Texas A&M COM – Renal-GU Block, 2018

Self-Assessment Quiz #2 – Answer Key

1. A 38-year-old woman presents to the clinic complaining of fatigue and red-brown urine for
the past 7 days. She reports no recent illness and takes no medications. She has noticed
decreased urine output despite her usual fluid consumption. She has been urinating once a
day, when she was urinating five times a day last week. She is afebrile, with a pulse of 84/min,
respiratory rate of 14/min, and blood pressure of 160/95 mmHg. Physical examination is
unremarkable. Laboratory evaluation is remarkable for elevated serum urea nitrogen and
creatinine (increased from baseline, which was normal one month ago). Urinalysis is
remarkable for red-brown color, 3+ blood and 1+ protein. Microscopic urine evaluation reveals
30 to 40 RBCs/HPF, dysmorphic RBCs, and 1 to 2 RBC casts/LPF. Which of the following
clinical presentations best describes this patient’s historical, clinical and laboratory findings?

A. Asymptomatic hematuria
B. Asymptomatic proteinuria
C. Essential hypertension
*D. Nephritic syndrome The patient is manifesting multiple findings that best fit the definition of
nephritic syndrome: hematuria with dysmorphic RBCs and RBC casts, oliguria and azotemia
and hypertension
E. Nephrotic syndrome

2. An investigator is reviewing adult human autopsy material for a study. She wants to
determine if the deceased patients had primary glomerular disease prior to death. As she
reviews histopathologic features of the study patients’ kidneys, which of the following findings
would most likely indicate primary glomerular disease in an adult study patient?

A. Glomerular basement membranes approximately 300 nm thick – normal finding in adults

*B. Glomerular hypercellularity Of the listed options, this is the only choice that indicates
primary glomerular disease.
C. Interstitial inflammation – suggests tubulointerstitial disease
D. Renal cysts – derive from tubules usually
E. Wedge-shaped renal cortical necrosis – suggests vascular occlusion

3. A 13-year-old female teenager presents with her mother to the clinic. She complains of
passing brown urine for the past 2 days. She admits to a sore throat and fever approximately 3
weeks ago, which resolved on their own. Her vital signs are remarkable for hypertension.
Physical examination is unremarkable. Dipstick urinalysis is positive for blood (3+) and protein
(1+). Microscopic urine evaluation reveals 30 to 40 RBCs/HPF and rare red blood cell
casts/LPF. Her serum urea nitrogen and creatinine are elevated above baseline. Which of the
following serologic findings in this patient would best support the most likely suspected
diagnosis?

A. High serum complement levels and undetectable antibody titers to streptococcal products
B. High serum complement levels and elevated antibody titers to streptococcal products
C. Low serum complement levels and undetectable antibody titers to streptococcal products
*D. Low serum complement levels and elevated antibody titers to streptococcal products – The
scenario fits best with post-infectious/post-streptococcal glomerulonephritis, which typically
presents with low serum complement levels and elevated ASO titers.
E. Normal serum complement levels and undetectable antibody titers to streptococcal products
F. Normal serum complement levels and elevated antibody titers to streptococcal products

4. A pathologist is reviewing a renal biopsy from a patient. The clinical history is not available
at the time of evaluation. The renal tissue shows focal and segmental sclerosis of some
glomeruli, especially those in the juxtamedullary region. Immunofluorescence studies show IgM
and C3 deposited in the areas of glomerular sclerosis. Electron microscopy shows foot process
effacement in podocytes and podocyte detachment. This patient most likely presented clinically
with which of the following?

A. Hematuria only
B. Hypertension only
C. Nephritic syndrome
*D. Nephrotic syndrome – The scenario describes features of focal and segmental
glomerulosclerosis (light, IF and EM), which typically presents with a nephrotic picture,
sometimes accompanied with hypertension (but not hypertension alone)
E. Rapidly progressive glomerulonephritis

5. A 7-year-old girl is brought to the clinic for evaluation of edema. Her past medical history is
unremarkable. Vitals signs reveal hypertension. Physical examination finds 2+ edema in
bilateral lower extremities. Laboratory evaluation reveals a mildly elevated serum urea nitrogen
and serum creatinine above her baseline. Urinalysis is remarkable for 3+ protein and 1+ blood.
Urine microscopy reveals 10 to 15 RBCs/HPF, rare RBC casts/LPF, and rare fatty casts/LPF. A
renal biopsy is subsequently performed. Glomerular electron microscopic findings are depicted
in the image. Which of the following is the most likely diagnosis?

A. Amyloidosis
B. Diabetic nephropathy
C. IgA nephropathy
*D. Membranoproliferative glomerulonephritis, type II – The scenario describes a mixed picture
with features of nephritic syndrome (hypertension, elevated BUN and serum creatinine,
hematuria with casts) and also nephrotic syndrome (edema, proteinuria, fatty casts). The image
depicts dark ribbon-like deposits on the subendothelial side of the glomerular basement
membrane. These features fit best with a diagnosis of membranoproliferative
glomerulonephritis, type II.
E. Membranous nephropathy
F. Post-infectious glomerulonephritis
6. A 43-year-old woman with a 20-year history of rheumatoid arthritis presents to the clinic with
a complaint of the recent onset of edema. She has intermittently been prescribed
immunosuppressants for her rheumatoid arthritis, and is on no other medications. Her past
medical history is otherwise unremarkable. Her vital signs are stable. Physical examination is
remarkable for mild arthritic deformities of the joints of her hands and 3+ edema in bilateral
lower extremities. Laboratory evaluation is significant for hypoalbuminemia and hyperlipidemia.
Urinalysis is remarkable for 4+ proteinuria. A 24-hour urine collection reveals loss of 8 grams of
protein/24 hours. A renal biopsy is performed, revealing the depicted findings by light
microscopy (H&E stain). Which of the following is most likely present on electron microscopic
evaluation of this specimen?

A. Foot process effacement with no deposits

B. Mesangial electron dense deposits
*C. Non-branching fibrils, 7.5 to 10 nm thick – The scenario describes a patient with long-
standing inflammation who has edema and a nephrotic picture. The image depicts a glomerulus
that is nearly replaced by nodular, eosinophilic (pink) material. In this setting, amyloidosis is
likely (probably AA type), which has non-branching fibrils that are 7.5 to 10 nm thick.
D. Subepithelial electron dense deposits with humps
E. Thickened glomerular basement membranes with no deposits
7. A 58-year-old woman presents to the clinic for evaluation of leg swelling for the past 2
weeks. She has had no recent illnesses and no recent history of travel. Her past medical
history is remarkable for hypertension which is well-controlled with lisinopril. Her vital signs are
unremarkable. Physical examination is remarkable for 3+ bilateral pitting edema to the mid-calf.
Cardiopulmonary examination is unremarkable. Laboratory evaluation reveals
hypoalbuminemia, hyperlipidemia, and proteinuria. A renal biopsy is performed, and
immunofluorescence microscopic findings with anti-IgG are shown in the image. Which of the
following is the most likely diagnosis?
A. Amyloidosis
*B. Membranous nephropathy – The scenario describes a nephrotic picture +/- hypertension in
an adult. Recall the differential diagnosis (see Robbins Table, slide 72 in Glomerular Disease
notes). The IF image shows a granular membranous pattern with IgG, which fits best with a
diagnosis of membranous nephropathy.
C. Diabetic nephropathy
D. IgA nephropathy
E. Goodpasture’s syndrome
8. An investigator is following a cohort of patients who have had renal transplants. Over the
course of the next 10 years, she finds that a subset of patients develop recurrent disease in
their transplanted kidneys. Patients with which of the following initial renal disorders are most
likely developing recurrent disease in this study?
A. Post-infectious glomerulonephritis – most recover without sequelae
B. Adult polycystic kidney disease – inherited; doesn’t recur in transplanted kidney because it
lacks genetic defect
*C. Focal and segmental glomerulosclerosis – Of the diseases listed, FSGS is most likely to
recur in transplants.
D. Minimal change disease – most recover with corticosteroid therapy
E. Alport syndrome – inherited disease of glomerular basement membrane

9. A 60-year-old woman presents to the clinic for follow-up. She has a history of recurrent
bladder infections and chronic pyelonephritis. She has no other significant past medical history.
On physical examination, she has mild hypertension. No edema is noted. If a renal biopsy were
to be performed in this patient, which of the following would most likely be present in her
kidney?
*A. Thyroidization of tubules – In a patient with known chronic pyelonephritis, thyroidization of
tubules (dilated tubules filled with proteinaceous material) is common, as is fibrosis and chronic
inflammation.
B. Papillary necrosis – no acute symptoms
C. Necrotizing arteriolitis – associated with accelerated hypertension
D. Onion-skinning of arterioles – associated with accelerated hypertension
E. Large numbers of bacteria – no acute symptoms

10. A 35-year-old patient undergoes evaluation for significant hypertension. She is found to
have fibromuscular dysplasia in her left renal artery. Which of the following is most likely also
present in this patient?
A. Decreased serum renin
*B. A left renal bruit – turbulent flow through the narrowed artery will cause a bruit
C. Hyperkalemia
D. Glomerular thrombi
E. Bilateral lower extremity purpura

11. A 40-year-old uncircumcised man from South America presents to the clinic with a
neglected, ulcerated bleeding mass on his penis. He subsequently undergoes a penectomy and
lymph node dissection, revealing an invasive squamous cell carcinoma of the penis with one
lymph node involved by metastasis. Which of the following infectious agents is most likely
associated with this tumor?

*A. Human papilloma virus, type 16 – Squamous cell carcinoma of the penis is often associated
with infection by HPV types 16 and 18 in the genital area.
B. Schistosoma hematobium
C. Chlamydia trachomatis
D. Bacille Calmette Guerin
E. Mycobacterium species

12. A 70-year-old woman presents to the clinic with painless gross hematuria. Her past medical
history is negative, except for a 60-pack-year history of smoking. On cystoscopy, she is found to
have a large papillary bladder tumor which is resected. No invasion is identified, but the tumor
has many mitoses, marked architectural disorganization, anaplastic nuclei, and large variation in
the size and shape of the tumor cell nuclei. Which of the following is the best diagnosis for this
tumor?

A. Urothelial hyperplasia
B. Urothelial Carcinoma In Situ – This would be a flat lesion with high-grade nuclear features
and no invasion.
C. Urothelial Carcinoma, Papillary, Low Grade
*D. Urothelial Carcinoma, Papillary, High Grade – The lesion is described as papillary, and the
described tumor shows high-grade features (many mitoses, marked architectural
disorganization, anaplastic nuclei).
E. Urothelial Neoplasm of Low Malignant Potential
13. A 60-year-old man presents to the clinic with back pain, fever, leukocytosis, and a tender
prostate. He is diagnosed with acute prostatitis. Which of the following is the most likely
causative agent for this disorder?

A. Mycobacterium tuberculosis
B. Human papilloma virus, type 18
*C. Gram negative rods – Acute bacterial prostatitis is usually caused by gram negative rods.
D. Fungal organisms
E. Ureaplasma urealyticum

14. A 70-year-old African American man is very concerned about having prostate cancer, since
his neighbor died of it. His own family history is negative for prostate cancer. He had a
transurethral resection of the prostate 12 years ago to relieve urinary obstruction, with good
results. He has had 3 urinary tract infections in the last five years. On physical examination, his
prostate is enlarged, soft, and boggy. His current serum prostate specific antigen (PSA) level is
4.2 ng/mL with 26% "free"; his total PSA level was 3.1 ng/mL eleven months ago. Which of the
following is most suspicious for malignancy in this patient?

A. Percent free PSA – reassuring, since greater than 25%

B. Total PSA – only minimally elevated
*C. PSA velocity – The velocity of his PSA (change over time) is most concerning, since it is 1.1
ng/ml per year (greater than 0.8 is suspicious).
D. Physical examination – not suspicious (no firm nodules)
E. History of urinary tract infections – no link to prostate cancer development

15. A 48-year-old Caucasian woman presents to the clinic with a chief complaint of recurrent
headache that is frontal in distribution, moderate to severe in severity, without aura or visual
changes and does not radiate. The patient’s headache frequency has been worsening over the
past 2 to 3 months. The patient also reports recurrent episodes of facial flushing, palpitations
and diaphoresis that seem to be occurring more frequently over the same time frame. Over the
past week, she reports recurrent panic attacks that seem to resolve after several minutes. The
patient does not have a previous diagnosis of hypertension and is not currently taking any
prescription medications. She reports taking occasional ibuprofen for her headache. Vital signs
include a pulse of 104/min and blood pressure of 188/116 mmHg. Physical examination is
without abdominal striae, rash, jugular venous distension or edema. Her heart rhythm is regular
and tachycardic without rub, murmur or gallop. Current serum laboratory studies obtained at
rest in the supine position reveal normal electrolytes with free plasma metanephrines showing a
3-fold elevation of normetanephrine from normal. Assuming this patient does not have essential
hypertension, which of the following is the most likely secondary cause of hypertension in this
patient?
A. Cushing’s syndrome
*B. Pheochromocytoma – The scenario describes typical symptoms of secondary hypertension
related to pheochromocytoma. The laboratory findings described (elevated free plasma
metanephrines) are supportive of that diagnosis.
C. Primary hyperaldosteronism
D. Bartter syndrome
E. Gitelman syndrome

16. A 50-year-old man experiences severe back pain after a heavy weight falls on his back at a
factory. A CT scan of the abdominal and thoracic region is performed as part of his emergent
evaluation in the emergency department. A left renal tumor measuring 5.0 cm is detected. The
tumor is subsequently removed by a partial nephrectomy, and is diagnosed as a chromophobe
carcinoma. Which of the following is the most likely microscopic description of this patient's
tumor?

A. Large amount of smooth muscle and blood vessels

B. Large cells with diffusely eosinophilic cytoplasm
*C. Dark cytoplasm peripherally with perinuclear clearing – Chromophobe carcinomas are best
described as having eosinophilic cytoplasm with perinuclear halos/clearing.
D. Cells with clear cytoplasm and uniform nuclei
E. Papillary cores with foamy macrophages

17. A 35-year-old patient presents to the clinic for evaluation. Family history is significant for a
father who had a kidney transplant and a paternal grandfather who died of end-stage renal
disease (ESRD). Vital signs are remarkable for a blood pressure of 150/90 mmHg. A CT scan
of the abdomen reveals a few cysts within the kidney. The cells of one of the ruptured cysts was
tested and had a PKD1 and a PKD2 mutation. The lack of cyst development in the patient can
best be explained by which of the following?

A. Allelic heterogeneity
B. Incomplete penetrance
C. Double heterozygosity
D. Locus heterogeneity
*E. Variable expression – This question is similar to #7 presented in Dr. Dobin’s study
questions. It takes a while for the second mutations to accumulate in the tubular cells.

18. A child presents with polyuria, polydipsia, anemia and medullary cysts in the kidney. The
child has normal development. The family history indicates that there are 10 siblings, 3
maternal aunts, 1 maternal uncle, 2 paternal aunts and living grandparents on both sides of the
family. Everyone in the family is healthy except one of the child’s siblings who presented with
similar features at 10 years of age. Which of the following is the most likely diagnosis?
A. Autosomal dominant polycystic kidney disease
B. Autosomal recessive polycystic kidney disease
C. Joubert syndrome
D. Medullary cystic kidney disease
*E. Nephronophthisis – Given the patient’s history (polyuria, polydipsia, anemia and
medullary cysts), and the family history (not many individuals affected), this suggests an
autosomal recessive disease, with nephronophthisis being the most likely.
19. A 22-year-old sexually active woman presents to the clinic with a complaint of dysuria,
urinary frequency and urgency for the past 2 days. She returned 1 day ago from a vacation with
her new boyfriend. Her past medical history is unremarkable. She is on no medications. Her
vital signs are stable and physical examination shows mild suprapubic tenderness. Given the
most likely diagnosis, which of the following is the most likely infecting organism?
*A. Escherichia coli – For this scenario, gram-negative bacilli, and specifically E. coli, is the most
common etiologic agent.
B. Staphylococcus saprophyticus
C. Enterococcus faecalis
D. Pseudomonas aeruginosa
E. Klebsiella pneumoniae

20. Each of the following patients submits urine to the laboratory for analysis and culture for
various reasons. All patients are asymptomatic. For each patient, the urine culture is found to
be positive for bacteria. For which of the following patients is it appropriate to treat for
asymptomatic bacteriuria?
A. A 45-year-old man who submitted a sample for pre-employment purposes
B. A 46-year-old woman who submitted a sample for health insurance purposes
*C. A 22-year-old woman who submitted a sample at pre-natal care clinic – See Dr. Midturi’s
slide #54. You don’t generally treat asymptomatic bacteriuria, except in pregnant, diabetic, or
immunosuppressed patients.
D. A 12-year-old adolescent male who submitted a sample for a pre-sports physical