Renal - Pathology Flashcards
1
Q
_____ (Red blood cells/White blood cells) are seen in the urine of patients with bladder cancer; also significant is the _____ (presence/absence) of casts.
A
Red blood cells; absence
2
Q
Name three diseases in which red blood cell casts are seen on urinalysis.
A
Glomerulonephritis, renal ischemia, or malignant hypertension
3
Q
Name three diseases in which white blood cell casts are seen on urinalysis.
A
Tubulointerstitial disease, acute pyelonephritis, or transplant rejection
4
Q
What types of casts would be seen in the urine of a patient with advanced renal disease or chronic renal failure?
A
Waxy casts
5
Q
In patients with acute cystitis, _____ (red blood cells/white blood cells) are found in the urine, as are the _____ (presence/absence) of casts.
A
White blood cells; absence
6
Q
The presence of casts in the urine indicates disease of which organ?
A
The kidneys
as opposed to the bladder or lower urinary tract
7
Q
What types of casts would be seen in the urine of a patient with acute tubular necrosis?
A
Granular (“muddy brown”) casts
8
Q
Name five primary glomerular causes of nephrotic syndrome.
A
Minimal change disease, membranous glomerulonephritis, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, mesangial proliferative glomerulonephritis
9
Q
Name three secondary causes of nephrotic syndrome.
A
Diabetic nephropathy, amyloidosis, and systemic lupus erythematosus
10
Q
Name seven causes of nephritic syndrome.
A
Immunoglobulin A nephropathy (Berger’s disease), poststreptococcal glomerulonephritis, systemic lupus erythematosus, thrombotic thrombocytopenic purpura - hemolytic uremic syndrome, Alport’s syndrome, membranoproliferative glomerulonephritis, and Henoch-Schönlein purpura
11
Q
Name three categories of etiologies for rapidly progressive glomerulonephritis.
A
Antiglomerular basement membrane antibodies, immune-complex mediated glomerulonephritis, and pauci-immune glomerulonephritis
12
Q
Which four diseases can cause immune-complex mediated rapidly progressive glomerulonephritis?
A
Henoch-Schönlein purpura, hypersensitivity vasculitis, cryoglobulinemia, and systemic lupus erythematosus
13
Q
Which four diseases can cause pauci-immune rapidly progressive glomerulonephritis?
A
Wegener’s granulomatosis, microscopic polyarteritis, Churg-Strauss syndrome, and polyarteritis nodosa
14
Q
What is the pattern of immunofluorescence in acute poststreptococcal glomerulonephritis?
A
Granular
15
Q
Which cause of nephritic syndrome is characterized by mesangial deposits of immunoglobulin A seen on immunofluorescence and electron microscopy?
A
Immunoglobulin A nephropathy (Berger’s disease)
16
Q
What cause of nephritic syndrome is characterized pathologically by a linear staining pattern with anti-glomerular basement membrane antibodies on immunofluorescence?
A
Goodpasture’s syndrome
17
Q
What type of hypersensitivity reaction is Goodpasture’s syndrome?
A
Type II hypersensitivity
18
Q
Which cause of nephritic syndrome is characterized pathologically by crescent-moon-shaped deposits in the urinary space seen by light microscopy and immunofluorescence?
A
Rapidly progressive (crescentic) glomerulonephritis
19
Q
What are the major symptoms of Goodpasture’s syndrome?
A
Hemoptysis and hematuria
20
Q
A genetic mutation in which protein results in Alport’s syndrome?
A
Collagen IV mutation
21
Q
What glomerular pathology is associated with mild renal disease that often follows an upper respiratory infection or gastroenteritis in adults?
A
Immunoglobulin A glomerulopathy (Berger’s disease)
22
Q
What cause of nephritic syndrome is characterized on histopathology by a basement membrane that appears to be split?
A
Alport’s syndrome
23
Q
A 10-year-old boy presents with swollen ankles and periorbital edema, which were beginning to resolve without intervention. On electron microscopy, a kidney biopsy is found to have subepithelial immune complex humps. What form of nephritic syndrome does he have?
A
Acute poststreptococcal glomerulonephritis
24
Q
Wegener’s granulomatosis is _____ (c-ANCA/p-ANCA) positive, while microscopic polyarteritis is _______ (c-ANCA/p-ANCA) positive.
A
c-ANCA; p-ANCA
25
Name three disease processes that result in rapidly progressive glomerulonephritis.
Goodpasture's syndrome, Wegener's granulomatosis, and microscopic polyarteritis
26
Which two ANCA-positive vasculitides can result in rapidly progressive glomerulonephritis?
Wegener's granulomatosis and microscopic polyarteritis
27
Which condition is associated with nerve disorders, ocular disorders, and deafness?
Alport's syndrome; symptoms are due to a mutation in type IV collagen
28
What do the crescent deposits in "crescentic" glomerulonephritis consist of?
Fibrin and plasma proteins with glomerular parietal cells, monocytes, and macrophages
29
Which cause of nephritic syndrome is characterized pathologically by enlarged hypercellular glomeruli, the presence of neutrophils, and a "lumpy-bumpy" appearance on light microscopy?
Acute poststreptococcal glomerulonephritis
30
What is the underlying mechanism resulting in diffuse proliferative glomerulonephritis due to systemic lupus erythematosus?
Subendothelial anti-DNA immune complex deposition
31
What are the findings on light microscopy and immunofluorescence in diffuse proliferative glomerulonephritis?
"Wire-looping" of capillaries on light microscopy and granular immunofluorescence due to subendothelial immune complex deposition
32
Diffuse proliferative glomerulonephritis is the most common cause of death in which systemic disease?
Systemic lupus erythematosus
33
What six features are the hallmarks of nephritic syndrome?
Hematuria, hypertension, oliguria, azotemia, with proteinuria and red blood cell casts in the urine
34
What is the most common cause of nephrotic syndrome in adults?
Membranous glomerulonephritis
35
What four features are the hallmarks of nephrotic syndrome?
Massive proteinuria, edema, fatty casts, and hyperlipidemia
36
In diabetic glomerulonephropathy, what causes the increased permeability and thickening of the glomerular basement membrane?
Nonenzymatic glycosylation of the glomerular basement membrane
37
Which types of nephrotic syndrome are characterized pathologically by a granular pattern seen on immunofluorescence?
Membranous and membranoproliferative glomerulonephritis
38
What are the characteristic findings in membranous glomerulonephritis on electron microscopy?
A "spike and dome" appearance with subepithelial deposits
39
When lupus presents as nephrotic syndrome, what renal pathology is likely to be found?
Membranous glomerulonephritis; diffuse capillary thickening with granular immunofluorescence
40
What are the characteristic findings of focal segmental glomerular sclerosis on light microscopy?
Sclerosis and hyalinosis of renal glomeruli
41
What cause of nephrotic syndrome is characterized pathologically by Kimmelstiel-Wilson lesions, mesangial expansion, and basement membrane thickening of renal glomeruli on light microscopy?
Diabetic glomerulonephropathy
42
In a patient with nephrotic syndrome due to amyloidosis, what are the characteristic findings on immunofluorescence?
Apple-green birefringence on a Congo red stain
43
Name three conditions that can predispose patients to nephrotic syndrome due to amyloidosis.
Multiple myeloma, tuberculosis, and rheumatoid arthritis; many chronic conditions are risk factors
44
Which type of renal pathology may present clinically as either nephritic or nephrotic syndrome?
Membranoproliferative glomerulonephritis
45
Membranoproliferative glomerulonephritis is associated with _____ (hepatitis B virus/HIV), while focal segmental glomerulosclerosis is associated with _____ (hepatitis C virus/HIV).
Hepatitis B virus; HIV
46
An 8-year-old girl who recently had viral gastroenteritis presents with edema and frothy urine. A renal biopsy shows foot process effacement on electron microscopy. What is her diagnosis and how would you treat her?
Minimal change disease, which should be treated with corticosteroids
47
Which type of nephrotic syndrome is characterized pathologically by diffuse capillary and basement membrane thickening seen on light microscopy?
Membranous glomerulonephritis
48
Name four etiologies of membranous glomerulonephritis.
Drugs, infections, systemic lupus erythematosus, and solid tumors
49
What is the pathogenesis of minimal change disease?
The effacement of epithelial foot processes on the glomeruli leads to the selective loss of albumin from plasma (not globulins) due to glomerular basement membrane polyanion loss and failure of the charge barrier
50
What is the most common glomerular disease seen in patients with HIV?
Focal segmental glomerular sclerosis
51
What are the electron microscopy findings in type I and type II membranoproliferative glomerulonephritis?
Type I findings consist of a "tram-track" appearance due to glomerular basement splitting caused by mesangial ingrowth; type II findings consist of "dense deposits"
52
Type I membranoproliferative glomerulonephritis is associated with hepatitis _____ and type II membranoproliferative glomerulonephritis is associated with _____ nephritic factor.
B; C3
53
In diabetic glomerulonephropathy, what causes mesangial expansion?
Nonenzymatic glycosylation of the efferent arterioles, leading to an increased glomerular filtration rate and thus mesangial expansion
54
What type of glomerular disease is characterized on histopathology by large, irregular subepithelial deposits or "humps"?
Acute glomerulonephritis
55
What type of glomerular disease is characterized on histopathology by subendothelial deposits?
Lupus glomerulonephritis
56
What type of glomerular disease is characterized on histopathology by mesangial deposits?
Immunoglobulin A nephropathy
57
Of what element are kidney stones most commonly composed?
Calcium in the form of calcium oxalate, calcium phosphate, or both
58
Name two severe complications that result from the presence of kidney stones.
Hydronephrosis and pyelonephritis
59
What is the second most common type of kidney stone composed of?
Ammonium magnesium phosphate (struvite)
60
What types of conditions lead to increased risk for development of calcium kidney stones?
Conditions that cause hypercalcemia, such as cancer, increased parathyroid hormone, increased vitamin D, and milk-alkali syndrome
61
What types of kidney stones appear radiopaque on x-rays?
Struvite (which can be radiopaque or radiolucent), calcium, and cystine stones (which appear faintly radiopaque)
62
Infection by what class of microbe causes the development of kidney stones composed of ammonium magnesium phosphate (struvite)?
Urease-positive bugs (*Proteus vulgaris, Staphylococcus, Klebsiella*) make urine alkaline and favor formation of struvite stones
63
What types of kidney stones appear radiolucent on x-rays?
Struvite (which can be either radiolucent or radiopaque) and uric acid
64
What type of kidney stone is strongly associated with hyperuricemia (gout)?
Uric acid kidney stones
65
Both antifreeze and vitamin C abuse can result in the formation of what type of crystals?
Oxalate crystals
66
What type of kidney stone develops most often as a consequence of the genetic disease cystinuria?
Cystine kidney stone
67
Are cystine stones treated with alkalinization or acidification of the urine?
Alkalinization of urine
68
What is the term for a very large kidney stone? Which type of stone is most likely to present this way?
A hexagonal stone, which is most likely a cystine kidney stone
69
An 80-year-old man with leukemia presents with hematuria and right-sided flank pain. With his medical history, what type of kidney stone is he at greatest for developing and how would you expect it to appear on x-ray?
Due to his leukemia (a disease with high cell turnover) he is at risk for developing uric acid stones due to hyperuricemia, which are radiolucent and do not appear on x-ray
70
What lifestyle factors are associated with an increased incidence of renal cell carcinoma?
Smoking and obesity
71
What is the most common renal malignancy in adulthood?
Renal cell carcinoma
72
Deletions on which chromosome are associated with renal cell carcinoma?
Gene deletion on chromosome 3
73
Renal cell carcinoma is most common in which demographic?
Men ages 50-70
74
What genetic disease is associated with bilateral renal cell carcinoma?
von Hippel-Lindau disease
75
What is the cellular origin of renal cell carcinoma?
Polygonal clear cells of the renal tubule
76
Name four paraneoplastic syndromes associated with renal cell carcinoma.
* Ectopic Erythropoietin
* Ectopic ACTH
* Ectopic PTHrP
* Stauffer Syndrome
77
Name six clinical manifestations of renal cell carcinoma.
Hematuria, palpable mass, secondary polycythemia, flank pain, fever, and weight loss
78
Via what route does renal cell carcinoma metastasize? To which organs?
Renal cell carcinoma spreads hematogenously via invasion of the inferior vena cava; it most commonly metastasizes to lung and bone
79
What is the most common renal malignancy of early childhood (ie, 2-4 years old)?
Wilms' tumor
80
Wilms' tumor is a component of the WAGR disease complex. What are the other components?
**WAGR** complex: **W**ilms' tumor, **A**niridia, **G**enitourinary malformation, and mental-motor **R**etardation
81
How does Wilms' tumor most commonly present?
As a large palpable abdominal mass and/or hematuria in young children; it may be associated with genetic hemihypertrophy syndromes
82
What gene deletion is associated with Wilms' tumor?
The deletion of *WT1* on chromosome 11 (tumor suppressor gene)
83
In which four anatomic structures of the urinary tract can transitional cell carcinoma occur?
Renal calyces, renal pelvis, ureters, and bladder
84
What is the most common tumor of the urinary tract system?
Transitional cell carcinoma
85
What is the most common clinical presentation of bladder cancer?
Painless hematuria
86
What exposures are associated with transitional cell carcinoma?
**P**henacetin, **S**moking, **A**niline dyes, and **C**yclophosphamide (remember: "problems in the **P**ee **SAC**")
87
In acute pyelonephritis, the renal cortex is _____ (affected/spared), the glomeruli are _____ (affected/spared), and the vessels are _____ (affected/spared).
Affected; spared; spared
88
What finding on urinalysis would suggest pyelonephritis in a febrile patient with flank tenderness?
White blood cell casts
89
A patient who presents with fever, nausea, vomiting, and costovertebral angle tenderness likely has what condition?
Acute pyelonephritis
90
In chronic pyelonephritis, what substance can fill the tubules of the renal nephrons?
Eosinophilic casts, a histopathologic biopsy finding known as thyroidization of the kidney
91
What gross anatomic changes of the kidneys occur with chronic pyelonephritis?
Coarse, asymmetric corticomedullary scarring and blunted calices
92
What are the presenting symptoms of drug-induced interstitial nephritis?
Fever, rash, hematuria, and costovertebral angle tenderness 1-2 weeks after drug exposure
93
How long after the ingestion of a substance does drug-induced interstitial nephritis occur? What lab findings are suggestive of the diagnosis?
After approximately 1-2 weeks a patient may present with pyuria (eosinophils) and azotemia
94
Name five types of drugs that are associated with interstitial nephritis.
Nonsteroidal antiinflammatory drugs, rifampin, diuretics, penicillin derivatives, and sulfonamides
95
What is the pathologic consequence on the kidneys of severe vasospasm and disseminated intravascular coagulation, often secondary to obstetric complications?
Diffuse cortical necrosis
96
Name two disease processes that are associated with diffuse cortical necrosis.
Obstetric catastrophes, such as abruptio placentae, and septic shock
97
Define diffuse cortical necrosis of the kidneys.
Acute generalized infarction of cortices of both kidneys
98
What is the treatment for acute tubular necrosis?
Dialysis until recovery of kidney function occurs
99
What is the most common cause of renal failure in hospitalized patients?
Acute tubular necrosis
100
What are three causes of acute tubular necrosis?
Renal ischemia (shock), crush injury to muscles (myoglobulinuria), and toxins
101
During which phase of acute tubular necrosis do most deaths occur?
During the initial oliguric phase if dialysis is not initiated
102
What is the pathophysiology of acute tubular necrosis?
Loss of renal tubule cell polarity, epithelial cell detachment, necrosis, and granular ("muddy brown") casts; the findings are due to acute toxic or ischemic injury
103
How long does it take to recover from acute tubular necrosis?
2-3 weeks
104
What is the clinical presentation of renal papillary necrosis?
Gross hematuria and proteinuria as the result of sloughing of the renal papillae
105
What are three general categories of renal dysfunction that can lead to acute renal failure?
Prerenal (eg, hypotension and reduced renal blood flow), intrinsic renal (eg, tubular necrosis), and postrenal (outflow obstruction)
106
What is acute renal failure?
A renal condition characterized by an abrupt decline in renal function with elevated blood urea nitrogen and creatinine levels over several days
107
Is urine osmolality highest in patients with prerenal, intrarenal, or postrenal causes of acute renal failure?
Prerenal
108
Reduced glomerular filtration rate as a result of hypotension and reduced renal blood flow results in the retention of what three substances by the kidney?
Sodium, water, and urea are retained in an attempt to maintain blood volume
109
Why does the blood urea nitrogen to creatinine ratio increase in patients who have low renal blood flow?
When renal blood flow and glomerular filtration rate are reduced, urea is retained to attempt to preserve blood volume; the resulting increase in blood urea nitrogen is also known as prerenal azotemia
110
Name two main causes of acute intrinsic renal failure.
Acute tubular necrosis and toxic injury
111
What finding is seen on urinalysis of patients with acute renal failure as a result of intrinsic renal disease?
Epithelial/granular casts
112
Name four possible causes of postrenal outflow obstruction that can lead to acute renal failure.
Kidney stones, benign prostatic hyperplasia, congenital anomalies, and neoplasia
113
True or False? Unilateral postrenal outflow obstruction can lead to acute renal failure.
FALSE
## Footnote
bilateral, not unilateral, postrenal outflow obstruction leads to acute renal failure
114
Is the urine sodium level highest in patients with prerenal, renal, or postrenal causes of acute renal failure?
Postrenal
115
Is the fractional excretion of sodium lowest in patients with prerenal, renal, or postrenal causes of acute renal failure?
Prerenal
## Footnote
a low fractional excretion of sodium shows the kidneys are functional and working to maintain blood volume
116
Is the blood urea nitrogen/creatinine ratio lowest in patients with prerenal, renal, or postrenal causes of acute renal failure (acute kidney injury)?
Renal
## Footnote
the injured kidneys are unable to absorb urea to maintain blood volume
117
A patient's urine osmolarity is \>500 mOsm/L, urine sodium level is \<10 mEq/L, fractional excretion of sodium is \<1%, and the blood urea nitrogen/creatinine ratio is \>20:1. Does the patient most likely have a prerenal, renal, or postrenal etiology of his acute renal failure?
Prerenal
118
A patient's urine osmolarity is \<350 mOsm/L, urine sodium level is \>20 mEq/L, fractional excretion of sodium is \>2%, and the blood urea nitrogen/creatinine ratio is \<15:1. Does the patient most likely have a prerenal, renal, or postrenal etiology of his acute renal failure?
Renal
119
A patient's urine osmolarity is \<350 mOsm/L, urine sodium level is \>40 mEq/L, fractional excretion of sodium is \>4%, and the blood urea nitrogen/creatinine ratio is \>15:1. Does the patient most likely have a prerenal, renal, or postrenal etiology of his acute renal failure?
Postrenal
120
In renal failure, is the potassium level abnormally high or low?
High
121
What are the two main forms of renal failure?
Acute (acute tubular necrosis or rapidly progressive glomerulonephritis) and chronic (diabetes and hypertension)
122
By what mechanism does renal failure lead to anemia?
Impaired erythropoietin production
123
Renal osteodystrophy as a part of the clinical abnormalities in patients with uremia is a result of the failure of what kidney function?
Production of active vitamin D, resulting in hypocalcemia and leading to a secondary increase in parathyroid hormone, resulting bone loss
124
In renal failure, is the total body sodium level (as opposed to serum concentration) abnormally high or low?
High
125
What acid-base disorder is a consequence of renal failure?
Metabolic acidosis
126
What electrolyte abnormality resulting from renal failure can lead to cardiac arrhythmia?
Hyperkalemia
127
Name three cardiovascular consequences of excess sodium and water retention in patients with renal failure.
Congestive heart failure, hypertension, and pulmonary edema
128
Name six signs and symptoms of uremia.
Nausea, anorexia, pericarditis, asterixis, encephalopathy, and platelet dysfunction
129
What metabolic diseases can cause Fanconi's syndrome?
Wilson's disease and glycogen storage diseases
130
What is Fanconi's syndrome?
A disease caused by defects in the proximal tubule transport of amino acids, glucose, phosphate, uric acid, and electrolytes
131
Which drugs can cause Fanconi's syndrome?
Expired tetracycline, cisplatin
132
What is the complication of the decreased phosphate reabsorption associated with Fanconi's syndrome?
Rickets
133
What is the result of the decreased bicarbonate reabsorption associated with Fanconi's syndrome?
Metabolic acidosis (type 2 renal tubular acidosis)
134
What is the result of the decreased proximal tubular sodium reabsorption of Fanconi's syndrome?
Hypokalemia; if the proximal tubule does not reabsorb sodium, the distal tubule must excrete more potassium to reabsorb sodium
135
Name the autosomal recessive disease that presents with multiple bilateral kidney cysts and renal failure in infancy.
Autosomal recessive polycystic kidney disease (infantile polycystic kidney disease)
136
What is autosomal dominant polycystic kidney disease?
An autosomal-dominant disease characterized by multiple bilateral cysts that destroy the kidney parenchyma during adulthood
137
Name five clinical manifestations of autosomal dominant polycystic kidney disease.
Flank pain, hematuria, hypertension, urinary tract infection, and progressive renal failure in adulthood
138
What mutation causes autosomal dominant polycystic kidney disease (formerly adult polycystic kidney disease)?
An autosomal dominant mutation in the *APKD1* or *APKD2* gene
139
What are the characteristics of renal medullary cystic disease?
Small kidneys on ultrasound, cysts in the medullary area that can sometimes lead to fibrosis and progressive renal insufficiency with urinary concentrating defects, and a very poor prognosis
140
Name three nonrenal pathologies associated with autosomal dominant polycystic kidney disease.
Polycystic liver disease, berry aneurysms, and mitral valve prolapse
141
What is the cause of death associated with autosomal dominant polycystic kidney disease?
Death is most commonly due to complications of chronic kidney disease or hypertension (due to increased renin production)
142
What liver disease is associated with autosomal recessive polycystic kidney disease?
Congenital hepatic fibrosis
143
What are the complications of autosomal recessive polycystic kidney disease in utero and after the neonatal period?
Renal failure in utero from autosomal recessive polycystic kidney disease can lead to the Potter sequence; after the neonatal period, potential complications include hypertension, portal hypertension, and progressive renal insufficiency
144
High serum levels of chloride are usually a result of what primary acid-base disturbance?
Non-anion gap acidosis
145
What are the consequences of low sodium levels?
Disorientation, stupor, and coma
146
What are four causes of low serum levels of chloride?
Metabolic alkalosis, hypokalemia, hypovolemia, and elevated aldosterone
147
U waves on electrocardiogram, flattened T waves, arrhythmias, and paralysis are consequences of a low serum level of what electrolyte?
Potassium
148
What are the symptoms of hypocalcemia?
Tetany and neuromuscular irritability
149
What are the symptoms of hypercalcemia?
Delirium, renal stones, and abdominal pain
150
What are two consequences of low serum levels of magnesium?
Neuromuscular irritability and arrhythmias
151
What are three consequences of high serum levels of magnesium?
Delirium, decreased deep tendon reflexes, and cardiopulmonary arrest
152
What are the consequences of low phosphate levels?
Bone loss and osteomalacia
153
What are the electrocardiogram findings associated with hyperkalemia?
Peaked T waves and widened QRS complexes
154
What are the consequences of high phosphate levels?
Metastatic calcification and renal stones
