Infectious/immunological Renal Disease Flashcards by Jacob Thorn

A 23-year-old woman presents with dysuria, increased urinary frequency, and suprapubic pain for two days. She has no fever or flank pain. Urinalysis shows leukocyte esterase and nitrites. Whatich of the following is the most likely causative organism?

Escherichia coli

Responsible pathogen for ~80% of UTIs

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A 35-year-old man with a history of renal transplant presents with worsening renal function and elevated creatinine. Biopsy shows viral inclusions in renal tubular epithelial cells. Which virus is most likely responsible?

BK virus

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Bladder squamous cell carcinoma

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A 27-year-old sexually active woman presents with dysuria and urinary urgency. Urinalysis is positive for leukocytes but negative for nitrites. The urine culture grows a catalase-positive, coagulase-negative, Gram-positive coccus. What is the most likely pathogen?

*Staphylococcus saprophyticus *

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A 52-year-old kidney transplant recipient presents with rising creatinine and fever. Urine PCR is positive for BK virus. What is the best initial management?

Reduce immunosuppressive therapy

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A 60-year-old man with diabetes and chronic Foley catheter use presents with fever, flank pain, and gross hematuria. Urine culture grows a Gram-negative, oxidase-positive, motile organism. What is the most likely pathogen?

*Pseudomonas aeruginosa *

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Which virulence factor of E. coli is most associated with its ability to cause pyelonephritis?

Adhesins (specifically PapG for UPEC)

Type 1 fimbriae (FimH) mediate attachment to urothelial cells, while P fimbriae (PapG) are important in pyelonephritis.

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B. Enterococcus faecalis
D. Pseudomonas aeruginosa
E. Staphylococcus saprophyticus

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What is the only bacterium of the normal GI flora that does not ferment lactose?

Proteus mirabilis

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B. Fosfomycin

When creatanine clearance falls below 30 mL/min, nitrofurantoin is contraindicated

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C. Direct contact with contaminated surfaces

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E. Biofilm production

Exotoxin A leads to host cell death

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UTI causing organism that is Gram (+), catalase negative, Aesculin positive, and can grow on 6.5% NaCl

Enterococcus faecalis

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What is the most common cause of acute interstitial nephritis?

Allergic reaction to drug

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Mr. Kent is a 32 year old male who is seeing you for dry mouth and dry eyes that has been going on for the past two weeks. He has no chronic medical conditions. His labs today demonstrate acute kidney disease; his labs 6 weeks ago were normal. His family history is significant for autoimmune disease on his mother’s side. You suspect the patient has acute interstitial nephritis. What is the most likely cause?

Sjogren syndrome

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You are seeing a patient who has red, painful eyes and acute kidney injury based on labs. On exam, you notice inflammatory changes in the iris. Which of the following patients is most likely to have this disorder?

A. A healthy 4 year old male

B. A healthy 15 year old female

C. A 34 year old female with a history of recurrent UTI

D. A 55 year old male who works in a battery disposal plant

B. 15 y/o female

Autoimmune uveitis

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Robin is a 3 year old male who presents for follow up of recurrent urinary tract infection. You are concerned he may have vesicoureteral reflux. What would be the most appropriate study to confirm your suspicions?

Voiding cystourethrogram

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Mr. Kinsella is a 50 year old male who recently emigrated Europe and is presenting to your clinic with a history of Balkan nephropathy. This nephropathy is the result of what exposure?

Aristolochic acid

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Mr. Davis is a 21 year old male with a history of chronic tubulointerstitial disease and prior lead exposure. How can you definitively diagnose him with lead toxicity?

Urine lead level after chelation

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Which specialty performs nephrectomy

Urology

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A. Omperazole
C. Chlorthalidone
E. TMS-SMX
F. Ibuprofen

Eosinophilia should make you think allergic acute interstitial nephritis

Acetaminophen use over two years can cause chronic interstitial nephritis

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B. Arthralgia
C. Rash
H. Fever

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C. ibuprofen

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What are examples of infectious etiologies that would potentially cause acute interstitial nephritis?

RMSF
EBV
Salmonella
Histoplamosis
TB

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E. Heavy metal exposure ## Footnote Negative anion gap indicates that it is a type II RTA - heavy metal exposure (generally affects PCT)

A. Papillary necrosis with calcifications in a garland pattern

B. Gout

Where does uric acid secretion occur in the nephron?

PCT

Mr. Lawrence is a 53 year old male with a history of chronic kidney disease, GERD, diabetes, hypertension, and coronary artery disease who is following up in your clinic after recent labs, which indicate worsening CKD as his eGFR has dropped from 45 to 25 mL/min. His medications include SGLT-2 inhbitor, H2 blocker, lisinopril, atorvastatin, carvedilol, and insulin. For which medications would you consider a dose decrease?

Insulin and H2 blocker ## Footnote Insulin is cleared by the kidney and can lead to hypoglycemia

An elevated sodium excretion fraction (above 2%) is consistent with what type of AKI?

Acute interstitial nephritis

What creatanine changes indicates an AKI?

A change in 0.3 mg/dL over 48 hrs. or increase in 50% over one week

Mr. Diaz is a 57 year old patient who is following up in your clinic after being diagnosed with end stage renal disease. As you discuss the next steps in care with him, what is he most likely to die from?

Cardiovascular disease

Ms. Robinson is a 30 year old patient who is about to start hemodialysis for end stage renal disease secondary to type 1 diabetes. She asks you about side effects of dialysis. What side effect would she be most likely to have?

Hypotension

Mr. Silver, a patient with a history of renal disease, is admitted to the hospital for nausea, vomiting, and altered mental status. He has asterixis on exam. What complication of kidney failure is likely causing his symptoms?

Uremia

When would you hold ACEi Rx?

Prerenal AKI ## Footnote Also hold metformin (can cause lactic acidosis)

A. Hold HCTZ B. Hold lisinopril C. Hold naproxen D. Hold metformin E Bolus normal saline F. Obtain urine studies

A. Prerenal AKI B. Intrarenal AKI F. Hypovolemia G. Oliguria H Acute tubular necrosis

C. Hyperphosphatemia (secondary hyperparathyroidism begins in 3a) D. Anemia E. Hyperkalemia F. Metabolic acidosis ## Footnote Hypertension begins in stage II

Patients with the nephrotic syndrome have increased _________ (serum levels) due to ________

Patients with the nephrotic syndrome have increased serum lipid levels (**hyperlipidemia**) due to **increased liver lipoprotein synthesis**.

Minimal change disease, the most common cause of ________ in children

Minimal change disease, the most common cause of **nephrotic syndrome **in children

Other than diabetes, what is the most common cause of nephrotic syndrome in adults?

Focal segmental glomerulosclerosis ## Footnote Focal segmental glomerulosclerosis, which is more common in African Americans and Hispanics, is the most common cause of the nephrotic syndrome in adults (other than diabetes). FSGS is characterized by sclerosis and hyalinosis of portions of some, but not all, glomeruli (segmental sclerosis of the glomeruli). EM demonstrates diffuse foot process effacement.

Microscopic examination of a renal biopsy examined by light microscopy from an adult who presented with signs of the nephrotic syndrome revealed thickening of the glomerular basement membrane. Electron microscopy shows uniform, dense subepithelial deposits. This disorder is most closely associated with increased serum levels of what?

Anti-neutrophil cytoplasmic antibodies ## Footnote A thickened glomerular basement membrane on light microscopy is consistent with membranous nephropathy. MGN is characterized by uniform, subepithelial, electron-dense immune deposits. Anti-phospholipase A2 receptor antibodies can be seen with membranous nephropathy.

Electron microscopic examination of a renal biopsy from a patient diagnosed with IgA nephropathy would most characteristically reveal what type of electron dense deposits?

Mesangial deposits ## Footnote IgA nephropathy (Berger disease), which frequently presents as recurrent, self-limited, painless hematuria that occur with an upper respiratory tract infection, is characterized by mesangial IgA deposits.

Rapidly progressive glomerulonephritis is characterized histologically by which one of the following? A. Fibrin crescents in Bowman space B. Fibrinoid necrosis of the afferent arterioles C. Fibromuscular hyperplasia of the renal artery

A. Fibrin crescents in Bowman space ## Footnote Rapidly progressive glomerulonephritis (crescentic GN) is characterized by finding crescents in the glomeruli, which are indicative of severe damage to the glomerular basement membrane. Crescents consist of glomerular parietal cells, lymphocytes, and macrophages along with abundant fibrin deposition.

A 43-year-old man presents with progressive renal failure and hematuria. No antineutrophil cytoplasmic antibodies (ANCA) are present. A renal biopsy reveals crescents within Bowman space of many glomeruli. A section from his kidney stained with fluorescein-conjugated antihuman IgG reveals linear IgG and C3 deposits in the glomerular basement membrane. Which one of the following is most likely to be present in this individual?

Anti-GBM antibodies ## Footnote Goodpasture disease (anti-GBM disease) can cause rapidly progressive glomerulonephritis with linear IgG and C3 deposits in the glomerular basement membrane (type 1 RPGN). Signs of Goodpasture syndrome include hemoptysis (from pulmonary hemorrhage) and hematuria (from glomerular bleeding).

An 8-year-old boy presents with hearing loss and intermittent red urine. A renal biopsy examined by EM shows thinning and splitting of the basement membrane forming a basket-weak appearance. What is the correct diagnosis?

Alport syndrome ## Footnote Thinning of the glomerular basement membrane forming a basket-weak appearance is seen in Alport syndrome, which is caused by an inherited defect in the formation of type IV collagen; patients have hearing loss, ocular abnormalities, hematuria, and progressive renal insufficiency.

What type of HSR is Goodpasture syndrome?

Type II hypersensitivity reaction

What kidney pathology leads to hypercoaguable states? | Why?

Nephrotic syndrome (loss of AT III)

What gross characteristic of urine is seen with nephrotic syndrome?

Foamy urine (due to proteinuria)

Nephrotic vs. nephritic syndrome | Diagram

Most common cause of nephrotic syndrome in adults?

Diabetes

Child develops generalized swelling and marked proteinuria. Dx?

## Footnote Effacement of foot processes is due to T cell secreted cytokines

Focal segmental glomerulosclerosis

Membranous glomerulonephropathy

Pathophysiology membranous glomerulonephropathy

Think AA amyloid RA and multiple myeloma

Two nephritic syndrome with subepithelial deposits

Rapidly progressive glomerulonephritis

Types of rapidly progressive glomerulonephritis characterized by immunoflourescence

Dx? ## Footnote Immunoflourescence of glomerulus

Goodpastures syndrome (type II HSR)

What are possible causes for each of the three types of rapidly progressive glomerulonephritis?

Type III - granulocytosis with polyangiits - presents with hematuria/hemoptysis (also upper resp stuff) p-ANCA - polyangiitis

Serum protein electrophoresis

Nodular glomerulosclerosis

Which one of the following is the most common cause of nephritic syndrome in adults and is characterized by episodic hematuria, especially following mucosal infections?

IgA nephropathy, which is the most common cause of nephritic syndrome in adults, is characterized by episodic hematuria, especially following mucosal infections.

Loss of which serum protein is responsible for the thrombotic and thromboembolic complications seen with the nephrotic syndrome?

oss of antithrombin III is responsible for the thrombotic and thromboembolic complications seen with the nephrotic syndrome.

A 61-year-old woman presents to the emergency room with a 3-day history of fever and chills. Physical examination finds right costovertebral angle tenderness. Analysis of the urine shows white blood cell and white blood cell casts. Ultrasound examination of the kidneys shows no signs of obstruction. A biopsy of her kidney would most likely show which one of the following? A) Glomerular eosinophilic nodules B) PMN leukocytes in tubules C) Tubular eosinophilic casts

B) PMN luekocytes in tubules ## Footnote The presence of white blood cell casts in the urine can confirm the diagnosis of pyelonephritis in patients with UTI symptoms. WBC casts form only in the renal tubules. Histologic sections of acute pyelonephritis, which presents with acute onset of high fever, chills, and flank pain, will show neutrophils (polymorphonuclear leukocytes) in the renal tubules and interstitium.

Two weeks after starting the drug ampicillin, a 42 year-old woman develops fever, a diffuse erythematous rash, hematuria, and oliguria with a rising serum BUN and creatinine level. No bacteria are seen in her urinary sediment, but numerous eosinophil are present. What is the correct diagnosis?

Acute interstitial nephritis ## Footnote Acute interstitial nephritis is characterized by fever, rash, and peripheral eosinophilia, with white blood cells (pyuria), white blood cell casts, and eosinophils in the urine. Most cases of acute interstitial nephritis are due to medications including nonsteroidal anti-inflammatory drugs, antibiotics, diuretics, and proton pump inhibitors.

Classic signs and symptoms of renal cell carcinoma include?

Hematuria, an abdominal mass, flank pain, and weight loss ## Footnote Sporadic and hereditary renal cell carcinomas are associated with mutations or deletions involving the VHL gene

Persistence of the allantois remnant can result in?

A patent urachus

Terminal hematuria due to bladder wall inflammation and ulcers is characteristic of what infection?

Schistosomiasis

A 35-year-old man with acute myelogenous leukemia and a white blood cell count of 100,000 cells/microL is treated with chemotherapy and develops oliguric renal failure. His urine pH is acidic and numerous rhomboid and needle-shaped crystals are noted in the urine. What is the best diagnosis?

Urate nephropathy ## Footnote Uric acid stones may form in patients with hyper-uricemia, such as patients with gout or patients with increased cell turn-over, such as being treated for leukemias or lymphomas (tumor lysis syndrome). Under microscopy uric acid appears as needle or rhomboid-shaped crystals.