Renal Path Flashcards
1
Q
If you see red cell casts, where is the blood coming from?
A
Glomerulous
2
Q
If you see cellular casts, what has happened?
A
Acute Tubular Necrosis
3
Q
What if you see granular casts?
A
Meh. Less specific.. could be tubular cells, white cells….
4
Q
What’s this?
A
Red Cell Cast
Indicates Nephritic Syndrome
5
Q
What is this?
What does it mean?
A
White cell cast
Indicates Infection in kidney (because formed cast)
6
Q
What’s this?
What does it mean?
A
Lipid cast (with characteristic maltese cross)
Indicates Nephrotic Syndrome
7
Q
What’s this?
What does it mean?
A
Epithelial cell cast
Indicates Acute Tubular Necrosis
8
Q
What might it mean to see broad casts?
A
Probably Chronic Renal Failure
9
Q
Azotemia vs Uremia
A
Azotemia = Increased BUN & Creatinine without disease
Uremia = same, but with disease. can affect any organ
10
Q
What are the different causes of azotemia or acute renal failure?
A
- Pre-renal
- Renal
- Post-renal
11
Q
BUN:Creatinine is >20:1
What is your dx?
A
Pre-renal Failure
12
Q
Causes of Acute Pre-Renal Failure?
A
Sudden hypotension
Decreased perfusion
13
Q
What is Nephritic Syndrome?
A
Renal failure with red cell casts
14
Q
What is Rapidly Progressive Glomerulonephritis?
A
Nephritic Syndrome + Acute Renal Failure
15
Q
What is the most common cause of nephritic syndrome?
A
Post-strep Glomerulonephritis
16
Q
Cuases of Rapidly Progressive Glomerulo-Nephritis?
A
-
Anti-GBM
- Goodpasture)
-
Immune Complex
- Post-infx
- SLE
- H-S purpura/IgA nephropathy)
-
ANCA-Associated (aka *pauci-immune *- don’t see anything on immunofluorescence)
- Wegener’s granulomatosis
- Microscopic angiitis
17
Q
Why do you get edema in nephrotic syndrome?
A
Lose a lot of protein, albumin decreases with it.
18
Q
Why do you get hyperlipidemia in nephrotic syndrome?
A
Liver makes more lipoprotein – trying to compensate for low protein
Will cause lipid cast formation
19
Q
What if you see lots of eosinophils in a cast?
A
Probably drug reaction (Acute Intersitial Nephritis)
20
Q
In what condition do you lose Foot Processes (F)?
A
Anything with Nephrotic Syndrome
21
Q
How is it that you can sometimes get hematuria but not proteinuria?
A
Complex charges (basement mem has GAGs that are negatively charged– keep out proteins)
22
Q
What stain is this?
What does it show?
A
Silver stain– shows membranes
23
Q
What is this? What does it show?
A
Immunofluorescence– shows immune deposits
24
Q
Types of Glomerulonephritis
A
Global: Entire glomerulus
Segmental: Part of glomerulus
Diffuse: >50% of glomeruli are affected
Focal:
25
Where can immune complexes be depositied in Glomerulonephritis?
Subepithelial (large or small)
Subendothelial
Mesangial
26
What disease & why?
**Diabetic Nephropathy**
* thickened GBM
* thickened arterioles
* Arteriosclerosis
27
What would urine show in patients with Diabetic Nephropathy?
*Proteinuria*
28
What are the key morpholic features of **diabetic nephropathy**?
* Thick GBM
* Mesangial sclerosis
29
What pattern of **sclerosis** is pretty specific for Diabetes?
_Nodular Glomerulosclerosis_
30
What are two diseases that can cause this?
Diabetes
HTN
31
What is a complication of diabetes in the kidney?
Infection (pyelonephritis w/ papillary necrosis) due to decreased neutrophil/macrophage function and poor vascular supply
32
Presentation of **Renal Amylodosis**?
Proteinuria, then nephrotic syndrome
33
How can you distinguish amyloidosis from diabetic nephropathy?
Congo Red Stain
34
What's this?
**amyloidosis**
35
What are the two main causes of amyloidosis?
* Monoclonal lymphoproliferative diseases (multiple myeloma) - **AL**
* Chronic inflammatory states - **AA**
36
Class II Lupus
Mesangioproliferative - like IgA
Hematuria, proteinuria
BUT has full house immunofluorescence
37
Lupus Classes III & IV are like what?
**Membranoproliferative** or **Post-Infectious (Acute Proliferative) GN**
38
How to you distinguish Lupus Class V (Membranous Glomerulonephritis) from Idiopathic Membranous?
Full house immunofluorscence with Lupus
39
Where are the deposits in Class II Lupus?
Mainly mesangial
40
Lupus Nephritis class IV
Hypercellular
Diffuse proliferative
Nephrititc, aggressive
Segmental necrosis
41
Lupus Class V histo
Spikes!
No inflamm infiltrate
Advanced sclerosis
Subepithelial intramembranous immune deposits
42
Linear Immune Deposits
**Anti-GBM disease**:
Abs attacking glomerular BM
43
Antigen-Antibody complexes most likely get caught WHERE?
_Subendothelial_ (classically, with **Lupus**)
44
**Nephritic syndrome**-- what will glomerulus look like?
Hypercellular (usually inflammatory)
45
**Rapidly Progressive Glomerulo-Nephritis (RPGN)**
What would you expect to see?
**Crescents**
46
Blood in urine. Otherwise healthy. Do biopsy, see this:
*Mesangial Hypercellularity* -- **IgA Nephropathy**
47
**IgA Nephropathy / Berger Disease**
## Footnote
IF: granular mesangial IgA deposition
LM: Mesangial expansion w/segmental sclerosis
48
IgA nephropathy + vasculitis = ?
**Henoch-Schonlein Purpura**
49
Celiac disease-- what type of immune nephropathy might you see?
IgA
50
Rapidly Progressive GN = ?
Nephritic Syndrome + Acute Renal Failure
51
What is this and what disease?
*Crescents*
**Rapidly Progressive Glomerulonephritis**
*(would also see large disruptions/gaps in BM)*
52
Anti-GBM: key feature in LM & IF?
* Linear IgG*
* Crescents*
53
Post-Infectious GN with crescents: good or bad sign?
Bad
54
RPGN with crescents + vasculitis
Pausi-Immune (negative IF)
**ANCA** present in serum!
55
Where do you see this?
Linear IgG
Anti-GBM disease, diabetes, Goodpasture Synd
56
Can **Pausi-immune associated vasculitis** affect other organs besides kidneys?
Yes-- could be Wegener's or Polyarteritis Nodosa
57
What is the classic cause of **Nephritic Syndrome**?
Post-strep (post-infectious)
58
Nephritic syndrome: main histologic feature
What will IM show?
Hypercellularity of neutrophils
IM: Granular- huge subepithelial deposits
59
Agressive **Post-Strep Glomerulonephritis** would show what histology?
Crescents
60
Nephrotic Syndrome: What will you always see on EM?
"Loss" of foot processes
61
**Nephrotic Syndrome: Minimal Change**
- demographics
- what will you see by LM? IF?
Kids
Normal LM and IF. (Can only see in EM)
62
**Focal Segmental Glomerulosclerosis:**
What will you see by LM? IF?
Prognosis?
Clinical S/S?
LM: **Focal segmental scarring** (can be missed by small bx-- will look like minimal change)
IF: Negative
Prognosis: poorer than *minimal change*
Clinical S/S: **hematuria + hypertension**
63
Nephrotic Syndrome: IF shows peripheral granular IgG-- what are your first thoughts?
Membranous (others don't show IF change)
64
Fatty Casts on urinalysis?
Nephrotic Syndrome
65
How much _proteinuria_ is needed to be diagnostic of **Nephrotic Syndrome**?
**\>3.5 g/day**
66
**Focal Segmental Glomerulosclerosis**, see this:
**_Collapsing glomerulopathy_**
poor prognosis
associated with **HIV**
67
See this:
**Membranous Glomeronephritis (stage 2)**
(BM growing up between deposits)
68
Lots of proteinuria & hematuria.
Disease?
H&E?
* *_Membranoproliferative_**: *hypercellular, lobulated* morphology
- poor prognosis :(
* *Double contours** on BM stain (caused by mesangial cell interposition & immune deposits splitting BM)
- indicative of **type I**
69
**Type II Membranoproliferative Glomerulonephritis:**
histo
serum marker?
Entire glomerular BM is one large dense deposit
**C3 Neprhitic Factor** in blood!! (keep complement activated)
70
Biposy of renal failure: scarred glomeruli = ?
**Chronic glomerulonephritis**
71
What is it?
Caused by?
Pathogenesis?
*Flea bitten kidney + Fibrinoid necrosis*
Caused by **Malignant HTN**
Ischemia of glomeruli -\> RAS activation -\> further HTN -\> further injury
72
Onion skin **Hyperplastic Arteriosclerosis**
Long standing malignant HTN
73
Malignant HTN caused by which kidney?
Little one (renal artery stenosis)
74
What group of diseases show little thrombi all over the glomerulus?
3 main causes?
**Thrombotic Microangiopathies:**
* Hemolytic-Uremic Syndrom (HUS)
* Atypical HUS
* Thrombotic Thrombocytopenia
75
What causes HUS?
Infection of intestinal bacteria (usually E.coli)
toxin (Shiga-like toxin) injure endothelial cells
Present with flu/diarrhea followed by bleeding issues
76
What causes **Atypical HUS?**
Hyperactive immunity- can't turn off complement
77
What causes **Thrombotic Thrombocytopenia?**
Functional deficiency of **ADAMTS13**
causes platelet aggregates (can't sufficiently cleave VWF)
78
Hydronephrosis:
caused by obstruction, reflux
79
Dx? Cause?
Hydronephrosis caused by reflux
80
**Acute tubular necrosis**
Epithlelial cell cast
Can be *ischemic* or *toxic*
Good prognosis if you get eliminate the cause[Next \>\>](https://www.brainscape.com/decks/953406/cards/41300353/next_card)
81
Normal
82
Dx? Presentation?
**_Alport Syndrome_**- multi-layered lamina densa
Present with *hematuria*, *proteinura, hearing loss, vision prob*
83
Thin Basement Membrane Disease
good prognosis (normal fx)
84
**Renal Dysplasia**- very *cystic,* show cartilage
benign, associated with other congential defects
85
**_AD-PDK_**
in adults, common
can get **Berry Aneurysm**
86
**_AR-PKD_**
kids, rare
87
Significance?
Dialysis-Assoc: some incr. risk for renal failure
Simple: meh. no.
88
1. What's this?
What would IF look like?
2. What's this?
What would they have in the blood?
3. What's this?
1. Large sub-epithelial hump
* IF*: granular
2. Dense Deposit Disease (MPGN 2)
* Serum*: C3 Nephritic Factor
3. Subendothelial Deposit (Lupus)
89
What's this?
Presentation?
IgA nephropathy
Mesangial prolif- mesangial IgA
Present with hematuria
90
Crescents - BAD prognosis
91
Prognosis? Other organs affected?
**_Anti-GBM disease_**
LM: Crescentic glomerulonephritis
IF: linear
Bad prog
Can affect Lung
92
Dx? What's in serum?
Crescentic Glomerulonephritis with Vasculitis
(Pauci-Immune)
ANCA in blood!
93
Hypercellular neutrophils. Post-infectious
More in kids
good prognosis
Granular IgG & C3 deposits
94
Large cellular glomeruli with neutrophils. Humps seen on right.
Post-infectious
95
**_Minimal change disease_**
Normal LM
IF negative
Loss of foot processes
96
Focal Segmental Glomerulosclerosis
97
1: small subepithelial deposits
98
2: BM starting to grow up between deposits (spikes)
99
spikes = **_Stage 2 Membranous_**
100
Stage 3:
IF: "STRING OF PEARLS"-- peripheral granular
101
Stage? Presentation of membranous?
4: thick membrane, few deposits
Present with Nephrotic Synd (proteinuria)
Can be seen w/ Lupus class V
102
**Membranous GN**
103
Stage 3- peripheral granular
104
Membranoproliferative Stage 1
105
Mesangial expansion into BM--
**Membranoproliferative GN type 1**
106
**Type 2 Membranoproliferative**
large dense glomerulus
107
C3 Nephritic Factor
108
* Minimal Change:
* Membranous:
* Lupus
* IgA: where are the deposits?
* T
* Type 2 MPGN?
* Post-Infectious
* Lupus deposits at?
* Amyloid deposited at?
* Amyloid appearance?
* 2 types of amyloid?
* Diseases with amyloid?
* Diabetes EM?
* Thin Basement Membrane Dis
EM:
* _Minimal Change_: Foot Process obliteration
* _Membranous_: Subepithelial deposits, spikes by LM
* _Lupus_: Mesangial deposits
* _IgA_: Mesangial deposits
* _Type 1 MPGN_: mesangium, subendothelial
* _Type 2 MPGN_: one large density
* _Post-Infectious_: huge subepithelial humps
* _Amyloid_: BM, mesangial deposits; skinny fibrils
* *2 types:* light chain (AL), chronic inflamm (AA)
* *Diseases assoc:* Myeloma, Lymphoma, autoimmune
* _Diabetes_: Very thick GBM, no deposits
* _Thin Basement Membrane Dz_: Thin BM
109
**_Diabetic Nephropathy:_**
very thick GBM, arteriosclerosis
110
Thick GBM
111
Mesangial sclerosis + thick GBM
112
*Nodular Glomerulosclerosis* seen in **Diabetes**
113
**Arteriosclerosis:**
Benign HTN, diabetes
114
**_Papillary Necrosis_**
caused by:
1. Pyelonephritis + Diabetes
2. Pyelonephritis + Obstruction
3. Analgesic Nephropathy
115
Amyloidosis or Diabetes
116
Amyloid
117
Class? Presentation? Differential?
Class 2: mesangial proliferation only
Present with hematuria
Looks like IgA nephropathy but full house IF
118
Type? Presentation? Differential?
Type 3: focal proliferative
Present with Nephritic Syndrome
Like Membranoproliferative but full house IF
119
Almost all glomeruli look like this.
Class?
Lupus Nephritis Class 4
120
_class 4_
121
Class?
Presentation?
Differential?
_Class V_: membranous
Present as Nephrotic
Looks like Idiopathic Membranous GN Full house IF
122
**Benign HTN**
arteriosclerosis-- granular appearance
Also can be caused by **diabetes**
123
**Malignant HTN**
Arteriolar Necrosis, petichial hemorrhage, onion skin arterioles
124
Little one (hypoperfused, increases renin)
125
Dx? Causes?
Thrombotic Microangiopathy
## Footnote
Caused by:
TTP: no ADAMTS13 (cleaves vWF)
HUS (food poisoing- toxin damages endoth cells)
Atypical HUS (Factor H)
126
Pyelonephritis
usually from cystitis (ascending)
Fecal flora
can also be from hematogenous spread
127
**_Papillary Necrosis_**
- Analgesic Nephropathy + Diabetes
- Pyelonephritis + Diabetes
- Pyelonephritis + Obstruction
128
**_Chronic Pyelonephritis_**
blunted calices
2 main causes: obstruction, reflux
Obstruction - diffuse
Reflux- @ poles
129
**_Xanthogranulomatous Pyelonephritis_**
can look like renal cell carinoma
usually from *Proteus*
130
Dx? Cause? Urinalysis?
Drug-Induced Interstitial Nephritis
NSAIDs, diuretics, abx...
Eosinophil cast
131
Meyloma Light Chain casts
132
**_Clear Cell Renal Cell Ca_**
assoc w/VHL mutation
133
Sarcomatoid Renal Cell CA
bad prognosis
134
Renal Vein invasion
135
Oncocytoma
Scar
Granular eosinophilic cells
Mitochondria
Benign
136
**_Chromophobe Renal Cell Carcinoma_**
Distinct membranes, large perinuclear halos, vesicles
Colloidal Fe +
137
Dx? associated with?
**_Angiomyelolipoma_**
associated with **Tuberous Sclerosis**
usually benign
138
Medullary Fibroma
common, benign
139
Baby with this tumor
Wilms.
Solid (not renal dysplasia), necrosis
140
_Blastema_: small round cells
_Epithelium_: tubule formation
_Stroma_: loose spindle cells
141
**_Wilm's tumor_**
primitive glomerular structures (lef)
Blastema
142
Blastmea
Epithelium
143
**ANAPLASIA**- bad prognosis
144
Urothelial Carcinoma (transitional cell ca)
145
**Papilloma**
benign
146
Inverted papilloma
benign
147
**Low Grade Papillary Urethelial Carcinoma**
rarely invades or metastasizes
148
**High-grade urothelial carcinoma**
necrosis, ugly nuclei
149
**Urothelial CA in situ**
Flat red patch grossly
Likely to invade
Positive cytology
150
Country association?
**_Squamous Cell Carcinoma_**
schistomiasis
**EGYPT!!!**
151
**Hyperacute Rejection**:
pre-formed antibodies
Thrombosis of vessels -\> necrosis
152
**_Acute Rejection:_**
Tubulitis
(Vasculitis)
153
**_Chronic Rejection_**
Fibrosis
Thick vessels
**Transplant Glomerulopathy:** (lamina rara interna thickening)
154
2 most common causes of this
Diabetes
Hypertension
155
What is the basic mechanism of **Hyaline Arteriosclerosis** in hypertension?
Endothelial cell damage
156
If you don't form ONE kidney - prognosis?
BOTH?
Unilateral kidney agenesis- okay
Bilateral- *stillborn*
157
Small, shrunken kidney. How can you tell if its congenital or acquired?
Prognosis?
Count the papillae... \< 6 = hypoplasia
Unilateral is good prognosis
Bilateral -\> renal failure
158
Common location of ectopic kidney?
Pelvis
159
Horshoe kidney: prognosis?
No
160
Double ureter: problem?
Meh. no.
161
Cystic abdominal mass in newborn?
Renal Dysplasia
fairly common
unilateral: good prog
bilateral: renal failure
162
Key histological feature of **Cystic Renal Dysplasia?**
Cartilage!
163
**_AD-PKD_**:
demographics
Bilateral or unilateral?
Complications?
Location?
Common; in _adults_
Large cysts
\*\*\*Bilateral!!!!! (if unilateral, think *Cystic Neoplasm*)
Associated with **Berry Aneurysms**!
Everywhere
164
**_AR-PDK_**
Demographics?
Complication?
Location?
Rare, in CHILDREN
*Always* Bilateral; small cysts (**Spongiform Kidney**)
Liver involvement (**congenital hepatic firosis**)
@ Collecting Duct ONLY
165
Alport's Syndrome:
* presentation
* genetics
* Key histological feature on EM
* Hematuria (later proteinuria, nephrotic synd)
May also have deafness or eye probs
* **XD** mutation for **Type IV collage**
* Layering of **Lamina Densa** in BM
166
**_Thin Basement Membrane Lesion_**
(Benign Familial Hematuria)
* Genetics?
* Prognosis?
* Familial, *asymptomatic* hematuria
* Mutation in Type IV collagen (a5)
* Normal renal function if heterozygous
167
What causes **hyperacute** rejection?
Pre-formed antibodies
*Somebody fucked up at the lab*
Causes very quick necrosis
168
Most common finding in **Acute** Rejection?
Diagnosis?
Timeframe?
**Tubulitis**- interstitial inflammation, maybe vasculitis
IF: **C4D!**
Can occur at ANY TIME
169
**Chronic rejection:**
Timeframe?
Findings?
Years
See fibrosis, thick vessels, thick GBM (transplant glomerulopathy)
170
**_Transplant Glomerulopathy:_**
Type of rejection?
What structure is affected?
Chronic rejection
**Lamina Rara Interna**
171
Bladder: Malignant cytology, but no mass- just red lesions. What is it?
Is this bad?
**Carcinoma *in situ***
Frequently invades
172
What is the #1 cause of urolithiasis?
**_Dehydration!!!!_**
173
What's the most common composition of stones?
What if the stone is hugeeeee?
Calcium
Huge stone = staghorn = Magnesium ammonium phosphate
174
**Uricemia** is associated with what diseases?
Gout
Cancer (lymphoma, leukemia)
175
What is it? Cause?
**Staghorn** stone: caused by *proteus* infection
176
Most common kidney tumor in adults?
Presentation?
**Renal Cell CA**
Big cystic mass
177
Most common renal cancer in kids?
**Wilm's**
178
Metastatic disease. Where is it likely coming from?
Kidney (**clear cell carcinoma**)
179
What is this? Associated gene mutation?
**Clear Cell Renal Carcinoma**
associated with Von HIppel Lindau
180
Chromophobe Renal Cell Carcinoma:
What are the structures seen in EM?
Cytoplasmic Vesicles
181
Kidney tumor. looks like this:
Prognosis? Invason?
**Sarcomatoid** (spindle cell) **Renal Cell _Carcinoma_**
Poor prognosis
Invade bone, lungs, **veins**
182
Renal Cell Carcinomas: paraneoplastic syndromes?
HTN
Hypercalcemia
Polycythemia
Hepatic dysfx
183
Oncocytoma vs. Chomophobe RCCa
**_Oncocytoma_**: scar, *granular* cells, Colloid Fe stain (-), benign, *mitochondria*
**_Chromophobe RCC_**: halos, Coll. Fe (+), malignant, *vescicles*
184
Patient with tuberous sclerosis. Find tumor in kidney. What is it most likely?
**Angiomyolipoma**
185
3 Components of **Wilms Tumors**
1. **Blastema** (small cells)
2. **Epithelium** (forming tubules)
3. **Stroma** (loose spindle cells)
186
What is a marker of poor prognosis in Wilms Tumor?
**_Anaplasia_**
- large pleimorphic hypechromatic nuclei (3x normal size)
187
How can you tell that this is Wilms Tumor instead of Renal Dysplasia?
Wilms tumor is *solid*
| (Renal dysplasia is cystic)
188
#1 symptom?
Urinalysis?
**Urothelial tumor** (aka Transitional Cell Ca)
Hematuria with FRESH RBCs (*not* casts)
189
#1 risk factor of Urithelial tumor?
SMOKING
Male, elderly
190
Chronic bladder irritation causes what kind of tumor?
Squamous cell carcinoma
191
papilloma
192
Inverted urothelial papilloma
193
**_High Grade Urothelial Carcinoma_**
papillary & solid architecture
*- necrosis* (yellow)
frequently invade
194
How can you get Invasive Carcinoma from normal urothelial tissue?
Normal --\> Carcinoma in situ --\> Invasive Carcinoma
OR
Normal --\> Low grade CA --\> High grade CA --\> Invasive CA
195
