nephritic syndrome is characterized by crescents, ANCA-negative forms with immune complexes or antiglomerular basement membrane antibodies; ANCA positive form with Wegener granulomatosis

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Rapidly progressive (crescentic) glomerulonephritis

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What type of nephritic syndrome is characterized by linear immunofluorescence caused by antiglomerular basement membrane antibodies

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Goodpasture syndrome

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What type of nephritic syndrome is characterized by split basement membranes

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Alport syndrome

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What glomerular disorder is characterized by mesangial IgA deposits

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IgA nephropathy (Berger disease)

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What glomerular disorder is characterized by tram-track appearance; deposits of C3, and dense deposits in one variant

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Membranoproliferative glomerulonephritis

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Define glomerulonephritis

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Renal disease characterized by inflammatory changes in glomeruli which are not the result of infection of the kidneys

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Define glomerulosclerosis

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Hyaline deposits or scarring within the renal glomeruli, a degenerative process occuring in association with renal arteriosclerosis or diabetes

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Define nephritis

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Inflammation of the kidneys

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Define pyelonephritis

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Inflammation of the renal parenchyma, calices, and pelvis, particularly due to local bacterial infection

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Define interstitial nephritis

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A form of nephritis in which the interstitial connective tissue is chiefly affected

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Define tubulointerstitial nephritis

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Nephritis affecting renal tubules and interstitial tissue, with infiltration by plasma cells and mononuclear cells; seen in lupus nephritis, allograft rejection, and methicillin sensitization.