Pathology
MESINA
SRS KIDNEY
1. Glomerulosclerosis is a feature of:
A. Diabetic nephropathy
B. Benign nephrosclerosis
C. Acute proliferative GN
D. Acute kidney injury
Rationale: The 3 morpholgic changes in diabetic nephropathy are
capillary basement thickening, diffuse mesangial glomerulosclerosis,
and nodular glomerulosclerosis. There are pinkish deposition
(extracellular collagenous matrix) in the mesangial matrix that can
obliterate the capillary loops. Nodular glumerosclerosis is the
pathognomonic lesion of diabetic nephropathy.
Why not:
B: Benign nephrosclerosis – aka arteriolar nephrosclerosis. Arterioles
show thickening and hyalinization of the wall with narrowing of the
lumen. This refers to the blood vessel wall, not the glomerulus.
C: Acute proliferative GN – enlarged and hypercellular glomeruli. This
shows hypercellularity, not sclerosis.
D: Acute kidney injury – tubular epithelial cells in the tubules are
necrotic, and many have become detached and been sloughed into the
tubular lumen. This refers to the tubules, not the glomerulus.
2. A 10 y/o girl develops hypertension and hematuria. A renal biopsy
reveals hypercellular glomeruli with the presence of red blood cells
and red cell casts in her urine sample. The most likely diagnosis based
on this information is:
A. Lupus nephritis
B. Membranoproliferative glomerulonephritis
C. Lipoid nephrosis
D. Poststreptococcal glormerulonephritis
Rationale: Poststreptococcal glomerulonephritis is the prototype of
nephritic syndrome. The predominating manifestation of nephritic
syndrome is hematuria with RBC and red cell casts in the urine with
accompanying signs and symptoms of oliguria, azotemia, hypertension,
edema, mild to moderate proteinuria. It is common in children
between 6-10 years old.
Why not:
A: Lupus nephritis is seen in patients with SLE. Systemic manifestations
are present.
B: Membranoproliferative glomerulitis is usually seen in adults 30-60
years old. Majority present with nephritic syndrome, although some
may have a combination of nephrotic/nephritic syndrome.
C: Lipoid nephrosis – aka minimal change disease. Massive proteinuria.
No hypertension or hematuria. Although the age group is similar with
PSGN, the striking manifestation is massive proteinuria not hematuria.
3. The clinical presentation of nephrotic syndrome can occur in the
following condition/s:
A. Exposure to penicillamine
B. SLE
C. Hep B infection
D. All of the above are correct
E. Only A and B
Rationale: These are all under secondary membranous
glomerulonephritis in association with other systemic diseases.
Membranous GN presents with nephritic syndrome.
Group 28 | SORSONA – SUNGA – SUNGA – SY – SY
DR.
4. Which is NOT a feature of malignant hypertension in the kidney?
A. Thickening and hyalinization of renal arterioles
B. Fibrinoid necrosis of arterioles
C. Characteristic onion skinning of the vessel wall
D. Concentric smooth muscle proliferation of the arterioles
Rationale: Fibrinoid necrosis of the intima of the renal arterioles are
involved in malignant HTN. There is a characteristic onion skinning or
concentric smooth muscle proliferation of the arterioles.
Thickening and hyalinization of renal arterioles are seen in benign
nephrosclerosis.
5. A clinical study is to be performed involving subjects with
membranous glomerulonephritis. Which would be the best clinical
feature to include in the inclusion criteria in choosing subjects for the
study?
A. Hypertension
B. Oliguria
C. Proteinuria of 4g/24 hr urine collection
D. Hypercholesterolemia
Rationale: Membranous GN falls under that manifest the nephrotic
syndrome, particularly seen in adults. Proteinuria is not selective
allowing most of plasma protein to pass through filtration barrier
causing massive proteinuria >3.5 g/24 hour urine collection. Other
secondary manifestations are just a consequence of massive
protienuria such as hypoalbuminemia, hyperlipidemia, generalized
edema, hypercholesterolemia. Membranous GN is characterized by
diffuse thickening of the glomerular capillary wall due to accumulation
of electron dense, Ig-containing deposits along the subepithelial side of
the BM. It does not respond well to corticosteroid.
Why not:
A & B: Hypertension and oliguria are clinical features of nephritic
syndrome.
D: Hypercholesterolemia is not the best clinical feature of membranous
GN.
6. Multiple myeloma, a nonrenal malignant tumor, primarily affects
what structure in the kidney?
A. Glomerulus
B. Tubulointerstitium
C. Blood vessel
D. All of the structures are equally affected
Rationale: Toxic protein involved in multiple myeloma: Bence Jones
protein that forms large cast causing obstruction to tubules causing
inflammatory reactions. Bence Jones protein combines with the urinary
glycoprotein (Tamm-Horsfall protein) under acidic conditions to form
large distinct tubular cast that obstruct the tubular lumens
7. The following features of minimal change disease are correct EXCEPT?
A. Most common cause of the nephrotic syndrome in children
B. Highly selective proteinuria
C. The absence of immune complex deposits in the glomerulus
D. Nonresponsive to corticosteroid therapy
Rationale: Important features in minimal change disease: It is the most
common form of nephrotic syndrome in children. It follows an URTI or
previous immunization. The type of proteinuria is selective, only
albumin passes filtration barrier. Despite absence of immune complex
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 PATHOLOGY SRS KIDNEY
deposit in the glomerulus, that’s why you don’t see changes in light
microscopy, still the pathology is attributed to immune dysfunction due
to presence of circulating T-cell like factor that produce injury to
podocytes. Diagnosis is based on clinical manifestation and they do
empiric treatment with corticosteroid. If they respond, most likely that
the diagnosis is minimal change disease. It is characterized by diffuse
effacement of foot processes of visceral epithelial cells (podocytes) in
glomeruli that appear virtually normal in light microscopy. No
hypertension or hematuria. Renal function remains good.
8. The gross feature of hydronephrosis can arise in the following
condition/s:
A. Bladder tumor
B. Ureteral stone
C. Benign prostatic hypertrophy
D. All of the choices are correct
Rationale: Hydronephrosis is a complication of any form of obstruction
distal to the kidney, at the level of the ureter, at the bladder, or at the
prostatic urethra. Hydronephrosis is the term used to describe dilation
of the renal pelvis and calyces associated with progressive atrophy of
the kidney due to obstruction to the outflow of urine.
9. Thyroidization characterized by atrophic tubules containing pinkish
proteinacious material is a feature of:
A. Acute pyelonephritis
B. Chronic pyelonephritis
C. Acute tubular necrosis
D. Amyloidosis
Rationale: Chronic pyelonephritis is the deformity of the kidney in the
form of scarring seen grossly. On a microscope examination, signs and
symptoms of chronic inflammation include interstitial fibrosis,
inflammation of the interstitium, atrophic tubules, flattening of tubular
epithelial cells (decreased size) and lastly accumulation/formation of
pinkish cast-like material within the lumen of the tubule
(“thyroidization” – as if looking at a thyroid follicle).
Why not:
A: Acute pyelonephritis – Characterized by the presence of interstitial
edema and suppurative inflammation of interstitium and tubules.
C: Acute tubular necrosis – Characterized by necrotic tubular epithelial
cells that are detached from the basement membrane and sloughed off
into the urine.
Amyloidosis – Pathologic proteinacious pink material but is most of the
time seen deposited within glomerulus or interstitium and blood
vessels
10. Which of the following would give rise to hemorrhagic cystitis?
A. Adenovirus infection
B. E. coli infection
C. Long term catheterization
D. Allergy
Rationale: Hemorrhagic cystitis is characterized by gross hematuria
which can be attributed to anti- cancer therapy like cyclophosphamide,
adenovirus infection, radiation therapy/exposure to hypogastric area.
Why not:
B: E. coli infection would have non-specific changes. E.coli (gram negs)
is an endogenous flora of the GIT that causes cystitis via ascending
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route. If acute, there would be interstitial edema, some hyperemia and
neutrophilic infiltration. If chronic, neutrophilic infiltrates will become
mononuclear infiltrates.
C: Long term catheterization leads to polypoid cystitis.
D: Allergies present with eosinophilic cystitis.
11. The following disease/s pose/s an increased risk in developing into a
carcinoma
A. Exstrophy
B. Urachal cyst
C. Analgesic nephropathy
D. All of the choices are correct
E. Only A and B are correct
Rationale: If there are metaplastic changes in the lining (in
exstrophy ,exposure of bladder mucosa to environment; urachal cyst, a
vestigial remnant of the urachus is lined by urothelium or metaplastic
glandular epithelium) and not corrected, these changes could give rise
to adenocarcinoma of the bladder. Analgesic nephropathy predispose
to the development of transitional cell carcinoma of renal pelvis.
12. Which of the following tumor/s is/are derived from urothelial
(transitional) cell?
A. Bladder tumors
B. Renal pelvis
C. Ureter
D. All of the choices are correct
Rationale: The most common primary malignant neoplasms are those
that arise from the lining. All these structures are lined by transitional
epithelium (from renal pelvis down to the bladder), so naturally,
carcinoma that will develop from these are that of urothelial cell
carcinoma or neoplasms.
13. A 5y/o boy was rushed to the ER due to persistent abdominal pain. PE
revealed severe abdominal tenderness, joint pains on the lower
extremities, and rashes on the legs and buttocks. Urinalysis revealed
microscopic hematuria and mild proteinuria. Renal biopsy revealed
positive findings of a glomerulopathy on light microscopy. What
would be the most significant immunoglobulin one would expect to
see on fluorescence microscopy?
A. IgG
B. IgM
C. IgA
D. No immune complex is formed
Rationale: The manifestations presented are from different systems of
the body (GIT, kidney, skin, musculoskeletal). One would suspect that
this is a glomerulopathy secondary to a systemic disorder. (DM, SLE,
amyloidosis, Henoch-Schonlein). Diagnois is Henoch-schonlein. Henoch-
schonlein presents with skin rashes over the legs and buttocks, GI
symptoms, and arthralgia. Renal manifestations are similar to that of
IgA nephropathy. So on immunofluorescence, the most significant
immunoglobulin would be IgA.
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 PATHOLOGY SRS KIDNEY

14. Infection of the urinary tract due to Proteus sp. can give rise to the
lesion/s:
A. Staghorn calculus
B. Xanthogranulomatous pyelonephritis
C. Malacoplakia
D. All of the choices are correct
E. A and B are correct

Rationale: Both staghorn calculus and xanthogranulomatous

pyelonephritis can be due to Proteus infection. Staghorn calculi are
magnesium ammonium phosphate stones formed largely after
infections by Proteus and Staphylococcus. Xanthogranulomatous
pyelonephritis is a special form of pyelonephritis that is attributed to
Proteus. The gross presentation of this can be mistaken for renal cell
carcinoma on imaging studies because it presents as a mass in the
kidney. Under the microscope, it is composed of foamy histiocytes with
accompanying mononuclear inflammation.

Jesus replied, "Truly I tell you, if you have faith AND do not doubt,
not only can you do what was done to the fig tree, but also you can say
to this mountain, 'Go, throw yourself into the sea,' and it will be done.
(Matthew 21:21)

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