Chap 20

Question 1

_ is incompatible with life found in stillborn infants. Due to this defect, amniotic fluid is not made, and the baby gets crushed consistent with potter’s sequence.

Answer 1

Bilateral agenesis

Question 2

_ is compatible with compatible with life without other abnormalities. The good kidney will become enlarged and hypertrophy, and some develop sclerosis and renal failure.

Answer 2

Unilateral agenesis

Question 3

how is a congenital hypoplastic kidney distinguished from an acquired atrophic kidney

Answer 3

A true hypoplastic kidney has reduced lobes and pyramids (

Question 4

Ectopic kidneys usually develop where?

Answer 4

Pelvic brim or within pelvis

Question 5

What are some common complications of ectopic kidneys?

Answer 5

The ectopic kidneys are usually small and symptomatic. They may cause torsion or obstruction of ureter, predisposing for inferior (pyelonephritis)

Question 6

A shorsehoe kidney is continuous across the anterior of the aorta and inferior vena cava and get caught by what structure?

Answer 6

Inferior mesenteric artery.

Question 7

Ectopic kidneys most common is fusion of which pole, upper or lower?

Answer 7

Lower pole (90% of cases)

Question 8

Horseshoe kidneys have an increased risk of

Answer 8

stone formation

Question 9

Cystic renal dysplasis is an abnormality in _

Answer 9

metanephrotic differentiation

Question 10

What is cystic renal dysplasia characterized by?

Answer 10

Histologically by the persistence in the kidney of abnormal structures (cartilage, undifferentiated mesenchyme, and immature collecting ducts) and by abnormal lobe organization. Large cysts surrounded by mesenchyme

Question 11

On gross examination, how does cystic renal dysplasia appear?

Answer 11

• uni or bi lateral cysts, with extremely enlarged kidneys

Question 12

A 60 year old woman who has been on dialysis for number of years presents to the ER with flank pain and renal insufficiency. Pt stated she saw blood in her urine earlier during the day. On PE an abdominal mass was palpated. You suspect that patient has 1. The major complication of this disease is 2.

Answer 12

1. Acquired (dialysis associated) cystic disease

2. Renal cell carcinoma

Question 13

Adult form of polycystic kidney disease has what kind of inheritance?

Answer 13

Autosomal dominant

Question 14

what is the pathogenesis of polycystic kidney disease?

Answer 14

Polycystic kidney disease genes (PKD1 and PKD2) on chromosome 16 and 14, respectively, are implicated in the generation of cyst via polycycstin protein abnormality leading to proliferation of different regions of the tubules

Question 15

Morphologically, this disease shows enlarged kidneys reaching enormous sizes (4kg/kidney). The surface appears entirely cystic though histology reveals functional parenchyma and arise from different regions of the tubules with cysts expressing variable epithelia.

Answer 15

Autosomal dominant polycystic kidney disease

Question 16

Patients presents with flank pain and renal insufficiency. she also stated that she has seen blood in her urine. On PE a large abdominal mass was palpable. On further examination abnormalities on PKD1 and PKD2 were noted and confimed autosomal dominant polycystic kidney disease. Extrarenal cyst is most often found where? and what is a common cause of death in these pts?

Answer 16

40% occur in the liver from biliary epithelium and are asymptomatic. Some occur in lungs or spleen; mitral valve prolapse in heart.

10% of deaths occur from intracranial berry aneurysms.

Question 17

what is the Gene implicated in autosomal recessive polycystic kidney disease and what does it encode and what’s messed up due to the mutation?

Answer 17

PHKD1 which codes for fibrocystin expressed in adult/fetal kidneys liver/pancreas. Mutation screws up collecting tubule+ biliary epithelium differentiation.

Question 18

Describe how the cysts appear in autosomal recessive PKD.

Answer 18

• enlarged, smooth surfaced, tiny elongated cysts along the interior perpendicular to the cortical surface. Lined by cuboidal cells cuz all cysts come from collecting tubules.

Question 19

What is the prognosis of autosomal recessive PKD?

Answer 19

highly fatal in infancy, obvious renal failure in all cases.

Question 20

Those infants who survive autosomal recessive PKD, will develop fibrosis of what other organ?

Answer 20

Liver, along with hypertension and splenomegaly.

Question 21

On radiology, simple localized renal cysts are often mistaken for tumors. Explain how they appear.

Answer 21

On radiology, a pts scan showed small cortical translucent, grey, glistening, that was lined by a single layered membrane.

Question 22

What possible symptoms do pts with simple renal cysts present with?

Answer 22

Usually pain and distention if the kidney bleeds into the cysts.

Question 23

Medullary sponge kidney is an innocuous medullary cystic disease that is found incidentally on radiograph. These pts have increased risk of _

Answer 23

Stones, hematuria, infections

Question 24

A. Juvenile nephronophthisis - Medullary cystic disease complex (malicious medullary cystic disease) is implicated due to abnormality in what gene? what protein does that gene make?
B. Adult form of nephronopthisis-Medullary cystic disease complex: what gene is implicated?

Answer 24

A. NPH gene which makes nephrocystin –> shrunken kidney

B. MCKD1

Question 25

Nephronophthisis-medullary cystic disease complex induces cysts formation in what location?

Answer 25

Corticomedullary junction and interstitial fibrosis.

Question 26

A 10 year old boy presents to the clinic with polyuria and polydypsia, urine was noticeably dilute. Radiograph was unremarkable. Family history is positive for an uncle who had a similar case and required a kidney transplant within 10 years after diagnosis. Genetics testing showed NPH gene abnormality. Due to this disease, cysts formation are localized to what location? and what is the prognosis?

Answer 26

Medullary cysts concentrated to the corticomedullary junction

Question 27

Cystic renal dysplasia has a good prognosis if _

Answer 27

unilateral and nephrectomy

Question 28

On IF glomerular damage due to Goodpasture’s appears as _

Answer 28

linear. Antibody-basement membrane due to Type II hypersensitivity.

Question 29

What is the hallmark of acute renal failure?

Answer 29

Azotemia, often with oliguria

Question 30

What is the common cause of prerenal azotemia?

Answer 30

Decreased blood flow to kidneys: Common cause of ARF.

Question 31

What is the BUN: Cr ratio in prerenal azotemia? how is Tubular function affect?

Answer 31

Greater than 15 (15 is normal) This increase is due to activation of RAAS. Tubular function is intact. FENa 500 indicating tubules retain function in concentrating urine

Question 32

What is the most common cause of postrenal azotemia?

Answer 32

Obstruction of the urinary tract downstream from kidney –> decreased outflow –> decreased GFR (due to increased back flow pressure) –> azotemia and oliguria.

Question 33

Explain early vs the chronic post renal azotemia

Answer 33

Early stage: Increased tubular pressure forces BUN into the blood thus BUN:Cr >15. Tubular function is normal.

Chronic stage: longstanding obstruction leads to tubular damage and thus tubular function is diminished thus BUN:Cr

Question 34

What are some intrarenal causes of azotemia?

Answer 34

1. Acute Tubular necrosis

2. Acute interstitialnephritis

Question 35

_ is the most common cause of acute renal failure where necrotic cells plug tubules and thus GFR decreased leading to intrarenal azotemia. On urine sample brown granular casts can be seen.

Answer 35

Acute tubular necrosis

Question 36

Due to acute tubular necrosis, explain how BUN:Cr; fractional excretion of sodium, ability to concentrate urine changes.

Answer 36

BUN:Cr 2%

Osm

Question 37

Common causes of acute tubular necrosis include:

Answer 37

1. Ischemia: PCT and TAL are susceptible. preceded by prerenal azotemia
2. Nephrotoxic agents such as aminoglycodies, heavy metas, myoglobunuria, ethyelen glycol, radiocontrast dye and urate (PCT is esp susceptible

Question 38

Pt presents with sudden onset of oliguria with brown, granular casts. Elevated BUN and Creatinine. Hyperkalemia with acidosis is also noted. Pt medical history includes chemotherapy for metastatic carcinoma. Pt was worked up for acute renal failure. In this situation how long is oliguria likely to persist before recovery of her acute renal failure?

Answer 38

2-3 weeks. Pt presented with acute tubular necrosis due to urate possibly from her chemo. Renal tubular cells are stable cells and so it’ll take 2-3 weeks before those cells can reenter cell cycle and regenerate.

Question 39

65 yr old Patient presents with oliguria, fever, and a rash. An urine sample was taken which showed increased eosinophils. Medical history includes hypertension which was managed well with beta blockers until recently and her cardiologist added a diuretic which she started taking 2 weeks ago.
A. what is the best diagnosis?
B. If this disease was to progress, what structures are likely to be involved?

Answer 39

A. Acute interstitial nephritis, which is a drug-induced HSR of interstitial and tubules; results in ARF (intrarenal). Common causes are NSAIDS, PCN, and diuretics
B. Renal papillary necrosis.

Question 40

What are some causes of renal papillary necrosis? How do these pts usually present?

Answer 40

Chronic analgesic abuse, DM, Sickle cell trait or disease, severe acute pyelonephritis. Usually present with gross hematuria and flank pain

Question 41

Glomerular disorders with proteinuria greater than 3.5/day is grossly defined as a _ syndrome

Answer 41

Nephrotic syndrome

Question 42

what some common findings with nephrotic syndrome?

Answer 42

• proteinuria (>3.5 g/day)
• hypoalbuminemia –> edema
• hypogammaglobuinemia –> risk of infection
• Hypercoagulable state (loss of antithrombin III)
• hyperlipidemia and hypercholesterolemia

Question 43

what are some common nephrotic syndrome

Answer 43

1. Minimal change disease (MCD)
2. Focal segmental glomerulonephrotic syndrome (FSGS)
3. Membranous nephropathy
4. membranoproliferative glomerulonephritis (type I and Type II)

Question 44

Focal segmental glomerulonephrotic syndrome (FSGS) is the most common cuase of nephrotic syndrome in what demographics?

Answer 44

Hispanics and african american

Question 45

FSGS is usually idiopathic, however, it has high association with _

Answer 45

• HIV +
• Heroin use
• Sickle cell disease

Question 46

Explain how FSGS appear on H&E

Answer 46

Only a segment of the glomeruli will be involved and the rest of the glomeruli will be normal. And since it’s focal, it’ll only affect SOME of the glomeruli, NOT ALL

Question 47

A 47 HIV+ patient presents with presents with >3.5gm of protein in a 24 hour urine collection and lipiduria. His serum albumin is 2.9gm/dL. He has generalized edema. He fails to respond to steroid therapy. He has slight microscopic hematuria.
A. what is the most likely diagnosis.
B. what are you likely to see on EM?
C. what are you likely to see on IF?
D. Since pt did not respond to steroid, what is the next best option for treatment?

Answer 47

A. FSGS
B. Effacement of foot processes
C. NO immune complex deposits; negative IF
D. Renin-Angiotensin system inhibitors.

Side note: if you have a pt with nephrotic syndrome and did not respond to steroid therapy and progressed to chronic renal failure, pt most likely has FSGS.

Question 48

What is the most common cause of nephrotic syndrome in Caucasian adults?

Answer 48

membranous nephropathy

Question 49

What are usual causes of membranous nephropathy?

Answer 49

• usually idiopathic; may be associated with HBV, HCV, solid tumors, SLE, drugs (NSAIDS, PCM)

Question 50

A 51 year old white female with lower extremity pitting edema and oliguria. He has 3.7gm of protein in a 24hr urine collection. A urine dipstick is positive for scant presence of microscopic red cells. Lab test shows hypoalbuminemia, and hyperlipidia although she has no history of cardiovascular disease. Past medical history includes SLE.
A. what is the most likely diagnosis?
B. What are you likely to find on H&E
C. what are you likely to find on IF (if present where would they located?)
D. What are likely to find on EM?

Answer 50

A. Membranous nephropathy.
B. Thick glomerular basement membrane
C. Due to immune complex deposition IF will appear granular
D. On EM you’ll find dome, spike, dome spike like pattern and this is due to podocytes responding to granular deposits on the basement membrane.

Question 51

What are the two mechanisms said to result in tubulointerstitial fibrosis?

Answer 51

A. Infarction to tubules, possibly from alteration of hemodynamics in FSGS conditions
B. Activation of tubule cells either from proteinuria or other cytokines. activated tubule cells express adhesion molecules and elute inflammatory cells that lead to fibrosis.

Question 52

Diffuse proliferation of glomerular cells with presence of leukocytes is defined as what disease?

Answer 52

Acute proliferative glomerulonephritis aka post streptococcal glomerulonephritis

Question 53

An 8 year old boy presents with malaise, fever, nausea, and hematuria. The boys mom indicated her son has just gotten over a strep throat but isn’t sure what is happening now. You suspect an complication of infection and so you do lab tests and one of the test shows elevated ASO tiers. In pathogenesis of kidney issues leading to hematuria,
A. antibody against what antigen results in immune complex formation and deposition?
B. What are you likely to see in H&E?
C. What are you likely to see on IF?
D. What are you likely to see on EM?
E. what is the prognosis with proper fluid/electrolyte therapy?
F. In rare cases, the kidney issue can progress to _

Answer 53

A. M protein antigen (ASO titer). after A beta-hemolytic pharyngitis or skin infection.
B. Enlarged and hypercellular glomeruli; tubules often contain red cells casts;
C. Granular deposits of IgM IgG, and C3
D. Discrete, amorphous, electron dense deposit on the subepithelial side (which is the immune complex), often termed “lumpy bumpy”
E. 95% recover well as Ag-Ab is cleared with fluid/electrolyte
F. 1% develop rapidly progressive glomerulonephritis. Prolonged and persistent proteinuria/abnormal GFR marks a poor prognosis

Question 54

45 year old female patient has suffered from hypertension with multifocal lung hemorrhage and renal disease for several years and control/management has been difficult. Now she has gross hematuria, oliguria and is rapidly progressing to anuria. her serum creatinine is significantly elevated, and red cells casts. Histology of her kidney showed crescents with proliferative parietal cells, macrophages, PMNs and fibrin strands between cells. IF showed granular pattern.
A. what is the diagnosis?
B. How does the kidney look grossly?
C. What is the best option of treatment in this case?

Answer 54

A. Type II RPGN (usually seen in postinfectious, SLE, or Henolch-Schloen)
B. Enlarged and pale kidney with cortical petchial hemorrhage.
C. Phasmapphoresis.

Question 55

What is the cause of Type I RPGN?

Answer 55

anti-GBM antibodies as in Goodpasture; anti-collgen type IV

Question 56

In Berger disease aka IgA nephropathy, IgA deposits are found where and what’s best mode for detection?

Answer 56

This is a primary renal disease (most common nephropathy worldwide) where IgA deposits are found in the mesangium detected by IF. Systemic disease can also cause IgA deposits as in henoch-Schonlein purpura)

Question 57

An 8 year old boy brought to the ER by his mother presents with episodic hematuria. Mom tells the doctor that her son was getting over a “cold”. He seemed well until recently when the boy told his mom his “pee appeared bright red”. On urine sample cast casts were seen.
A. what is the diagnosis?
B. Specifically what is being being deposited in the kidney that’s causing the hematuria? What part of the kidney are the deposits?
C. What are you likely to see on IF?
D. What are you likely to see on H&E?
E. what is the pathogenesis of the injury?
F. What is the outcome if left untreated?

Answer 57

A. IgA Nephropathy
B. IgA1 (a form of IgA) deposited in mesangium of glomeruli
C. On IF, Granular mesangial pattern is seen
D. Microscopically, you’ll see mesangial proliferation or overt crescentic glomerulonephritis
E. After an upper respiratory infection/mucosal infection, IgA and IgA-complexes are formed that circulate in blood. some IgA become trapped in glomerulus leading to complement activation and glomerular injury
F. If left untreated, progresses to eventual renal failure.

Question 58

A 17 year old boy with a history of HBV infection, presents to the ER with severe proteinuria, slight hematuria, and pitting edema. On Lab, hypocomplementemia was indicated. On H&E of the kidney, thick capillary with tram-like appearance was seen.
A. What is the diagnosis?
B. What is the pathogenesis?
C. what specific kidney structures are involved?
D. what are you likely to see on IF
E. What are you likely to see on EM?
F. does does the two types of this disease differ?
G. Which has the worst prognosis, type I or II?

Answer 58

A. membranoproliferative glomerulonephritis Type I
B. Deposition of immune complex in subendothelial cells and mesangial deposits of C3 and IgG or IgM
C. immune complex deposition with subendothelial and mesangial deposits of C3 and IgG or IgM
D. IgG, IgM and C3 in a granular pattern pushed to the periphery
E. Subendothelial deposits (capillary lumen side, with RBCs)
F. Type I: subendothelial; associated with HBV and HCV, mostly a nephritic syndrome. Type II: Intramembranous; associated with C3 npehritic factor, an autoantibody that stablizes the C3 convertase, can be nephritic or nephrotic.
G. Type II, no effective treatment exists.

Question 59

Uncontrolled diabetes can lead to nephrotic syndrome.
A. Explain how
B. what you’re likely to see on H&E that is pathognomonic for this disorder.
C. What tx do these pts usually do well on?

Answer 59

High serum glucose leads to nonenzymatic glycosylation of vascular basement membrane. this is the first change that’s seen. This leads to BM becoming leaky and so protein leaks out leading to hyaline arteriosclerosis –> thickening of the blood vessels walls –> decreased caliber of the lumen (preferentially in the efferent arteriole). This builds up back pressure in the glomeruli –> hyperfiltration which begins first by microalbuminuria, eventually sclerosis of the mesengium leading to nephrotic syndrome.
B. On H&E you’ll see sclerosis of mesangium and formation of Kimmelsteil-Wilson nodules.
C. ACE inhibitors which works to slow the progression of hyperfiltration

Question 60

Explain the pathogenesis of how a nephrotic syndrome develops.

Answer 60

1. An initial event causes derangement of glomerular cpaillaries with increased permeability to protein with resultant proteinuria.
2. Albumin leaks out along with proteinuria leading to decreased colloid pressure
3. Edema: periorbital or peripheral
4. Hyperlipidemia/cholesteremia

Question 61

What is the most common nephrotic syndrome in adults?

Answer 61

membranous glomerulonephropathy

Question 62

Does membranous glomerulonephropathy respond well to Corticosteroids therapy?

Answer 62

No

Question 63

membranous glomerulonephropahty is a chronic immune complex deposition disease that can be idiopathic, however is associated nonidiopathic cuases such as _

Answer 63

LSE, drugs (PCM), tumors, metals (drugs/mercury), or infections (HCV, HBV, shistosomiasis, malaria)

Question 64

What is the most common cause of nephrotic syndrome in children?

Answer 64

minimal change disease.

Question 65

A 4 year old child presents with 4g of protein reflected in a 24 hour urine collection. He has periorbital edema.
A. How will corticosteroid therapy affect his condition?
B. What are you likely to see on EM?
c. how does the glomeruli appear on light microscopy?
D.

Answer 65

A. Responds very well to steroid therapy
B. Effaced foot processes, vacules, and fused podoyctes, which are actually just flattened epithelium
C. On LM glomerulus appear normal

Question 66

A 7 year old child presents with 3.6gm of protein in a 24 hour urine collection and lipiduria. His serum albumin is 2.9 mg/dL. he has generalized edema. Doc suspecting that it is minimal change disease, gives him steroid, however child does not improve.
A. What is the likely diagnosis?
B. what are you likely to find on biopsy?
C. What are you likely to find on IF?
D. What are you likely to see on EM?
E. In what racial / pt population demographics is this disease most common?

Answer 66

A. FSGS
B. Only a segment of the glomeruli will be involved and the rest of the glomeruli will be normal. and since its focal, it’ll only affect some of the glomeruli, not all.
C. IF is negative
D. EM will show affected areas with mesangial sclerosis and foot process fusion (effacement of the foot process)
E. Hispanics and African Americans. Also seen in patients who have HIV, are heroin user, have sickle cell disease.

Question 67

FSGS due to HIV has morphological distinctions. What are they?

Answer 67

Collapsing glomerulosclerosis where there are complete glomerular collapse and sclerosis with focal segmental changes of FSGS.

Question 68

Is alport’s syndrome nephritic or nephrotic?

Answer 68

Nephritic

Question 69

What is the inheritance pattern of Alport’s syndrome?

Answer 69

X-linked recessive

Question 70

Explain the pathogenesis of Alports

Answer 70

X linked disorder involving collagen formation. Defective glomerular basement membrane as a result of a defect in type IV collagen synthesis. There is a lack of alpha chains, particularly alpha 5 chain of collagen type IV

Question 71

A 5 year old boy presents with the doctor with visual problems. It was also noted that boy has diminished hearing. Upon workup, microscopic hematuria was detected on his urine sample.
A. what is the most likely diagnosis?
B. What are you likely to see on EM?
C. Overt kidney failure is likely to occur between what age?

Answer 71

A. Alport syndrome
B. alternating thickening and thinning glomerular basement membrane with lamination of the lamina densa.
C. 20-50 years.

Question 72

A 5 year old boy friends to his doc for a regular checkup. On UA, slight hematuria was noted. Everything else otherwise was normal. Further testing showed a defect in Type IV collagen formation.
A. what is the most likely diagnosis?
B. WHat are you likely to find on EM?
C. What is the progoniss?

Answer 72

A. Thin basement membrane disease
B. thining of glomerular basement membrane, with NO IgA immune deposition in the mesangium. (thus not IgA nephropathy).
C. Prognosis is excellent with maintenance of normal renal function throughout life.

Question 73

The common glomerular lesions associated with systemic disease include _

Answer 73

1. Lupus
2. Henoch-Schonlein Purpura
3. Amyoidosis (associated with MM)
4. Fibrillary glomerulonephritis (like amylodoisis except IgG and C3 on IF)
5. Essential Mixed cryoglobulinemia (associated with HepC)
6. Plasma Cell dyscarias (like amyloidosis and MM, light chain or monoclonal immune deposits)
7. bacterial endocarditis
8. Diabetic glomerulosclerosis/nepropathy

Question 74

In Lupus associated gomerulus lesion where do the antibody-antigen complex deposit?

Answer 74

glomerular filtration barrier. macrophages activation leads to injury and eventual fibrosis of the glomerulus and even some vasculitidies. Hematuria, acute nephritis, nephrotic syndrome and hypertension and eventually renal failure.

Question 75

Pt presents with puritic skin rahses on extensor surfaces of arms and legs. On examination the skin lesions contained necrotizing vasculitis within microhemorrhage. Further workup shoed IgA deposits on renal mesangium, some C3.
A. what is the most likely diagnosis?
B. What other kidney disease it this most associated with?

Answer 75

A. Henoch-Schonlein purpura

B. IgA nephropathy (Berger’s syndrome)

Question 76

Amyloidosis associated glomerular lesion, light chain deposits are located where?
B. what are you likely to find on UA?

Answer 76

large blood flows: glomerular capilaries and mesangium. In EM you’d see massive baement membrane without any deposits.
B. heavy proteinueira (large Uprotein/Ucreatinien ratio) with only trace protein on dipstick.

Question 77

56 year old patient presents to the ER complaining of oliguria. On Lab and UA microalbuminuria proteinuria were present. Morphologicaly, there were capillary basement membrane thickening, concomitantly with tubular basement membrane thickening. There were also diffuse mesangial sclerosis and nodular glomerulosclerosis known as Kimmelsteil-Wilson disease. what is the most likely diagnosis?

Answer 77

Diabetic glomerulosclerosis/nephropathy.

Question 78

Acute tubular necrosis is diagnostic with an urine sample that contains _

Answer 78

muddy-brown/granular casts on urine microscopy. aka renal failure casts

Question 79

Pyelonephritis is defined as

Answer 79

infection of the ureters and renal pelvis resulting in tubules, interstitium, and pelvis being affected by infection

Question 80

Commonly pyelonephritis is caused by ascending infection from a lower urinary tract infection. what are the most common causative agents of such infections which can lead to pyelonephritis?

Answer 80

E coli, proteus, Klebsiella, enterobacter, and staph

Question 81

Vesiculoreteal reflux is implicated in ascending infection leading to pyelonephritis, how?

Answer 81

Vesicolouretal reflux allows bacteria to gain access to ureters thereafter an easy route to ascend to the kidneys.

Question 82

39 yr old woman presents with severe malaise, and a high grade fever. she also complained of dysuria/frequency with sudden onset of pain in the costovertebral angle (Flank pain). Urine culture was positive for growth, and UA was positive for white cell casts.
A. what is the diagnosis?
B. Morphologiclaly what are you likely to find?
C. Start the patient on treatment and does well and recovers. What are you likely to find on morphology weeks later?

Answer 82

A. Acute pyelonephritis
B. Hallmark finding: patchy interstitial supprative inflammation, intratubular WBC aggregates (which will be seen in UA as WBC casts) and tubular necrosis. Affects upper and lower poles more than middle. Papillary necrosis is seen in diabetics with distal pyramid necrosis
C. fibrosis of the underlying renal pelvis and calyces.

Question 83

Tubulointerstial inflammation causing discrete, corticomedullary scars overlying dilated, blunted and deformed calyces are characteristics of what? What would be a poor prognostic finding?

Answer 83

A. Chronic pyelonephritis due to recurrent ascending infections.
B. Proteinuria

Question 84

A 60-year-old man with a history of osteoarthritis has been awaiting hip replacement surgery for 3 years. During his annual physical, he reports that no amount of analgesic can relieve his constant pain and NSAIDS. Patient now presents to the ER with a high grade fever and rash for the past day. Upon work up, oliguria and increased serum Creatinine is noted suggestive of acute renal failure. A renal biopsy shows eosinophilic infiltration and areas of healing and scarring. What is the most likely explanation for this patient’s acute renal failure?

Answer 84

Tubulointerstitial nephritis caused by use of use of NSAIDS. Drugs act as a hapten until concentrated in the tubules for excretion in urine whereby activation of IgE and T/B plasma cells in the localized area.

Question 85

A 60-year-old man with a history of osteoarthritis has been awaiting hip replacement surgery for 3 years. During his annual physical, he reports that no amount of analgesic can relieve his constant pain. Laboratory results reveal that his renal function has deteriorated when compared to his last office visit 2 years ago. Serum creatinine is 2.0 mg/dL and urinalysis shows 1+ proteinuria. There are no abnormalities seen on microscopy of the urine. A renal biopsy shows eosinophilic infiltration and diffuse parenchymal inflammation. What is the most likely explanation for this patient’s deterioration in renal function?

B. In this setting, damage to what structures occur first?

C. these patients are at increased risk for developing what neoplasm?

Answer 85

Toxic tubulointerstial nephritis aka Analgesic nephropathy. The question stem describes a patient who is overusing analgesics. In this scenario, the most likely explanation for deterioration in renal function is NSAID-induced toxic tubulointerstitial nephritis (TIN).

B. papillary necrosis, followed by tubulointerstittial nephritis.

C. Transitional cell carcinoma of the renal pelvis

Question 86

A 77 year old male with difficulty to control hypertension and hyperlipidemia presents to his doctor with complaining of oliguria. The doc suspects benign nephrosclerosis, however, the doc does a through work up because these pts are at increased risk of what kidney issues?
B. On morphology what are you likely to find?

Answer 86

Chronic renal failure.
B. sclerosis from medial and intimal thickening of arteries that are hyalinized with typical arteriolar changes. Overall the kidneys are normal to small with a leathery appearance in gross.

Question 87

A 65 year poorly controlled hypertensive pt presents with oliguria, papilledema, and slight retinopathy. UA showed proteinuria, hematuria. Lab showed slightly increased serum creatinine. Morphologically fibrinoid necrosis and onion skinning of basement membrane was noted.
A. what is the diagnosis?
B. What is the pathogenesis of the morphological changes?

Answer 87

A. malignant hypertension nephrosclerosis
B. Extreme BP –> endothelial cell damage, increased permeability, platelet activation, fibrin extravasation, necrosis, all summing up into fibrinoid necrosis. Kidney becomes ischemic and RAAS is activated which makes the HTN worse and cycle repeats.

Question 88

Unilateral renal artery stenosis is relatively uncommon and can result from: A.
B. These patients do very well with _

Answer 88

A. cardiovascular changes (plaques) that lead to decreased RBF elaborating ANGII via RAS
B. ACEI or ARB and surgery is definitive therapy

Question 89

What is the pentad associated with Thrombotic thrombocytopenia purpura TTP?

Answer 89

thrombocytopenia, microangiopathic hemolytic anemia, thrombosis.

Question 90

Hemolytic uremic syndrome (HUS) is similar to TPP but without _

Answer 90

neurologic symptoms but with renal failure.

Question 91

Classic (childhood) HUS is commonly cuased by _. How do these kids usually present?

Answer 91

E.coli hamburgers (0157:H7) containing shigga-like toxin. Toxin cuaes denudation of epithelium and decreased NO synthesis. Sudden onset of hemtemesis and melena following flu-like prodrome. Oliguria/hematuria/hemolytic anemia may follow. Managed by dialysis

Question 92

Adult HUS are usually caused by secondary or systemic disease such as _

Answer 92

LSE/Antiphosphlipid antibodies = HUS without immune deposition

• Infection
• Complication of pregnancy
• vascular renal disease (wegner’s sclerderma, HTN)
• Chemo

Question 93

In familial HUS, the defect is in what protein?

Answer 93

Compliment regulatory proteins leading to complement C3 activation, thrombosis and capillary destruction results.

Question 94

Idiopathic HUS is linked to _ gene

Answer 94

platelet aggregation ADAMTS gene

Question 95

A pt with sickle cell anemia presents for his routine blood transfusion. On work up he was noted to have hematuria, dilute urine, and 2.5g proteinuria. On EM aggregates were found around the vasa recta which is the likely cause of his decrease concentrating ability leading to dilute urine. What is the best diagnosis?

Answer 95

Sickle cell nephropathy.

Question 96

A pt presents with dysuria, fever, chills and perianal pain. On PE, a rectal exam proved a tender and soft prostate.
A. what is the likely diagnosis?
B. What are you likely to find on prostatic secretion analysis?
C. What is the common cause?
D. With frequent episodes of this event, what is it likely to progress to and how would the patient present then?

Answer 96

A. Acute bacterial prostatitis
B. greater than 9 neutrophils per high power view
C. E.coli and sometimes Staph or Enteroccoccus from a lower UTI (cysttis)
D. With frequent bouts of UTI –> frequent prostatic infection–> Chronic bacterial prostatitis. Pt will present with dysuria, but Pelvic discomfort and lower back pain will also be prominent. On EM you’ll see plasma cells, lymphocytes and macrophages in chronic forms vs acute form which will only show neutorphils

Question 97

How is granulomatous prostatitis usually diagnosed and what does this disease usually mimic?

Answer 97

Diagnosed histologically which may be necrotizing or nonnecrotizing. Mimics prostatic carcinoma. Usually due secondary to surgical manipulation or stromal infiltration of prostatic fluid

Question 98

Explain the pathogenesis of BPH

Answer 98

with age, hormonal levels changes. Estrogen increase sensitivity for DHT receptors in prostate, testosterone really doesn’t play any role. DHT (from Leydig cell) has an increased selectivity on epithelial nuclear androgen receptors that induce glandular and stromal proliferation

Question 99

A 85 year old African American presents to his doctor’s office with increasing complaints of nocturia, urgency, hesitancy, inability to stop/dribbling. On a rectal exam a firm rubbery mass was palpated. he is otherwise healthy.
A. What is the likely diagnosis
B. Enlargement usually beings on what locations?
C. What is a possible treatment?

Answer 99

A. BPH
B. transitional and periurethral zones
C. 5-alpha-reductase (testosterone –> DHT) inhibitor or surgery (older tx)

Question 100

A 65 year old male presents to your Harlem, NY office complaining of nocturia, urgency, hesitancy, inability to stop/dribbling. Pt also complains of pain with urination multiple times in the past year. His BMI is 29. On a rectal exam, firm, discrete nodules were palpated. You talk with the patient about possible causes of this symptoms and decided to screen the patient for PSA and PAP level. Both PSA and PAP were elevated although percent of free PSA were relatively low. You decide to a biopsy of the mass which confirms the diagnosis.
A. what is the likely diagnosis?
B. On biopsy, how would this disease differ from BPH?
C. What is the significance of the doubling time for these cells?
D. Morphologically where are the cell growth usually found?
E. Presence of what is a precursor for malignancy in these type of tumors?
F. According to Gleanson Grading system, what score is considered a benign tumor?
G. At What stage would you likely to see this invade to seminal vesicle?

Answer 100

A. Prostatic adenocarcinoam
B. BPH is usually involving double layers. adenocarcinomas are single layer of epithelium
C. Doubling time is slow (2-4 years) thus has an excellent 10 year survival rate (depending on stage)
D. Found in peiropheral zones with only a single layer of epithelial cells. In BPH it’ll be double layer and found on the periurethral and transitional zones
E. Prostatic Intraepithelial neoplasia (PIN) is a precursor for malignancy
F. A score of 2 (1+1) would be considered benign while a score of 10 would be considered malignant (5+%)
G. Stage III Capsular involvement or invasion to seminal vesicle.

Question 101

An Urothelial carcinoma that has an association with smoking and old age is _

Answer 101

transitional cell carcinoma

Question 102

An urothelial carcinoma that has an association with schistosomiasis infection is _

Answer 102

squamous cell carcinoma

Question 103

Babies with a mass in the kidney is usually have what tumors? What if the baby also has an elevated levels of VMA?

Answer 103

Wilm’s tumor. With elevated VMA it’s neuroblastoma

Question 104

A 35 patient presents with renal colic and a sharp flank pain. UA was positive for slight hematuria. On imagining staghorn caliculi was present. What is the likely diagnosis?

Answer 104

Struvite stones ( magnesium ammonium phosphate slats). Caused by urea-splitting bacteria.

Note: staghorn caliculi is also seen in cystine stones, but those usually occur in children.

Question 105

What is the most common renal stones?

Answer 105

Calcium oxalate stones. (75%) associated with hypercalciuria w/wo hypercalcemia.

Question 106

Patients with gout, or any leukemias are at increased risk of what kidney stones?

Answer 106

Uric acid stones

Question 107

Which kidney stone is associated with genetic disease that prevent reabsopriton of protein from the lumen.

Answer 107

Cystiene stones.

Question 108

_ is a benign tumor that appears small, pale, yellow gray, well-circumscribed nodules within the renal cortex.

Answer 108

Renal papillary adenoma

Question 109

_ is a tiny nonmalignant, gray-white firm nodules found within the pyramids and is associated with tuberous sclerosis where the tumor is called an angiomyolipoma.

Answer 109

Renal fibroma or hamartoma

Question 110

_ is an epithelial tumor composed of large, eosinophilic cells with benign looking nuclei and monster nucleoli, and on EM massive amounts of mitochondria is seen.

Answer 110

Oncocytoma

Question 111

Pt presents with hematuria. On lab pt was found to have polycythemia. On genetic studies, VHL gene mutation was shown.
A. what is the diagnosis?
B. large clear cells form from epithelium of what strutures?
C. Unilateral or bilateral?
D. What color do the masses usually appear?

Answer 111

A. Clear cell carcinoma, a form of renal cell carcinoma.
B. Proximal tubular epithelium
C. Unilateral
D. yellow cuz of foam like fat cells

Question 112

A 60 year old female who has been on dialysis for 9 years awaiting a renal transplant, presents with hematuria. On lab pt was found to have polycythemia. On Ct a 3cm mass was found on the right kidney, and 2cm mass on the left kidney.
A. what is the likely diagnosis?
B. What is the cause?
C. malignant cells arise from what structures?

Answer 112

A. Papillary carcinoma
B. associated with dialysis-associated cystic disease
C. Cuboidal or columnar epithelium arranged in papillary pattern.

Question 113

_ is a form of renal cell carcinoma with an eosinopholic cytoplasm, perinuclear halo, localized to vasculature.

Answer 113

Chromophobe

Question 114

what is the triad of symptoms associated with renal cell carcinoma and which one is the most common?

Answer 114

Hematuria (most common and reliable), flank pain, and mass)

Question 115

What are some of the most common paraneoplastic syndrome associated with renal cell carcinoma?

Answer 115

Polycythemia (Epo), hypercalcemia (PTH), hypertension (Aldo, renin), Cushings (ACTH), and femininzation (androgens)

Question 116

A 2 year old child presents to ER with nausea and hematuria. The child also appeared hypertensive and has been for almost a year. On PE, a abdominal mass was palpable. CT genetic studies confirmed diagnosis.
A. What is the diagnosis?
B. What gene is implicated in the disease?
C. What is the prognosis?

Answer 116

A. Wilm’s tumor (nephroblastoma)
B. WT-1
C. Pronosis of a unilateral tumor is good (90% survival)

Question 117

A 33-year-old female presents with recent onset of painful urination, fever, and right flank pain. Urinary sediment analysis is positive for the presence of white blood cell casts and Gram-negative bacteria. She has not recently started any new medications. What is the most likely diagnosis in this patient?

1. Pelvic Inflammatory Disease
2. Acute Interstitial Nephritis
3. Pyelonephritis
4. Cystitis
5. Appendicitis

Answer 117

3. Pyelonephritis

This patient is suffering from acute pyelonephritis. In the setting of systemic febrile illness, white blood cell casts on urinary sediment analysis are pathognomonic for pyelonephritis.

Acute pyelonephritis is most common in pre-menopausal females and Esherichia coli is the most common causative organism. Vesicoureteral reflux with secondary ascending infection from the bladder is the mechanism by which bacteria gain exposure to the kidney and may result in acute pyelonephritis. Clinical clues to pyelonephritis include nausea/vomiting, fever, flank pain, costovertebral angle (CVA) tenderness, urinary frequency/urgency, and dysuria.

Colgan et al. describe the diagnostic approach to acute pyelonephritis. The diagnosis is often made by the history and physical examination. Fever is common, though may be absent early in the infection and nearly all patients have flank pain. Therefore, a lack of flank pain should raise suspicion for other potential etiologies.

Ramakrishnan et al. summarize the therapeutic approach to treating acute pyelonephritis. Uncomplicated pyelonephritis can be treated as an outpatient, often successfully with a fluoroquinolone. Other oral options include amoxicillin-clavulanate, cephalosporins and trimethoprim-sulfamethoxazole.

Question 118

A 34-year-old female presents to her primary care physician with complaints of fevers, nausea/vomiting, and severe left flank pain that has developed over the past several hours. She denies any prior episodes similar to her current presentation. Physical examination is significant for a body temperature of 39.1 C and costovertebral angle tenderness. A urinalysis and urine microscopy are ordered. Which of the following findings on kidney histology would be expected in this patient?

1. Interstitial fibrosis and lymphocytic infiltrate
2. Neutrophils filling the lumens of the renal tubules
3. Thickening of the capillaries and glomerular basement membrane
4. Scarring of the glomeruli
5. Enlarged, hypercellular glomeruli with ‘wire-looping’ of capillaries

Answer 118

2. Neutrophils filling the lumens of the renal tubules.

This patient’s presentation is most consistent with acute pyelonephritis. The histology of acute pyelonephritis consists of neutrophils filling the renal tubular lumens.

Question 119

A 22-year-old sexually active, otherwise healthy female presents to her primary care physician complaining of several days of dysuria, frequency, urgency, and suprapubic pain. She denies fever, flank pain, vaginal itching, or vaginal bleeding/discharge. Which organism is most likely responsible for this patient’s symptoms?

1. Staphylococcus saprophyticus
2. Chlamydia trachomatis
3. Proteus mirabilis
4. Klebsiella pneumoniae
5. Escherichia coli

Answer 119

5. E.coli

The patient in this vignette is exhibiting symptoms classic for a urinary tract infection, or cystitis. The most common cause of uncomplicated cystitis and pyelonephritis is E. coli.

Question 120

A female infant is born with a mutation in PKD1 on chromosome 16. An abdominal ultrasound performed shortly after birth would most likely reveal which of the following?

1. Bilateral kidney enlargement
2. Microscopic cysts
3. Horseshoe kidney
4. Adrenal atrophy
5. Normal kidneys

Answer 120

5. Normal kidneys

PKD1 is a mutation present in 90% of autosomal dominant polycystic kidney disease (formerly “adult” PKD). In infants with ADPKD, ultrasound will show normal kidneys. Although microscopic cysts are present at birth, they are too small to be detected on abdominal ultrasound.

Question 121

A 35-year-old male with a history of hypertension presents with hematuria and abdominal discomfort. Ultrasound and CT scan reveal large, bilateral cysts in all regions of the kidney. The patient’s disease is most commonly associated with:

1. Aortic stenosis
2. Berger’s disease
3. Diabetes mellitus
4. Berry aneurysm
5. Henoch-Schonlein purpura

Answer 121

4. Berry aneurysm

The patient’s symptoms and imaging findings are suggestive of adult polycystic kidney disease, or autosomal dominant polycystic kidney disease (ADPKD). ADPKD is associated with Berry aneurysms in the circle of Willis in 10-15% of patients.

Question 122

A 10-year-old Caucasian female with Turner’s syndrome underwent an abdominal imaging study and was discovered that the poles of her kidneys were fused inferiorly. Normal ascension of kidney during embryological development would be prevented by which of the following anatomical structures?

1. Inferior vena cava
2. Superior mesenteric artery
3. Inferior mesenteric artery
4. Celiac artery
5. Splenic artery

Answer 122

3. IMA

The patient described in the question stem has a horseshoe kidney, the most common congenital kidney disorder. In horseshoe kidney, the isthmus of the kidney gets trapped behind the inferior mesenteric artery as the kidneys ascend during embryonic life.

Question 123

A 40-year-old male presents to the emergency room following a motorcycle accident. His blood pressure on arrival is 70/50 mmHg and his heart rate is 130 bpm. During hospitalization, he developed oliguria and has urine studies shown in Figure A. He is eventually discharged from the hospital with restored renal function. Which of the following was responsible for this patient’s kidney problems?

1. Acute pyelonephritis
2. Diabetic glomerulopathy
3. Rapidly progressive glomerulonephritis
4. Acute tubular necrosis
5. Membranous glomerulonephritis

Answer 123

4. Acute tubular necrosis

This patient’s renal failure was due to ischemic acute tubular necrosis, secondary to hypovolemia. Acute tubular necrosis classically results in oliguria, “muddy brown” pigmented renal tubular cell casts as seen in Figure A, hyperkalemia, and anion gap metabolic acidosis.

Question 124

A 62-year-old man presents to the emergency room with an acute myocardial infarction. Twenty-four hours after admission to the cardiac intensive care unit, he develops oliguria. Laboratory tests show that his serum BUN is 59 mg/dL and his serum creatinine is 6.2 mg/dL. Renal biopsy reveals necrosis of the proximal tubules and thick ascending limb of Henle’s loop. Which of the following would you most likely observe on a microscopic examination of this patient’s urine?

1. White blood cell casts
2. Fatty casts
3. Muddy brown casts
4. Hyaline casts
5. Broad waxy casts

Answer 124

3. muddy brown cast

This patient’s presentation is consistent with acute tubular necrosis (ATN). Muddy brown casts are part of the classic presentation of ATN.

Question 125

A 48-year-old woman is admitted to the hospital with sepsis and treated with gentamicin. One week after her admission, she develops oliguria and her urine shows muddy brown casts on light microscopy. Days later, her renal function begins to recover, but she complains of weakness and develops U waves on EKG as shown in Image A. Which laboratory abnormality would you most expect to see in this patient?

1. Hypocalcemia
2. Hypokalemia
3. Hyponatremia
4. Hypoglycemia
5. Hypermagnesemia

Answer 125

2. Hypokalemia

This patient’s initial presentation is consistent with acute tubular necrosis (ATN) due to aminoglycoside toxicity. While hospitalized, she progresses from the acute phase of ATN to the recovery phase of ATN. During the recovery phase, she develops hypokalemia, which results in weakness and EKG changes.

Question 126

A 45-year-old female presents to the emergency department with gross hematuria and acute, colicky flank pain. She denies any previous episodes of hematuria. She reports taking high doses of acetaminophen and aspirin over several weeks due to persistent upper back pain. The patient’s blood pressure and temperature are normal, but she is found to have proteinuria. Physical examination is negative for palpable flank masses. Which of the following is the most likely diagnosis:

1. Diffuse cortical necrosis
2. Chronic pyelonephritis
3. Autosomal dominant polycystic kidney disease
4. Papillary necrosis
5. Acute Nephrolithiasis

Answer 126

4. Papillary necrosis

Acute onset of gross hematuria, colicky flank pain, and proteinuria are characteristic of renal papillary necrosis.

Answer 1: Diffuse cortical necrosis is marked by acute infarction of both kidneys. It is associated with obstetric catastrophes and septic shock.

Question 127

A previously healthy 9-year-old, Caucasian girl presents to your office with severe abdominal pain. Her mother also mentions that she has been urinating significantly less lately. History from the mother reveals that the girl suffers from acne vulgaris, mild scoliosis, and had a bout of diarrhea 3 days ago after a family barbecue. Lab work is done and is notable for a platelet count of 97,000 with a normal PT and PTT. The young girl appears dehydrated, yet her serum electrolyte levels are normal. What is the most likely etiology of this girl’s urinary symptoms?

1. Hypothalamic dysfucntion
2. Surreptitious laxative use
3. Toxic shock syndrome
4. Shiga toxin production from Shigella
5. Shiga-like toxin production from EHEC

Answer 127

5: Shiga-like toxin production from EHEC

This patient’s presentation is consistent with hemolytic uremic syndrome (HUS). HUS is most frequently due to infection with Shiga-like toxin-producing Escherichia coli O157:H7 following ingestion of contaminated hamburger meat which likely occurred at the family barbecue mentioned in this question.

Question 128

A 49-year-old female with a history of alcoholism was found lying unconscious on a bench at a local park and rushed to the emergency department. Upon arrival, the patient regained consciousness and complained of intense bilateral flank pain and a recent decrease in urination. Urine microscopy demonstrated abundant square crystals of calcium oxalate that looked like “folded envelopes.” Which of the following findings is most likely to be seen in this patient:

1. Metabolic alkalosis
2. Anion gap metabolic acidosis
3. Non-anion gap metabolic acidosis
4. Respiratory acidosis
5. Respiratory alkalosis

Answer 128

2. Anion gap metabolic acidosis

This patient is suffering from acute renal failure secondary to ethylene glycol (antifreeze) ingestion. Ehtylene glycol ingestion produces anion gap metabolic acidosis.

Question 129

A 55-year-old man with a history of chronic glomerulonephritis due to IgA nephropathy presents to your office with bone pain. Which of the following laboratory findings would you most expect upon analysis of this patient’s serum?

1. Increased PTH, decreased calcium, increased phosphate, decreased calcitriol
2. Decreased PTH, increased calcium, increased phosphate, increased calcitriol
3. Increased PTH, increased calcium, decreased phosphate, decreased calcitriol
4. Decreased PTH, decreased calcium, increased phosphate, decreased calcitriol
5. Normal PTH, normal calcium, normal phosphate, normal calcitriol

Answer 129

1. Increased PTH, decreased calcium, increased phosphate, decreased calcitriol

This patient’s presentation is consistent with osteodystrophy secondary to chronic renal failure resulting in secondary hyperparathyroidism. This condition presents with increased PTH, decreased calcium, increased phosphate, and decreased calcitriol.

Question 130

A 65-year-old man with a longstanding history of poorly-controlled hypertension and no recent illness or cardiac disease presents to clinic complaining of chest pain that is worse on inspiration and relieved by sitting forward. Vital signs are stable. On exam, you detect a friction rub. Routine labs show K 7.5 and Cr 5.1. If this patient’s clinical signs and laboratory findings are indicative of a chronic condition, what would be expected on urinary analysis?

1. Muddy brown granular casts
2. Red blood cell casts
3. White blood cell casts
4. Fatty casts
5. Broad and waxy casts

Answer 130

5. Broad and waxy cast

This patient is presenting with uremic pericarditis secondary to renal failure. Broad and waxy casts are seen on urinary analysis in chronic renal failure.

Question 131

A 72-year-old female recently fractured her hip in a fall. She suffers from regular joint pain in her fingers, and hip X-rays reveal low bone mineral density. She has a history of diabetes mellitus and was diagnosed 2 years ago with end-stage renal disease. Serum phosphate levels are markedly elevated. Which of the following likely contributes to her orthopedic problems?

1. Decreased serum aldosterone
2. Increased serum parathyroid hormone
3. Increased serum glucose
4. Chronic hypertension
5. Chronic hypovolemia

Answer 131

2. Increased serum parathyroid hormone

The patient’s symptom profile suggests renal osteodystrophy, which is mostly likely due to secondary hyperparathyroidism

Question 132

Multiple patients present to your office with hematuria following an outbreak of Group A Streptococcus. Biopsy reveals that all of the patients have the same disease, characterized by large, hypercellular glomeruli with neutrophil infiltration. Which patient has the best prognosis?

1. 65-year-old nulliparous woman
2. 50-year-old man with a history of strep infection
3. 8-year-old boy who undergoes no treatment
4. 38-year-old man with sickle cell trait
5. 18-year-old man treated with corticosteroids

Answer 132

3. 8-year-old boy who undergoes no treatment

Age is the most important prognostic factor in post-streptococcal glomerulonephritis. Ninety-five percent of affected children recover completely, compared with 25% of adults over 60 years old.

Question 133

A 10-year-old boy presents to your office with cola-colored urine and periorbital edema. His mother is extremely concerned, especially given that her son has been entirely healthy except for a sore throat a few weeks ago. Which of the following would you be LEAST likely to observe on a kidney biopsy of this patient?

1. “Lumpy-bumpy” appearance on immunofluorescence
2. Subepithelial electron dense deposits on electron microscopy
3. Polyclonal IgG and C3 deposition on immunofluorescence
4. Linear IgG deposition along the basement membrane on immunofluorescence
5. Large, hypercellular glomeruli on light microscopy

Answer 133

4. Linear IgG deposition along the basement membrane on immunofluorescence
   This patient’s clinical presentation of nephritic syndrome is consistent with post-streptococcal glomerulonephritis, also known as post-infectious GN. Linear IgG deposition along the basement membrane is characteristic of Goodpasture syndrome (anti-glomerular basement membrane disease) and would not likely be seen in this patient’s kidney biopsy.

Question 134

A 9-year-old Caucasian girl presents to your office with hematuria. An electron micrograph of her renal biopsy is shown below in Figure A. Which of the following is the most likely composition of the structures marked by the white arrows?

1. Albumin
2. Non-enzymatic glycosylation
3. IgA
4. IgG
5. IgG, IgM, C3

Answer 134

5. IgG, IgM, C3

The patient’s presentation and EM are consistent with post-streptococcal (postinfectious) glomerulonephritis. The white arrows demonstrate epimembranous immune complex deposits of IgG, IgM and C3.

Question 135

A 6-year-old boy presents to your office with hematuria. Two weeks ago the patient had symptoms of a sore throat and fever. Although physical exam is unremarkable, laboratory results show a decreased serum C3 level and an elevated anti-DNAse B titer. Which of the following would you most expect to see on renal biopsy?

1. Large, hypercellular glomeruli on light microscopy
2. Polyclonal IgA deposition on immunofluorescence
3. Immune complex deposits with a “spike and dome” appearance on electron microscopy
4. Wirelooping and hyaline thrombi on light microscopy
5. Antibodies to GBM resulting in a linear immunofluorescence pattern

Answer 135

1. Large, hypercellular glomeruli on light microscopy
   This patient’s presentation and laboratory results are consistent with post-streptococcal (post-infectious) glomerulonephritis (PSGN). On light microscopy, PSGN will show large, hypercellular glomeruli with neutrophil infiltration.

Question 136

A 21-year-old male presents to your office with hematuria 3 days after the onset of a productive cough and fever. Following renal biopsy, immunofluorescence shows granular IgA deposits in the glomerular mesangium. Which of the following do you suspect in this patient?

1. Lipoid nephrosis
2. Berger’s disease
3. Poststreptococcal glomerulonephritis
4. Systemic lupus erythematosus
5. HIV infection

Answer 136

2. Burger’s disease

Hematuria and immunofluorescence findings of IgA deposits in the mesangium suggest Berger’s disease (IgA glomerulonephropathy). Berger’s disease can occur concurrently or within several days of an infection.

Question 137

A 25-year-old male visits his primary care physician with complaints of hemoptysis and dysuria. Serum blood urea nitrogen and creatinine are elevated, blood pressure is 160/100 mm Hg, and urinalysis shows hematuria and RBC casts. A 24-hour urine excretion yields 1 gm/day protein. A kidney biopsy is obtained, and immunofluorescence shows linear IgG staining in the glomeruli. Which of the following antibodies is likely pathogenic for this patient’s disease?

1. Anti-DNA antibody
2. Anti-neutrophil cytoplasmic antibody (C-ANCA)
3. Anti-neutrophil perinuclear antibody (P-ANCA)
4. Anti-glomerular basement membrane antibody (Anti-GBM)
5. Anti-phospholipid antibody

Answer 137

4. Anti-glomerular basement membrane antibody (Anti-GBM)

The patient’s clinical picture, laboratory data, urinalysis, and light microscopy are consistent with Goodpasture syndrome. Goodpasture syndrome is a type II hypersensitivity reaction characterized by autoantibodies to the glomerular basement membrane (anti-GBM).

Question 138

Three weeks after recovering from pharyngitis, a nine-year-old girl presents with periorbital edema and dark brown urine. An image of the kidney biopsy is shown in Figure A. What is responsible for these changes?

1. Proliferation of glomerulus parietal cells with fibrin and C3b accumulation
2. IgA deposition and subsequent mesangial proliferation
3. Neutrophil infiltration in response to immune complex deposition along the glomerulus basement membrane and mesangium
4. Loss of negative charge on the glomerular basement membrane
5. Widespread intermembraneous deposits due to an autoantibody against C3 convertase

Answer 138

3. Neutrophil infiltration in response to immune complex deposition along the glomerulus basement membrane and mesangium

This young girl has acute poststreptococcal glomerulonephritis (PSGN) weeks after a streptococcal pharyngitis. Histopathology reveals immune complex deposition along the glomerular basement membrane (GBM) and mesangium and neutrophil infiltration.

Question 139

A 37-year-old man presents with significant hematuria and hemoptysis. The results of the immunoflouresence are shown in Figure A. What pathologic changes would be expected under light microscopy?

1. “Wire looping” of the capillaries
2. Hypercellular glomeruli
3. Crescentic glomerulonephritis
4. Focal proliferative glomerulonephritis
5. Normal glomeruli

Answer 139

3. Crescentic glomerulonephritis

The clinical scenario and attached image are consistent with Goodpasture syndrome, a type of rapidly progressive crescentic glomerulonephritis (RPGN).

Question 140

A 62-year-old man presents to his primary care doctor complaining of recent-onset hemoptysis. He has not had any fevers, night sweats, or weight loss. He recently traveled to Italy with his wife. He has a 5 pack-year smoking history. On review of systems, he reports that his urine has been “red-tinged” for several months. Urinalysis reveals the findings shown in Figure A. He is referred to a nephrologist and undergoes a renal biopsy. Immunofluorescence staining of the biopsy is shown in Figure B. Which of the following is the most likely underlying pathogenesis of his disease?

1. Type III hypersensitivity reaction
2. Antibodies to collagen type IV
3. Presence of C-ANCA
4. Mycobacterial infection
5. Metastatic malignancy

Answer 140

2. Antibodies to collagen type IV

This patient has pulmonary hemorrhage and nephritic syndrome. His renal biopsy shows linear deposition of antibodies along the basement membrane in the glomerulus, a finding characteristic of Goodpasture disease.

Question 141

A 5-year-old female presents to your office with periorbital edema and proteinuria. Her mother reports that she “just got over a cold” last week. On examination, you note a pulse rate of 70/minute and a blood pressure of 95/53. Which protein(s) would likely be found in large amounts in this patient’s urine?

1. IgG
2. IgA
3. Albumin
4. Albumin and IgG
5. Albumin, IgG, and IgA

Answer 141

3. Albumin
   This patient’s presentation is consistent with minimal change disease (MCD), the most common nephrotic syndrome in children. In MCD, T-cell cytokines cause the glomerular basement membrane to lose negative charge, resulting in SELECTIVE proteinuria in which albumin (but not immunoglobulins) is lost.

Question 142

An 11-year-old boy presents to your office with pitting edema and proteinuria exceeding 3.5g in 24 hours. You suspect that this patient has experienced a loss of polyanions in his glomerular basement membranes. Which of the following findings would confirm your diagnosis?

1. WBC casts in the urine
2. RBC casts in the urine
3. Selective albuminuria
4. Negatively birefringent crystals in the urine
5. Bence-Jones proteinuria

Answer 142

3. Selective albuminuria

The patient described in the question stem has minimal change disease (MCD), the most common cause of the nephrotic syndrome in children. MCD results in selective albuminuria.

Question 143

A 7-year-old male suffers from generalized edema. Urine protein excretion is 5.2 g over 24 hours and serum analysis reveals hyperlipidemia. The patient responds to treatment with prednisone, and, 8 weeks later, his urine does not contain measurable protein. If a kidney biopsy had been performed while the patient’s condition was pathologic, which of the following would you expect to find upon glomerular electron microscopy?

1. Effacement of podocyte foot processes
2. Subepithelial ‘spike and dome’ deposits
3. Subepithelial humps
4. Thin glomerular basement membrane
5. Subendothelial thickening

Answer 143

1. Effacement of podocyte foot processes

Question 144

A 57-year-old female visits her primary care physician with 2+ pitting edema in her legs. She takes no medications and does not use alcohol, tobacco, or illicit drugs. 4.5 grams of protein are collected during 24-hour urine excretion. A kidney biopsy is obtained. Examination with light microscopy shows diffuse thickening of the glomerular basement membrane. Electron microscopy shows subepithelial spike and dome deposits. Which of the following is the most likely diagnosis:

1. Minimal change disease
2. Postinfectious glomerulonephritis
3. Focal segmental glomerulosclerosis
4. Rapidly progressive glomerulonephritis
5. Membranous glomerulopathy

Answer 144

5. Membranous glomerulopathy

The patient’s symptoms and urine studies are indicative of nephrotic syndrome. Diffuse thickening of the glomerular basement membrane (GBM) and subepithelial spike and dome deposits are features of membranous glomerulopathy.

Question 145

A 6-year-old girl presents to your clinic two weeks after receiving a routine immunization in preparation for a trip overseas. Periorbital edema is present on exam and 24 hour urine collection shows excretion of 4.3 grams of protein/day. Which pathological change would likely be seen on microscopy?

1. Linear IgG deposition on light microscopy
2. IgA-immune complexes in the mesangium on electron microscopy
3. “Tram-track” appearance on light microscopy
4. Subepithelial deposits with “spike and dome” appearance on electron microscopy
5. Podocyte effacement on electron microscopy

Answer 145

5. Podocyte effacement on electron microscopy

The clinical scenario describes a child who is suffering from nephrotic syndrome secondary to minimal change disease (MCD). The pathognomic histologic finding is podocyte effacement on electron microscopy.

Question 146

A 55-year-old African American male presents to his primary care physician with complaints of persistent back pain and fatigue over 12 months. Physical examination reveals a blood pressure of 190/150 mm Hg, and laboratory tests reveal hyperlipidemia and a serum creatinine level of 3.0 mg/dL. 4.5 g of protein are excreted in the urine over 24 hours. Renal biopsy shows eosinophilic, acellular material in the glomerular tuft and capillary walls that display apple green-colored birefringence in polarized light upon Congo red tissue staining. The patient most likely suffers from which of the following:

1. Membranous nephropathy
2. Focal segmental glomerular sclerosis
3. Drug-induced acute tubular necrosis
4. Multiple myeloma
5. Malignant hypertension

Answer 146

4. MM

The patient’s clinical findings suggest amyloidosis (due to multiple myeloma), which can lead to nephrotic syndrome.

Question 147

A 67-year-old man presents to your office with a chief complaint of constipation and many other perturbing minor medical concerns. He reports tiring easily, which he attributes to old age and years of persistent pain in his back and ribs. A complete blood count shows low hemoglobin and elevated serum creatinine. A peripheral blood smear shows stacks of red blood cells among other findings, and serum electropheresis reveals an abnormal concentration of protein resulting in a spike. Which of the following additional findings would you expect to see in this patient?

1. Early satiety and splenomegaly
2. Smudge cells on peripheral smear
3. An elevated PSA and a nodular prostate
4. Bence-Jones proteins in the urine
5. No additional findings - normal aging explains symptoms

Answer 147

4. Bence-Jones proteins in the urine

This patient’s presentation is classic for multiple myeloma. Multiple myeloma results in large eosinophilic casts made of Bence-Jones proteins that can be seen on urine microscopy.

Multiple myeloma is cancer of monoclonal plasma cells resulting in the production of large amounts of IgG (55%) or IgA (25%). The amount of light chains (Bence-Jones protein) filtered exceeds the resorptive capacity of the tubule. These proteins precipitate and form large eosinophilic casts, which then obstruct the tubule and interfere with renal function.

Question 148

A 57-year-old male with diabetes mellitus type II presents for a routine check-up. His blood glucose levels have been inconsistently controlled with medications and diet since his diagnosis 3 years ago. At this current visit, urinalysis demonstrates albumin levels of 250 mg/day. All prior urinalyses have shown albumin levels below 20 mg/day. At this point in the progression of the patient’s disease, which of the following is the most likely finding seen on kidney biopsy?

1. Normal kidney biopsy, no pathological finding is evident at this time
2. Glomerular hypertrophy with slight glomerular basement membrane thickening
3. Glomerular basement membrane thickening and mesangial expansion
4. Kimmelstiel-Wilson nodules and tubulointerstitial fibrosis
5. Significant global glomerulosclerosis

Answer 148

3. Glomerular basement membrane thickening and mesangial expansion

This patient is suffering from incipient diabetic nephropathy (DN). This stage of DN is characterized by microalbuminuria, which is defined as excretion of 30 to 300 mg/day of albumin. Kidney biopsy findings associated with the incipient stage of diabetic nephropathy include thickening of the glomerular basement membrane and expansion of the mesangium.

Question 149

A 26-year-old male currently undergoing standard therapy for a recently diagnosed active tuberculosis infection develops sudden onset of fever and oliguria. Laboratory evaluations demonstrate high levels of eosinophils in both the blood and urine. Which of the following is most likely responsible for the patient’s symptoms:

1. Rifampin
2. Isoniazid
3. Pyrazinamide
4. Ethambutol
5. Return of active tuberculosis symptoms secondary to patient non-compliance with anti-TB regimen

Answer 149

1. Rifampin

This presentation is consistent with acute drug-induced tubulointerstitial nephritis (TIN). Acute drug-induced TIN occurs as a combined type I and type IV hypersensitivity reaction 1-2 weeks after administration of certain drugs: Beta-lactam antibiotics (penicillin), rifampin, sulfonamides, NSAIDs, and diuretics. The rifampin component of the standard anti-TB regimen of isoniazid, rifampin, and pyrazinamide is most likely responsible for the onset of symptoms seen in this patient.

Question 150

A 60-year-old man with a history of osteoarthritis has been awaiting hip replacement surgery for 3 years. During his annual physical, he reports that no amount of analgesic can relieve his constant pain. Laboratory results reveal that his renal function has deteriorated when compared to his last office visit 2 years ago. Serum creatinine is 2.0 mg/dL and urinalysis shows 1+ proteinuria. There are no abnormalities seen on microscopy of the urine. A renal biopsy shows eosinophilic infiltration and diffuse parenchymal inflammation. What is the most likely explanation for this patient’s deterioration in renal function?

1. Focal segmental glomerulosclerosis
2. Ischemic acute tubular necrosis
3. Nephrotoxic acute tubular necrosis
4. Toxic tubulointerstitial nephritis
5. Rapidly progressive glomerulonephritis

Answer 150

4. Toxic tubulointerstitial nephritis

The question stem describes a patient who is overusing analgesics. In this scenario, the most likely explanation for deterioration in renal function is NSAID-induced toxic tubulointerstitial nephritis (TIN).

Question 151

A 71-year-old male presents to your office with painless hematuria and left costovertebral angle pain. His body mass index is 33 kg/m^2. A renal biopsy is shown in Figure A. The patient’s mass is most likely a malignancy of which of the following:

1. Tubular epithelial cells
2. Perirenal adipose cells
3. Metastatic adrenocortical carcinoma
4. Mesangial cells
5. Visceral epithelial cells

Answer 151

1. Tubular epithelial cells.

The patient presents with classic symptoms of renal cell carcinoma (RCC), including painless hematuria and costovertebral angle pain. Renal cell carcinoma is a malignancy of proximal tubular epithelial cells.

RCC symptoms include painless hematuria, costovertebral angle pain, fever and weight loss. Smoking and obesity are risk factors. Histology shows rounded or polygonal clear cells with abundant clear cytoplasm filled with glycogen and lipid (see image in questions stem). Prognosis is poor, especially if there is involvement of the renal vein.

Question 152

A 65-year-old man with a 40 pack-year history of smoking presents with right costovertebral angle pain, hematuria, fever, and a palpable mass in the right lower quadrant. A chest radiograph reveals multiple nodular masses in the lungs. A biopsy is performed. What is the likely diagnosis?

Answer 152

Renal cell carcinoma

Question 153

A 15-month-old male is brought in for a routine exam. His mother reports he is not eating as much as he was previously. On exam the infant is appropriate, alert, and orientated. Abdominal exam indicates a large mass on the right side. The mass is deep and firm and its margins are not palpable. Labs are normal. A biopsy is obtained. What is the likely diagnosis?

Answer 153

Wilm’s Tumor

Question 154

A 24 year-old male presented to his physician with a homogenous, painless testicular swelling that he noticed for the past two weeks. After ultrasound and blood tests, he subsequently underwent a radical inguinal orchiectomy and pathology was consistent with seminoma. Which of the following would you expect to see in a tissue sample from the patient’s orchiectomy?

1. Lobules of large cells with prominent nuclei and watery cytoplasm
2. Schiller-Duval bodies
3. Reinke crystals
4. Tubular papillary architecture with necrosis
5. Mature derivatives of endoderm, mesoderm, and ectoderm

Answer 154

1. Lobules of large cells with prominent nuclei and watery cytoplasm

Lobules of large cells with prominent nuclei and watery cytoplasm
Seminomas are the most common testicular tumor in males. Though malignant, seminomas have an excellent prognosis if treated early. Seminomas spread first to the para-aortic lymph nodes and then hematogenously. The tumor is treated with orchiectomy followed by radiation if there is suspicion that the disease has spread outside of the testes.

Question 155

A 45-year-old man presents with a 3-day history of right-sided flank pain due to a lodged ureteral stone. What changes would be expected to be seen at the level of glomerular filtration?

1. Increase in glomerular capillary oncotic pressure
2. Increase in Bowman’s space capillary oncotic pressure
3. Increase in Bowman’s space hydrostatic pressure
4. Increase in filtration fraction
5. No change in filtration fraction

Answer 155

3. Increase Bowman’s space capillary oncotic pressure

Obstruction of the ureter, as can occur with utereolithiasis, causes an increase in pressure proximal to the obstruction that transmits back to the level of the glomerulus (Bowman’s space) and can lead to hydronephrosis.

Question 156

A 72-year-old male presents to his primary care physician with urinary hesitancy and urinary dribbling that began 6 weeks ago and has gradually worsened. Rectal exam reveals a markedly enlarged prostate. CT scan demonstrates dilated ureters and renal pelvises. Which of the following likely accounts for the CT scan results:

1. Urethral obstruction
2. Autosomal dominant polycystic kidney disease
3. Prerenal azotemia
4. Elevated serum PSA
5. Multiple endocrine neoplasia type 1

Answer 156

1. Urethral obstruction

The patient’s clinical scenario suggests urethral obstruction due to prostatic hyperplasia. Prolonged obstruction can lead to hydronephrosis as seen in the patient’s CT scan.

Question 157

A 45-year-old Caucasian male with a history of chronic myeloid leukemia for which he is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. His serum creatinine is 3.0 mg/dL and is urine pH is 5.0. You diagnose nephrolithiasis. His kidney stones, however, are not visible on abdominal x-ray. His stone is most likely composed of which of the following?

1. Calcium oxalate
2. Calcium phosphate
3. Magnesium ammonium phosphate
4. Uric acid
5. Cystine

Answer 157

4. Uric acid

Uric acid kidney stones are often associated with leukemia and myeloproliferative disorders.

This patient is most likely suffering from tumor lysis syndrome, in which chemotherapy treatment causes tumor cells to lyse and release uric acid (a metabolite of tumor nucleic acid). Note that uric acid stones require an acidic environment to precipitate, while magnesium ammonium phosphate (struvite) stones require an alkaline environment to precipitate. Uric acid stones also form secondary to gout and renal tubular acidosis.

Question 158

Following passage of a calcium phosphate stone, a 55-year-old male visits his physician to learn about nephrolithiasis prevention. Which of the following changes affecting urine composition within the bladder are most likely to protect against crystal precipitation?

1. Increased calcium, increased citrate, increased oxalate, increased free water clearance
2. Decreased calcium, increased citrate, increased oxalate, increased free water clearance
3. Decreased calcium, decreased citrate, increased oxalate, increased free water clearance
4. Decreased calcium, increased citrate, decreased oxalate, increased free water clearance
5. Decreased calcium, increased citrate, increased oxalate, decreased free water clearance

Answer 158

4. Decreased calcium, increased citrate, decreased oxalate, increased free water clearance.

The composition of urine is a critical factor in the process of crystal precipitation and stone formation. Increases in the concentrations of the stone-forming compounds calcium and oxalate can lead to the precipitation of these substances in the urine causing stones to form, while high fluid intake and an associated increase in free water clearance dilutes urine and is protective against stone formation. Urinary citrate binds ionized calcium, preventing stone precipitation and leading to calcium excretion.

Question 159

A 12-year-old boy presents with right flank pain and hematuria. His older brother has had several similar episodes in the past. Results of microscopic urinalysis are shown in Figure A. Which of the following tests can be used to help confirm the underlying diagnosis?

1. Cyanide-nitroprusside test
2. Serum uric acid concentration
3. Urine uric acid concentration
4. Urine culture
5. Urease test

Answer 159

1. Cyanide-nitroprusside test.

This boy has the classic presentation of kidney stones, a positive family history, and microscopic analysis showing hexagonal-shaped crystals. These findings are suggestive of cystinuria, which can be confirmed with the cyanide-nitroprusside test.

Kidney stones classically present with abrupt-onset renal colic and severe flank pain, which usually radiates toward the abdomen and groin. Patients often have dysuria and hematuria. Kidney stones are most often seen in adults in their 30’s-40’s. When kidney stones are seen in children, hereditary predisposing factors should be considered. Kidney stones can be of several types, including calcium stones, struvite stones, uric acid stones, and cystine stones.

Question 160

A 49-year-old African American female with a history of chronic myeloid leukemia for which she is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. Her serum creatinine is 3.3 mg/dL. What is the preferred preventative therapy that could have been administered to this patient to prevent her complication of chemotherapy?

1. Diuresis
2. Acidification of the urine
3. Colchicine
4. Steroids
5. Dialysis

Answer 160

1. Diuresis.

This patient most likely has acute kidney injury (AKI) and a renal stone secondary to tumor lysis syndrome (TLS). The chief TLS prevention is hydration and diuresis to increase urine flow rate.

Question 161

A female infant is born with a mutation in PKD1 on chromosome 16. An abdominal ultrasound performed shortly after birth would most likely reveal which of the following?

1. Bilateral kidney enlargement
2. Microscopic cysts
3. Horseshoe kidney
4. Adrenal atrophy
5. Normal kidneys

Answer 161

1. Normal kidneys

PKD1 is a mutation present in 90% of autosomal dominant polycystic kidney disease (formerly “adult” PKD). In infants with ADPKD, ultrasound will show normal kidneys. Although microscopic cysts are present at birth, they are too small to be detected on abdominal ultrasound.

Autosomal dominant polycystic kidney disease results in large, bilateral cysts that ultimately destroy renal parenchyma in adulthood. This presents with flank pain, hematuria, hypertension, urinary infection, and progressive renal failure. Polycystic liver disease, berry aneurysms, and mitral valve prolapse are associated conditions. Autosomal recessive polycystic kidney disease is a disease with renal cysts that can become apparent in utero and result in renal failure and is associated with Potter’s sequence. Concerns in the neonatal period include hypertension and renal failure.

Question 162

A 35-year-old male with a history of hypertension presents with hematuria and abdominal discomfort. Ultrasound and CT scan reveal large, bilateral cysts in all regions of the kidney. The patient’s disease is most commonly associated with:

1. Aortic stenosis
2. Berger’s disease
3. Diabetes mellitus
4. Berry aneurysm
5. Henoch-Schonlein purpura

Answer 162

4. Berry Aneurysm.

The patient’s symptoms and imaging findings are suggestive of adult polycystic kidney disease, or autosomal dominant polycystic kidney disease (ADPKD). ADPKD is associated with Berry aneurysms in the circle of Willis in 10-15% of patients.

ADPCKD usually presents in the 3rd or 4th decade of life. It is marked by multiple, large, bilateral cysts in all regions of the kidney. Cysts may also occur in the liver (30%), pancreas and spleen. Associated complications include berry aneurysm, mitral valve prolapse (MVP), and diverticulosis. Patients are at increased risk for renal cell carcinoma.

Question 163

A 53-year-old man has passed darker urine for the past week. On physical examination there are no abnormal findings. A urinalysis shows pH 5.5, specific gravity 1.013, 2+ blood, no protein, and no glucose. A urine cytology is performed and there are atypical cells seen. A cystoscopy is performed, but no mucosal lesions are noted. He has a 60 pack year history of smoking cigarettes. Which of the following is the most likely diagnosis?

A Adenocarcinoma of prostate

B Urothelial carcinoma of renal pelvis

C Acute interstitial nephritis

D Nodular glomerulosclerosis

E Squamous cell carcinoma of penis

Answer 163

B. Urothelial carcinoma of renal pelvis.

The lack of findings in the bladder, but the presence of atypical cells along with hematuria suggests that there is a malignant lesion and it is located higher in the urinary tract. His history of smoking increases the risk for urothelial carcinomas and for renal cell carcinomas.

Question 164

A 62-year-old man has had back pain for the past 8 months. He has had a productive cough for the past 2 days. On physical examination his temperature is 39°C and there is dullness to percussion at the right lung base. Laboratory studies show 4+ gram-positive diplococci in the sputum. A chest radiograph shows right lower lobe consolidation. An abdominal CT scan shows multiple lytic lesions of the vertebrae. On the day prior to death his serum urea nitrogen was 63 mg/dL with creatinine 7.1 mg/dL. A dipstick urinalysis was normal. At autopsy, his kidneys are firm and pale. Microscopically, there is abundant pink hyaline material in glomeruli and around small vessels. This material stains positively with Congo red. Which of the following laboratory findings was most likely to have been present in this patient in the week prior to death?

A Positive antinuclear antibody test

B Serum glucose of 210 mg/dL

C CD4 lymphocyte count of 110/microliter

D Total serum protein of 9.2 g/dL

E Serum prostate specific antigen of 11.8 ng/mL

Answer 164

D. Total serum protein of 9.2 g/dL

The findings are consistent with renal amyloid deposition with multiple myeloma. The total protein is elevated from increased serum monoclonal immunoglobulin. Myeloma can produce lytic bone lesions and patients often develop infections with encapsulated bacteria. The excessive light chain production leads to AL amyloid deposition. Bence-Jones proteinuria is often present, but the urine dipstick is most sensitive for albumin, not globulins.

Question 165

what type of kidney stones is more often found in women and almost always result of urinary tract infections?

Answer 165

Struvite stones. Organism involved proteus valguaris, kelbseilla are common culprit. they make the urine more alkaline and changes pH and changes uria to ammonia.

Question 166

A 52-year-old previously healthy man has experienced episodes of discomfort with urination for 3 months. There are no remarkable findings on physical examination. Laboratory studies include a urinalysis that reveals 1+ blood. Microscopic urine examination shows numerous RBCs, a few WBCs, and no casts. A urine culture is negative. A plain film radiograph of the pelvis shows a rounded, 1 cm radiopaque lesion in the region of the bladder. Which of the following laboratory test findings is most likely to be present in this man?

A Albuminuria

B Hypercalciuria

C Transaminasemia

D Hemoglobinuria

E Hyperuricemia

Answer 166

B. Hypercalciuria

The findings suggest a bladder calculus. Most stones are composed of calcium with oxalate or phosphate. The calcium content makes them radiopaque, unlike pure uric acid stones that are often radiolucent (by conventional x-ray) and which are not very common. The most common cause for urinary tract calculi is idiopathic hypercalciuria.

Question 167

A 72-year-old man has been feeling tired and lethargic for 5 months. He has noted increasing hesitancy with urination. On physical examination his prostate is diffusely enlarged. Laboratory studies show sodium 139 mmol/L, potassium 4.0 mmol/L, chloride 104 mmol/L, CO2 25 mmol/L, creatinine 1.9 mg/dL, and glucose 81 mg/dL. Which of the following renal abnormalities is most likely to be present in this man?

A Cortical atrophy

B Glomerulonephritis

C Papillary necrosis

D Polycystic change

E Renal cell carcinoma

Answer 167

A. Cortical atrophy

The prostatic hyperplasia could lead to obstructive uropathy with bilateral hydronephrosis, renal cortical atrophy, and eventual chronic renal failure.

Question 168

A 36-year-old woman has urinary frequency with dysuria for the past 4 days. On physical examination she has no flank pain or tenderness. A urinalysis reveals sp. gr. 1.014, pH 7.5, no glucose, no protein, no blood, nitrite positive, and many WBC’s. She has a serum creatinine of 0.9 mg/dL. Which of the following is the most likely diagnosis?

A Lupus nephritis

B Urinary lithiasis

C Acute cystitis

D Malakoplakia

E Urothelial carcinoma

Answer 168

C. Acute cystitis

These are features of acute inflammation. There are no casts, because the infection involves just the bladder, though such an infection could ascend to produce pyelonephritis. Urinary tract infections are more common in women because of the shorter urethra.

Question 169

A 69-year-old man incurs blunt force trauma from a fall. On physical examination he has a contusion on his lower back. An abdominal CT scan shows 3 peripheral 1 to 2 cm cysts in his kidneys. The kidneys are normal in size. Laboratory studies show a serum urea nitrogen of 16 mg/dL and creatinine of 1.1 mg/dL. A urinalysis reveals no blood, ketones, protein, or glucose. Microscopic urinalysis reveals a few oxalate crystals. Which of the following is the most likely diagnosis?

A Polycystic kidney disease

B Hydronephrosis

C Renal atherosclerosis

D Simple cortical cysts

E Recurrent pyelonephritis infection

Answer 169

D. Simple cortical cysts

Simple renal cysts typically do not interfere with renal function. A few small cysts can be found in many older persons and are inconsequential. They will appear as incidental findings in radiologic imaging studies. The trauma might cause hemorrhage into a cyst.

Question 170

A clinical study is performed with pediatric subjects who had a diagnosis of minimal change disease. These patients were observed to have prominent periorbital edema at diagnosis. Laboratory test findings from serum and urine tests were analyzed. Which of the following urinalysis test findings is most likely to have been consistently present in these subjects?.

A Nitrite positive

B Proteinuria >3.5 gm/24 hours

C Hematuria with >10 RBC/hpf

D Calcium oxalate crystsls

E Renal tubular epithelial cells and casts

Answer 170

B. Proteinuria >3.5 gm/24

This is the definition of nephrotic syndrome. MCD produces a nephrotic syndrome, with significant albuminuria. A single urine specimen will not suffice for the definition of nephrotic syndrome (though it could be extrapolated, given the daunting task of 24 hour urine collection in children).

Question 171

A 12-year-old boy is a member of a family with a history of renal disease, with males more severely affected than females. He is found to have auditory nerve deafness, corneal dystrophy, and ocular lens dislocation. A urinalysis shows microscopic hematuria. A renal biopsy is performed. Microscopically, the glomeruli show glomerular capillaries with irregular basement membrane thickening and attenuation with splitting of the lamina densa. The mesangial matrix is increased and epithelial cells may appear foamy. Which of the following is the most likely diagnosis?

A Goodpasture syndrome

B IgA nephropathy

C Alport syndrome

D Dominant polycystic kidney disease

E Diabetes mellitus, type I

Answer 171

C. Alport syndrome

Hereditary nephritis (Alport syndrome) is not associated with immune complexes, but with a genetic defect of type IV collagen production. In most families, it is inherited in an X-linked dominant pattern. Symptoms usually appear at ages 5 to 20, with overt renal failure between ages 20 to 50.

Question 172

A clinical study is performed of laboratory findings in subjects with renal diseases. Loss of physiologic function accompanies many diseases. One renal physiologic function affects thirst. Loss of which of the following renal functions is most likely to be identified by laboratory measurement of the urine specific gravity following water deprivation?

A Filtration

B Reabsorption

C Secretion

D Concentration

E Blood flow

Answer 172

D. Concentration

Renal concentrating ability is reflected by the specific gravity. In a person with normal concentrating capacity, less water intake is reflected by an increased specific gravity.

Question 173

A 45-year-old woman has had increasing malaise for the past year. On physical examination her blood pressure is 265/150 mm Hg. Laboratory studies show a plasma renin activity of 9 ng/mL/hr. She then suffers a ‘stroke’ with a right basal ganglia hemorrhage and dies. At autopsy the kidneys are bilaterally small with granular surfaces. Microscopically they show hyperplastic arteriolosclerosis with fibrinoid necrosis, petechial hemorrhages, and microinfarcts in the cortices. Which of the following conditions is most likely to be her underlying cause of death?

A Diabetes mellitus, type II

B Fibromuscular dysplasia

C Factor V Leiden mutation

D Analgesic abuse

E Systemic sclerosis

Answer 173

E. systemic sclerosis

She has findings of hyperplastic arteriolosclerosis with severe, malignant hypertension. Renal disease is likely to complicate diffuse scleroderma, but not the more limited form of scleroderma sometimes called ‘CREST’ syndrome.

Question 174

A 3-year-old child has become more irritable over the past two months and does not want to eat much at meals. On physical examination the pediatrician notes an enlarged abdomen and can palpate a mass on the right. An abdominal CT scan reveals a 10 cm solid mass involving the right kidney. The resected mass has a microscopic appearance with sheets of small blue cells along with primitive tubular structures. The child receives chemotherapy and radiation therapy, and there is no recurrence. Which of the following neoplasms is this child most likely to have had?

A Angiomyolipoma

B Renal cell carcinoma

C Urothelial carcinoma

D Wilms tumor

E Medullary fibroma

Answer 174

D. Wilm’s tumor

This is the classic age, histopathology, and location for Wilms tumor. These childhood neoplasms, when treated properly, have a very good prognosis.

Question 175

A 5-year-old boy is noted to have increased puffiness around his eyes for the past week, and he has been less active than normal. On physical examination he has periorbital edema. Vital signs include T 37°C, P 75/minute, RR 22/minute, and BP 140/90 mm Hg. A urinalysis reveals sp. gr. 1.010, pH 6.5, no glucose, 4+ protein, no blood, no casts, and no ketones. Microscopic urinalysis reveals oval fat bodies, but no WBC’s or RBC’s. He improves following a course of corticosteroid therapy. Which of the following renal lesions is most likely to have been present in this boy?

A Glomerular crescent formation

B Podocyte foot process effacement

C Patchy acute tubular necrosis

D Hyperplastic arteriolosclerosis

E Mesangial immune complex deposition

Answer 175

B. Podocyte foot process effacement

This is minimal change disease, the most common cause for nephrotic syndrome in children, and fusion of podocyte foot processes is the only pathologic finding present (on electron microscopy). Most patients respond to corticosteroid therapy.

Question 176

A clinical study is performed involving subjects with glomerulonephritis. One group of subjects has a diagnosis of crescentic glomerulonephritis and another group has membranous nephropathy. Which one of the following laboratory findings is most likely to be found in the absence of other findings in subjects with membranous nephropathy?

A Rapid onset

B Red blood cell casts

C Oliguria

D Albuminuria

E Hypertension

Answer 176

D. Albuminuria

Proteinuria may be present with nephritic syndromes (characterized by RBCs spilled into the urine from the glomeruli), but it is usually not marked, as in nephrotic syndrome. Membranous nephropathy typically produces nephrotic syndrome that is predominantly albuminuria. Diseases with crescents, such as membranoproliferative glomerulonephritis, lead to nephritic syndrome.

Question 177

A 51-year-old man is hospitalized for acute myocardial infarction. He has decreased cardiac output with hypotension requiring multiple pressor agents. His urine output drops over the next 3 days. His serum urea nitrogen increases to 59 mg/dL, with creatinine of 2.9 mg/dL. Urinalysis reveals no protein or glucose, a trace blood, and numerous hyaline casts. Five days later, he develops polyuria and his serum urea nitrogen declines. Which of the following pathologic findings in his kidneys is most likely to have caused his azotemia?

A Patchy tubular necrosis

B Podocyte foot process effacement

C Glomerular crescent formation

D Hyperplastic arteriolosclerosis

E Mesangial immune complex deposition

Answer 177

A. Patchy tubular necrosis

He has findings of ischemic acute tubular necrosis (ATN) from heart failure with hypotension. A clue is the >20:1 ratio of urea nitrogen to creatinine, which occurs early in the course, from prerenal azotemia. As the disease progresses, the ratio begins to approach 10:1, typical for intrinsic renal diseases. ATN may also be produced by toxins such as ethylene glycol in antifreeze, but the tubular necrosis is more diffuse.

Question 178

A clinical study is performed to determine the value of percutaneous renal biopsy. The medical records of subjects with renal diseases are analyzed to note the circumstances in which the results of a renal biopsy facilitated choice of therapy that improved prognosis. In which of the following situations is a percutaneous needle biopsy of the kidney most useful?

A Fever and flank pain with suspected acute pyelonephritis

B Prostatic hyperplasia with suspected hydronephrosis

C Premature neonate with suspected polycystic kidney disease

D Abdominal pain with suspected renal cyst

E Acute renal failure with suspected systemic lupus erythematosus

Answer 178

E. acute renal failure with suspected SLE

Therapy may depend upon determination of the severity and nature of the renal disease with SLE.

Question 179

A 56-year-old man complains of dull flank pain for the past month. On physical examination he has tenderness to percussion at the right costovertebral angle. Laboratory studies show microscopic hematuria but no proteinuria or glucosuria. A urine cytology shows no atypical cells. A CBC shows WBC count 7800/microliter, Hgb 21.1 g/dL, Hct 63.5%, MCV 94 fL, and platelet count 195,000/microliter. His serum urea nitrogen is 15 mg/dL and creatinine 1 mg/dL. Which of the following radiographic findings is most likely to be present in this man?

A Hydronephrosis on intravenous pyelogram

B Renal mass on abdominal CT scan

C Radiopaque ureteral calculus on an abdominal plain film

D Enlarged, multicystic kidneys on abdominal ultrasound

E Pelvic abscess below the bladder on MR imaging

Answer 179

B. Renal mass on abdominal CT scan

The polycythemia suggests a paraneoplastic syndrome, and a renal cell carcinoma is a likely candidate for the primary lesion. The flank pain and hematuria can be explained by the mass effect from a renal cell carcinoma.

Question 180

A 43-year-old man goes to his physician for a routine check of his health status. He is found to have a blood pressure of 150/95 mm Hg. His urinalysis shows pH 6.5, specific gravity 1.015, no glucose, blood, or protein, and no casts. His serum creatinine is 1.4 mg/dL. If he is not treated, which of the following conditions will most likely cause his death?

A Intracerebral hemorrhage (stroke)

B Aortic aneurysm rupture

C Congestive heart failure

D Chronic renal failure

E Intracranial aneurysm rupture

Answer 180

C. Congestive heart failure

Hypertension leads to cardiac enlargement, then dilation, and eventual heart failure. This is the most common outcome with untreated hypertension.

Question 181

A 20-year-old previously healthy man has been feeling tired for the past 5 days. He then passes dark-colored urine. On physical examination his blood pressure is 160/90 mm Hg. Laboratory studies show his serum creatinine is 4.4 mg/dL and BUN 40 mg/dL. A urinalysis reveals pH 6, specific gravity 1.011, 3+ blood, 1+ protein, no glucose, and no ketones. On urine microscopic examination there are numerous RBC casts. Which of the following pathologic findings on renal biopsy is most likely to be present in this man?

A Glomerular crescents

B Widened proximal tubules

C Neutrophilic infiltrates

D Basememt membrane thickening

E IgA deposited in glomerular capillaries

Answer 181

A. Glomerular crescents

Question 182

A 43-year-old man has had increasing malaise for the past 3 weeks. On physical examination he has a blood pressure of 150/95 mm Hg and 1+ pitting edema of the lower extremities to the knees. Dipstick urinalysis shows no glucose, blood, ketones, nitrite, or urobilinogen, and the microscopic urinalysis reveals no RBC/hpf and only 1 WBC/hpf. Additional laboratory studies show a 24 hour urine protein of 4.1 gm. His serum creatinine is 3.5 mg/dL with urea nitrogen of 38 mg/dL. His hepatitis B surface antigen is positive. Which of the following is the most likely diagnosis?

A Membranous nephropathy

B Systemic lupus erythematosus

C Acute tubular necrosis

D Diabetic nephropathy

E Post-streptococcal glomerulonephritis

Answer 182

A. Membranous nephropathy

Membranous nephropathy is the most common cause for nephrotic syndrome in adults. Some cases are associated with underlying infections or malignancies, but in most cases the cause is unknown. There is diffuse thickening of the glomerular capillary basement membrane from immune deposits.

Question 183

A 60-year-old woman is admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. There is difficulty maintaining adequate blood pressure and tissue perfusion for 3 days. Her serum lactate becomes elevated. Her serum urea nitrogen increases to 44 mg/dL and creatinine to 2.2 mg/dL. Granular and hyaline casts are present on microscopic urinalysis. Which of the following renal lesions is most likely to be present in this situation?

A Chronic pyelonephritis

B Acute tubular necrosis

C Nodular glomerulosclerosis

D Renal vein thrombosis

E Minimal change disease

Answer 183

A. Acute tubular necrosis

Ischemia, typically in hypotensive hospitalized patients, is the most frequent antecedent to acute tubular necrosis (ATN), and ischemic heasrt disease with coronary syndromes including MI’s are common. This is a pre-renal form of azotemia, and note the BUN:Cr ratio more than 20:1.

Question 184

A 50-year-old man was diagnosed at age 15 with type 1 diabetes mellitus. His disease has been poorly controlled, as evidenced by elevated hemoglobin A1C levels. He develops a non-healing ulcer of his foot at age 35. At age 45, he has an increasing serum urea nitrogen and a urinalysis shows sp gr 1.012, pH 6.5, 1+ protein, no blood, 1+ glucose, negative leukocyte esterase, negative nitrite, and no ketones. Which of the following renal diseases is he most likely to have?

A Nodular glomerulosclerosis

B Hyperplastic arteriolosclerosis

C Papillary necrosis

D Crescentic glomerulonephritis

E Pyelonephritis

Answer 184

A. Nodular glomerulosclerosis

Nodular glomerulosclerosis is a typical complication of long-standing diabetes mellitus. Microalbuminuria may preceed development of other abnormalities.

Question 185

A 39-year-old woman is found to have a blood pressure of 160/105 mm Hg while at a free health screening clinic. She feels fine and has had no major medical problems in her life. An abdominal ultrasound reveals that the left kidney is smaller than the right, but that neither is cystic and no masses appear to be present. MR angiography reveals focal narrowing with thickening and beading of the left main renal artery. A urinalysis reveals no abnormal findings. She has an elevated plasma renin. Which of the following is the most likely diagnosis?

A Diabetes mellitus

B Antiphospholipid syndrome

C Fibromuscular dysplasia

D Thrombotic thrombocytopenic purpura

E Cholesterol emboli syndrome

Answer 185

C. FIbromuscular dysplasia
Fibromuscular dysplasia is an uncommon but surgically treatable cause for hypertension. The abnormal segment of artery can be treated with angioplasty or removed and replaced with a graft. She has a ‘Goldblatt’ kidney from narrowing of one renal artery, leading to an increase in renin, with hypertension, and the subsequent hypertensive changes can eventually damage the opposite kidney.

Question 186

A 70-year-old woman has had a fever for the past 3 days. She has burning dysuria. On physical examination her temperature is 37.8°C and there is dull pain on palpation of her left lower back. Laboratory studies show Hgb 13.3 g/dL, Hct 40.2%, and WBC count 12,300/microliter with differential count 72 segs, 9 bands, 13 lymphs, 5 monos, and 1 eosinophil. A urine dipstick analysis shows sp gr. 1.017, pH 6, leukocyte esterase positive, nitrite positive, protein negative, glucose negative, and blood negative. Which of the following microscopic urinalysis findings would be most diagnostic for her renal disease?

A Dysmorphic red blood cells

B Oval fat bodies

C Renal tubular epithelial cells

D White blood cell casts

E Triple phosphate crystals

Answer 186

D. WBC cast

The WBC casts are most characteristic for an acute interstitital nephritis (acute pyelonephritis). The casts can only come from distal tubules / collecting ducts. The positive leukocyte esterase and nitrite are typical for acute inflammation with bacterial infection of the urinary tract.

Question 187

A 53-year-old woman has had chronic arthritis pain for the past 3 years. She has taken 2 gm of phenacetin and acetaminophen a day for her pain over that time. She now has increasing fatigue. There are no abnormal findings on physical examination. Laboratory studies show her serum urea nitrogen is 52 mg/dL and creatinine 5.4 mg/dL. Which of the following pathologic findings is most likely to occur in her kidneys?

A Papillary necrosis

B Focal segmental glomerulosclerosis

C Nephrocalcinosis

D Acute interstitial nephritis

E Arteriolosclerosis

Answer 187

A. Papillary necrosis

She has analgesic abuse nephropathy which leads to papillary necrosis and chronic interstitial nephritis with tubular atrophy (though the renal columns are spared). There is also risk for development of urothelial carcinoma. The analgesics implicated may include combinations of phenacetin, acetaminophen, and aspirin.

Question 188

A 25-year-old woman has been hospitalized for treatment of a Staphylococcus aureus abscess of her left thigh complicating a puncture wound. The wound is incised and drained and she receives antibiotic therapy. She is improving and discharged home a week later, but the next day she develops a fever. On physical examination her temperature is 38.1°C and there is a diffuse erythematous skin rash of her trunk and extremities. A urinalysis shows sp gr 1.020, pH 6.5, 1+ blood, 1+ protein, no glucose, and no ketones. There are 10-20 WBCs/hpf and 1-5 RBCs/hpf, and a few eosinophils are noted on urine microscopic examination. Which of the following is the most likely diagnosis?

A Acute tubular necrosis

B Septicemia with pyelonephritis

C Drug-induced interstitial nephritis

D Hemolytic-uremic syndrome

E Post-infectious glomerulonephritis

F Urinary tract infection

Answer 188

C. Drug-induced interstitial nephritis

This allergic response can occur following drug therapy with such antibiotic agents as methicillin, as well as some diuretics and NSAIDs. This allergic response with acute interstitial nephritis may be unrelated to the amount of drug and duration of therapy. This condition is treated by stopping the drug.

Question 189

A 39-year-old previously healthy man has the sudden onset of severe right flank pain that comes in waves all night long. When he is seen in the emergency room, after waiting for two hours, he is exhausted. On physical examination there are no abnormal findings. Urinalysis reveals no ketones, glucose, protein, nitrite, or urobilinogen, but blood is present. Urine microscopic examination shows many RBCs but few WBCs. The specific gravity is 1.015 and the pH is 5.5. Which of the following is the most likely diagnosis?

A Nodular prostatic hyperplasia

B Membranous nephropathy

C Ureteral calculus

D Renal angiomyolipoma

E Urothelial carcinoma of bladder

Answer 189

C. Ureteral calculus

These acute symptoms are typical for a calculus that is being passed down the ureter, with intermittent contractions producing colicky pain. 5 to 10% of persons may pass a urinary stone at some point in their life. Non-contrast CT scanning is a good diagnostic study. Most calculi will pass spontaneously, but analgesics are needed. NSAIDS work well except when renal function is impaired; opiates may be considered. Other patients waiting in the ER would gladly let this man be seen first, and the ER staff should triage patients in acute distress first.

Question 190

A 15-year-old girl has had increasing lethargy following a bout of the ‘flu’ 3 weeks ago. On physical examination there are no abnormal findings. Her condition does not improve after 3 weeks on corticosteroid therapy, so a renal biopsy is performed and microscopic examination shows segmental sclerosis of 3 of 10 glomeruli. Immunofluorescence studies and electron microscopy do not show immune deposits. Which of the following is the most likely outcome for this girl’s condition?

A Progression to chronic renal failure

B Improvement with additional corticosteroid therapy

C Development of restrictive lung disease

D Discovery of an underlying malignancy

E Remission following dietary change

Answer 190

A. Progression to chronic renal failure

The findings point to focal segmental glomerulosclerosis (FSGS), which leads to chronic renal failure in half of cases. The lack of resolution with corticosteroid therapy and the progression to chronic renal failure is what sets FSGS apart from minimal change disease. FSGS is idiopathic, so there is unlikely to be an underying condition.

Question 191

A 59-year-old man notes blood in his urine for the past week. On physical examination there are no abnormal findings. A urinalysis confirms the presence of blood, but no proteinuria or glucosuria. A urine culture is negative. A cystoscopy is performed, and a 3 cm exophytic mass is seen in the dome of the bladder. A biopsy of this mass is performed and microscopic examination reveals fibrovascular cores covered by a thick layer of transitional cells. Which of the following risk factors is most likely to have led to development of this lesion?

A Diabetes mellitus

B Recurrent urinary tract infection

C Therapy with methicillin

D Cigarette smoking

E Tuberous sclerosis

F Use of NSAIDS

Answer 191

D. Cig smoking

He has a urothelial carcinoma of the urinary bladder, and smokers are at increased risk for this cancer. These cancers can be multiple and recurrent. Additional less common risk factors include exposure to aniline dyes and to beta-naphthylamine compounds. Drugs that increase the risk include analgesic phenacetin and the chemotherapy agent cyclophosphamide.

Question 192

A 53-year-old woman has noted fever and right-sided flank pain for the past 3 days. On physical examination her temperature is 38.4°C and there is right costovertebral angle tenderness. A urinalysis reveals sp. gr. 1.010, pH 7.5, no glucose, no protein, no ketones, and 1+ blood. Many WBCs and WBC casts are seen on urine microscopic examination. An abdominal radiograph reveals a radiopaque calculus that forms a cast of a dilated right renal collecting system. A urine culture grows Proteus vulgaris. Which of the following crystals is most likely to be seen in large numbers on microscopic urinalysis in this woman?

A Calcium oxalate

B Cystine

C Calcium phosphate dihydrate

D Uric acid

E Magnesium ammonium phosphate

Answer 192

E. Magnesium ammonium phosphate

She has a staghorn calculus and acute pyelonephritis. These ‘infection stones’ are typically the ‘triple phosphate’ stones whose formation is aided by infection with urea-splitting bacteria such as Proteus.

Question 193

A 60-year-old man was diagnosed last year with adenocarcinoma of the lung, and he underwent right lower lobectomy. For the past 3 weeks he has had increasing malaise. On physical examination he has pitting edema to his knees and presacral edema. Abdominal and chest CT scans show scattered hepatic mass lesions and hilar lymphadenopathy. A urinalysis reveals 4+ proteinuria, and his 24 hour urine protein is 2.7 gm. His serum urea nitrogen is 55 mg/dL with creatinine of 6.1 mg/dL. A renal biopsy is performed, and there is focal deposition of IgG and C3 with a granular pattern. Which of the following forms of glomerular disease is he most likely to have?

A Membranous nephropathy

B Rapidly progressive glomerulonephritis

C Nodular glomerulosclerosis

D Chronic glomerulonephritis

E Dense deposit disease

Answer 193

A. Membranous nephropathy

Most cases of membranous nephropathy are idiopathic, but in some patients there is a history of an infection or a malignancy (usually lung) with antigenemia that drives the immune deposition in the glomerular capillary basement membranes. Membranous nephropathy produces primarily proteinuria. Note the BUN:Cr ratio here close to 10:1 that suggests intrinsic renal disease.

Question 194

A clinical study is performed with subjects born with congenital urinary tract anomalies. Their records are reviewed to assess the development of long term complications. One group of subjects is found to have an increased risk for both infection and development of a carcinoma. Which of the following congenital urinary tract anomalies is most likely to carry this risk?

A Unilateral renal agenesis

B Bladder exstrophy

C Bilateral ureteral duplication

D Horseshoe kidney

E Medullary sponge kidney

Answer 194

B. Bladder exstrophy

Bladder exstrophy is a serious condition, and requires surgical repair. The exposed bladder predisposes to infection. There is a long-term risk for carcinoma, such as bladder adenocarcinoma or colonic adenocarcinoma.

Question 195

A 57-year-old man has had dysuria for the past week. Over the past 2 days he has experienced shaking chills. On physical examination his temperature is 39.3°C. A urinalysis shows sp gr 1.016, pH 6, 1+ glucose, 1+ blood, no ketones, and no protein. Urine microscopic examination shows numerous WBCs and WBC casts. His serum creatinine is 1.5 mg/dL and glucose 155 mg/dL with hemoglobin A1C 8.7%. A renal ultrasound scan shows a 0.3 cm free floating echodense object in the left renal pelvis. Which of the following complications has this man most likely developed?

A Acute tubular necrosis

B Aspergillus fungus ball

C Cystine-containing calculus

D Hematoma formation

E Papillary necrosis

F Renal cell carcinoma

G Urothelial carcinoma

Answer 195

E. Papillary necrosis

A calculus may form as a consequence of infection, but such stones are typically formed of magnesium ammonium phosphate.

Question 196

A 48-year-old woman has had increasing malaise for the past 6 months. On physical examination there are no abnormal findings except for diminished sensation to pinprick and light touch in her lower legs and feet. She is afebrile and normotensive. Laboratory studies show serum creatinine 4.5 mg/dL, urea nitrogen 42 mg/dL, glucose 130 mg/dL, and hemoglobin A1C 7.9%. A urinalysis shows 1+ glucose, 1+ protein, no blood, and no ketones. Urine microscopic examination shows 1 RBC/hpf and 1 WBC/hpf. Which of the following pathologic abnormalities is she most likely to have in her kidneys?

A Acute pyelonephritis

B Acute tubular necrosis

C Chronic glomerulonephritis

D Hydronephrosis

E Hyperplastic arteriolosclerosis

F Membranous nephropathy

G Nodular glomerulosclerosis

H Polycystic change

Answer 196

G. Nodular glomerulosclerosis

The classic lesion with diabetes mellitus is nodular glomerulosclerosis, which gradually reduces renal function. Diffuse glomerulosclerosis may also be present. Microscopic albuminuria may be the clue that diabetic nephropathy is developing. The glucosuria suggests poor control of glycemia, confirmed by the elevated Hgb A1c.

Question 197

Question 35
A 49-year-old woman has been hospitalized for the past 10 days for treatment of bronchopneumonia. She has developed chills and fever over the past 2 days. On physical examination her temperature is 38.8°C and she has a diffuse erythematous skin rash. Laboratory studies show serum creatinine 2.2 mg/dL and glucose 73 mg/dL. A peripheral blood smear reveals eosinophilia. On urinalysis she has 2+ proteinuria but no blood, glucose, or ketones. Which of the following is the most likely diagnosis?

A Post-streptococcal glomerulonephritis

B Drug-induced interstitial nephritis

C IgA nephropathy

D Acute tubular necrosis

E Acute serum sickness

Answer 197

B. Drug-induced interstitial nephritis

These findings are typical for a drug-induced acute interstitial nephritis. The eosinophilia is seen with allergic phenomena (as in a drug allergy).

Question 198

A 59-year-old man has experienced lower back pain for 4 months. On physical examination there are no abnormal findings. A urinalysis shows microscopic hematuria, but no proteinuria or glucosuria. An abdominal CT scan reveals a 6 cm solid mass in the upper pole of the right kidney. A right nephrectomy is performed, and the grossly variegated mass is seen microscopically to be composed of nests of cells with clear cytoplasm. Which of the following laboratory test findings likely to be associated with this lesion?

A Hypercalcemia

B Increased catecholamines

C Positive serology for hepatitis B surface antigen

D Hyponatremia

E Hyperaldosteronemia

Answer 198

A. Hypercalcemia

This paraneoplastic effect can occur with renal cell carcinomas. The hypercalcemia is most likely related to elaboration of parathormone-related peptide (PTHrP) by the neoplasm.

Question 199

A 30-year-old man has noted puffiness around his eyes and swelling of his feet for the past 2 weeks. On physical examination his blood pressure is 155/95 mm Hg. Urine microscopic examination reveals oval fat bodies. Which of the following conditions is he most likely to have?

A Ascending pyelonephritis

B Nephritic syndrome

C Nephrotic syndrome

D Obstructive uropathy

E Renal infarction

F Papillary necrosis

Answer 199

C. Nephrotic syndrome

Oval fat bodies appear in association with pronounced proteinuria and lipiduria. These bodies represent degenerating, sloughed tubular cells that are filled with lipid. The tubular cells try to reabsorb the spilled protein and lipid and get overwhelmed.

Question 200

Question 42
A 55-year-old man is found down and unconscious. On physical examination he is afebrile. After catheterization, he passes a small amount of dark urine. The urine dipstick test for blood is positive but no red blood cells are seen on microscopic examination of the urine sediment. Which of the following is the most likely diagnosis?

A Post-streptococcal glomerulonephritis

B Renal papillary necrosis

C Ureteral lithiasis

D Rhabdomyolysis

E Renal infarction

Answer 200

D. Rhabdomyolysis

The dipstick test is sensitive for both hemoglobin and myoglobin. Myoglobinuria may occur with rhabdomyolysis from muscle injury. Trauma, including prolonged immobilization in one position, may cause muscle injury.

Question 201

Epithelial crescents is associated with what nephritic syndrome?

Answer 201

RPGN

Question 202

RPGN is divided into three groups based on IF findings. Indicate which of these antibodies is associated with which type.
A. Anti-glomerular basement membrane disease
B. Immune complex disease
C. absence of anti-GBM antibodies and immune complex

Answer 202

A. Type I (Goodpasture syndrome – needs plasmapheresis)
B. Type II (associated with Lupus, Henoch-schonlein purpura)
C. Type III (includes granulomatosis iwth polyangiitis (ANCA-assoicated vasculitis) and microscopic polyangiitis.

Question 203

Necrotizing papilitis with papillary necrosis is a complication of _

Answer 203

acute pyelonephritis and diabetics are particular prone to this development.

Question 204

Most common cause of UTI in older women is e.coli and often presents with WBC casts.  Seeing WBC casts in urine sample indicates the infection has spread to 
A. urethra
B. Bladder
C. Cervix
D. kidney
E. Ureters

Answer 204

D. Kidney.

Casts are formed in the renal tubules.

Question 205

Presence of Bence Jones proteinuria is a characteristic of what disease?

Answer 205

Multiple Myeloma

Question 206

A 63-year-old man has noted increasing back pain for 7 months. He has had three respiratory tract infections with Streptococcus pneumoniae during the past year. On examination, he has pitting edema to his thighs. Laboratory studies show total serum protein, 9.6 g/dL; albumin, 3.5 g/dL; creatinine, 3 mg/dL; urea nitrogen, 28 mg/dL; and glucose, 79 mg/dL. Urinalysis shows proteinuria of 4 g/24 hr, but no glucosuria or hematuria. Abdominal CT scan shows enlarged kidneys without cysts or masses. A renal biopsy specimen stained
with H&E shows deposits of amorphous pink material within glomeruli, interstitium, and arteries. Which of the following diseases is he most likely to have?

A Analgesic nephropathy

B ANCA-associated granulomatous vasculitis

C Type 2 diabetes mellitus

D Membranous nephropathy

E Multiple myeloma

F Systemic lupus erythematosus

Answer 206

E. MM.

There is a large amount of serum globulin, back pain from lytic lesions, immunosuppression with recurrent in- fections, and amyloid deposition enlarging the kidneys, all consistent with multiple myeloma. This AL amyloid deposi- tion occurs in 6% to 24% of myeloma cases, and can involve kidneys. Patients with myeloma often have Bence Jones pro- teinuria (not detected by the standard dipstick urinalysis), and some have cast nephropathy, which can cause acute or, more commonly, chronic renal failure.