Renal Path (Holanda) Flashcards
What are the characteristics of the following three main clinical renal syndromes?
acute kidney injury: ________
nephrotic syndrome: _______
nephritic syndrome: ________
acute kidney injury: oliguria (low urine output) and rapid rise in serum creatinine
nephrotic syndrome: severe proteinuria
nephritic syndrome: hematuria
(She stressed this is an important slide to know)
where does acute kidney injury most commonly occur?
in the proximal tubule
what is the defect that is associated with nephrotic syndrome?
glomerular capillary filtration defect (usually in the podocyte side of the urinary space)
what is the injury most commonly associated with nephritic syndrome?
it is usually due to breaks in the glomerular capillary loops, causing red cells to spill out into the urinary space
what two lab values would indicate an acute kidney injury?
serum creatinine and blood urea nitrogen (BUN)
glomerular sclerosis, interstitial fibrosis, and tubular atrophy are all common findings in ____ kidney disease
chronic
which of the following statements regarding immunofluorescence staining in the glomerulus is FALSE?
A. Renal biopsy is routinely stained for IgM, IgA and IgG
B. Mesangial pattern is indicative of IgA nephropathy
C. A granular capillary loop pattern indicates membranous nephropathy
D. immunofluorsecence stains for some complement proteins and the kappa/lambda light chains
E. A linear capillary loop pattern indicates lupus nephritis
E. Linear capillary loop patterning is indicative of Anti-GBM disease. Mesangial and Granular patterns may be indicative of lupus or IgA nephropathy (see below).
mechanisms of this type of kidney disease include immune complex mediated, t-cell mediated, and genetic structural disorders (ie, Alport’s syndrome)
glomerular
syndrome that results from a defect in the collagen type IV gene, which causes structural weakness to the glomerular basement membrane
Alport’s syndrome
All of the following are true of acute tubular necrosis EXCEPT:
A. It is the most common cause of acute kidney injury
B. It is often caused by hypovolemia, ischemia or drug toxicity
C. It is usually irreversible
D. Caused by injury to tubular epithelial cell
E. Characterized by acute onset of kidney injury with development of oliguria
C. On the contrary, acute tubular necrosis is often reversible.
a key feature of this disease is evidenced by eosinophilic granules in the cytoplasm, as shown below:
acute interstitial nephritis; commonly caused by drugs
key findings in this disease are tubular dilation with necrotic debris, and flattening of tubular epithelial cells, as shown below:
acute tubular necrosis
key physical findings in this disease include signs of infection and histological/gross findings show abscesses of neutrophilic infiltrates (see below); symptoms often are abated with antibiotic treatment
Acute pyelonephritis; very similar in appearance to acute interstitial nephritis but the inflammatory infiltrates include many more neutrophils
dilated atrophic tubular cells filed with hyaline casts, surrounded by swaths of fibrotic tissue is characteristic of what chronic disease?
chronic pyelonephritis; cells resemble thyroid
A 55 year old woman was involved in a car accident. She was in hypovolemic shock due to loss of blood.
She has reduced urinary output in the ICU.
Her serum creatinine was 3.5mg/dL( Normal < 1.0mg/dL)
Urine microscopic examination – normal ( no red cells, no proteinuria)
What clinical renal syndrome does she have?
acute tubular necrosis
In a patient with acute tubular necrosis, what changes would a biopsy show?
A. Interstitial inflammation with eosinophils
B. Dilated tubules with necrotic material
C. Hypercellular glomeruli
D. Interstitial inflammation with numerous neutrophils
B
features of this disease include dark colored urine due to erythrocytes, and may be accompanied by acute kidney injury, as indicated by serum creatinine and BUN
(acute) nephritic syndrome
this is the most common type of primary glomerulonephritis worldwide, which particularly affects African American young adults and is characterized by recurrent hematuria
IgA nephropathy; H&E shows mesangial proliferation (>3 cells in each mesangial region, see below)
_____ is a clinical sign that indicates progressive IgA disease, and may call for steroids or other immunosuppressives (varying success rate)
proteinuria
this disease is a vasculitic variant of IgA nephropathy usually seen in children, and features arthritis, abdominal pain and rashes
Henoch Schonlein purpura (HSP)
rare disease that is most often inherited in an x-linked dominant pattern and presents with sensorineural deafness and microscopic hematuria
Alport’s syndrome; microscopy of this would show variability in the thickness of the glomerular basement membranes (see below). Also characteristic is a “basket weave” pattern of the membrane.
what 2 conditions cause acute nephritic syndrome?
crescentic glomerulonephritis and diffuse proliferative glomerulonephritis
This type of glomerulonephritis shown below is illustrated by the compression and breaking of capillary loops (black stained) and the leaking of fibrotic material into the Bowman’s space:
crescentic glomerulonephritis; she stressed that crescentic GN always implies vasculitis.
disease that is the type I subcategory of crescentic glomerulonephritis, characterized by abnormal production of antibodies against collagen type IV in the GBM
Goodpasture’s disease (anti-GBM disease); as with all crescentic GN diseases, you treat this with high dose steroids, toxic agents and plasmapheresis
what are the 2 immune complex diseases of type II crescintic glomerulonephropathy?
IgA nephropathy/HSP and Lupus nephritis
type III crescentic GN disease that is often associated with anti-neutrophil cytoplasmic antibody (ANCA) that affects the small vessels and may lead to pulmonary renal syndrome
pauci-immune crescentic glomerulonephritis; classic example = wegener’s granulomatosis
this type of acute nephritc syndrome is characterized by endocapillary proliferation of inflammatory cells, that occlude the capillaries as shown below:
diffuse proliferative GN; this is caused by either proliferative (active) lupus nephritis or acute post-strep GN
Type of GN that affects children following a respiratory infection, who may present with acute nephritic syndrome, HTN, and low complement (C3) levels -shown below as bright dots in immunofluorescence:
acute post-streptococcal GN; high lab levels of ASO also usually detected
(ASO = antistreptolysin O. Streptolysin O is a toxin produced by multiple strains of streptococci)
Key features of this disease include endocapillary proliferation (with crescents forming) in the glomerulus, a “full house” pattern of immunofluorescence due to complete activation of complement and IGs, and subendothelial deposits (they look like coal in electroscopy)
active lupus nephritis (aka proliferative lupus nephritis)
A patient presents with rapid rise in serum creatinine over 2 weeks.
Urinalysis showed numerous red blood cells.
What syndrome complex does she have?
A) Acute kidney injury
B) Nephrotic syndrome
C) Acute nephritic syndrome
D) Chronic kidney disease
C
A 60 M presents with low grade fever and decreased urination
Has history of back pain for which he took ibuprofen for 6 days prior to current symptoms.
Labs show elevated creatinine and trace RBCs
Microscopy revealed eosinophilc cells. What is the likely diagnosis?
A. Acute tubular necrosis
B. Acute interstitial nephritis
C. Acute pyelonephritis
D. Active lupus nephritis
E. Alport’s syndrome
B. Acute interstitial nephritis is suggested by eosinophilic granular cells and patient’s recent drug use for back pain. These findings go hand in hand with AIN.
All of the following are charcteristics associated with nephrotic syndrome EXCEPT:
A. Generalized edema
B. High grade proteinuria
C. Hyperalbuminemia
D. Hyperlipidemia
E. Diabetic neuropathy
C. This disease is associted with low levels of albumin (hypoalbuminemia)
common in children, this disease shows normal glomeruli, tubules and interstitium, but diffused and effaced foot processes of podocytes on an electron microscopy
minimal change disease
scarring in the glomerulus (below), common in african americans, and often presents with hypertension and proteinuria
focal segmental glomerulosclerosis (FSGS); electron microscopy would also show foot process effacement, similar to minimal change disease
disease associated with thickened capillary loops in the glomerulus - subendothelial immune deposits show up as spikes in electron miscroscopy and granular patterning of IgG in immunofluorescence
membranous nephropathy
All of the following are true statements regarding membranous nephropathy EXCEPT:
A. It is associated with Lupus
B. It may be cause by penacilliamine drug use
C. It is associated with varius malignancies
D. 85% of cases are idiopathic
E. It is associated with hepatitis C
E. Membranous nephropathy is associated with hepatitis B, not C.
The main finding associated with this disease is nodular golmerulosclerosis, as shown below:
diabetic nephropathy
condition caused by hemolytic uremic syndrome and TTP, malignant hypertension and anti-phospholipid syndrome; microscopic findings include “onion skinning” of arterioles (below) and schistocytes that get stuck in the capillaries
thrombotic microangiopathy
Onset of symptoms in this disease tend to appear in the 4th decade of life, and include flank pain and hematuria; about 5% of patients may have a saccular aneurysm in the Circle of Willis
adult polycystic kidney disease (APKD)
what type of lesion is shown here?
crescentic GN
What type of lab would you order to confirm crescentic glomerulonephritis?
A. 24 hour protein urine excretion
B. Anti-glomerular basement membrane antibody
C. Anti-nuclear antibody (ANA)
D. Anti-neutrophil cytoplasmic antibody (ANCA)
E. All of the above
E
A 20 year old presents with generalized edema and 6 grams of protein in the urine in 24 hours. Immunofluorescence shows IgG, C3, kappa and lambda light chains in a granular capillary loop pattern. Light and electron microscopy show spikes of subendothelial deposits. What is the diagnosis?
membranous nephropathy
