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ADV PATH > 1M-KIDNEY > Flashcards

1M-KIDNEY Flashcards

1
Q

Renal biopsy indiations

A 
o Diagnosis
o Evolution of the disease
o Prognosis
o Treatment
o Renal transplant
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2
Q

Adequate renal biopsy for focal lesions (irregular/ crescentic lesions)

A

10 glomeruli for irregular and crescentic proliferation

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3
Q

Adequate renal biopsy for extensive lesions (Diffuse lesions)

A

Single glomerulus may be sufficient

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4
Q

Accdg to guideline, how many glomeruli should be examined to properly assess the extent of the disease

A

At least 5-10 glomeruli

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5
Q

2 ways of doing renal biopsy

A

o Percutaneous route - using a cutting needle

o Open biopsy - direct exposure of the kidney; wedge sampling of outer cortex

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6
Q

Needles used for renal biopsy

A

o 16-18 gauge for adults

o 18-gauge needle for children

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7
Q

Biopsy specimen should be divided into __ ?

A

o Light microscopy
o Electron microscopy
o Immunofluorescence

● If you have two cores: one will be for EM and the other is for IF and LM.
● If the core is too small: specimen should be divided for EM and IF

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8
Q

Ideally, how many biopsy cores should be obtained when a needle biopsy is performed

A

Two biopsy cores

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9
Q 
● Fixative – 10% formalin
● Routine evaluation
   - H&E
   - PAS
   - Methenamine silver
   - Trichome stain
A

LIGHT MICROSCOPY

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10
Q 
● Fixation
   o Glutaraldehyde solution
● Tissue embedding
   o Epoxy resins
● Stains
   o Toluidine blue or methylene blue
● For ultrastructural study
   o sections double stained with uranyl acetate
and lead citrate
A

ELECTRON MICROSCOPY

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11
Q

Measurement of sample for EM

A

0.5-1 mm in thickness

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12
Q

o Snap frozen in liquid nitrogen or in isopentane cooled on dry ice
o Frozen sections are cut and stained
with specific antibodies and examined under ultraviolet
light using either transmitted or incident illumination.

A

IMMUNOFLUORESCENCE

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13
Q

Direct vs indirect immunofluorescence

A

o Direct immunofluorescence performed on frozen
sections is the simpler, faster, and most satisfactory
method for the routine evaluation of a renal biopsy

o Indirect methods may be used for extra sensitivity or
for a specific antibody

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14
Q

Measurement of sample for IF

A

2–4 μm thick

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15
Q

Immunostaining useful for antibody-mediated acute allograft rejection

A

C4d

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16
Q

Most common cause of idiopathic nephrotic

syndrome in children

A

MINIMAL CHANGE DISEASE

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17
Q

It was suggested to be caused by circulating factors, produced by
lymphocytes that can damage your glomerular
permeability barrier.

A

MINIMAL CHANGE DISEASE

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18
Q

(+) Heavy proteinuria (selective type) - leading to nephrotic syndrome
(+) Microscopic hematuria (<15%)
(+) HTN (<20%)

A

MINIMAL CHANGE DISEASE

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19
Q

LM:

  • normal
  • minimal meningeal prominence/ lipoid nephrosis
  • podocyte hypertrophy may be seen
A

MINIMAL CHANGE DISEASE

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20
Q

IF: negative for immunoglobulins and complements

A

MINIMAL CHANGE DISEASE

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21
Q

EM:

- Extensive podocyte effacement

A

MINIMAL CHANGE DISEASE

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22
Q

T or F: MCD occurs in children and has poor prognosis

A

FALSE

*It has a very good prognosis because children respond to steroids

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23
Q

T or F: Complete remission from MCD is possible

A

TRUE

*Complete remission is common within 8 weeks
of starting corticosteroid therapy.

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24
Q

(+) Proteinuria - nephrotic

(+) High incidence of progressive renal failure

A

FOCAL AND SEGMENTAL

GLOMERULOSCLEROSIS

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25
Q

Usually a result of circulating permeability factors leading to epithelial cell injury.

A

FOCAL AND SEGMENTAL

GLOMERULOSCLEROSIS

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26
Q

Usual causes of FSGS

A

Drugs, viral infections,

healed glomerulonephritis, and structural adaptive responses.

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27
Q 
LM: more pink areas because of the
sclerosis
IF: Nonspecific trapping of IgM and C3 in sclerosed
segments
EM: Extensive foot process effacement
A

FOCAL AND SEGMENTAL

GLOMERULOSCLEROSIS

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28
Q

Glomerular disease characterized
by subepithelial immune complex deposits and variable basement membrane thickening, without
infiltration by inflammatory cells.

  • More common in adults
  • Proteinuria
  • Progression to chronic renal disease
A

MEMBRANOUS GLOMERULONEPHRITIS

-aka. membranous nephropathy

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29
Q

A large majority of MGN cases, this condition occurs in what form?

A

Primary/idiopathic form

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30
Q

LM: Uniform capillary wall thickening, sometimes with spike and dome pattern; stained with PAS
IF: IgG and C3 granular deposits
EM: Four stages of subepithelial and intramembranous deposits

A

MEMBRANOUS GLOMERULONEPHRITIS

-aka. membranous nephropathy

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31
Q

A clinical syndrome
characterized by persistent proteinuria,
hypertension, and progressive decline in renal function.

A

DIABETEC NEPHROPATHY

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32
Q

Considered as the leading cause of ESRD,

A

DIABETEC NEPHROPATHY

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33
Q

Earliest manifestation of DIABETEC NEPHROPATHY

A

Microalbuminuria

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34
Q

Most consistent over manifestation of DIABETEC NEPHROPATHY

A

Proteinuria (nonselective type)

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35
Q

LM: Nodular and diffuse mesangial sclerosis; insudative lesions
IF: IgG linear staining along capillary walls and tubular basement membranes
EM: Diffuse thickening of basement membranes; increased mesangial matrix

A

DIABETEC NEPHROPATHY

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36
Q

What do you call the very prominent nodular pattern present on some Diabetic nephropathies?

A

Kimmelstiel-Wilson nodules

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37
Q

This results from the deposition of circulating
immune complexes in the glomerular mesangium,
leading to the activation of the complement cascade
via the alternative pathway.

A

IgA Nephropathy/ Berger Disease

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38
Q

o Autosomal dominant
o (+) Nephritic syndrome
o IgA deposition in the mesangium
o IF & EM: IgA reactivity and deposition

A

IgA Nephropathy/ Berger Disease

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39
Q

Severe form of GN

A

CRESCENTIC GLOMERULONEPHRITIS

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40
Q

o Rapid progressive loss of renal function
o Hematuria, RBC casts, variable proteinuria and severe oliguria
o Nephritic syndrome

A

CRESCENTIC GLOMERULONEPHRITIS

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41
Q

Criteria for crescentic glomerulonephritis or RPGN in LM

A

50% or more glomeruli show crescents

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42
Q 
DDx for CGN
LM: unremarkable
IF: linear lace-like in GBM
EM: Absent deposits
Serology: Anti-GBM Ab
Comments: No small vessel vasculitis
Other assoc: Goodpasture syndrome
A

ANTI-GLOMERULAR BASEMENT MEMBRANE NEPHRITIS

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43
Q 
DDx for CGN
LM: unremarkable
IF: Absent
EM: Absent
Serology: ANCA +
Comments: Vasculitis
Other assoc: Polyangitis
A

PAUCI-IMMUNE GLOMERULONEPHRITIS

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44
Q

DDx for CGN
LM: Variable mesangial or endocapillary proliferation
IF: Present (varies on dse entity)
EM : Electron-dense deposits present
Serology: ANA, ds-DNA, ASO, cryoglobulins
Comments: Vasculitis present (less common)
Other assoc: Lupus nephritis, IgA nephropathy, infxn-assoc GN

A

IMMUNE COMPLEX-MEDIATED GLOMERULOBEPHRITIS

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45
Q

o Acute, sudden, suppression of renal function
o Tubular epithelial injury
o Rapid increase of serum creatinine, oliguria or anuria

A

ACUTE TUBULAR NECROSIS

46
Q

More common type of Acute tubular necrosis

A

Ischemic Acute Tubular Necrosis

47
Q

Tubular necrosis seen in patients who underwent hypovolemic shock

A

ISCHEMIC ACUTE TUBULAR NECROSIS

48
Q

(+) Minimal cellular swelling to denudation and desquamation of tubular cells
(+) Hypoperfusion of the kidney
• Starts with the most proximal portion of the tubules

A

ISCHEMIC ACUTE TUBULAR NECROSIS

49
Q
  • Chemically induced injury
  • Extensive necrosis along proximal segments
  • Glomeruli is spared
A

TOXIC ACUTE TUBULAR NECROSIS

50
Q

Indications of renal biopsy if renal transplant rejection is present

A

to evaluate the intensity and nature of the rejection and to predict the potential reversibility of the lesion.

51
Q

Reasons for failure of graft

A

rejection, nephrotoxicity caused by immunosuppressive drugs or other causes like necrosis, infection, vascular problem or urinary outflow tract

52
Q

Transplant rejection that occurs within minutes or hours after revascularization

A

HYPERACUTE REJECTION

53
Q

• Abrupt cessation of urine flow
• Mottling cyanosis and diminished turgor in graft
• Due to interaction of preformed circulating
antibodies in the recipient with antigen on donor endothelial cells such as HLA, ABO

A

HYPERACUTE REJECTION

54
Q

Transplant rejection seen months after the transplant

A

ACUTE REJECTION

55
Q

Two types of acute rejection

A
  • Antibody mediated rejection

- Acute T-cell mediated rejection

56
Q

Antibody mediated rejection vs. Acute T-cell mediated rejection

A

ANTIBODY MEDIATED REJECTION

  • Caused by anti donor specific antibodies (DSA)
  • Directed against graft endothelium in glomeruli and peritubular capillaries
  • Glomerular endothelial cell swelling, increase cellularity and fibrin thrombi
  • Endolithiasis or fibrinoid necrosis

ACUTE T CELL MEDIATED REJECTION

  • Interstitial edema and focal lymphocytic infiltration
  • Dense lymphocytic plasma cell and monocytic infiltrates
  • Tubulitis – reliable marker of acute rejection
57
Q

Transplant rejection from several months to several years

A

CHRONIC REJECTION

58
Q

Most common cause of graft failure after the initial 6-12 months post transplantation

A

CHRONIC REJECTION

59
Q
  • Progressive and irreversible
  • End stage of repeated episodes of Ab-mediated rej. &/or T-cell mediated rejection
  • Gradual decrease in renal function
  • Proteinuria, nephrotic range, hypertension
A

CHRONIC REJECTION

60
Q
  • Congenital dse (seen in infants & children 3-6 y/o)
  • Classic presentation as abdominal mass
  • Hematuria, flank pain and hypertension
A

WILM’S TUMOR/ nephroblastoma

61
Q

Gene involved in Wilm/s tumor

A

Chromosome 11

62
Q
  • Fleshy, solitary, well-circumscribed and soft
  • Hemorrhage, cystic change and necrosis
  • Fibrous septation
A

WILM’S TUMOR/ Nephroblastoma

63
Q

Conditions assoc with the highest risk of Nephroblastoma

A
  • WAGR
  • Beckwith-Wiedemann Syndrome
  • Denys-Drash
64
Q

T or F: When Wilm’s tumor is found in adolescents & adults, or at extra renal sites, it has a good prognosis.

A

FALSE

  • Significantly worse clinical outcomes
65
Q

Imaging studies: intrarenal mass that displaces and distorts the collecting system; foci of calcification

A

Wilm’s tumor

66
Q

2 year old child presented with sudden abdominal pain. The mother of the patient stated that the pain started after the child had a fall while playing around. what is your diagnosis and what is the reason behind the pain?

A

Dx: Wilm’s tumor

Reason for pain: (+) hemorrhage in the mass when the child fell

67
Q

Three histologic components of Nephroblastoma

A
  • Undifferentiated blastema: dark staining cells in aggregates
  • Mesenchymal/ stromal tissue: spindle cells in between; lighter region
  • Epithelial tissue: form your tubular structures
68
Q

Immunostaining of WT’s histologic components

A
  • Epithelial elements: keratin, EMA
  • Mesenchymal elements: Myogenin, desmin
  • Neural elements (if present): neuron-specific enolase, glial fibrillary acidic protein, and S-100 protein
69
Q

Molecular genetic features of Wilm’s tumor

A

WT1 in 11p13

  • point mutation in Deny-Drash
  • deletion in WAGR syndrome

WT2 in 11p15.5
- Beckwith-Wiedmann syndrome

70
Q

Most common renal tumor in adults

A

RENAL CELL CARCINOMA

71
Q

An adult male complained of flank pain and hematuria. Upon inspection, an abdominal mass is present.

PMH: hypertension
PSHx: cigarette smoking

Dx?

A

Renal Cell Carcinoma

72
Q

RCC diagnostic triad

A
  • Hematuria
  • Abdominal mass
  • Flank pain
73
Q

Most common manifestation of RCC

A

Hematuria

74
Q

Most common histologic type of RCC

A

Clear cell RCC

75
Q

Which histologic type of RCC?

  • Well-delineated tumor, solid, golden yellow, centered on cortex
  • (+) Hemorrhage, necrosis, cystic change
  • Clear cytoplasm, centrally located hyperchromatic nuclei
  • delicate fibrovascular network
A

CLEAR CELL RCC

76
Q

Positive immunohistochemical stains for Clear cell RCC

A
  • Keratins and EMA
  • CD10, PAX2, PAX8
  • Co expression of keratin and vimentin: take note bec not present in normal tubular cells
  • Keratin and PAX 8: determination of metastasis
77
Q

Clear cell RCC: DDx and Negative stains

A
  1. Adrenal cortical carcinoma
    - RCC is (-) for: inhibin, melan a, sf-1
  2. Clear cell CA of the ovary
    - RCC is (-) for: 34betaE12, ck7
  3. Clear cell CA of the thyroid
    - RCC is (-) for: thyroglobulin, TTF-1
  4. Mesothelioma
    - RCC is (-) for: calretenin, mesothelin, ck5/6
78
Q

Grading System for Clear Cell RCC (& Papillary RCC)

A

Grade 1: Nucleoli absent/ inconspicuous; basophilic

2: Conspicuous & eosinophilic at x400
3: Conspicuous & eosinophilic at x100
4: Extreme nuclear pleomorphism &/or rhabdoid or sarcomatoid differentiation

79
Q

Second most common type of RCC

A

Papillary RCC

80
Q

Type 1 vs Type 2 papillary RCC

A

Type 1:
- Tumors that are well-differentiated, encapsulated, cystic that form complex papillary structures

Type 2:

  • High grade renal cell carcinoma that attempts to form papillary structure
  • We have nuclear grade 4 with only focal papillary formation
81
Q

Gross: well-circumscribed, generally solitary, gray-brown in color, and absent or minimal hemorrhage or necrosis

Microscopic: sharply-defined cytoplasmic membrane
with abundant cytoplasm, granular, eosinophilic
-Has perinuclear clearing

A

CHROMOPHOBE RENAL CELL CARCINOMA

82
Q
  • Centered in the medulla
  • Have destructive infiltrative growth
  • They are in tumor cell aggregates trying to infiltrate the stroma with a significant desmoplastic reaction
  • Considered as high-grade tumor: usually in stage 3 or stage 4
  • Extensive and hyperchromatic
A

COLLECTING DUCT CARCINOMA

83
Q

A high grade tumor that is extensively pleomorphic and hyperchromatic

Composed of high grade cells with rhabdoid and cauliform tumor cells

A

RENAL MEDULLARY CARCINOMA

84
Q

RCC subtype seen in younger patients especially with African descent and sickle cell trait

A

RENAL MEDULLARY CARCINOMA

85
Q

Strongest prognostic factor for RCC

A

Staging

86
Q

Usual location for RCC distant metastases

A

Lungs and bones

87
Q

An important indicator of relapse

A predictor of survival especially in clear cell carcinoma

A

Microscopic grade (/nuclear grade)

88
Q

RCC staging

A

Primary Tumor (pT)

  • pTX: primary tumor cannot be assessed
  • pT0: no evidence of primary tumor
  • pT1a: ≤ 4 cm, limited to the kidney
  • pT1b: > 4 cm and ≤ 7 cm, limited to the kidney
  • pT2a: > 7 cm and ≤ 10 cm, limited to the kidney
  • pT2b: > 10 cm, limited to the kidney
  • pT3a: invades renal vein/branches, perirenal fat, renal sinus fat or pelvicaliceal system
  • pT3b: extends into vena cava below the diaphragm
  • pT3c: extends into vena cava above the diaphragm or invades vena cava wall
  • pT4: invades beyond Gerota fascia, including direct extension to adrenal gland
89
Q

Solid tumor with mahogany brown color and central stellate scar

A

RENAL CELL ONCOCYTOMA

90
Q

Express pncytokeratin, low molecular weight keratin, CD117, and E-cadherin

A

RENAL CELL ONCOCYTOMA

91
Q

Which histologic type of RCC?

  • Well-delineated tumor, solid, golden yellow, centered on cortex
  • (+) Hemorrhage, necrosis, cystic change
  • Clear cytoplasm, centrally located hyperchromatic nuclei
  • delicate fibrovascular network
A

CLEAR CELL RCC

92
Q

Positive immunohistochemical stains for Clear cell RCC

A
  • Keratins and EMA
  • CD10, PAX2, PAX8
  • Co expression of keratin and vimentin: take note bec not present in normal tubular cells
  • Keratin and PAX 8: determination of metastasis
93
Q

Clear cell RCC: DDx and Negative stains

A
  1. Adrenal cortical carcinoma
    - RCC is (-) for: inhibin, melan a, sf-1
  2. Clear cell CA of the ovary
    - RCC is (-) for: 34betaE12, ck7
  3. Clear cell CA of the thyroid
    - RCC is (-) for: thyroglobulin, TTF-1
  4. Mesothelioma
    - RCC is (-) for: calretenin, mesothelin, ck5/6
94
Q

Grading System for Clear Cell RCC (& Papillary RCC)

A

Grade 1: Nucleoli absent/ inconspicuous; basophilic

2: Conspicuous & eosinophilic at x400
3: Conspicuous & eosinophilic at x100
4: Extreme nuclear pleomorphism &/or rhabdoid or sarcomatoid differentiation

95
Q

Second most common type of RCC

A

Papillary RCC

96
Q

Type 1 vs Type 2 papillary RCC

A

Type 1:
- Tumors that are well-differentiated, encapsulated, cystic that form complex papillary structures

Type 2:

  • High grade renal cell carcinoma that attempts to form papillary structure
  • We have nuclear grade 4 with only focal papillary formation
97
Q

Gross: well-circumscribed, generally solitary, gray-brown in color, and absent or minimal hemorrhage or necrosis

Microscopic: sharply-defined cytoplasmic membrane
with abundant cytoplasm, granular, eosinophilic
-Has perinuclear clearing

A

CHROMOPHOBE RENAL CELL CARCINOMA

98
Q
  • Centered in the medulla
  • Have destructive infiltrative growth
  • They are in tumor cell aggregates trying to infiltrate the stroma with a significant desmoplastic reaction
  • Considered as high-grade tumor: usually in stage 3 or stage 4
  • Extensive and hyperchromatic
A

COLLECTING DUCT CARCINOMA

99
Q

A high grade tumor that is extensively pleomorphic and hyperchromatic

Composed of high grade cells with rhabdoid and cauliform tumor cells

A

RENAL MEDULLARY CARCINOMA

100
Q

RCC subtype seen in younger patients especially with African descent and sickle cell trait

A

RENAL MEDULLARY CARCINOMA

101
Q

Strongest prognostic factor for RCC

A

Staging

102
Q

Usual location for RCC distant metastases

A

Lungs and bones

103
Q

An important indicator of relapse

A predictor of survival especially in clear cell carcinoma

A

Microscopic grade (/nuclear grade)

104
Q

RCC staging

A

Primary Tumor (pT)

  • pTX: primary tumor cannot be assessed
  • pT0: no evidence of primary tumor
  • pT1a: ≤ 4 cm, limited to the kidney
  • pT1b: > 4 cm and ≤ 7 cm, limited to the kidney
  • pT2a: > 7 cm and ≤ 10 cm, limited to the kidney
  • pT2b: > 10 cm, limited to the kidney
  • pT3a: invades renal vein/branches, perirenal fat, renal sinus fat or pelvicaliceal system
  • pT3b: extends into vena cava below the diaphragm
  • pT3c: extends into vena cava above the diaphragm or invades vena cava wall
  • pT4: invades beyond Gerota fascia, including direct extension to adrenal gland
105
Q

Solid tumor with mahogany brown color and central stellate scar

A

RENAL CELL ONCOCYTOMA

106
Q

Express pancytokeratin, low molecular weight keratin, CD117, and E-cadherin

A

RENAL CELL ONCOCYTOMA

107
Q

Yellow to brown tumor with focal hemorrhage; 1/3 of patients have tuberculous sclerosis; majority in adults

A

ANGIOMYOLIPOMA

108
Q

Micro:

  • Mixture of fatty tissue, vascular structures, and muscular tissues
  • Irregular due to tortuosity and lack of elastic tissue
A

ANGIOMYOLIPOMA

109
Q
  • Granular tumor
  • Common in renal pelvis and ureter
  • Sx: Hematuria
  • Assoc w/ hydronephrosis & enlargement of ureter
A

UROTHELIAL CELL CARCINOMA/ Transitional cell CA

110
Q

Greatest risk factor for Urothelial cell CA

A

Smoking

111
Q

Diagnosis of Urothelial Cell CA

A

via intravenous retrograde pyelography

ADV PATH (10 decks)

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