Nephrology Picture Diagnosis

Question 1

Answer 1

ATN (acute tubular necrosis)

Question 2

Answer 2

hydronephrosis

Question 3

Answer 3

pyelonephritis

• WBC cast

Question 4

Answer 4

“Maltese cross” appearance of oval fat bodies seen in nephrotic syndrome

Question 5

Answer 5

hydronephrosis

Question 6

Answer 6

hydronephrosis

Question 7

Answer 7

dysmorphic erythrocytes (“Mickey Mouse” ears appearance)

Question 8

Answer 8

fundoscopic examination indicating hypertensive retinopathy

Question 9

Answer 9

• white arrows = generalized arteriolar narrowing
• black arrows = compared with venule diameter

Question 10

Answer 10

peaked T waves characteristic of hyperkalemia

Question 11

Answer 11

hypocalcemia

Question 12

Answer 12

erythrocyte cast indicative of glomerular disease

Question 13

Answer 13

urenic frost

Question 14

Answer 14

calcium oxalate DIhydrate crystals

• envelope-shaped
• associated with hyperoxaluria and calcium oxalate stone formation

Question 15

Answer 15

leukocytes in setting of UTI

Question 16

Answer 16

ADPKD

Question 17

Answer 17

ADPKD

Question 18

Answer 18

• hypokalemia
• initially, T waves decrease in amplitude
• ST segment flattens
• then U waves appear after the T waves
• the U waves ultimately replace the T waves completely
• this may give the impression of QT prolongation, but it is really a QU interval

Question 19

Answer 19

tuberous sclerosis

Question 20

Answer 20

angiokeratomas in Fabry disease

Question 21

Answer 21

“storiform” pattern seen in IgG4-related disease

Question 22

Answer 22

granular casts suggestive of acute tubular necrosis (ATN)

Question 23

Answer 23

isomorphic RBCs

Question 24

Answer 24

crenated RBCs

Question 25

Answer 25

dysmorphic RBCs

Question 26

Answer 26

budding yeast

Question 27

Answer 27

lipid droplets

Question 28

Answer 28

WBCs

Question 29

Answer 29

renal tubular epithelial (RTE) cells

Question 30

Answer 30

hyaline casts

Question 31

Answer 31

RTE cell cast

Question 32

Answer 32

RBC cast

Question 33

Answer 33

WBC casts

Question 34

Answer 34

granular casts

Question 35

Answer 35

uric acid crystals

Question 36

Answer 36

calcium oxalate cystals (monohydrate) - "dumbell" shape

Question 37

Answer 37

acyclovir crystals

Question 38

Answer 38

granular casts (muddy brown casts) suggestive of ATN

Question 39

Answer 39

granular casts

Question 40

Answer 40

- Effacement of proximal tubule cells - Loss of brush border - Patchy loss of tubular cells - Focal tubule dilation - Tubular casts - Areas of cellular regeneration in recovery

Question 41

Answer 41

osmotic nephrosis

Question 42

Answer 42

diabetic nephropathy - Kimmelstiel-Wilson nodules (arrows)

Question 43

Answer 43

IgA nephropathy

Question 44

Answer 44

IgA nephropathy

Question 45

Answer 45

minimal change disease - foot process effacement

Question 46

Answer 46

advanced FSGS

Question 47

Answer 47

C1q nephropathy

Question 48

Answer 48

dense deposit disease

Question 49

Answer 49

C3 glomerulopathy

Question 50

Answer 50

membranous nephropathy - Jones silver stain - small spike-like projections

Question 51

Answer 51

membranoproliferative glomerulonephritis (MPGN) - diffuse endocapillary hypercellularity - looks lobular - PAS stain

Question 52

Answer 52

membranoproliferative glomerulonephritis (MPGN) - diffuse endocapillary hypercellularity - extensive duplication of GBM - Jones silver stain

Answer 53

MPGN - IF - smooth outline of sausage-shaped, chunky peripheral loop deposits and scattered mesagnial deposits

Question 54

Answer 54

fibrillary GN - LM pattern varies - this case shows moderate mesangial proliferation and occasional BM double contours - Jones silver stain

Question 55

Answer 55

fibrillary GN - may be lobular or nodular proliferative pattern, which may resemble diabetic nephropathy - PAS stain

Question 56

Answer 56

acute postinfectious GN - C3 positivity - predominant starry-sky pattern - more elongated deposits, "garland pattern" (bottom) - anti-C3 IF x 400

Question 57

Answer 57

IgA nephropathy - crescentic injury

Question 58

Answer 58

IgA nephropathy - predominantly mesangial pattern - anti-IgA IF x 400

Question 59

Answer 59

light chain deposition disease (LCDD) - minimal mesangial expansion - mild increase in mesangial cellularity and matrix - specific dx made by IF and confirmed by EM

Question 60

Answer 60

light chain deposition disease (LCDD) - characteristic nodular appearance - may be difficult to distinguish from diabetic nephropathy, BUT BM not as prominent - need IF and EM to confirm dx

Question 61

Answer 61

light chain deposition disease (LCDD) - kappa monoclonal light chain staining tubular basement membranes - anti-kappa IF x 100

Question 62

Answer 62

light chain deposition disease (LCDD) - finely granular deposits found along internal aspect of GBM - EM x 11,250

Question 63

Answer 63

light chain deposition disease (LCDD) - granular deposits found along internal aspect of GBM - EM x 40,000

Question 64

Answer 64

- light and heavy chain deposition disease (LHCDD) - membranoproliferative pattern w/ increased mesangial cells and matrix - confirmed by IF and EM - Jones silver stain, x 400

Question 65

Answer 65

- light and heavy chain deposition disease (LHCDD) - nodular glomerulosclerosis, INDISTINGUISHABLE from LCDD on LM - confirmed by IF and EM - Jones silver stain, x 200

Question 66

Answer 66

- light and heavy chain deposition disease (LHCDD) - strong glomerular capillary loop and mesangial staining in a smudgy, continuous pattern along GBM - also tubular BM staining (left) - anti-IgG IF, x 400

Question 67

Answer 67

light and heavy chain deposition disease (LHCDD) - subendothelial and subepithelial deposits - coarsely fibrillar substructure

Question 68

Answer 68

light and heavy chain deposition disease (LHCDD) - frequent tubular BM deposits - EM, x 25,625

Question 69

Answer 69

amyloidosis - segmental amorphous, eosinophilic, fluffy "cotton candy" in mesangium

Question 70

Answer 70

amyloidosis - massive amyloid deposits in glomeruli and arterioles - nodular appearance d/t amorphous, acellular eosinophilic pale material - H&E, x 100

Question 71

Answer 71

amyloidosis - apple-green birefringence w/ Congo red stain and viewed under polarized light

Question 72

Answer 72

HIV-associated nephropathy (HIVAN) - microcystic tubular injury and collapse of glomerular tuft

Question 73

Answer 73

HIV-associated nephropathy (HIVAN) - glomerulus w/ collapsing form of injury

Question 74

Answer 74

sickle cell nephropathy - massive sludging of RBCs - H&E, x 100

Question 75

Answer 75

sickle cell nephropathy - sickling causing congestion in glomerulus and peritubular capillaries - H&E, x 100

Question 76

Answer 76

sickle cell nephropathy - capillary loop greatly distorted d/t swollen endothelial cells and interposition w/o well-defined immune complexes

Question 77

Answer 77

Fabry disease - vacuolated, honeycomb appearance - results from accumulation of abnormal glycosphingolipid in Fabry disease

Question 78

Answer 78

Fabry disease - lysosomal inclusions and myelin bodies, especially in podocytes - toluidine blue-stained

Question 79

Answer 79

Fabry disease - myelin bodies and lysosomal inclusions, some of which are lamellated

Question 80

Answer 80

Fabry disease - lysosomal inclusion w/ myelin body appearance in the podocyte

Question 81

Answer 81

Fabry disease - lysosomal inclusions w/ lamellated structure - "zebra bodies"

Question 82

Answer 82

lipoprotein glomerulopathy - massive intraluminal pale lipid thrombi in glomerular capillaries

Question 83

Answer 83

lipoprotein glomerulopathy - intracapillary thrombi stain brightly positive for lipid - oil red O stain, x 200

Question 84

Answer 84

lecithin-cholesterol acyltransferase (LCAT) deficiency - focal prominent endocapillary foam cell infiltration - PAS, x 200

Question 85

Answer 85

- lecithin-cholesterol acyltransferase (LCAT) deficiency - numerous lipid inclusion seen w/i intracapillary foam cells - EM, x 8000

Question 86

Answer 86

- minimal change disease - normal LM - diffuse effacement of foot processes by EM

Question 87

Answer 87

focal segmental glomerulosclerosis - sharply defined segmental sclerosis - obliteration of capillary loops - increased matrix - no deposits - diffuse foot process effacement by EM

Question 88

Answer 88

collapsing glomerulopathy - segmental or global collapse of capillary tuft w/ overlying visceral epithelial cell hyperplasia - no deposits

Question 89

Answer 89

focal segmental glomerulosclerosis, tip lesion - segmental sclerosis confined to proximal tubular pole - often has endocapillary hypercellularity w/ foam cells and overlying visceral epithelial cell hyperplasia - foot processes diffusely and globally effaced, even in glomeruli and segments w/o the tip lesions - no deposits

Question 90

Answer 90

dense deposit disease - membranoproliferative pattern - endocapillary hypercellularity and glomerular basement membrane double contours - GBM is altered by dense deposits in a ribbon-like pattern, w/ mesangial dense material as well

Question 91

Answer 91

membranous nephropathy - no evident proliferation by LM - global subepithelial deposits (may be seen by LM) by GBM spike reaction on silver stain

Question 92

Answer 92

membranous nephropathy - in earliest stages, deposits do not stain w/ silver may be seen in tangential sections as holes, producing a corkboard appearance

Question 93

Answer 93

membranous nephropathy - early basement membrane reaction develops, visualized as small spikes on silver stain

Question 94

Answer 94

membranous nephropathy - basement membrane reaction may encircle deposits, w/ ensuing double contours and a ladder-type appearance on silver stain

Question 95

Answer 95

membranous nephropathy - in far advanced cases, deposits may become partially resorbed, leaving a rarefied area of the GBM as seen by EM

Question 96

Answer 96

membranoproliferative glomerulonephritis (MPGN) - endocapillary proliferation/hypercellularity and GBM double contours - d/t mesangial and subendothelial deposits, w/ resultant interposition and new basement membrane being laid down, causing the "split" appearance

Question 97

Answer 97

membranoproliferative glomerulonephritis (MPGN) - in the early stages, only mesangial and enocapillary hypercellularity may be seen by LM, w/o GBM reaction yet

Question 98

Answer 98

membranoproliferative glomerulonephritis (MPGN) - interposed cells, both monocytes/macrophages and mesangial cells, migrating in between the GBM and endothelium, present in response to subendothelial depositis

Question 100

Answer 100

membranoproliferative glomerulonephritis (MPGN) - interposed cells and new GBM reaction devlop in response to the subendothelial deposits - these cells and deposits do NOT stain w/ silver, and thus the capillary wall has a double contour "TRAM-TRACK" appearance

Question 101

Answer 101

acute postinfectious glomerulonephritis - exudative hypercellularity w/ numerous polymorphonuclear leukocytes and endocapillary hypercellularity - scattered mesangial and large hump-shaped subendothelial deposits

Question 102

Answer 102

IgA nephropathy - mesangial cell and matrix increase - mesangial deposits