Renal Pathology

Renal Pathology Indian Medical PG Question 1: Indications for use of cyclophosphamide in SLE are:

• A. Arthritis
• B. Diffuse proliferative glomerulonephritis (Correct Answer)
• C. Oral ulcers
• D. Anti D NA antibody +ive patients

Renal Pathology Explanation: Diffuse proliferative glomerulonephritis - **Cyclophosphamide** is a potent immunosuppressant often used in severe manifestations of **systemic lupus erythematosus (SLE)**, particularly **lupus nephritis**. - **Diffuse proliferative glomerulonephritis (class IV lupus nephritis)** is a severe form of kidney involvement in SLE, characterized by significant inflammation and immune complex deposition, for which cyclophosphamide is a first-line treatment due to its ability to induce remission and prevent progression to end-stage renal disease. *Arthritis* - **Arthritis** in SLE is typically managed with less aggressive therapies such as **NSAIDs**, **hydroxychloroquine**, or low-dose **corticosteroids** [1]. - Cyclophosphamide is generally reserved for life-threatening or organ-threatening manifestations due to its significant side effects. *Oral ulcers* - **Oral ulcers** in SLE are usually a mild cutaneous manifestation and are managed with topical treatments, **hydroxychloroquine**, or occasionally low-dose **systemic corticosteroids**. - The use of cyclophosphamide for oral ulcers would be inappropriate given its toxicity profile. *Anti D NA antibody +ive patients* - While **anti-dsDNA antibodies** are characteristic of SLE and often correlate with disease activity, particularly **lupus nephritis**, their presence alone does not indicate the need for cyclophosphamide [2]. - The decision to use cyclophosphamide is based on the presence of severe organ-threatening disease, not solely on antibody positivity.

Renal Pathology Indian Medical PG Question 2: MC cause of nephrotic syndrome in adults:-

• A. Minimal change disease
• B. Focal segmental glomerulosclerosis (Correct Answer)
• C. Good-pasture syndrome
• D. Membranous GN

Renal Pathology Explanation: **Focal segmental glomerulosclerosis** - **Focal segmental glomerulosclerosis (FSGS)** is the most common cause of **primary nephrotic syndrome in adults**, particularly in African Americans and individuals with HIV or obesity [1]. - It involves **scarring** of some glomeruli (focal) and only parts of affected glomeruli (segmental), leading to **proteinuria** and progression to end-stage renal disease [2]. *Minimal change disease* - While it is the most common cause of **nephrotic syndrome in children**, it accounts for a smaller proportion of adult cases [1]. - Characterized by normal-appearing glomeruli on light microscopy but **effacement of foot processes** on electron microscopy. *Good-pasture syndrome* - This is an **autoimmune disease** causing rapidly progressive glomerulonephritis, often associated with **pulmonary hemorrhage** [3]. - It is a much rarer cause of nephrotic syndrome and is characterized by **anti-GBM antibodies** [3]. *Membranous GN* - It is a common cause of **nephrotic syndrome in adults**, particularly in Caucasians, but **Focal Segmental Glomerulosclerosis (FSGS)** has surpassed it as the overall most common primary cause. - Characterized by thickening of the **glomerular basement membrane** due to immune complex deposition, often detected by **anti-PLA2R antibodies** [2].

Renal Pathology Indian Medical PG Question 3: Which of following is not seen in nephritic syndrome -

• A. HTN
• B. Hypocholestremia (Correct Answer)
• C. Hematuria
• D. Edema

Renal Pathology Explanation: ***Hypocholestremia*** - **Hypocholesterolemia** (low cholesterol) is not characteristic of nephritic syndrome; rather, **hypercholesterolemia** is a feature often associated with nephrotic syndrome [1] due to increased hepatic lipoprotein synthesis. - Nephritic syndrome is primarily associated with **inflammation** and **glomerular damage**, leading to hematuria, proteinuria, and renal impairment [1], without directly causing hypocholesterolemia. *HTN* - **Hypertension** is a common finding in nephritic syndrome due to fluid retention [2] and activation of the **renin-angiotensin-aldosterone system** (RAAS) resulting from impaired renal function. - The inflammatory damage to the glomeruli reduces the kidney's ability to excrete sodium and water, contributing to elevated blood pressure. *Hematuria* - **Hematuria** (blood in the urine), often macroscopic or microscopic, is a hallmark of nephritic syndrome due to the inflammatory damage to the **glomerular basement membrane**, allowing red blood cells to leak into the urine [1]. - The presence of **red blood cell casts** in the urine strongly indicates a nephritic process. *Edema* - **Edema** (swelling), particularly periorbital and peripheral, is frequently observed in nephritic syndrome as a result of **sodium and water retention** by the impaired kidneys [1][2]. - This fluid overload occurs even with relatively modest proteinuria, differentiating it from the more severe edema seen in nephrotic syndrome which is primarily due to hypoalbuminemia.

Renal Pathology Indian Medical PG Question 4: Which of the following is not a complication of nephrotic syndrome?

• A. Hypoalbuminemia (Correct Answer)
• B. Infection risk
• C. Hypertension
• D. Hypercoagulability

Renal Pathology Explanation: ***Hypoalbuminemia*** - **Hypoalbuminemia** is a *defining feature* of nephrotic syndrome, not a complication. - It results from the **massive urinary protein loss** that is central to the diagnosis of nephrotic syndrome [1]. *Infection risk* - Patients with nephrotic syndrome are at increased risk of **infections** due to urinary loss of immunoglobulins and complement factors [1]. - This often manifests as **peritonitis**, cellulitis, or pneumonia. *Hypertension* - **Hypertension** is a common complication, often due to **fluid retention**, activation of the **renin-angiotensin-aldosterone system**, and underlying renal dysfunction [1]. - It contributes to the progression of kidney disease and cardiovascular morbidity. *Hypercoagulability* - **Hypercoagulability** is a significant complication caused by urinary loss of **antithrombin III** and other anticoagulant proteins, coupled with increased synthesis of prothrombotic factors [1]. - This increases the risk of **thromboembolic events**, such as deep vein thrombosis and pulmonary embolism.

Renal Pathology Indian Medical PG Question 5: The best response to steroids is observed with –

• A. Focal glomerulonephritis
• B. Lipoid nephrosis (Correct Answer)
• C. Membranous GN
• D. Membranoproliferative GN

Renal Pathology Explanation: ***Lipoid nephrosis*** - Also known as **Minimal Change Disease**, it is the most common cause of **nephrotic syndrome in children** and responds very well to steroid therapy [1]. - The disease involves effacement of podocyte foot processes without significant visible damage under light microscopy, leading to increased glomerular permeability to protein, but the condition is highly responsive to **immunosuppression with corticosteroids** [1]. *Focal glomerulonephritis* - This term usually refers to **Focal Segmental Glomerulosclerosis (FSGS)**, which typically has a much poorer response to steroids compared to minimal change disease [1]. - While some variants of FSGS can respond to steroids, the response rate is significantly lower than that seen in lipoid nephrosis, and it often progresses to **end-stage renal disease**. *Membranous GN* - **Membranous glomerulonephritis** has a variable response to steroids, with some patients achieving remission but many requiring more aggressive immunosuppression or demonstrating steroid resistance. - It is characterized by **subepithelial immune complex deposition** and glomerular basement membrane thickening, which is a different pathological process from lipoid nephrosis. *Membranoproliferative GN* - **Membranoproliferative glomerulonephritis (MPGN)** typically responds poorly to corticosteroids and often requires more potent immunosuppressive agents or specific therapies depending on its underlying cause (e.g., complement-mediated). - MPGN involves mesangial and endothelial proliferation, along with characteristic changes in the glomerular basement membrane, indicating a more severe and less steroid-responsive form of glomerular injury.

Renal Pathology Flashcard 1 of 5

Question: Hemolytic uremic syndrome, Graft rejection, Acute cortical necrosis, Chronic glomerulonephritis and Alport syndrome, all lead to _____ nephrocalcinosis

Answer: cortical

Renal Pathology Flashcard 2 of 5

Question: In _____ nephritis, immunofluorescence (IF) on kidney biopsy specimen shows positive IF IgM, IgG, IgA and Complement C1q, C3c.

Answer: Lupus

Renal Pathology Flashcard 3 of 5

Question: _____ glomerulonephritis is characterized by crescents in Bowman's space of the glomeruli (light microscopy)

Answer: Rapidly progressive

Renal Pathology Flashcard 4 of 5

Question: Resolving phase of post-streptococcal glomerulonephritis will present with deposits in the _____

Answer: mesangium

Renal Pathology Flashcard 5 of 5

Question: The given immunoflorescence pattern is suggestive of _____:

Answer: Membranous nephropathy