Renal Pathology Practice Questions

Q: If a kidney biopsy is done in a patient with bronchogenic carcinoma who presents with nephrotic syndrome, which lesion will most likely be seen?

Membranous GN. ***Membranous GN*** - **Membranous glomerulonephritis (MGN)** is the most common cause of **paraneoplastic nephrotic syndrome** in adults, especially in association with solid tumors such as **bronchogenic carcinoma** [1]. - The tumor releases antigens, forming **immune complexes** that deposit in the glomerular basement membrane, leading to characteristic **subepithelial deposits** with a granular pattern of IgG and C3 on immunofluorescence [1]. *Focal proliferative GN* - **Focal proliferative glomerulonephritis** is less commonly associated with solid tumors causing nephrotic syndrome. - It is more typically seen in immune complex-mediated diseases like **IgA nephropathy** or **lupus nephritis**, where it might present with hematuria and proteinuria rather than pure nephrotic syndrome. *Minimal change disease* - While a common cause of nephrotic syndrome in children, and sometimes in adults, **minimal change disease** is rarely paraneoplastic [1]. - It is characterized by **diffuse effacement of foot processes** on electron microscopy without significant immune complex deposition [1]. *Focal segmental glomerulosclerosis* - Although **focal segmental glomerulosclerosis (FSGS)** can cause nephrotic syndrome in adults, it is not the most common paraneoplastic glomerulopathy with solid tumors [2]. - FSGS involves **segmental scarring** of some glomeruli and is associated with various secondary causes like viral infections (HIV) or drug use, but less frequently with bronchogenic carcinoma directly [1], [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 919-921, 927-928. [2] 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: A patient with chronic hypertension will show which of the following changes on histology of the kidney?

Hyaline arteriosclerosis. ***Hyaline arteriosclerosis*** - This condition is characterized by **homogeneous pink appearance** of arterial walls on histology due to plasma protein leakage, commonly seen in chronic hypertension [1]. - It represents **injury** and **remodeling** of the renal vasculature due to the prolonged pressure load, often leading to renal impairment [1,2]. *Onion skin lesions* - Typically associated with **hyperplasia of smooth muscle cells** in the walls of arteries, seen more in conditions like **malignant hypertension** [3,4]. - These lesions are not a hallmark of chronic hypertension, where changes are more subtle and involve primarily hyaline changes [3]. *Hyperplastic arteriosclerosis* - Involves **proliferation of smooth muscle cells and fibroblasts**, leading to a thickened wall, usually noted in cases of acute or severe hypertension [4,5]. - It is less common compared to **hyaline arteriosclerosis** in chronic hypertension scenarios, which is characterized by more insidious changes [3]. *Vessel lumen dilatation* - Typically not observed in chronic hypertension; chronic changes lead to **narrowing** due to arterial wall thickening [1]. - Rather, chronic hypertension results in **stenosis** and not an **enlargement** of vessel lumens [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 943-945. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 541-542. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 498-499. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 945. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 276-277.

Q: Which condition is characterized by wire loop lesions in the glomeruli?

Systemic Lupus Erythematosus (SLE). ***SLE*** - Wire loop lesions in glomeruli are a classic histological finding in **Systemic Lupus Erythematosus (SLE)**, indicating severe glomerulonephritis. - These lesions result from **subendothelial immune complex deposits**, leading to a distinctive appearance on renal biopsy [1]. *Amyloidosis* - Characterized by **polarized light appearance** of apple-green birefringence due to amyloid deposits, not wire loop lesions. - Renal involvement occurs with **nodular glomerulosclerosis**, shown by different histological patterns. *Nephrotic* - Refers to a syndrome characterized by **heavy proteinuria**, **hypoalbuminemia**, and **edema**, but not specifically wire loop lesions. - The histopathology typically reveals **minimal change disease** or **focal segmental glomerulosclerosis**, not wire loops. *IgA nephropathy* - Generally presents with **IgA deposits** in mesangial regions causing **hematuria** and mild proteinuria. - It does not exhibit wire loop lesions, which are characteristic of **lupus nephritis** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, p. 232.

Q: The characteristic immunoglobulin abnormality in IgA nephropathy is:

Galactose-deficient IgA1. ***Galactose-deficient IgA1*** - **IgA nephropathy** is characterized by the presence of circulating **galactose-deficient IgA1** molecules, which are recognized as autoantigens. - These abnormal IgA1 molecules deposit in the **glomeruli**, leading to inflammation and kidney damage. *Complement C5b-9* - **Complement C5b-9** is the **membrane attack complex (MAC)**, a component of the complement cascade involved in tissue damage. - While complement activation occurs in IgA nephropathy, C5b-9 is a downstream effector, not the primary immunoglobulin abnormality. *TGF-β* - **TGF-β** is a **cytokine** involved in fibrosis and immune regulation, playing a role in the progression of kidney disease. - It is not an immunoglobulin and does not represent the primary immunologic abnormality in IgA nephropathy. *Interleukin-6* - **Interleukin-6 (IL-6)** is a **pro-inflammatory cytokine** involved in immune responses and B cell differentiation. - Although IL-6 may contribute to the inflammatory process in IgA nephropathy, it is not the characteristic immunoglobulin abnormality.

Q: Which of the following histological features is characteristic of Alport syndrome?

Basket weave appearance of the glomerular basement membrane. ***Basket weave appearance of the glomerular basement membrane*** - This characteristic **basket weave appearance** with splitting, lamination, and thickening/thinning of the **lamina densa** is a classic ultrastructural finding in Alport syndrome, identifiable with electron microscopy. - It results from mutations in **Type IV collagen**, which is a crucial component of the GBM. *Diffuse thinning of the glomerular basement membrane* - While Alport syndrome can present with areas of focal thinning, **diffuse thinning of the glomerular basement membrane** alone is more characteristic of **thin basement membrane disease** (benign familial hematuria). - Alport syndrome typically shows abnormal thickness and lamellation in addition to thinning. *Irregularities in the lamina densa* - **Irregularities in the lamina densa** are a general feature of many glomerular diseases; however, the specific **basket weave appearance** with splitting and variable thickness is what distinguishes Alport syndrome. - This option is too general and doesn't capture the unique ultrastructural changes seen in Alport syndrome. *Interstitial fibrosis and glomerulosclerosis* - **Interstitial fibrosis and glomerulosclerosis** are features that develop in the later stages of many progressive kidney diseases, including Alport syndrome, representing **chronic kidney damage**. - These are common non-specific findings of established kidney disease and not an early, characteristic histological feature for diagnosing Alport syndrome.

Q: Immunofluorescence staining pattern from a kidney biopsy from a 35-year-old patient presenting with proteinuria, a malar rash, joint pain, and positive ANA and anti-dsDNA antibodies has been shown below. The immunofluorescence panel shows positivity for IgG, IgA, IgM, C3, and C1q (full-house pattern). What is the most likely diagnosis?

Lupus Nephritis (LN). ***Lupus Nephritis*** - Characterized by **immune complex deposition** in the glomeruli leading to **proteinuria**, which is consistent with the patient's presentation [1]. - The immunofluorescence staining pattern in lupus nephritis classically shows a **full-house pattern**, with positivity for **IgG, IgA, IgM, C3, and C1q**, which is highly characteristic and distinguishes it from other immune-complex glomerulonephritides [1]. *PSGN* - Post-streptococcal glomerulonephritis typically occurs following a **Group A streptococcal infection**, which is not indicated in this patient's history. - Immunofluorescence pattern would show **lumpy-bumpy** deposition primarily of **IgG and C3**, differing from lupus nephritis patterns [2]. PSGN does not produce the full-house pattern of IgG, IgA, IgM, C3, and C1q seen in lupus nephritis. *FSGS* - Focal segmental glomerulosclerosis frequently presents with **nephrotic syndrome** and may show some **IgM** staining, but it does not present with the immunofluorescence pattern or systemic involvement seen in lupus nephritis [1]. - The condition is often associated with **obesity** or **HIV**, rather than the systemic autoimmune features as in lupus nephritis [1]. *Goodpasture syndrome* - Goodpasture syndrome involves **anti-GBM antibodies** leading to glomerulonephritis and pulmonary hemorrhage, with a specific linear pattern on immunofluorescence [2]. - The clinical presentation typically includes **hemoptysis** and renal failure alongside proteinuria, not solely presenting with isolated proteinuria. **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. 526-527, 530-533. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 915.

Q: Michaelis-Gutmann bodies are seen in:

Malakoplakia. ***Malakoplakia*** - **Michaelis-Gutmann bodies** are pathognomonic histological features of **malakoplakia**, a chronic inflammatory condition. - These bodies are characteristic laminated, intracellular, and extracellular calcium-containing concretions found within **macrophages** (Von Hansemann cells). *Melioidosis* - **Melioidosis** is caused by the bacterium *Burkholderia pseudomallei* and is characterized by abscess formation, not Michaelis-Gutmann bodies. - It can present with diverse clinical manifestations ranging from localized infection to severe sepsis. *Brucellosis* - **Brucellosis** is a zoonotic infection caused by *Brucella* species, typically presenting with fever, sweats, and arthralgia, and is not associated with Michaelis-Gutmann bodies. - Histologically, it often involves granulomatous inflammation. *Tularemia* - **Tularemia**, caused by *Francisella tularensis*, is characterized by ulceroglandular disease, pneumonia, or typhoidal forms, and does not involve Michaelis-Gutmann bodies. - Histopathology typically reveals suppurative granulomas.

Q: What is the mode of inheritance for the most common mutation in Alport syndrome, which is found in the COL4A5 gene?

X-linked inheritance, primarily affecting males. ***X-linked*** - The most common mutation in **Alport syndrome** occurs in the **COL4A5** gene, which is primarily associated with X-linked inheritance. - Males are more severely affected due to their single X chromosome, while females may present with milder symptoms. *Autosomal recessive* - Alport syndrome is not primarily transmitted through **autosomal recessive inheritance**, though there are rare forms that can be. - The typical inheritance pattern linked to **COL4A5 mutations** is X-linked rather than autosomal. *Variable, autosomal dominant or autosomal recessive* - This option suggests a **variable mode of inheritance**, which is misleading as the most common form related to COL4A5 is specifically X-linked. - Alport syndrome does exhibit some forms of **autosomal dominant transmission**, but it is not the most common. *Autosomal dominant* - While some forms of Alport syndrome can be autosomal dominant, the **predominant mutations** are X-linked, particularly in the COL4A5 gene. - Patients with autosomal dominant forms usually have a less severe disease course compared to those with X-linked forms.

Q: A 40-year-old man presented with painless haematuria. Bimanual examination revealed a ballotable mass over the right flank. Subsequently, right nephrectomy was performed, and the mass was found to be composed of cells with clear cytoplasm. Areas of haemorrhage and necrosis were frequent. Cytogenetic analysis of this mass is likely to reveal the abnormality of which chromosome?

Chromosome 3. ***Chromosome 3*** [1][2] - Associated with **clear cell renal carcinoma**, which is indicated by the presentation of a **painless mass and hematuria** in the patient [3]. - Cytogenetic analysis often reveals **aberrations involving chromosome 3, particularly 3p deletions** [2]. *Chromosome 17* - Notably associated with **other cancers** like breast cancer (BRCA1) and not specifically linked to renal cell carcinoma. - Cytogenetic abnormalities in this chromosome are less relevant for **clear cell features** observed in the tumor. *Chromosome 1* - This chromosome is involved in the genetic predisposition of various tumors but is **not primarily associated** with clear cell renal carcinoma. - There are no specific **cytogenetic alterations** related to this type of kidney cancer found on chromosome 1. *Chromosome 11* - Although chromosome 11 can have alterations in some cancers, it is **not directly related** to clear cell renal carcinoma. - Functions of this chromosome are more commonly linked with **Wilms' tumor or other hematological malignancies**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, p. 959. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 958-959. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 959-961.

Q: The cytogenetics of chromophilic renal cell carcinoma is characterized by:

Trisomy 7/17. ***Trisomy 7/17*** - Chromophilic renal cell carcinoma is notably characterized by **trisomy of chromosomes 7 and 17**, which is frequently observed in these tumors [1]. - This genetic alteration is associated with **proliferative changes** in renal cells leading to tumor development. *Loss 3p* - Loss of the **3p chromosome** is more commonly associated with **clear cell renal cell carcinoma**, not chromophilic types [1]. - It involves the **VHL gene**, which is not a primary characteristic of chromophilic renal cell carcinoma. *Mutant VHL gene* - Mutations in the **VHL gene** are primarily linked with **clear cell renal cell carcinoma** and hereditary conditions like **Von Hippel-Lindau syndrome**. - Chromophilic renal cell carcinoma typically does not involve these mutations as a defining feature. *Loss of 5q3* - Loss of **5q3** is not a recognized hallmark for chromophilic renal cell carcinoma; it lacks significance in this context. - This genetic aberration is often unrelated to the development or progression of chromophilic tumors. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 957-959.

Question 1

If a kidney biopsy is done in a patient with bronchogenic carcinoma who presents with nephrotic syndrome, which lesion will most likely be seen?

Accepted Answer

Membranous GN

Answer

Focal segmental glomerulosclerosis

Answer

Focal proliferative GN

Answer

Minimal change disease

Question 2

A patient with chronic hypertension will show which of the following changes on histology of the kidney?

Accepted Answer

Hyaline arteriosclerosis

Answer

Vessel lumen dilatation

Answer

Hyperplastic arteriosclerosis

Answer

Fibrinoid necrosis

Question 3

Which condition is characterized by wire loop lesions in the glomeruli?

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

IgA nephropathy

Answer

Amyloidosis

Answer

Membranous nephropathy

Question 4

The characteristic immunoglobulin abnormality in IgA nephropathy is:

Accepted Answer

Galactose-deficient IgA1

Answer

Complement C5b-9

Answer

TGF-β

Answer

Interleukin-6

Question 5

Which of the following histological features is characteristic of Alport syndrome?

Accepted Answer

Basket weave appearance of the glomerular basement membrane

Answer

Diffuse thinning of the glomerular basement membrane

Answer

Irregularities in the lamina densa

Answer

Interstitial fibrosis and glomerulosclerosis

Question 6

Immunofluorescence staining pattern from a kidney biopsy from a 35-year-old patient presenting with proteinuria, a malar rash, joint pain, and positive ANA and anti-dsDNA antibodies has been shown below. The immunofluorescence panel shows positivity for IgG, IgA, IgM, C3, and C1q (full-house pattern). What is the most likely diagnosis?

Accepted Answer

Lupus Nephritis (LN)

Answer

Goodpasture Syndrome

Answer

Post-Streptococcal Glomerulonephritis (PSGN)

Answer

Focal Segmental Glomerulosclerosis (FSGS)

Question 7

Michaelis-Gutmann bodies are seen in:

Accepted Answer

Malakoplakia

Answer

Melioidosis

Answer

Brucellosis

Answer

Tularemia

Question 8

What is the mode of inheritance for the most common mutation in Alport syndrome, which is found in the COL4A5 gene?

Accepted Answer

X-linked inheritance, primarily affecting males

Answer

Variable inheritance patterns

Answer

Autosomal dominant inheritance

Answer

Autosomal recessive inheritance

Question 9

A 40-year-old man presented with painless haematuria. Bimanual examination revealed a ballotable mass over the right flank. Subsequently, right nephrectomy was performed, and the mass was found to be composed of cells with clear cytoplasm. Areas of haemorrhage and necrosis were frequent. Cytogenetic analysis of this mass is likely to reveal the abnormality of which chromosome?

Accepted Answer

Chromosome 3

Answer

Chromosome 1

Answer

Chromosome 11

Answer

Chromosome 17

Question 10

The cytogenetics of chromophilic renal cell carcinoma is characterized by:

Accepted Answer

Trisomy 7/17

Answer

Loss of chromosome 3p

Answer

Loss of chromosome 5q3

Answer

Mutant VHL gene

Renal Pathology — MCQs

Renal Pathology — MCQs

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