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Renal

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Answer 50 questions in 15 minutes.
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1. in acute post strep GN - What do you see on LM - EM and IF

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2. What are the associated paraneoplastic syndromes wth RCC
Sodium dependent transporters in proximal tubules - 3 distinct carrier systems - competitive inhibition within each group
No
Amyloidosis
Ectopic EPO - ACTH - PTHrP - prolactin

3. Subendothelial immune complexes with granular IF
Men 50 to 70 - inc incidence with smoking and obesity
Drugs - infections - SLE - solid tumors - most common cause of adult nephrotic syndrome
Na and volume loss
Membranoproliferative glomerulonephritis

4. WBC casts - ddx
Most of the bicarb - sodium - chloride - and water
Tubulointerstitial inflammation - acute pyelonephritis - transplant rejection
Inc GFR and mesangial expansion
PAH is freely filtered and actively secreted - all PAH entering kidney is secreted

5. What is the effect of of PTH on the distal convoluted tubule
Inc Ca/Na exchange to inc Ca reabsoprtion
White cell casts
20 percent
AR - congenital hepatic fibrosis - renal failure in utero leading to potters - beyond = HTN - portal HTN - progressive renal insuff

6. What 3 things stimulate the release of renin - and Where is it released from
Cystine - 2ndary to cystinuria - hexagonal - treat with alkalization of urine
Dec BP - dec in Osm - inc sympathetic tone - released from kidneys
Inhibiting renal production of prostaglandins which keep the afferent arteriole vasodilated to maintain GFR
PH = pKa + log bicarb/0.03PCO2

7. diffuse
Invades IVC and spreads hematogenously
Dec renal bicarb reabsorption - delayed
All glomeruli
Becomes concentrated and hypertonic

8. What is the least common kidney stone - What causes it and How do you treat it
Cystine - 2ndary to cystinuria - hexagonal - treat with alkalization of urine
Involves glomeruli and other organs
Decreased - ATN - ischemia - toxins leads to obstruction and backflow - dec GFR - BUN reabsorption is impaired
Sodium dependent transporters in proximal tubules - 3 distinct carrier systems - competitive inhibition within each group

9. massive proteinuria (>3.5g/day) frothy urine - hyperlipidemia - fatty casts - edema
NC - inc - inc
Eosinphilic casts in tubules
Nephrotic syndrome
Von hippel laundau and gene deletion in chromosome 3

10. gross hematuria and proteinuria possibly triggered by infxn or immune stimulus - dz - path associated conditions
Cx<GFR
Deficiency in neutral amino acid (tryptophan) transporter - resulting in pellagra
Renal papillary necrosis - sloughing of renal papillae - DM - acute pyelonephritis - phenacetin - sickle cell
Hydronephrosis and pyelonephritis

11. What is the prognosis of RPGN
Poor - days to weeks
Involves glomeruli and other organs
Radiopaque
GFR x plasma concentration

12. What is the BUN/Cr ratio in instrinsic renal ARF and why
Decreased - ATN - ischemia - toxins leads to obstruction and backflow - dec GFR - BUN reabsorption is impaired
Von hippel laundau and gene deletion in chromosome 3
No
ANP

13. What needs to happen for postrenal obstruction to creat ARF
Needs to be bilateral
Dec renal bicarb reabsorption - delayed
AR - congenital hepatic fibrosis - renal failure in utero leading to potters - beyond = HTN - portal HTN - progressive renal insuff
Diarrhea - glue - RTA - hyperchloremia

14. What therapy does miminal change respond to...
Corticosteroids
Hyperkalemia - inhibition of ammonium excretion in proximal tubule - decrease urine pH due to dec bufferiing capacity
Dialysis cysts
PH = pKa + log bicarb/0.03PCO2

15. What are JG cells and what substance do they secrete
Solute is reabsorbed less quickly than water or net secretion of substance
Hyperceullular glomeruli
Bladder cancer
Modified smooth muscle of afferent arteriole - secrete renin

16. What is the ddx for a metabolic acidosis with nl anion gap (8-12)
Radiopaque
Hyperkalemia
Diarrhea - glue - RTA - hyperchloremia
Dec - inc - dec

17. What is the 60-40-20 rule of body weight
Acute tubular necrosis - renal ischemia (shock - sepsis) - crush injury (myoglobinuria) - toxins - muddy brown casts
60% total body water - 40% ICF - 20% ECF
Type 1 - GBM splitting caused by mesangial growth - HBV - HCV
Decreased - ATN - ischemia - toxins leads to obstruction and backflow - dec GFR - BUN reabsorption is impaired

18. hyaline casts ddx
Nonspecific
Ectopic EPO - ACTH - PTHrP - prolactin
<3.5 g /day
Most of the bicarb - sodium - chloride - and water

19. What is the effect of AT II on efferent arterioles
Hypokalemia - risk for Ca containing kidney stones
Renal artery - interlobar a - interlobular a
Kids - triggered by recent infxn or immune stimulus - selective loss of albumin not globulins
Contrict leading to inc FF - preserver renal GFR in low volume states

20. What change (lack of) is common in children with renal failure
Uric acid - hyperuricemia - dz with inc cell turnover like leukemia
Growth retardation and developmental delay
Filtered - secreted
GFR x plasma concentration

21. What is the effect of AT II on GFR - FF and Na
Goodpastures - type II hypersens - antibodies to GBM and alveolar BM - linear IF - Wegeners (c - ANCA) - mircoscopic polyangiitis (p - ANCA)
Inc GFR - in FF but WITH compensatory Na reabsorption in proximal and distal nephron
Calcium (oxalate or phosphate or both) - hypercalcemia caused by cancer - inc PTH
Insertion of Na channel on luminal side

22. What cells create the epithelial layer of the glomerular filtration barrier
PAH is freely filtered and actively secreted - all PAH entering kidney is secreted
Hematuria - palpable mass - polycythemia - flank pain - fever and weight loss
Podocytes foot processes
Dec plasma Ca - inc plasma PO4 - dec plasma 1 -25 OH2 vit D

23. How does Wilms tumor present
Huge palpable flank mass and hematuria
2 ways - base exchanger and between epithelial cells
Inulin
Ammonia - buffer for secreted H+

24. What is transporter in the thick ascneding loop of Henle indirectly induces the paracellular reabsorption of Mg and Ca
White cell casts
Segmental sclerosis and hylanosis
NKCC
Dec BP - dec in Osm - inc sympathetic tone - released from kidneys

25. How do struvite stones appear on xray
Solute and water are reabsorbed at the same rate
Acute tubular necrosis - renal ischemia (shock - sepsis) - crush injury (myoglobinuria) - toxins - muddy brown casts
Radiopaque
Advanced renal dz - CRF

26. In renal failure What are the consquence sof Na/H20 retention
1/4 plasma - and 3/4 interstitial volume
Mutation in type IV collagen - split BM - nerve disorders - ocular disorders - X- linked dominant
CHF - pulmonary edema - HTN
Diuretics - vomiting - antacid - hyperaldosteronism

27. no net secretion or reabsorption of x
Actively reabsorbs NaCl - diluting - makes urine hypotonic
Cx = GFR
Macula densa and JG cells
Vasa recta - interlobular v - interlobar v - renal v

28. What does ADH do in the collecting tubule
Acts on V2 receptors leading to insertion of aquaporins on luminal side
Cx = GFR
Dec - dec - dec
Inc renal calcium reabsorption and dec renal phosphate reabsoprtion - BUT also stimulates the prox tub cells to make 1 -25 (OH)2 vit D which inc intestinal absorption of both Ca and PO4

29. What happens to pH - PCO2 and bicarb in metabolic acidosis
Complications of chronic kidney disease or HTN
Intra = HIKIN!
Inc in concentration - not amout - due to water reabsorption
Dec - dec - dec

30. Focal
Passively reabsorbs water via medullary hypertonicity
Dec BP - dec in Osm - inc sympathetic tone - released from kidneys
Few glomeruli
LM - wire looping of caps - EM - subendothelial DNA- anti - DNA IC - IF- granular

31. What is the net effect of ANP
LM- glomeruli enlarged and hypercellular - PMNs - 'lumpy- bumpy' appearance EM - supepithelial immunce complex humps - IF- granular
Inc - dec - dec
Hyperkalemia
Na and volume loss

32. Why can inulin be used to calculate GFR?
Freely filtered and neither absorbed or secreted
ADPKD
Passively reabsorbs water via medullary hypertonicity
Negative charge

33. net tubular secretion of x
160-200 - 350
Few glomeruli
Cx>GFR
Decreased - ATN - ischemia - toxins leads to obstruction and backflow - dec GFR - BUN reabsorption is impaired

34. What is the net effect of PTH
Converts 25- OH vitamin D to 1 -25 -(OH)2 vitamin D which inc intestinal reabsorption of both calcium and phosphate
Needs to be bilateral
Crescent - moon shape
Inc in Ca and PO4 absoprtion from the gut

35. What effect does afferent arteriole cxn have on RPF - GFR and FF
Ammonium magnesium phosphate (struvite) - infection with urease pos magnesium or radiolucent bugs like (proteus - staph - klebs)
Dec - dec - NC
Intra = HIKIN!
Hyperceullular glomeruli

36. Bergers' disease - which antibody and What do you see on LM and IF
Antifreeze - ethyelene glycol or vit C abuse
ANP
Inc synthesis of IgA and LM and IF - Ics depsoti in mesangium
Inulin

37. In what disease in FSGS the most common glomerular disease
Tubulointerstitial inflammation - acute pyelonephritis - transplant rejection
White cell casts
Respiratory compensation in response to metabolic acidosis - PC02 in 0.7mmHg for every mEq/L bicarb
HIV

38. By what percentage does EPRF underestimage true RPF
Renal artery - interlobar a - interlobular a
Diarrhea - glue - RTA - hyperchloremia
Sodium dependent transporters in proximal tubules - 3 distinct carrier systems - competitive inhibition within each group
By 10%

39. What is the genetic etiology of wilms tumor and What is WAGR complex
Tumor suppresor gene WT1 on chrom 11 - WAGR =Wilms - Aniridia - Genitourinary malformation and mental - motor Retardation
Dilate the afferent arteriole - inc RPF - inc GFR - FF is the same - NSAIDs reverse
Fibrin and plasma proteins (C3b) with glomerular function parietal cells - monocytes and MACS
Ammonia - buffer for secreted H+

40. What are the main causes of membranous GN
Diabetic glomerulonephropathy
Anion gap = na - (Cl + bicarb)
Hypervent - early high altitude - aspirin ingestion early
Drugs - infections - SLE - solid tumors - most common cause of adult nephrotic syndrome

41. What is the compensatory response in metabolic alkalosis
Excreted - filtered
ADPKD
Hypovent - immediate
LM- glomeruli enlarged and hypercellular - PMNs - 'lumpy- bumpy' appearance EM - supepithelial immunce complex humps - IF- granular

42. What happens to Cl in the proximal 1/3 of the proximal tubule relative to Na
Apical face - K/H ATPase exchanger - H- ATPase secretion basolateral face - Cl/HCO3 exchanger
Reabsorption is slower at first - then matches Na more distally thus relative concentration inc before it plateaus
Huge palpable flank mass and hematuria
RTA type 4 (hyperkalemic)

43. What is the cutoff of proteinuria in nephritic syndrome
ADPKD
<3.5 g /day
Renal papillary necrosis - sloughing of renal papillae - DM - acute pyelonephritis - phenacetin - sickle cell
Calcium (oxalate or phosphate or both) - hypercalcemia caused by cancer - inc PTH

44. What happens in the collecting tubules
RPF/(1- Hct)
Inc renal bicarb resabsoprtion - delayed
Reabsorb Na in exchange for secreting K and H
Acute tubular necrosis

45. What percentage of ECF is plasma and What is interstitial volume
Hyperkalemia - inhibition of ammonium excretion in proximal tubule - decrease urine pH due to dec bufferiing capacity
EPO - endothelial cells of peritubular capillaries
Passively reabsorbs water via medullary hypertonicity
1/4 plasma - and 3/4 interstitial volume

46. primary glomerular dz
Involves only glomeruli
Vasa recta - interlobular v - interlobar v - renal v
Acute - ATN - or chronic - HTN - DM
Inc renal bicarb resabsoprtion - delayed

47. benign - common - incidental finding of renal cysts - thin - nonenhancing - cortical - fluid filled
Simple cysts
Preservation of renal fxn in low volume states with simultaneous Na reabsorption to dec additional volume loss
Nephritic syndrome
Approx measure of GFR - slightly overestimates because creatinine is secreted in by the renal tubules

48. net tubular reabsorption of x
Under and under
Cx<GFR
Failure of vit d hydroxylation - ca wasting - phosphate retention - sencondary hyperPTH
Hypovent - immediate

49. in TCC - What does painelss hematuria suggest
Bladder cancer
Diuretics - vomiting - antacid - hyperaldosteronism
RTA type 4 (hyperkalemic)
HIV

50. What is the formula for filtration fraction
Failure of EPO
GFR/RPF
Simple cysts
Inc

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Renal

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