Renal pathology Practice Questions

Q: A 62-year-old male presented with left-sided flank mass which was nodular along with left-sided varicocele. Surgical extraction of the kidney is given in the image below. What is the most likely diagnosis?

Renal cell carcinoma. ***Renal cell carcinoma*** - The presence of a **left-sided flank mass** and a **left-sided varicocele** in a 62-year-old male is highly suggestive of renal cell carcinoma [1]. The varicocele is often due to tumor thrombus extending into the **left renal vein**, obstructing venous drainage from the testis [1]. - Renal cell carcinoma is the most common primary renal malignancy and can present with a palpable mass, hematuria, and flank pain [2]. *Papillary necrosis* - This condition is characterized by **ischemic necrosis** of the renal papillae, often associated with analgesic abuse, diabetes mellitus, or sickle cell disease. - It typically presents with hematuria, flank pain, and signs of urinary tract infection, but not usually a palpable flank mass or varicocele. *Hemangioma* - A **hemangioma** is a benign vascular tumor that is typically small and asymptomatic, or may cause hematuria if it ruptures. - It is not associated with a large palpable flank mass or varicocele, which are signs of a more aggressive or space-occupying lesion. *Angiomyolipoma* - An **angiomyolipoma** is a benign tumor composed of blood vessels, smooth muscle, and adipose tissue, often associated with **tuberous sclerosis**. - While it can present as a renal mass, it is typically benign and does not cause a varicocele due to venous obstruction, nor does it usually have the nodular, aggressive appearance implied by the clinical presentation. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 959-961. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 492-493.

Q: A 58-year-old diabetic patient presents with frothiness in the urine. Which of the following is the diagnosis?

Nodular glomerulosclerosis. ***Nodular glomerulosclerosis*** - **Nodular glomerulosclerosis**, specifically **Kimmelstiel-Wilson nodules**, is a characteristic histopathological finding in **diabetic nephropathy** [1]. - Frothy urine in a diabetic patient is a strong indicator of **proteinuria**, a hallmark of diabetic nephropathy, which progresses to nodular glomerulosclerosis [2]. *Focal segmental glomerulosclerosis* - While FSGS can cause proteinuria and frothy urine, it is not the **primary or most characteristic renal lesion** directly associated with long-standing diabetes. - FSGS is often idiopathic or secondary to other conditions like **HIV**, drug use, or obesity, rather than diabetes itself. *Basement membrane thickening* - **Basement membrane thickening** is an early and diffuse change in diabetic nephropathy [2], but it is a **precursor** to more advanced lesions like nodular glomerulosclerosis, not the definitive diagnosis for significant proteinuria. - While present, it doesn't fully explain the degree of proteinuria suggested by "frothiness" as well as nodular changes. *Crescentic glomerulonephritis* - **Crescentic glomerulonephritis** is characterized by rapid decline in renal function and the formation of **crescents** in Bowman's capsule, often due to severe glomerular inflammation. - It is typically associated with conditions like **Goodpasture's syndrome**, **ANCA-associated vasculitis**, or **lupus nephritis**, and is not a primary manifestation of diabetic kidney disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1121-1122. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, p. 1121.

Q: Identify the lesion in HIV positive patient.

Collapsing glomerulopathy. ***Collapsing glomerulopathy*** - This is a severe form of **focal segmental glomerulosclerosis (FSGS)** [3][4], specifically associated with **HIV-associated nephropathy (HIVAN)** [1][2]. - It is characterized by the collapse of the glomerular tuft and prominent visceral epithelial cell hyperplasia [1][2]. *Lipoid nephrosis* - Also known as **minimal change disease**, it is the most common cause of nephrotic syndrome in children. - It is not typically associated with HIV infection; instead, it is often idiopathic or linked to NSAID use or Hodgkin lymphoma. *Starry sky kidney* - This term describes the appearance of **acute post-streptococcal glomerulonephritis (APSGN)** on immunofluorescence, due to granular deposits of C3 and IgG in the mesangium and capillary walls. - It is an immune-complex mediated disease following streptococcal infection, not directly associated with HIV. *Wire loop lesions* - These are characteristic findings in **lupus nephritis**, specifically in diffuse proliferative glomerulonephritis (Class IV lupus nephritis). - They represent subendothelial immune complex deposits, which are not a feature of HIV-associated nephropathy. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 531-532. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 924-925. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 923-924. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 530-531.

Q: Identify the lesion shown in kidney biopsy of 6-year-old child with recurrent U.T.I and vesico-ureteric reflux.

Focal segmental glomerulosclerosis. ***Focal segmental glomerulosclerosis*** - **Focal segmental glomerulosclerosis (FSGS)** can be a secondary complication of conditions causing **glomerular hyperfiltration** and injury, such as long-standing **vesicoureteral reflux (VUR)** and recurrent **urinary tract infections (UTIs)** leading to **reflux nephropathy**. - The chronic inflammation and scarring from recurrent UTIs and VUR can lead to localized areas of **sclerosis** in the glomeruli [1]. *Diffuse glomerulosclerosis* - **Diffuse glomerulosclerosis** implies widespread scarring of most glomeruli, which is less specific for the given clinical scenario. - It is more commonly associated with advanced **diabetic nephropathy** or other widespread chronic kidney diseases. *Kimmelstiel Wilson change* - **Kimmelstiel-Wilson lesions** are specific nodular glomerulosclerosis changes seen in **diabetic nephropathy**. - This finding is highly characteristic of **diabetes mellitus** and would not be expected in a 6-year-old child with recurrent UTIs and VUR. *Wire loop lesions* - **Wire loop lesions** are characteristic of **diffuse proliferative glomerulonephritis**, particularly seen in **lupus nephritis (Class III or IV)**. - These lesions represent **subendothelial immune complex deposits** and are not typically associated with recurrent UTIs and VUR in children. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 913-914.

Q: Which urine crystals are shown in the figure below?

Calcium oxalate. ***Calcium oxalate*** - Calcium oxalate crystals are typically **envelope-shaped** (octahedral) or **dumbbell-shaped**. - They are commonly found in **acidic urine** and are associated with **kidney stones** [1]. *Uric acid* - Uric acid crystals often appear as **rhombic plates**, **rosettes**, or **barrels**. - They are typically **yellow-brown** and are associated with gout or high purine diets [1]. *Calcium phosphate* - Calcium phosphate crystals commonly appear as **amorphous granules** or **prisms/needles** in **alkaline urine** [1]. - They can form calcium phosphate stones, which are less common than oxalate stones. *Cystine* - Cystine crystals are **hexagonal plates** and are colorless. - Their presence indicates **cystinuria**, an inherited metabolic disorder. *Triple phosphate* - Triple phosphate (struvite) crystals have a distinctive **"coffin-lid"** shape (rectangular prisms with oblique ends). - They form in **alkaline urine**, often associated with urease-producing bacterial infections (e.g., *Proteus*, *Klebsiella*), and can form staghorn calculi [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 539-540.

Q: The resected specimen of a kidney is seen below. What is the diagnosis?

Flea bitten kidney of malignant hypertension. ***Flea bitten kidney of malignant hypertension*** - The term "flea-bitten kidney" describes the gross appearance of the kidney in **malignant hypertension**, characterized by numerous pinpoint hemorrhages on the cortical surface [1]. - These hemorrhages result from the rupture of **arterioles and capillaries** due to severe, uncontrolled high blood pressure [1]. *Amyloidosis* - In **amyloidosis**, the kidneys typically appear enlarged, pale, and waxy due to the deposition of **amyloid protein**. - It does not typically present with the characteristic pinpoint hemorrhages seen in a "flea-bitten" appearance. *Acute poststreptococcal glomerulonephritis* - In **acute poststreptococcal glomerulonephritis (APSGN)**, the kidneys are usually enlarged and pale, often with a smooth surface. - While there can be some congestion, the classic "flea-bitten" appearance with widespread petechial hemorrhages is not a typical gross finding. *Chronic glomerulonephritis* - **Chronic glomerulonephritis** typically leads to shrunken, granular, and scarred kidneys due to long-standing inflammation and fibrosis. - The gross appearance is usually one of atrophy and scarring, not the acute hemorrhagic spots described as "flea-bitten." **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 945.

Q: The following is the FITC for IgG stained kidney specimen. What is this suggestive of?

SLE. ***SLE*** - **Lupus nephritis** (a kidney manifestation of SLE) often shows a "full house" immunofluorescence pattern, including **IgG deposition**, along with IgA, IgM, C3, and C1q [1]. - The presence of **IgG staining** in a kidney biopsy is a common finding in various forms of lupus nephritis, such as diffuse proliferative glomerulonephritis [1,5]. *Buerger's disease* - This is a **vasculitis** primarily affecting small and medium-sized arteries and veins, typically in the limbs. - It does **not primarily involve the kidneys** with IgG deposition and is not diagnosed via kidney biopsy immunofluorescence. *Goodpasture syndrome* - Characterized by **linear deposition of IgG** along the glomerular basement membrane (GBM) on immunofluorescence. - While it involves IgG, the question implies a more general IgG staining, and Goodpasture's has a very specific **linear pattern**, which is distinct from the granular or mesangial patterns often seen in SLE [2]. *Membranous glomerulonephritis* - This condition is characterized by **granular subepithelial deposits of IgG and C3** along the glomerular basement membrane [1]. - While it involves IgG, the question's image (if implied) would likely show a more diffuse, granular pattern, and SLE can also present with IgG, but often with other immune complex components, making SLE a broader and often more complex picture [2]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 532-533. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 911. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 230-232.

Q: A 50-year-old male presented with blurring of vision. Urine examination shows proteinuria. Fundus shows dot and hemorrhage with microaneurysm. Kidney biopsy picture given below shows:

Kimmelstiel Wilson nodules. ***Kimmelstiel Wilson nodules*** - The clinical presentation of blurring of vision, proteinuria, and fundus findings of dot and hemorrhage with microaneurysm are classic for **diabetic nephropathy** and **diabetic retinopathy** [1]. - **Kimmelstiel Wilson nodules** are pathognomonic for diabetic nephropathy, representing nodular glomerulosclerosis [1]. *Crescents* - **Crescents** are characteristic of rapidly progressive glomerulonephritis (RPGN), which typically presents with acute renal failure and hematuria, not primarily blurring of vision and proteinuria as the initial presentation. - While RPGN can cause proteinuria, the specific fundus findings and the chronic nature implied by the question point away from an acute crescentic glomerulonephritis. *Amyloid deposition* - **Amyloid deposition** in the kidney can cause proteinuria and renal impairment, but it is typically associated with systemic amyloidosis, which would have other organ involvement (e.g., cardiomegaly, hepatosplenomegaly, neuropathy). - The specific fundus findings of dot and hemorrhage with microaneurysm are not characteristic of amyloidosis but are highly suggestive of diabetic retinopathy. *Focal segmental sclerosis* - **Focal segmental glomerulosclerosis (FSGS)** is a common cause of proteinuria and nephrotic syndrome, but it is not directly linked to the specific fundus findings of diabetic retinopathy. - While FSGS can occur in various conditions, it is not the primary renal lesion expected with the described ocular and systemic features of diabetes. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1121-1122.

Q: Immunofluorescence staining pattern from a kidney biopsy from a 35-year-old patient presenting with proteinuria has been shown below. What is the most probable cause? (AIIMS Nov 2018)

Lupus nephritis. ***Lupus nephritis*** - The image likely shows a **"full house" immunofluorescence pattern** (deposits of IgG, IgA, IgM, C3, and C1q), which is characteristic of **lupus nephritis** [1]. - This pattern indicates immune complex deposition in the glomeruli, a hallmark of systemic lupus erythematosus affecting the kidneys [1]. *FSGS* - **Focal segmental glomerulosclerosis (FSGS)** typically shows **negative immunofluorescence** or only non-specific IgM and C3 in sclerotic areas [3,4]. - It does not present with the diffuse, multi-immunoglobulin deposition seen in the characteristic "full house" pattern. *PSGN* - **Post-streptococcal glomerulonephritis (PSGN)** characteristically shows a **"starry sky" or granular pattern** of C3 and IgG deposition, often with a dominant C3 [2]. - It does not typically show the full spectrum of immunoglobulins and complement components seen in lupus nephritis. *Goodpasture syndrome* - **Goodpasture syndrome** is characterized by a **linear deposition of IgG** along the glomerular basement membrane (GBM) on immunofluorescence [2]. - This pattern is distinct from the granular, multi-immunoglobulin deposition seen in immune complex-mediated diseases like lupus nephritis. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 532-533. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 915. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 530-531. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 531-532.

Question 1

A 62-year-old male presented with left-sided flank mass which was nodular along with left-sided varicocele. Surgical extraction of the kidney is given in the image below. What is the most likely diagnosis?

Accepted Answer

Renal cell carcinoma

Answer

Papillary necrosis

Answer

Hemangioma

Answer

Angiomyolipoma

Answer

Oncocytoma

Question 2

A 58-year-old diabetic patient presents with frothiness in the urine. Which of the following is the diagnosis?

Accepted Answer

Nodular glomerulosclerosis

Answer

Focal segmental glomerulosclerosis

Answer

Basement membrane thickening

Answer

Crescentic glomerulonephritis

Answer

Diffuse glomerulosclerosis

Question 3

Identify the lesion in HIV positive patient.

Accepted Answer

Collapsing glomerulopathy

Answer

Lipoid nephrosis

Answer

Starry sky kidney

Answer

Wire loop lesions

Answer

Focal segmental glomerulosclerosis (FSGS)

Question 4

Identify the lesion shown in kidney biopsy of 6-year-old child with recurrent U.T.I and vesico-ureteric reflux.

Accepted Answer

Focal segmental glomerulosclerosis

Answer

Diffuse glomerulosclerosis

Answer

Kimmelstiel Wilson change

Answer

Wire loop lesions

Answer

Membranous glomerulonephritis

Question 5

Which urine crystals are shown in the figure below?

Accepted Answer

Calcium oxalate

Answer

Uric acid

Answer

Calcium phosphate

Answer

Cystine

Answer

Triple phosphate

Question 6

The resected specimen of a kidney is seen below. What is the diagnosis?

Accepted Answer

Flea bitten kidney of malignant hypertension

Answer

Amyloidosis

Answer

Acute poststreptococcal glomerulonephritis

Answer

Chronic glomerulonephritis

Answer

Acute tubular necrosis

Question 7

The following is the FITC for IgG stained kidney specimen. What is this suggestive of?

Accepted Answer

SLE

Answer

Post-streptococcal glomerulonephritis

Answer

Goodpasture syndrome

Answer

Membranous glomerulonephritis

Answer

IgA nephropathy

Question 8

A 60-year-old man presents with complaints of frothy urine and facial swelling. The DIF and electron microscopic picture is shown below. Diagnosis is: (AIIMS May 2017)

Accepted Answer

Membranous glomerulopathy

Answer

Membranoproliferative nephritis

Answer

Minimal change disease

Answer

Focal segmental glomerulosclerosis

Answer

IgA nephropathy

Question 9

A 50-year-old male presented with blurring of vision. Urine examination shows proteinuria. Fundus shows dot and hemorrhage with microaneurysm. Kidney biopsy picture given below shows:

Accepted Answer

Kimmelstiel Wilson nodules

Answer

Crescents

Answer

Amyloid deposition

Answer

Focal segmental sclerosis

Answer

Diffuse glomerulosclerosis

Question 10

Immunofluorescence staining pattern from a kidney biopsy from a 35-year-old patient presenting with proteinuria has been shown below. What is the most probable cause? (AIIMS Nov 2018)

Accepted Answer

Lupus nephritis

Answer

FSGS

Answer

PSGN

Answer

Goodpasture syndrome

Answer

IgA nephropathy

Renal pathology — MCQs

Renal pathology — MCQs

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