Robbin's Review - Ch.20 (Kidney)

A 58-year-old man is in stable condition after an acute myocardial infarction. Two days later, his urine output decreases, and the serum urea nitrogen level increases to 3.3 mg/dL. Oliguria persists for 5 days, followed by polyuria for 2 days. He is discharged from the hospital. Which of the following renal lesions best explains these renal abnormalities? □ (A) Acute tubular necrosis □ (B) Benign nephrosclerosis □ (C) Acute renal infarction □ (D) Hemolytic-uremic syndrome □ (E) Rapidly progressive glomerulonephritis

A. Acute tubular necrosis

A 24-year-old man is awakened at night because of severe lower abdominal pain that radiates to the groin. The pain is very intense and comes in waves. The next morning, he notices blood in his urine. He has no underlying illnesses and has been healthy all his life. On physical examination, he is afebrile and has a blood pressure of 110/70 mm Hg. Laboratory studies show serum Na+, 142 mmol/L; K+, 4 mmol/L; Cl−, 96 mmol/L; CO2, 25 mmol/L; glucose, 74 mg/dL; creatinine, 1.1 mg/dL; calcium, 9.1 mg/dL; and phosphorus, 2.9 mg/dL. Urinalysis shows a pH of 7; specific gravity of 1.020; and no protein, glucose, ketones, or nitrite. The patient is advised to drink more water. He likes iced tea and consumes large quantities over the course of a hot summer. He continues to have similar episodes. Which of the following substances is most likely to be increased in his urine? □ (A) Calcium oxalate □ (B) Cystine □ (C) Magnesium ammonium phosphate □ (D) Mucoprotein □ (E) Uric acid

A. Calcium oxalate

A sexually active, 26-year-old man has had pain on urination for the past 4 days. On physical examination, there are no lesions on the penis. He is afebrile. Urinalysis shows no blood, ketones, protein, or glucose. Microscopic examination of the urine shows few WBCs and no casts or crystals. What infectious agent is most likely to produce these findings? □ (A) Chlamydia trachomatis □ (B) Mycobacterium tuberculosis □ (C) Herpes simplex virus □ (D) Candida albicans

A. Chlamydia trachomatis

A 42-year-old man has experienced increasing malaise for the past month. He is bothered by increasing swelling in the hands and legs. On physical examination, there is generalized edema. He is afebrile, and his blood pressure is 140/90 mm Hg. Urinalysis shows a pH of 6.5; specific gravity 1.017; 4+ proteinuria; and no blood, glucose, or ketones. Microscopic examination of the urine shows no casts or RBCs and 2 WBCs per high-power field. The 24-hour urine protein level is 4.2 g. A renal biopsy specimen is obtained, and immunofluorescence staining with antibody to the C3 component of complement produces the pattern shown in the figure. Which of the following underlying disease processes is most likely to be present? □ (A) Chronic hepatitis B □ (B) AIDS □ (C) Multiple myeloma □ (D) Recurrent urinary tract infection □ (E) Nephrolithiasis

A. Chronic Hepatitis B

One week after a mild flulike illness, a 9-year-old boy has an episode of hematuria that subsides within 2 days. One month later, he tells his parents that his urine is red again. On physical examination, there are no significant findings. Urinalysis shows a pH of 7; specific gravity 1.015; 1+ proteinuria; 1+ hematuria; and no ketones, glucose, or urobilinogen. The serum urea nitrogen level is 36 mg/dL, and the creatinine level is 3.2 mg/dL. A renal biopsy specimen shows diffuse mesangial proliferation and electron-dense deposits in the mesangium. Which of the following mechanisms is most likely to produce these findings? □ (A) Deposition of immune complexes containing IgA □ (B) Formation of antibodies against type IV collagen □ (C) Virus-mediated injury to the glomeruli □ (D) Cytokine-mediated injury to the glomerular capillaries □ (E) Congenital defects in the structure of glomerular basement membranes

A. Deposition of immune complexes containing IgA

A 12-year-old girl has experienced increasing malaise for the past 2 weeks. On physical examination, she has periorbital edema. The child is afebrile. Laboratory findings show proteinuria on dipstick urinalysis, but no hematuria or glucosuria. Microscopic examination of the urine shows numerous oval fat bodies. The serum creatinine level is 2.3 mg/dL. She receives a course of corticosteroid therapy, but does not improve. A renal biopsy is done; the biopsy specimen shows that approximately 50% of the glomeruli in the specimen are affected by the lesion shown in the figure. What is the most likely diagnosis? □ (A) Focal segmental glomerulosclerosis □ (B) Lipoid nephrosis □ (C) Membranoproliferative glomerulonephritis type I □ (D) Membranoproliferative glomerulonephritis type II □ (E) Nodular glomerulosclerosis □ (F) Postinfectious glomerulonephritis □ (G) Rapidly progressive glomerulonephritis

A. Focal segmental glomerulosclerosis

A 60-year-old man presents with a feeling of fullness in his abdomen and a 5-kg weight loss over the past 6 months. Physical examination is normal. Laboratory studies show hemoglobin of 8.2 g/dL, hematocrit of 24%, and MCV of 70 μm3. Urinalysis shows 3+ hematuria, but no protein, glucose, or leukocytes. Abdominal CT scan shows an 11-cm mass in the upper pole of the right kidney. A right nephrectomy is performed, and on gross examination the mass invades the renal vein. Microscopic examination of the mass shows cells with abundant clear cytoplasm. Which of the following molecular abnormalities is most likely to be found in tumor cell DNA? □ (A) Homozygous loss of the von Hippel-Lindau (VHL) gene □ (B) Mutational activation of the MET proto-oncogene □ (C) Trisomy of chromosome 7 associated genes □ (D) Integration of human papillomavirus-16 (HPV-16) □ (E) Microsatellite instability

A. Homozygous loss of the von Hippel-Lindau gene

A 62-year-old man has had several episodes of hematuria over the past week. He has not experienced increased urinary frequency or dysuria. On physical examination, there are no remarkable findings. Urinalysis shows 4+ hematuria. The urine culture is negative. A cystoscopy is performed, and a 2-cm sessile, friable mass is seen on the right bladder wall. A biopsy specimen is obtained; the microscopic appearance is shown in the figure. Which of the following risk factors is most important in the pathogenesis of this bladder lesion? □ (A) Smoking cigarettes □ (B) Schistosomiasis □ (C) Diabetes mellitus □ (D) Chronic bacterial cystitis □ (E) Nodular prostatic hyperplasia

A. Smoking cigarettes

A 72-year-old man with Alzheimer disease dies of pneumonia. The gross appearance of the right kidney at autopsy is shown in the figure. The left kidney is normal in size, with a smooth cortical surface and a single 0.6-cm, fluid-filled cyst. The appearance of the right kidney is most suggestive of renal injury from which of the following? □ (A) Ureteral obstruction □ (B) Benign nephrosclerosis □ (C) Analgesic abuse □ (D) Chronic pyelonephritis □ (E) Diabetes mellitus

A. Ureteral obstruction

A 33-year-old woman has had fever and increasing fatigue for the past 2 months. Over the past year, she has noticed soreness of her muscles and joints and has had a 4-kg weight loss. On physical examination, her temperature is 37.5°C, pulse is 80/min, respirations are 15/min, and blood pressure is 145/95 mm Hg. She has pain on deep inspiration, and a friction rub is heard on auscultation of the chest. Laboratory findings show glucose, 73 mg/dL; total cholesterol, 160 mg/dL; total protein, 5.2 g/dL; albumin, 2.9 g/dL; total bilirubin, 0.9 mg/dL; and creatinine, 2.4 mg/dL. Serum complement levels are decreased. CBC shows hemoglobin of 9.7 g/dL, platelet count of 85,000/mm3, and WBC count of 3560/mm3. A renal biopsy specimen shows a diffuse proliferative glomerulonephritis with extensive granular immune deposits of IgG and C1q in capillary loops and mesangium. After being treated with immunosuppressive therapy consisting of prednisone and cyclophosphamide, her condition improves. Which of the following serologic studies is most likely to be positive in this patient? □ (A) Anticentromere antibody □ (B) Anti-double-stranded DNA antibody □ (C) Anti-DNA topoisomerase I antibody □ (D) Anti-glomerular basement membrane antibody □ (E) Antihistone antibody □ (F) ANCA □ (G) Antiribonucleoprotein

B. Anti- ds DNA Ab

A 45-year-old man has experienced increasing malaise, nausea, and reduced urine output for the past 3 days. On physical examination, he is afebrile and normotensive. Laboratory findings show a serum creatinine level of 2.5 mg/dL. Urinalysis shows hematuria, but no pyuria or glucosuria. A renal biopsy is done; the immunofluorescence pattern with antifibrinogen is shown in the figure. Which of the following additional studies is most useful for classification and treatment of this disease? □ (A) ANA titer □ (B) Anti-glomerular basement membrane antibody test □ (C) HIV titer □ (D) Quantitative serum immunoglobulins □ (E) Rheumatoid factor □ (F) Urine immunoelectrophoresis

B. Anti-glomerular basement membrane Ab test

A 66-year-old woman died of an acute myocardial infarction. At autopsy, both kidneys were decreased in size (about 120 g each) with a finely granular cortical surface. The representative appearance of the kidney under high magnification is shown in the figure. Which of the following clinical abnormalities most likely accompanied this lesion? □ (A) Oliguria □ (B) Benign hypertension □ (C) Malignant hypertension □ (D) Hematuria □ (E) Flank pain

B. Benign hypertension

A 45-year-old Hispanic man has had increasing malaise with headaches and easy fatigability for the past 3 months. Physical examination reveals his blood pressure is 200/100 mm Hg. There are no palpable abdominal masses and no costovertebral tenderness. Laboratory studies show hemoglobin, 9.5 g/dL; hematocrit, 28.3%; MCV, 92 μm3; creatinine, 4.5 mg/dL; and urea nitrogen, 42 mg/dL. Urinalysis reveals 3+ hematuria and 3+ proteinuria, but no glucose or leukocytes. A renal biopsy is done; light microscopic examination of the biopsy specimen shows that approximately 50% of the glomeruli appear normal, but the rest show that a portion of the capillary tuft is sclerotic. Immunofluorescence staining shows IgM and C3 deposition in these sclerotic areas. Past history is significant for repeated episodes of passing dark brown urine, which failed to respond to corticosteroid therapy. Which of the following mechanisms is most likely responsible for his disease? □ (A) Deposition of immune complexes containing microbial antigens □ (B) Dysfunction of the podocyte slit diaphragm apparatus □ (C) Deposition of anti-glomerular basement membrane antibodies □ (D) Inherited defect in the basement membrane collagen □ (E) Deposition of C3 nephritic factor (C3NeF)

B. Dysfunction of the podocyte slit diaphragm apparatus

A 56-year-old man has had back pain and has passed dark-colored urine for the past month. On physical examination, there is right costovertebral angle tenderness. Urinalysis shows a pH of 6; specific gravity 1.015; 2+ hematuria; and no protein, glucose, or ketones. Microscopic examination of the urine shows numerous RBCs, few WBCs, and no casts or crystals. The figure shows the representative gross appearance of the renal lesion. Which of the following laboratory findings is most likely to be reported? □ (A) Elevated serum cortisol level □ (B) Elevated hematocrit □ (C) Ketonuria □ (D) Decreased creatinine clearance □ (E) Increased plasma renin activity

B. Elevated hematocrit

A 65-year-old woman has recently experienced several transient ischemic attacks. On physical examination, the only abnormal finding is a blood pressure of 150/95 mm Hg. Urinalysis shows 1+ proteinuria, and no glucose, blood, or ketones. Microscopic examination of the urine shows no RBCs or WBCs and few oxalate crystals. On abdominal ultrasound, the kidneys are slightly decreased in size. Which of the following renal lesions is most likely to be present in this patient? □ (A) Crescentic glomerulonephritis □ (B) Hyaline arteriolosclerosis □ (C) Mesangial cell proliferation □ (D) Arteriolar fibrinoid necrosis □ (E) Acute tubular necrosis □ (F) Interstitial nephritis

B. Hyaline arteriolosclerosis

Three years ago, a 47-year-old woman had a mastectomy of the right breast to remove an infiltrating ductal carcinoma. She now has bone pain, and a radionuclide scan shows multiple areas of increased uptake in the vertebrae, ribs, pelvis, and right femur. Urinalysis shows a specific gravity of 1.010, which remains unchanged after water deprivation for 12 hours. She undergoes several courses of chemotherapy over the next year. During this time, the serum urea nitrogen level progressively increases. Which of the following abnormal laboratory findings is most likely to be reported for this patient? □ (A) Hepatitis B surface antigenemia □ (B) Hypercalcemia □ (C) Hypercholesterolemia □ (D) Hypergammaglobulinemia □ (E) Hyperglycemia □ (F) Hyperuricemia

B. Hypercalcemia

A 58-year-old woman dies of a cerebral infarction. Laboratory findings before death included serum urea nitrogen level of 110 mg/dL and creatinine level of 9.8 mg/dL. At autopsy, the kidneys are small (75 g) and have a coarsely granular surface appearance. Microscopic examination shows sclerotic glomeruli, a fibrotic interstitium, tubular atrophy, arterial thickening, and scattered lymphocytic infiltrates. Which of the following clinical findings was most likely reported on the patient's medical history? □ (A) Rash □ (B) Hypertension □ (C) Hemoptysis □ (D) Lens dislocation □ (E) Pharyngitis

B. Hypertension

A 53-year-old woman has had dysuria and urinary frequency for the past week. On physical examination, her temperature is 38°C, and she has pain on palpation over the left costovertebral angle. Laboratory findings show glucose, 177 mg/dL; hemoglobin A1c, 9.8%; hemoglobin, 13.1 g/dL; platelet count, 232,200/mm3; and WBC count, 11,320/mm3. Urinalysis shows a pH of 6.5; specific gravity 1.016; 2+ glucosuria; and no blood, protein, or ketones. Microscopic examination of the urine shows numerous neutrophils, and a urine culture is positive for Escherichia coli. Which of the following complications is most likely to develop in this patient? □ (A) Acute tubular necrosis □ (B) Necrotizing papillitis □ (C) Crescentic glomerulonephritis □ (D) Hydronephrosis □ (E) Renal calculi

B. Necrotizing papillits

Several members of a family developed chronic renal failure by age 50 years. Most are males. The affected individuals also developed visual problems. Some younger family members have proteinuria and hematuria on urinalysis. A renal biopsy specimen from a 20-year-old man shows prominent tubular foam cells and glomerular basement membrane thickening and thinning. Family members with this disease are most likely to have which of the following additional manifestations? □ (A) Watery diarrhea □ (B) Nerve deafness □ (C) Presenile dementia □ (D) Dilated cardiomyopathy □ (E) Infertility

B. Nerve deafness

A 61-year-old woman sees the physician because she has experienced increasing malaise for the past 5 years. On physical examination, there are no abnormalities other than a blood pressure of 150/95 mm Hg. One week later, she dies suddenly. At autopsy, both kidneys have the external (left panel) and bisected (right panel) appearance as shown in the figure. Which of the following conditions was the most probable cause of death? □ (A) Metastatic Wilms tumor □ (B) Ruptured berry aneurysm □ (C) Acute tubular necrosis □ (D) Disseminated intravascular coagulation □ (E) Pneumothorax

B. Ruptured berry aneurysm

A 30-year-old woman with a history of recurrent urinary tract infections has had a high fever for the past 3 days. On physical examination, her temperature is 38.4°C. There is marked abdominal tenderness on deep palpation. A renal ultrasound scan shows an enlarged right kidney with pelvic and calyceal enlargement and cortical thinning; the left kidney appears normal. A right nephrectomy is done, and microscopic examination shows inflammatory infiltrates extending from the medulla to the cortex, with tubular destruction and extensive interstitial fibrosis. Lymphocytes, plasma cells, and neutrophils are abundant. Which of the following is most likely to produce these findings? □ (A) Benign nephrosclerosis □ (B) Vesicoureteral reflux □ (C) Lupus nephritis □ (D) Systemic amyloidosis □ (E) Congestive heart failure □ (F) Autosomal-dominant polycystic kidney disease

B. Vesicoureteral reflux

A 60-year-old, previously healthy man sees his physician because he feels feverish and weak. He reports passing dark-colored urine on several occasions during the past month, but has no urinary frequency, dysuria, or nocturia. On physical examination, his temperature is 37.8°C, and blood pressure is 125/85 mm Hg. A dipstick urinalysis shows 4+ hematuria; 1+ proteinuria; and no glucose or ketones. Which of the following procedures is the most appropriate in management of this patient? □ (A) Straining of urine for calculi □ (B) Urine microbiologic culture □ (C) Abdominal CT scan for renal mass □ (D) Collection of a 24-hour urine specimen for protein

C. Abdominal CT scan for renal mass

A previously healthy, 21-year-old man sees his physician because he notices blood in his urine. He reports no dysuria, frequency, or hesitancy of urination. On physical examination, there are no abnormal findings. Laboratory findings show a serum urea nitrogen level of 39 mg/dL and creatinine level of 4.1 mg/dL. A renal biopsy specimen is obtained; the immunofluorescence pattern of staining with antibody against human IgG is shown in the figure. Which of the following serum laboratory studies is most likely to be positive in this patient? □ (A) Antistreptolysin O antibody □ (B) HIV antibody □ (C) Anti-glomerular basement membrane antibody □ (D) Hepatitis B surface antibody □ (E) C3 nephritic factor

C. Anti-glomerular basement membrane Ab

A 32-year-old man has developed a fever and skin rash over the past 3 days. Five days later, he has increasing malaise and visits his physician. On physical examination, the maculopapular erythematous rash on his trunk has nearly faded away. His temperature is 37.1°C, and blood pressure is 135/85 mm Hg. Laboratory studies show a serum creatinine level of 2.8 mg/dL and blood urea nitrogen level of 29 mg/dL. Urinalysis shows 2+ proteinuria; 1+ hematuria; and no glucose, ketones, or nitrite. The leukocyte esterase result is positive. Microscopic examination of urine shows RBCs and WBCs, some of which are eosinophils. What is the most likely cause of this patient's condition? □ (A) Urinary tract infection □ (B) Congestive heart failure □ (C) Antibiotic use □ (D) Streptococcal pharyngitis □ (E) Poorly cooked ground beef

C. Antibiotic use

A 58-year-old woman sees her physician for a routine health maintenance examination. The only abnormality on physical examination is a blood pressure of 168/109 mm Hg. Urinalysis shows a pH of 7.0; specific gravity 1.020; 1+ proteinuria; and no blood, glucose, or ketones. An abdominal ultrasound scan shows bilaterally and symmetrically small kidneys with no masses. The ANA test result is negative. The serum urea nitrogen level is 51 mg/dL, and the creatinine level is 4.7 mg/dL. The hemoglobin A1c concentration is within the reference range. What is the most likely diagnosis? □ (A) Lupus nephritis □ (B) Autosomal-dominant polycystic kidney disease □ (C) Chronic glomerulonephritis □ (D) Nodular glomerulosclerosis □ (E) Amyloidosis

C. Chronic glomerulonephritis

A 50-year-old woman has had fever and flank pain for the past 2 days. On physical examination, her temperature is 38.2°C, pulse is 81/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. Urinalysis shows no protein, glucose, or ketones. The leukocyte esterase test is positive. Microscopic examination of the urine shows numerous polymorphonuclear leukocytes and occasional WBC casts. Which of the following organisms is most likely to be found in the urine culture? □ (A) Mycobacterium tuberculosis □ (B) Mycoplasma hominis □ (C) Escherichia coli □ (D) Group A streptococcus □ (E) Cryptococcus neoformans

C. E.coli

A 35-year-old, previously healthy man is found dead in his home. At autopsy, the medical examiner notices bilaterally enlarged kidneys that contain multiple, irregularly arranged cysts of different shapes and sizes. There is a 0.5-cm nonruptured intracerebral berry aneurysm of the anterior communicating artery. There are scattered 1- to 2-cm, fluid-filled liver cysts involving 10% of the parenchymal volume. Postmortem laboratory testing of the urine and blood shows markedly elevated levels of cocaine and its metabolite, benzoylecgonine. Which of the following is the most appropriate conclusion to be drawn from these findings? □ (A) He had lesions related to chronic use of cocaine □ (B) He had autosomal-recessive polycystic kidney disease, but survived to adulthood □ (C) His surviving family (children, siblings, and parents) should be evaluated for a similar condition □ (D) The immediate cause of death is berry aneurysm □ (E) The underlying cause of death is autosomal-dominant polycystic kidney disease

C. His surviving family should be evaluated for a similar condition

A 45-year-old man has had headaches, nausea, and vomiting that have worsened over the past 5 days. He has started "seeing spots" before his eyes. On physical examination, his blood pressure is 268/150 mm Hg. Urinalysis shows 1+ proteinuria; 2+ hematuria; and no glucose, ketones, or leukocytes. The serum urea nitrogen and creatinine levels are elevated. Which of the following histologic findings is most likely to be seen in this patient's kidneys? □ (A) Nodular glomerulosclerosis □ (B) Segmental tubular necrosis □ (C) Hyperplastic arteriolosclerosis □ (D) Mesangial IgA deposition □ (E) Glomerular crescents

C. Hyperplastic arteriolosclerosis

A 31-year-old woman experiences abdominal pain and sees her physician 1 week later after noticing blood in her urine. She has had three episodes of urinary tract infection during the past year. There are no remarkable findings on physical examination. Urinalysis shows 2+ hematuria; 1+ proteinuria; hypercalciuria; and no glucose or ketones. Microscopic examination of the urine shows numerous RBCs and oxalate crystals. An intravenous pyelogram shows linear striations radiating into the renal papillae, along with small cystic collections of contrast material in dilated collecting ducts. She is advised to increase her daily intake of fluids, and her condition improves. Which of the following conditions is most likely to be associated with these findings? □ (A) Autosomal-dominant polycystic kidney disease □ (B) Gout □ (C) Medullary sponge kidney □ (D) Multicystic renal dysplasia □ (E) Autosomal-recessive polycystic kidney disease □ (F) Urothelial carcinoma □ (G) Vesicoureteral reflux

C. Medullary sponge kidney

A 38-year-old woman sees her physician because she has been feeling tired and lethargic for several months. On physical examination, she is afebrile, and her blood pressure is 140/90 mm Hg. Laboratory findings show hemoglobin, 10.3 g/dL; hematocrit, 30.9%; platelet count, 310,700/mm3; and WBC count, 5585/mm3. The serum creatinine level is 5.8 mg/dL. C3 nephritic factor is present in serum, and the ANA test result is negative. Urinalysis shows 2+ proteinuria. A renal biopsy is done; microscopic examination shows hypercellular glomeruli and prominent electron-dense deposits along the lamina densa of the glomerular basement membrane. Which of the following forms of glomerulonephritis is most likely to be present in this patient? □ (A) Postinfectious glomerulonephritis □ (B) Rapidly progressive glomerulonephritis □ (C) Membranoproliferative glomerulonephritis □ (D) Chronic glomerulonephritis □ (E) Membranous glomerulonephritis

C. Membranoproliferative glomerulonephritis

A 25-year-old man has a 5-year history of celiac sprue. Several days after a mild upper respiratory infection, he begins passing dark red-brown urine. The dark urine persists for the next 3 days and then becomes clear and yellow, only to become red-brown again 1 month later. There are no remarkable findings on physical examination. Urinalysis shows a pH of 6.5; specific gravity 1.018; 3+ hematuria; 1+ proteinuria; and no glucose or ketones. Microscopic examination of the urine shows RBCs and no WBCs, casts, or crystals. A 24-hour urine protein level is 200 mg. A renal biopsy specimen from the glomeruli of this patient is most likely to show which of the following alterations? □ (A) Subepithelial electron-dense deposits □ (B) Granular staining of the basement membrane by anti-IgG antibodies □ (C) Mesangial IgA staining by immunofluorescence □ (D) Diffuse proliferation and basement membrane thickening □ (E) Thrombosis in the glomerular capillaries

C. Mesangial IgA staining by immunofluorescence

Over the past 72 hours, a 44-year-old man has experienced worsening headache, nausea, and vomiting. On physical examination, his blood pressure is 276/158 mm Hg, and there is bilateral papilledema. Urinalysis shows 2+ proteinuria; 1+ hematuria; and no glucose or ketones. Which of the following renal lesions is most likely to be present in this patient? □ (A) Papillary necrosis □ (B) Acute infarction □ (C) Necrotizing arteriolitis □ (D) Acute tubular necrosis □ (E) Acute pyelonephritis

C. Necrotizing arteriolitis

The top of the diaper is often noted to be damp on a girl infant. Radiologic imaging with contrast enhancement shows that there is a connection from the bladder to umbilicus. What is the most likely diagnosis? □ (A) Congenital diverticulum □ (B) Exstrophy □ (C) Persistent urachus □ (D) Vesicoureteral reflux □ (E) Vitelline duct remnant

C. Persistent urachus

A 47-year-old man has had a decreased urine output over the past 10 days. On physical examination, he is afebrile. Urinalysis shows 1+ proteinuria, 4+ hematuria, urobilinogen, and no glucose or ketones. Microscopic examination of the urine shows few WBCs and some RBCs with RBC casts. A renal biopsy is done, and the light microscopic appearance of a PAS-stained specimen is shown in the figure. What is the most likely clinical course in this patient? □ (A) Acute renal failure that is reversible with supportive therapy □ (B) Slowly developing renal failure that is unresponsive to corticosteroid treatment □ (C) Rapidly progressive renal failure accompanied by hemoptysis □ (D) Stable clinical course with intermittent hematuria □ (E) Fever, leukocytosis, and endotoxic shock

C. Rapidly progressive renal failure accompanied by hemoptysis

A 65-year-old woman has experienced increasing malaise with nocturia and polyuria for the past year. On physical examination, her blood pressure is 170/95 mm Hg. Urinalysis shows a pH of 7.5; specific gravity 1.010; 1+ proteinuria; and no glucose, blood, or ketones. The tests for leukocyte esterase and nitrite yield positive results, and levels of serum urea nitrogen and serum creatinine are elevated. Her clinical course is characterized by worsening renal failure, and she dies of bronchopneumonia. At autopsy, the kidneys are shrunken but unequal in size, and have deep, irregular surface scars. On sectioning, the calyces underlying the cortical scars are blunted and deformed. What is the most likely cause of renal failure in this patient? □ (A) Chronic glomerulonephritis □ (B) Essential hypertension □ (C) Reflux nephropathy □ (D) Autosomal-dominant polycystic kidney disease □ (E) Systemic lupus erythematosus

C. Reflux nephropathy

For the past 20 years, a 69-year-old man with chronic arthritis has taken more than 3 g of analgesics per day, including phenacetin, aspirin, and acetaminophen. He sees his physician because of increasing malaise, nausea, and diminished mentation. On physical examination, his blood pressure is 156/92 mm Hg. Laboratory findings show serum urea nitrogen level of 68 mg/dL and creatinine level of 7.1 mg/dL. CBC shows hemoglobin, 11.7 g/dL; hematocrit, 35.1%; platelet count, 188,500/mm3; and WBC count, 5385/mm3. Which of the following renal diseases is this patient most likely to develop? □ (A) Hydronephrosis □ (B) Chronic glomerulonephritis □ (C) Renal papillary necrosis □ (D) Renal cell carcinoma □ (E) Acute tubular necrosis

C. Renal papillary necrosis

A 19-year-old woman has had a fever and chills accompanied by right flank pain for the past 3 days. On physical examination, her temperature is 38.3°C, her blood pressure is 150/90 mm Hg, and there is right costovertebral angle tenderness. Laboratory findings show a serum glucose level of 77 mg/dL and creatinine level of 1 mg/dL. Urinalysis shows a pH of 6.5; specific gravity 1.018; and no protein, blood, glucose, or ketones. Microscopic examination of the urine shows many WBCs and WBC casts. Which of the following factors is most important in the pathogenesis of the renal disease affecting this patient? □ (A) Age □ (B) Sex □ (C) Vesicoureteral reflux □ (D) Blood pressure □ (E) Focus of infection in the lungs

C. Vesicoureteral relfux

A 7-year-old boy is recovering from impetigo. Physical examination shows a few honey-colored crusts on his face. The crusts are removed, and a culture of the lesions grows group A Streptococcus pyogenes. He is treated with antibiotics. One week later, he develops malaise with nausea and a slight fever and passes dark brown urine. Laboratory studies show a serum antistreptolysin O titer of 1:1024. Which of the following is the most likely outcome? □ (A) Development of rheumatic heart disease □ (B) Chronic renal failure □ (C) Lower urinary tract infection □ (D) Complete recovery without treatment □ (E) Progression to crescentic glomerulonephritis

D. Complete recovery w/o treatment

A 7-year-old boy is brought to the physician by his mother, who is concerned because he has become less active over the past 10 days. On physical examination, the boy has facial puffiness. Urinalysis shows no blood, glucose, or ketones, and microscopic examination shows no casts or crystals. The serum creatinine level is normal. A 24-hour urine collection yields 3.8 g of protein. He improves after corticosteroid therapy. He has two more episodes of proteinuria over the next few years, both of which respond to corticosteroid therapy. A renal biopsy is done. What is the most likely mechanism causing his disease? □ (A) Immune complex-mediated glomerular injury □ (B) Verocytotoxin-induced endothelial cell injury □ (C) Cytotoxic T cell-mediated tubular epithelial cell injury □ (D) Cytokine-mediated visceral epithelial cell injury □ (E) IgA-mediated mesangial cell injury

D. Cytokine-mediated visceral epithelial cell

A 50-year-old woman with diabetic nephropathy receives a renal allograft. An episode of acute cellular rejection requires an increase in immunosuppressive therapy. She develops dysuria. On examination, she has suprapubic pain on palpation. A urinalysis shows hematuria. Cystoscopy is performed, and 3- to 4-cm soft, yellow, slightly raised mucosal plaques are seen. Biopsy specimens of these lesions are taken and microscopically show mucosal infiltration by foamy macrophages with abundant PAS-positive cytoplasmic granules and small, laminated mineralized concretions. Which of the following organisms is most likely to be found in her urine? □ (A) Adenovirus □ (B) Candida albicans □ (C) Chlamydia trachomatis □ (D) Escherichia coli □ (E) Schistosoma haematobium

D. E.coli

Several days after eating a hamburger, chili, and ice cream at a home barbecue, a 5-year-old girl develops cramping abdominal pain and diarrhea. The next day, she has decreased urine output. On physical examination, there are petechial hemorrhages on the skin. Her temperature is 37°C, pulse is 90/min, respirations are 18/min, and blood pressure is 90/50 mm Hg. A stool sample is positive for occult blood. Laboratory findings show hemoglobin, 10.8 g/dL; hematocrit, 32.4%; platelet count, 64,300/mm3; and WBC count, 6480/mm3. The peripheral blood smear shows schistocytes, and the serum D-dimer level is elevated. Which of the following is the most likely causative organism? □ (A) Candida albicans □ (B) Proteus mirabilis □ (C) Clostridium difficile □ (D) Escherichia coli □ (E) Staphylococcus aureus

D. E.coli

After eating a cheeseburger, French fries, and ice cream for dinner one night, a 6-year-old girl develops nausea, mild abdominal cramping, and a slight fever. Three days later, her parents notice that she is passing dark stools and dark urine and appears fatigued and weak. On physical examination, she has a temperature of 37.9°C, pulse of 88/min, respirations of 18/min, and blood pressure of 140/90 mm Hg. Scattered petechiae are present on the extremities. Laboratory findings show a serum creatinine level of 2.2 mg/dL and urea nitrogen level of 20 mg/dL. Urinalysis shows a pH of 6; specific gravity 1.016; 2+ hematuria; and no protein or glucose. A renal biopsy specimen shows small thrombi within glomerular capillary loops. Which of the following diseases is most likely to produce these findings? □ (A) Postinfectious glomerulonephritis □ (B) Wegener granulomatosis □ (C) Hereditary nephritis □ (D) Hemolytic-uremic syndrome □ (E) IgA nephropathy

D. Hemolytic-uremic syndrome

A 29-year-old woman sees her physician because she has had a fever and sore throat for the past 3 days. On physical examination, her temperature is 38°C. The pharynx is erythematous, with yellowish tonsillar exudate. Group A Streptococcus pyogenes is cultured. She is treated with ampicillin and recovers fully in 7 days. Two weeks later, she develops fever and a rash, and notices a slight decrease in urinary output. Her temperature is 37.7°C, and there is a diffuse erythematous rash on the trunk and extremities. Urinalysis shows a pH of 6; specific gravity 1.022; 1+ proteinuria; 1+ hematuria; and no glucose or ketones. Microscopic examination of the urine shows RBCs and WBCs, including eosinophils, but no casts or crystals. What is the most likely cause of her disease? □ (A) Deposition of immune complexes with streptococcal antigens □ (B) Hematogenous dissemination of septic emboli □ (C) Renal tubular cell necrosis caused by bacterial toxins □ (D) Hypersensitivity reaction to ampicillin □ (E) Formation of antibodies against glomerular basement membrane

D. Hypersensitivity reaction to ampicillin

A 63-year-old man has noted increasing back pain for 7 months. He has had three respiratory tract infections with Streptococcus pneumoniae within the past year. On examination, he has pitting edema to his thighs. Laboratory studies show total serum protein, 9.6 g/dL; albumin, 3.5 g/dL; creatinine, 3 mg/dL; urea nitrogen, 28 mg/dL; and glucose, 79 mg/dL. Urinalysis shows proteinuria of 4 g/24 hr, but no glucosuria or hematuria. Abdominal CT scan shows enlarged kidneys without cysts or masses. A renal biopsy specimen shows deposits of amorphous pink material within glomeruli, interstitium, and arteries with H&E stain. Which of the following diseases is he most likely to have? □ (A) Analgesic nephropathy □ (B) Diabetes mellitus □ (C) Membranous glomerulonephritis □ (D) Multiple myeloma □ (E) Systemic lupus erythematosus □ (F) Wegener granulomatosis

D. Multiple Myeloma

A 79-year-old man has had increasing back pain and fatigue for the past 6 months. On physical examination, there are no remarkable findings. Laboratory studies include a CBC with hemoglobin of 9.6 g/dL, platelet count of 241,600/mm3, and WBC count of 7160/mm3. The serum total protein is 9.8 g/dL, albumin is 3.6 g/dL, glucose is 72 mg/dL, creatinine is 3.3 mg/dL, and urea nitrogen is 30 mg/dL. A dipstick urinalysis shows a pH of 7; specific gravity 1.011; and no blood, protein, or glucose. One month later, he develops a cough with fever, and Streptococcus pneumoniae is cultured from his sputum. Despite antibiotic therapy, he develops sepsis and dies. At autopsy, the kidneys are normal in size, but microscopic examination shows dilated tubules filled with amorphous blue-to-pink casts and occasional multinucleated giant cells. What is the most likely underlying cause of this patient's death? □ (A) Cystinuria □ (B) Diabetes mellitus □ (C) Gout □ (D) Multiple myeloma □ (E) Parathyroid adenoma □ (F) Systemic lupus erythematosus

D. Multiple Myeloma

A 49-year-old man goes to his physician for a checkup and is found on physical examination to have a blood pressure of 160/110 mm Hg, but no other abnormalities. Laboratory studies show serum glucose of 75 mg/dL, creatinine of 1.3 mg/dL, and urea nitrogen of 20 mg/dL. His plasma renin is elevated. CT angiography shows marked stenosis of his renal arteries. He is treated with an angiotensin-converting enzyme inhibitor. A week later, he has a headache for which he takes ibuprofen. Over the next day, his urine output decreases. A reduction in which of the following chemical mediators most likely caused his reduced urine output? □ (A) Aldosterone □ (B) Histamine □ (C) Nitric oxide □ (D) Prostaglandin □ (E) Tumor necrosis factor

D. Prostaglandin

For the past 6 months, a 72-year-old woman has noticed a slowly enlarging mass on the urethra. The mass causes local pain and irritation and is now bleeding. Physical examination shows a 2.5-cm warty, ulcerated mass protruding from the external urethral meatus. There are no lesions on the labia or vagina. A biopsy specimen of the lesion is most likely to identify which of the following? □ (A) Embryonal rhabdomyosarcoma □ (B) Leiomyoma □ (C) Papilloma □ (D) Squamous cell carcinoma □ (E) Syphilitic chancre

D. Squamous cell carcinoma

A 51-year-old woman has had recurrent urinary tract infections for the past 15 years. On many of these occasions, Proteus mirabilis was cultured from her urine. For the past 4 days, she has had a burning pain on urination and urinary frequency. On physical examination, her temperature is 37.9°C, pulse is 70/min, respirations are 15/min, and blood pressure is 135/85 mm Hg. There is marked tenderness on deep pressure over the right costovertebral angle and on deep abdominal palpation. Urinalysis shows a pH of 7.5; specific gravity 1.020; 1+ hematuria; and no protein, glucose, or ketones. Microscopic examination of the urine shows many RBCs, WBCs, and triple-phosphate crystals. Which of the following renal lesions is most likely to be present? □ (A) Renal cell carcinoma □ (B) Acute tubular necrosis □ (C) Malignant nephrosclerosis □ (D) Staghorn calculus □ (E) Papillary necrosis

D. Staghorn calculus

A 65-year-old man recently retired after many years in a job that involved exposure to aniline dyes, including ß- naphthylamine. One month ago, he had an episode of hematuria that was not accompanied by abdominal pain. On physical examination, there are no abnormal findings. Urinalysis shows 4+ hematuria, and no ketones, glucose, or protein. Microscopic examination of the urine shows RBCs that are too numerous to count, 5 to 10 WBCs per high-power field, and no crystals or casts. The result of a urine culture is negative. What is the most likely diagnosis? □ (A) Renal cell carcinoma □ (B) Hemorrhagic cystitis □ (C) Tubercular cystitis □ (D) Urothelial carcinoma □ (E) Squamous cell carcinoma of the urethra

D. Urothelial carcinoma

A 17-year-old boy is involved in a motor vehicle accident in which he sustains severe blunt trauma to the extremities and abdomen. Over the next 3 days, he develops oliguria and dark brown urine. The urine dipstick analysis is positive for myoglobin and for blood, but microscopic examination of the urine shows no RBCs. His serum urea nitrogen level increases to 38 mg/dL, and he undergoes hemodialysis for 3 weeks. His condition improves, but the urine output remains greater than 3 L/day for 1 week before the urea nitrogen returns to normal. Which of the following renal lesions was most likely present in this patient? □ (A) Malignant nephrosclerosis □ (B) Renal vein thrombosis □ (C) Membranous glomerulonephritis □ (D) Acute pyelonephritis □ (E) Acute tubular necrosis

E. Acute tubular necrosis

A 15-year-old boy has been passing dark-colored urine for the past month. On physical examination, he has bilateral sensorineural hearing loss and corneal erosions. Urinalysis shows a pH of 6.5; specific gravity 1.015; 1+ hematuria; 1+ proteinuria; and no ketones, glucose, or leukocytes. The serum creatinine level is 2.5 mg/dL, and the urea nitrogen level is 24 mg/dL. A renal biopsy specimen shows tubular epithelial foam cells by light microscopy. By electron microscopy, the glomerular basement membrane shows areas of attenuation, with splitting and lamination of lamina densa in other thickened areas. What is the most likely diagnosis? □ (A) Acute tubular necrosis □ (B) Berger disease □ (C) Membranous glomerulonephritis □ (D) Diabetic nephropathy □ (E) Alport syndrome

E. Alport syndrome

A 28-year-old woman has had dysuria, frequency, and urgency for the past 2 days. On physical examination, her temperature is 37.6°C. A urine culture grows greater than 100,000 colonies/mL of Escherichia coli. She is treated with antibiotic therapy. If the problem continues to recur, the patient is likely to be at greatest risk for development of which of the following renal diseases? □ (A) Diffuse glomerulosclerosis □ (B) Chronic glomerulonephritis □ (C) Amyloidosis □ (D) Membranous glomerulonephritis □ (E) Chronic pyelonephritis

E. Chronic pyelonephritis

A 49-year-old man saw his physician because he had increased swelling in the extremities for 2 months. Physical examination showed generalized edema. A 24-hour urine collection yielded 4.1 g of protein and albumin and globulins. Extensive testing did not indicate the presence of a systemic disease, such as diabetes mellitus or systemic lupus erythematosus. He did not respond to a course of corticosteroid therapy. A renal biopsy was done, and microscopic examination showed diffuse thickening of the basement membrane. Immunofluorescence staining with antibody to the C3 component of complement was positive in a granular pattern in the glomerular capillary loops. Two years later, he experiences increasing malaise. Laboratory studies now show serum creatinine level of 4.5 mg/dL and urea nitrogen level of 44 mg/dL. Which of the following immunological mechanisms was most likely responsible for the glomerular changes observed in the biopsy specimen? □ (A) Antibodies that react with basement membrane collagen □ (B) Antibodies against streptococci that cross-react with the basement membrane □ (C) Release of cytokines by inflammatory cells □ (D) Cytotoxic T cells directed against renal antigens □ (E) Deposition of immune complexes on the basement membrane

E. Deposition of immune complexes on the basement membrane

The parents of a 6-year-old girl notice that she has become increasingly lethargic over the past 2 weeks. On examination by the physician, she has puffiness around the eyes. Her temperature is 36.9°C, and blood pressure is 100/60 mm Hg. Laboratory findings show a serum creatinine level of 0.7 mg/dL and urea nitrogen level of 12 mg/dL. Urinalysis shows a pH of 6.5; specific gravity 1.011; 4+ proteinuria; and no blood or glucose. The 24-hour urine protein level is 3.8 g. The child's condition improves after glucocorticoid therapy. Which of the following findings by electron microscopy is most likely to characterize this disease process? □ (A) Subepithelial electron-dense humps □ (B) Reduplication of glomerular basement membrane □ (C) Areas of thickened and thinned basement membrane □ (D) Increased mesangial matrix □ (E) Effacement of podocyte foot processes

E. Effacement of podocyte foot processes

A 28-year-old, previously healthy man suddenly develops severe abdominal pain and begins passing red urine. There are no abnormalities on physical examination. Urinalysis shows a pH of 7; specific gravity 1.015; 1+ hematuria; and no protein, glucose, or ketones. The patient is given a device to use in straining the urine for calculi. The next day, the patient recovers a 0.3-cm stone that is sent for analysis. The chemical composition is found to be calcium oxalate. What underlying condition is most likely to be present? □ (A) Gout □ (B) Acute cystitis □ (C) Diabetes mellitus □ (D) Primary hyperparathyroidism □ (E) Idiopathic hypercalciuria

E. Idiopathic hypercalciuria

A 25-year-old woman experiences sudden onset of fever, malaise, and nausea. On physical examination, her temperature is 38.2°C, pulse is 85/min, respirations are 18/min, and blood pressure is 140/90 mm Hg. A routine urinalysis shows 1+ proteinuria, 4+ hematuria, and no ketones or glucose. RBC casts are seen on microscopic examination of the urine. A renal biopsy is performed, and light microscopic examination shows marked glomerular hypercellularity with neutrophils in glomerular capillary loops. Immunofluorescence microscopy shows granular deposition of IgG and C3 in glomerular capillary basement membranes. Electron microscopy shows electron-dense subepithelial "humps." What is the most likely diagnosis? □ (A) Goodpasture syndrome □ (B) Systemic amyloidosis □ (C) Membranous glomerulonephritis □ (D) Diabetes mellitus □ (E) Postinfectious glomerulonephritis

E. Postinfectious glomerulonephritis

A 77-year-old man has had increasing difficulties with urination for the past 2 years. He has difficulty starting and stopping the urine stream. On physical examination, his temperature is 37°C, and blood pressure is 130/85 mm Hg. The figure shows the representative gross appearance of the bladder. Which of the following laboratory findings is most likely to be reported in this patient? □ (A) Positive ANA test result □ (B) Urine culture positive for Mycobacterium tuberculosis □ (C) Hemoglobin concentration of 22.5 g/dL □ (D) Schistosoma haematobium eggs in urine □ (E) Prostate-specific antigen level of 5 ng/mL

E. Prostate-specific Ag level of 5 ng/mL

A 26-year-old man is involved in a motor vehicle accident and sustains acute blood loss. He is hypotensive for several hours before paramedical personnel arrive. They stabilize the bleeding and transport him to a hospital, where he receives a transfusion of 3 U of packed RBCs. Over the next week, the serum urea nitrogen level increases to 48 mg/dL, the serum creatinine level increases to 5 mg/dL, and the urine output decreases. He undergoes hemodialysis for the next 2 weeks and then develops marked polyuria, with urine output of 2 to 3 L/day. His recovery is complicated by bronchopneumonia, but renal function gradually returns to normal. The patient's transient renal disease is best characterized by which of the following histologic features? □ (A) Glomerular crescents in Bowman space □ (B) Interstitial lymphocytic infiltrates □ (C) Arteriolar fibrinoid necrosis □ (D) Nodular glomerulosclerosis □ (E) Rupture of tubular basement membrane

E. Rupture of tubular basement membrane

A 42-year-old man has had right flank pain for the past 2 days. On physical examination, his temperature is 37.4°C, pulse is 70/min, respirations are 14/min, and blood pressure is 130/85 mm Hg. Laboratory studies show a serum creatinine level of 1.1 mg/dL. Urinalysis shows no blood, protein, or glucose, and microscopic examination of the urine shows no WBCs or RBCs. Abdominal CT scan shows a 7-cm eccentric lesion of the upper pole of the right kidney. The lesion is well circumscribed and cystic with a thin wall and focal hemorrhage. What is the most likely diagnosis? □ (A) Acute pyelonephritis □ (B) Acute tubular necrosis □ (C) Diabetic nephropathy □ (D) Hydronephrosis □ (E) Simple renal cyst □ (F) Rapidly progressive glomerulonephritis □ (G) Renal cell carcinoma □ (H) Urothelial carcinoma

E. Simple renal cysts

A 4-year-old girl has complained of abdominal pain for the past month. On physical examination, she is febrile, and palpation of the abdomen shows a tender mass on the right. Bowel sounds are present. Laboratory studies show hematuria without proteinuria. Abdominal CT scan shows a 12-cm, circumscribed, solid mass in the right kidney. A right nephrectomy is done; the gross appearance of the mass is shown in the figure. What is the most likely diagnosis? □ (A) Angiomyolipoma □ (B) Interstitial cell tumor □ (C) Renal cell carcinoma □ (D) Transitional cell carcinoma □ (E) Wilms tumor

E. Wilms tumor

A 58-year-old, relatively healthy man sees his physician for a routine health maintenance examination. Physical examination shows mild hypertension. Laboratory findings show a serum creatinine level of 2.2 mg/dL and urea nitrogen level of 25 mg/dL. Microalbuminuria is present, with excretion of 250 mg/day of albumin. Two years later, he returns for a follow-up visit. He is now hypertensive and has a serum creatinine level of 3.8 mg/dL, urea nitrogen level of 38 mg/dL, and 24-hour urine protein level of 2.8 g. A renal biopsy is done; the light microscopic appearance of a PAS-stained specimen is shown in the figure. Which of the following laboratory findings is most likely to be abnormal in this patient? □ (A) Anti-glomerular basement membrane antibody □ (B) ANA □ (C) ANCA □ (D) Antistreptolysin O □ (E) C3 nephritic factor □ (F) Hemoglobin A1c

F. Hgb A1c

A 55-year-old woman has had poorly controlled hyperglycemia for many years. She sees her physician after experiencing burning pain on urination for 3 days. Physical examination shows a 2-cm ulceration on the skin of the heel and reduced sensation in the lower extremities. Her visual acuity is 20/100 bilaterally. Urinalysis shows 1+ proteinuria; 2+ glucosuria; and no blood, ketones, or urobilinogen. A urine culture contains more than 100,000 colony-forming units/mL of Klebsiella pneumoniae. Which of the following pathologic findings is most likely to be present in both kidneys? □ (A) Deposits of IgG and C3 in the glomerular basement membrane □ (B) Effacement of podocyte foot processes □ (C) Glomerular crescents □ (D) Mesangial deposits of IgA □ (E) Necrotizing granulomatous vasculitis □ (F) Nodular hyaline mesangial masses □ (G) Thickening and thinning of the glomerular basement membrane

F. Nodular hyaline mesangial masses

A 17-year-old girl has had arthralgias and myalgias for several months. During the past week, she has noticed a decreased output of urine, which is reddish brown. On physical examination, her blood pressure is 160/100 mm Hg, and she has an erythematous malar skin rash. The ANA and anti-double-stranded DNA test results are positive. The serum urea nitrogen level is 52 mg/dL. Which of the following urinalysis findings is most likely to be reported for this patient? □ (A) Eosinophils □ (B) Glucose □ (C) Ketones □ (D) Myoglobin □ (E) Oval fat bodies □ (F) RBC casts □ (G) Triple phosphate crystals □ (H) Uric acid crystals □ (I) Waxy casts

F. RBC casts

A 20-year-old woman, G1, P0, who is in the third trimester, has felt minimal fetal movement. An ultrasound scan shows a markedly decreased amniotic fluid index characteristic of oligohydramnios. She gives birth to a stillborn male fetus at 33 weeks' gestation. At autopsy, there are deformations resulting from marked oligohydramnios, including flattening of the facies, varus deformities of the feet, and marked pulmonary hypoplasia. Microscopic examination of the liver shows multiple epithelium-lined cysts and a proliferation of bile ducts. Which of the following best describes the appearance of the kidneys in this fetus? □ (A) Bilaterally enlarged kidneys replaced by 1- to 4-cm, fluid-filled cysts □ (B) Bilaterally shrunken kidneys with uniformly finely granular cortical surfaces □ (C) Decreased overall size of the right kidney and normal-sized left kidney □ (D) Irregular cortical scars in asymmetrically shrunken kidneys with marked calyceal dilation □ (E) Marked bilateral renal pelvic and calyceal dilation with thinning of the cortices □ (F) Normal-sized kidneys with smooth cortical surfaces □ (G) Symmetrically enlarged kidneys composed of small, radially arranged cysts

G. Symmetrically enlarged kidneys composed of small, radially arranged cysts

A 28-year-old man is diagnosed with acute myelogenous leukemia (M2). After induction with a multiagent chemotherapy protocol, he has an episode of lower abdominal pain accompanied by passage of red-colored urine. He has no fever, dysuria, or urinary frequency. On physical examination, there are no remarkable findings. Urinalysis shows a pH of 5.5; specific gravity 1.021; 2+ hematuria; and no protein, ketones, or glucose. There are no remarkable findings on an abdominal radiograph. Which of the following additional urinalysis findings is most likely to be reported for this patient? □ (A) Bence Jones protein □ (B) Eosinophils □ (C) Myoglobin □ (D) Oval fat bodies □ (E) RBC casts □ (F) Triple phosphate crystals □ (G) Uric acid crystals □ (H) Waxy casts □ (I) WBC casts

G. Uric acid crystals

A 32-year-old man with a history of intravenous drug use comes to the emergency department because he has had a high fever for the past 2 days. On physical examination, his temperature is 38.4°C. He has a palpable spleen tip, bilateral costovertebral angle tenderness, and diastolic cardiac murmur. Laboratory findings show a serum urea nitrogen level of 15 mg/dL. Urinalysis shows 2+ hematuria, and no glucose, protein, or ketones. A blood culture is positive for Staphylococcus aureus. Which of the following best describes the kidneys in this patient? □ (A) Bilaterally enlarged kidneys replaced by 1- to 4-cm, fluid-filled cysts □ (B) Bilaterally shrunken kidneys with uniformly finely granular cortical surfaces □ (C) Irregular cortical scars in asymmetrically shrunken kidneys with marked calyceal dilation □ (D) Marked bilateral renal pelvic and calyceal dilation with thinning of the cortices □ (E) Normal-sized kidneys with smooth cortical surfaces □ (F) Scattered petechial hemorrhages in slightly swollen kidneys □ (G) Wedge-shaped regions of yellow-white cortical necrosis involving both kidneys

G. Wedge-shaped regions of yellow-white cortical necrosis involving both kidneys

A 44-year-old man has developed a fever, nonproductive cough, and decreased urine output over the past 3 days. On physical examination, his temperature is 37.7°C, and blood pressure is 145/95 mm Hg. He has sinusitis. On auscultation, crackles are heard over all lung fields. A chest radiograph shows bilateral patchy infiltrates and nodules. The serum creatinine level is 4.1 mg/dL, and the urea nitrogen level is 43 mg/dL. The results of serologic testing are negative for ANA, but positive for C-ANCA. A renal biopsy specimen shows glomerular crescents and granulomatous vasculitis. The result of immunofluorescence staining with anti-IgG and anti-C3 antibodies is negative. What is the most likely diagnosis? □ (A) Focal segmental glomerulosclerosis □ (B) Goodpasture syndrome □ (C) Lupus nephritis □ (D) Membranoproliferative glomerulonephritis type II □ (E) Membranous glomerulonephritis □ (F) Postinfectious glomerulonephritis □ (G) Wegener's granulomatosis

G. Wegener's granulomatosis