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First Aid > Renal - Pathology (1) > Flashcards

Renal - Pathology (1) Flashcards

1
Q

Casts in urine

  • Presence of casts indicates that…
  • Bladder cancer, kidney stones Ž–>
  • Acute cystitis –>Ž
  • RBC casts seen in…
  • WBC casts seen in…
  • Fatty casts seen in…
  • Granular casts seen in…
  • Waxy casts seen in…
  • Hyaline casts seen in…
A
  • Presence of casts indicates that…
    • Hematuria/pyuria is of renal (vs. bladder) origin.
  • Bladder cancer, kidney stones Ž–>
    • Hematuria, no casts.
  • Acute cystitis –>Ž
    • Pyuria, no casts.
  • RBC casts seen in…
    • Glomerulonephritis, ischemia, or malignant hypertension.
  • WBC casts seen in…
    • Tubulointerstitial inflammation, acute pyelonephritis, transplant rejection.
  • Fatty casts (“oval fat bodies”) seen in…
    • Nephrotic syndrome.
  • Granular (“muddy brown”) casts seen in…
    • Acute tubular necrosis.
  • Waxy casts seen in…
    • Advanced renal disease/chronic renal failure.
  • Hyaline casts seen in…
    • Nonspecific, can be a normal finding, often seen in concentrated urine samples.
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2
Q

Nomenclature of glomerular disorders

  • For each
    • Characteristics
    • Example
  • Focal
  • Diffuse
  • Proliferative
  • Membranous
  • 1° glomerular disease
  • 2° glomerular disease
A
  • Focal
    • Characteristics: < 50% of glomeruli are involved
    • Ex: Focal segmental glomerulosclerosis
  • Diffuse
    • Characteristics: > 50% of glomeruli are involved
    • Ex: Diffuse proliferative glomerulonephritis
  • Proliferative
    • Characteristics: Hypercellular glomeruli
    • Ex: Mesangial proliferative
  • Membranous
    • Characteristics: Thickening of glomerular basement membrane
    • Ex: Membranous nephropathy
  • 1° glomerular disease
    • Characteristics: Involves only glomeruli, thus a 1° disease of the kidney
    • Ex: Minimal change disease
  • 2° glomerular disease
    • Characteristics: Involves glomeruli and other organs, thus a disease of another organ system, or a systemic disease that has impact on the kidney
    • Ex: SLE, diabetic nephropathy
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3
Q

Glomerular diseases

  • Nephritic syndrome
  • Nephrotic syndrome
  • Both
A
  • Nephritic syndrome
    • Acute poststreptococcal glomerulonephritis
    • Rapidly progressive glomerulonephritis
    • Berger disease (IgA glomerulonephropathy)
    • Alport syndrome
    • *Classic nephritic disorders can exhibit nephrotic features
  • Nephrotic syndrome
    • Focal segmental glomerulosclerosis
    • Membranous nephropathy
    • Minimal change disease
    • Amyloidosis
    • Diabetic glomerulonephropathy
  • Both
    • Diffuse proliferative glomerulonephritis
    • Membranoproliferative glomerulonephritis
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4
Q

Nephrotic vs. nephritic syndrome

  • For each
    • Presentation
    • Associations
  • Nephrotic syndrome
  • Nephritic syndrome
A
  • Nephrotic
    • Presentation
      • NephrOtic syndrome presents with massive prOteinuria (> 3.5 g/day, frothy urine), hyperlipidemia, fatty casts, edema.
    • Associations
      • Associated with thromboembolism (hypercoagulable state due to AT III loss in urine) and increased risk of infection (loss of immunoglobulins).
  • Nephritic
    • Presentation
      • NephrItic syndrome = an Inflammatory process.
      • When it involves glomeruli, it leads to hematuria and RBC casts in urine.
    • Associations
      • Associated with azotemia, oliguria, hypertension (due to salt retention), and proteinuria (< 3.5 g/day).
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5
Q

Focal segmental glomerulosclerosis

  • Type of disease
  • LM
  • IF
  • EM
  • Most common cause of…
  • Due to…
  • Treatment
A
  • Type of disease
    • Nephrotic syndrome
  • LM
    • Segmental sclerosis and hyalinosis [A].
  • IF
    • (-)
  • EM
    • Effacement of foot process similar to minimal change disease.
  • Most common cause of…
    • Nephrotic syndrome in African Americans and Hispanics.
  • Due to…
    • Can be idiopathic or associated with HIV infection, sickle cell disease, heroin abuse, massive obesity, interferon treatment, and chronic kidney disease due to congenital absence or surgical removal.
  • Treatment
    • Inconsistent response to steroid therapy and may progress to chronic renal disease.
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6
Q

Membranous nephropathy

  • Type of disease
  • LM
  • IF
  • EM
  • Most common cause of…
  • Due to…
  • Treatment
A
  • Type of disease
    • Nephrotic syndrome
  • LM
    • Diffuse capillary and GBM thickening [B].
  • IF
    • Granular as a result of immune complex deposition.
    • Nephrotic presentation of SLE.
  • EM
    • “Spike and dome” appearance with subepithelial deposits.
  • Most common cause of…
    • 1° nephrotic syndrome in Caucasian adults.
  • Due to…
    • Can be idiopathic or associated with antibody to phospholipase A2 receptor, drugs (e.g., NSAIDs, penicillamine), infections (e.g., HBV, HCV), SLE, or solid tumors.
  • Treatment
    • Poor response to steroid therapy and may progress to chronic renal disease.
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7
Q

Minimal change disease (lipoid nephrosis)

  • Type of disease
  • LM
  • IF
  • EM
  • Most common in…
  • Due to…
  • Associations
  • Treatment
A
  • Type of disease
    • Nephrotic syndrome
  • LM
    • Normal glomeruli (lipid may be seen in PCT cells).
  • IF
    • (-)
  • EM
    • Effacement of foot processes [C].
  • Most common in…
    • Children.
  • Due to…
    • May be triggered by recent infection, immunization, or immune stimulus.
  • Associations
    • May be associated with Hodgkin lymphoma (e.g., cytokine-mediated damage).
  • Treatment
    • Excellent response to corticosteroids.
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8
Q

Amyloidosis

  • Type of disease
  • LM
  • Most commonly involved organ
  • Associations
A
  • Type of disease
    • Nephrotic syndrome
  • LM
    • Congo red stain shows apple-green birefringence under polarized light.
  • Most commonly involved organ
    • Kidney (systemic amyloidosis).
  • Associations
    • Associated with chronic conditions (e.g., multiple myeloma, TB, rheumatoid arthritis).
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9
Q

Membranoproliferative glomerulonephritis

  • Type of disease
  • Type I
    • Deposits
    • Associations
  • Type II
    • Deposits
    • Associations
A
  • Type of disease
    • Nephritic syndrome that can also present with nephrotic syndrome
  • Type I
    • Subendothelial immune complex (IC) deposits with granular IF
      • “Tram-track” appearance due to GBM splitting caused by mesangial ingrowth [D].
    • Associated with HBV, HCV.
      • May also be idiopathic.
  • Type II
    • Intramembranous IC deposits
      • “Dense deposits.”
    • Associated with C3 nephritic factor (stabilizes C3 convertase –>Ž decreased serum C3 levels).
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10
Q

Diabetic glomerulonephropathy

  • Type of disease
  • LM
  • Nonenzymatic glycosylation of…
A
  • Type of disease
    • Nephrotic syndrome
  • LM
    • Mesangial expansion, GBM thickening, eosinophilic nodular glomerulosclerosis (Kimmelstiel-Wilson lesion) [E].
  • Nonenzymatic glycosylation of…
    • GBM ŽŽ–> increased permeability, thickening.
    • Efferent arterioles Ž–> increased GFR Ž–> mesangial expansion.
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11
Q

Acute poststreptococcal glomerulonephritis

  • Type of disease
  • LM
  • IF
  • EM
  • Characteristics
  • Findings
A
  • Type of disease
    • Nephritic syndrome
  • LM
    • Glomeruli enlarged and hypercellular.
  • IF
    • (“Starry sky”) granular appearance (“lumpy-bumpy”) due to IgG, IgM, and C3 deposition along GBM and mesangium.
  • EM
    • Subepithelial immune complex (IC) humps.
  • Characteristics
    • Most frequently seen in children.
    • Occurs ~2 weeks after group A streptococcal infection of the pharynx or skin.
    • Resolves spontaneously.
    • Type III hypersensitivity reaction.
  • Findings
    • Presents with peripheral and periorbital edema, dark urine (cola-colored), and hypertension.
    • Increased anti-DNase B titers and decreased complement levels.
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12
Q

Rapidly progressive glomerulonephritis (RPGN)

  • Type of disease
  • LM and IF
  • Several disease processes may result in this pattern, including:
  • Prognosis
A
  • Type of disease
    • Nephritic syndrome
    • AKA rapidly progressive (crescentic) glomerulonephritis (RPGN)
  • LM and IF
    • Crescent-moon shape [A].
    • Crescents consist of fibrin and plasma proteins (e.g., C3b) with glomerular parietal cells, monocytes, and macrophages.
  • Several disease processes may result in this pattern, including:
    • Goodpasture syndrome
      • Type II hypersensitivity
      • Antibodies to GBM and alveolar basement membrane –>Ž linear IF
      • Hematuria/hemoptysis.
    • ƒƒGranulomatosis with polyangiitis (Wegener)
      • PR3-ANCA/c-ANCA.
    • ƒƒMicroscopic polyangiitis
      • MPO-ANCA/p-ANCA.
  • Prognosis
    • Poor prognosis.
    • Rapidly deteriorating renal function (days to weeks).
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13
Q

Diffuse proliferative glomerulonephritis (DPGN)

  • Type of disease
  • LM
  • IF
  • EM
  • Due to…
  • Most common cause of…
A
  • Type of disease
    • Can present as nephrotic syndrome and nephritic syndrome concurrently.
  • LM
    • “Wire looping” of capillaries.
  • IF
    • Granular.
  • EM
    • Subendothelial and sometimes intramembranous IgG-based ICs often with C3 deposition.
  • Due to…
    • SLE or MPGN.
  • Most common cause of…
    • death in SLE.
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14
Q

IgA nephropathy (Berger disease)

  • Type of disease
  • LM
  • IF
  • EM
  • Presentation
A
  • Type of disease
    • Nephritic syndrome
  • LM
    • Mesangial proliferation.
  • IF
    • IgA-based IC deposits in mesangium.
  • EM
    • Mesangial IC deposits.
  • Presentation
    • Seen with Henoch-Schönlein purpura.
    • Often presents/flares with a URI or acute gastroenteritis.
    • Episodic hematuria with RBC casts.
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15
Q

Alport syndrome

  • Type of disease
  • Due to…
  • Findings
A
  • Type of disease
    • Nephritic syndrome
  • Due to…
    • Mutation in type IV collagen –>Ž thinning and splitting of the glomerular basement membrane.
    • Most commonly X-linked.
  • Findings
    • Glomerulonephritis, deafness, and, less commonly, eye problems.
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16
Q

Kidney stones

  • Findings
  • Treatment
A
  • Findings
    • Can lead to severe complications, such as hydronephrosis and pyelonephritis.
    • Presents with unilateral flank tenderness, colicky pain radiating to groin, and hematuria.
  • Treatment
    • Treat and prevent by encouraging fluid intake.
17
Q

Calcium kidney stones

  • % content of kidney stones
  • Precipitates at…
  • X-ray findings
  • Urine crystal
  • Characteristics
  • Due to…
  • Treatment
  • Most common kidney stone presentation
A
  • % content of kidney stones
    • 80%
  • Precipitates at…
    • Increased pH (calcium phosphate)
    • Decreased pH (calcium oxalate)
  • X-ray findings
    • Radiopaque
  • Urine crystal
    • Envelope [A] or dumbbell shaped
  • Characteristics
    • Calcium oxalate, calcium phosphate, or both.
    • Oxalate crystals can result from ethylene glycol (antifreeze), vitamin C abuse, or Crohn disease.
  • Due to…
    • Promoted by hypercalciuria (idiopathic or 2° to conditions that cause hypercalcemia, such as cancer and  PTH).
  • Treatment
    • Treatments for recurrent stones include thiazides and citrate.
  • Most common kidney stone presentation
    • Calcium oxalate stone in a patient with hypercalciuria and normocalcemia.
18
Q

Ammonium magnesium phosphate (struvite) kidney stones

  • % content of kidney stones
  • Precipitates at…
  • X-ray findings
  • Urine crystal
  • Due to…
  • Treatment
A
  • % content of kidney stones
    • 15%
  • Precipitates at…
    • Increased pH
  • X-ray findings
    • Radiopaque
  • Urine crystal
    • Coffin lid [B]
  • Due to…
    • Caused by infection with urease (+) bugs (Proteus mirabilis, Staphylococcus, Klebsiella) that hydrolyze urea to ammonia –>Ž urine alkalinization.
    • Can form staghorn calculi [C] that can be a nidus for UTIs.
  • Treatment
    • Eradication of underlying infection and surgical removal of stone.
19
Q

Uric acid kidney stones

  • % content of kidney stones
  • Precipitates at…
  • X-ray findings
  • Urine crystal
  • Risk factors
  • Associations
  • Treatment
A
  • % content of kidney stones
    • 5%
  • Precipitates at…
    • Decreased pH
  • X-ray findings
    • RadiolUcent
    • Visible on CT and ultrasound, but not x-ray
  • Urine crystal
    • Rhomboid or rosettes [D]
  • Risk factors
    • Decreased urine volume, arid climates, and acidic pH.
  • Associations
    • Strong association with hyperuricemia (e.g., gout).
    • Often seen in diseases with increased cell turnover, such as leukemia.
  • Treatment
    • Alkalinization of urine.
20
Q

Cystine kidney stones

  • % content of kidney stones
  • Precipitates at…
  • X-ray findings
  • Urine crystal
  • Due to…
  • Findings
  • Treatment
A
  • % content of kidney stones
    • 1%
  • Precipitates at…
    • Decreased pH
  • X-ray findings
    • Radiopaque
  • Urine crystal
    • Hexagonal [E]
  • Due to…
    • Mostly seen in children, 2° to cystinuria.
  • Findings
    • Can form staghorn calculi.
    • Sodium nitroprusside test (+).
  • Treatment
    • Alkalinization of urine and hydration.

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