Renal: Miscellaneous

Question 1

Hyaline casts

Answer 1

Normal finding, but an increased amount suggests volume depletion

Question 2

Red cell casts, dysmorphic red cells

Answer 2

Glomerulonephritis

Question 3

White cells, eosinophils

Answer 3

Allergic interstitial nephritis, atheroembolic disease

Question 4

Granular casts, renal tubular cells, “muddy brown cast”

Answer 4

ATN

Question 5

White cells, white cell casts

Answer 5

Pyelonephritis

Question 6

Postinfectious glomerulonephritis (nephritic)

Answer 6

Classically associated with recent group A beta hemolytic streptococcal infection (S pyogenes), but can be seen with any infection (2-6 weks prior).

Will see oliguria, edema, hypertension, tea or cola colored urine

Immune complex mediated. Will see low serum C3. ASO titer. Lumpy bumpy immunofluorescence.

Treat with diuretics to prevent fluid overload

Question 7

IgA nephrophathy (Berger’s disease) (nephritic)

Answer 7

The most common type of nephritic syndrome. Typically follows upper respiratory or GI infection. May be seen in HSP.

Symptoms of episodic gross hematuria or persistent microscopic hematuria.

Immune complex mediated. Normal C3.

Treat with glucocorticoids for select patients. ACEIs in patients with proteinuria. 20% progress to ESRD

Question 8

Wegener’s granulomatosis (nephritic)

Answer 8

Granulomatous inflammation of the respiratory tract and kidney with necrotizing vasculitis.

Presents with fever, weight loss, hematuria, hearing disturbances, respiratory and sinus symptoms. Cavitary pulmonary lesions bleed and lead to hemoptysis.

Pauci-Immune. Presence of c-ANCA. Renal biopsy shows necrotizing glomerulonephritis with few immunoglbulin deposits on immunofluorescence.

Treat with high dose corticosteroids and cytotoxic agents. Patients tend to have frequent relapses.

Question 9

Goodpasture’s syndrome (nephritic)

Answer 9

Rapidly progressing glomerulonephritis with pulmonary hemorrhage; peak incidence is in males in their mid-20s

Hemoptysis, dyspnea, possible respiratory failure. No upper respiratory tract involvement.

Anti-GBM. Linear anti GBM deposits on imunofluorescnce, iron deficiency anemia, hemosiderin filled macrophages in sputum, pulmonary infiltrates on CXR.

Treat with plasma exchange therapy, pulsed steroids. May progress to ESRD.

Question 10

Alport’s syndrome (nephritic)

Answer 10

Hereditary glomerulonephritis; presents in boys 5-20 years of age

Asymptomatic hematuria associated with sensorineural deafness and eye disorders

Anti GBM also. GBM splitting on EM.

Progresses to renal failure. Anti-GBM nephritis may recur after transplant.

Question 11

Minimal change disease (nephrotic)

Answer 11

The most common cause of nephrotic syndrome in children. Idiopathic. Secondary causes include NSAIDs and heme malignancies

Presents with infections and thrombotic events. Sudden onset of edema.

LM appears normal, EM shows fusion of epithelial foot processes with lipid laden renal cortices

Treat with steroids (good prognosis)

Question 12

Focal segmental glomerulosclerosis (nephrotic)

Answer 12

Idiopathic, IV drug use, HIV, obesity.

The typical patient is a young AA male with uncontrolled hypertension (the disease leads to HTN)

Microscopic hematuria; biopsy shows sclerosis in capillary tufts

Treat with prednisone, cytotoxic therapy, ACEIs/ARBs to reduce proteinuria

Question 13

Membranous nephropathy (nephrotic)

Answer 13

The most common nephropathy in caucasian adults. Secondary causes includes solid tumor malignancies and immune complex disease. Secondary cuases includes solid malignancies and immune complex disease.

Associated with HBV, syphilis, malaria, and gold.

Spike and dome appearance due to granular deposits of IgG and C3 at the basement membrane.

Treat with prednisone and cytotoxic therapy for severe disease

Question 14

Diabetic nephropathy (nephrotic)

Answer 14

Has 2 characterstic forms: diffuse hyalinization and nodular glomerulosclerosis (kimmelstiel wilson lesions)

Patients generally have long-standing, poorly controlled DM with evidence of retinopathy or neuropathy

Thickened GBM; increased mesangial matrix!

Treat with tight control of blood sugar, ACEIs for type 1 DM and ARBs for type 2 DM.

Question 15

Lupus nephritis (both nephritic and nephrotic)

Answer 15

Classified as WHO types I-VI. Both nephrotic and nephritic.

Proteinuria or RBCs on UA in the context of SLE

Mesangial proliferation, subendothelial and/or subepithelial immune complex deposition

Treat with prednisone and cytotoxic therapy

Question 16

Renal amyloidosis (nephrotic)

Answer 16

Primary (plasma cell dyscrasia) and secondary (infectious or inflammatory)

Patients may have multiple myeloma or a chronic inflammatory disease

Nodular glomerulosclerosis, EM reveals amyloid fibrils, apple green birefringenence with congo red stain

Treat with prednisone and melphalan. Bone marrow transplanation may be used for multiple myeloma.

Question 17

Membranoproliferative nephropathy (nephrotic)

Answer 17

Can also be nephritic. Type I is associted with HCV, cryoglobulinemia, SLE, and subacutebacterial endocarditis

Idiopathic form is present at 8-30 years of age. Slow progression to renal failure.

Tram track, double layered basement membrane. Type I has subendothelial dposits and mesangial deposits; all 3 types have low serum C3.

Treat with corticosteroids and cytotoxic agents may help.