Renal papillary necrosis classically presents with gross hematuria, acute flank pain,
and passage of tissue fragments in urine. It is most commonly seen in patients with
sickle cell disease or trait, diabetes mellitus, analgesic nephropathy, or severe
obstructive pyelonephritis.

A 17-year-old female presents to your office with urinary frequency, urgency, and
burning during urination. She has also noticed a scant vaginal discharge. The
symptoms started two days ago. Which of the following additional findings would be
most suggestive of pyelonephritis in this patient?
• A. Abdominal pain
• B. Fever
• C. Microscopic hematuria
• D. Bacteriuria
• E. White blood cell casts
F. Sterile pyuria

A 17-year-old female presents to your office with urinary frequency, urgency, and
burning during urination. She has also noticed a scant vaginal discharge. The
symptoms started two days ago. Which of the following additional findings would be
most suggestive of pyelonephritis in this patient?
• A. Abdominal pain
• B. Fever
• C. Microscopic hematuria
• D. Bacteriuria
• E. White blood cell casts

🔹(Choice A) Abdominal pain is a non-specific symptom. It can be seen in acute
pyelonephritis and in a large number of other conditions, like pelvic inflammatory
disease.
🔹(Choice B) Fever is a sign of any systemic infection. In acute pyelonephritis, it may
also be accompanied by shaking chills, nausea, vomiting, diarrhea, muscle aches,
and anorexia.
🔹(Choices C and D) Bacteriuria and microscopic hematuria are found in both upper
(acute pyelonephritis) and lower (cystitis, urethritis) UTIs.


🔺
WBC casts are formed in tubules, and are pathognomonic for acute pyelonephritis
when accompanied by systemic manifestations of febrile illness. WBC casts are
also seen with acute interstitial nephritis, but clinical presentation is different in that
patients have only a low-grade fever and do not experience painful urination.

A 47-year-old male treated for sinusitis with ampicillin later develops fever,
maculopapular skin rash, and oliguria. His serum creatinine level is 2.4 mg/dL. Urine
sediment microscopy reveals red blood cells, neutrophils, and eosinophils. The
pathologic process in this patient's kidney most likely involves which of the following?
A. Small renal arterioles
B. Glomeruli
C. Renal interstitium
D. Renal papillae
E. Calyces and ureters
F. Bladder

Fever, maculopapular rash and symptoms of acute renal failure one to three weeks
after beginning treatment with a ß-lactam antibiotic or a number of other drugs are
highly suggestive of acute interstitial nephritis. Peripheral eosinophilia and
eosinophiluria are important clinical clues. Symptoms resolve completely after
cessation of the medication.

A 65-year-old man comes to the emergency department due to severe lower abdominal pain and nausea. He also has not been able to urinate for the past 24 hours. The patient has a history of hypertension and benign prostatic hyperplasia. On examination, a large mass is palpable in the suprapubic area. Multiple attempts at urethral catheterization are unsuccessful, and an ultrasound-guided midline
suprapubic cystostomy is planned. Which of the following is the most likely sequence of structures traversed by the trocar and cannula during the procedure?
A. Skin, superficial fascia, aponeurosis, transversalis fascia, bladder wal
B. Skin, superficial fascia, aponeurosis, transversalis fascia, peritoneum,
bladder wall
C. Skin, superficial fascia, transversalis fascia, aponeurosis, bladder wall
D. Skin, superficial fascia, transversalis fascia, aponeurosis, peritoneum,
bladder wall
E. Skin, superficial fascia, transversalis fascia, bladder wall

The bladder is extraperitoneal. In placement of a suprapubic cystostomy, the trocar and cannula will pierce the layers of the abdominal wall but will not enter the peritoneum.

A 21-year-old previously healthy man comes to the emergency department with acute onset of severe left scrotal pain and nausea. The pain started after he returned home from the gym following an intense workout. He denies any trauma,fever, or dysuria. Examination shows a swollen and tender left testis that lies higher than the right testis. Doppler ultrasound shows no arterial blood flow in the left
spermatic cord entering the testis. Which of the following is the likely origin of the artery involved in this patient's condition?
A. Abdominal aorta
B. External iliac artery
C. Internal iliac artery
D. Internal pudendal artery
E. Obturator artery
F. Renal artery

Renal pathology 👇🏻

A 56-year-old man who was recently diagnosed with colon cancer suffers from
generalized edema. His urine protein excretion is 4.5 g over 24 hours. Kidney
biopsy shows glomerular capillary wall thickening without an increase in cellularity.
When the sample is stained with silver methenamine, irregular spikes protruding
from the glomerular basement membrane are seen. This patient most likely suffers
from which of the following?
A. Anti-GBM disease
B. Membranous glomerulopathy
C. Membranoproliferative glomerulonephritis
D. Postinfectious glomerulonephritis
E. Focal segmental glomerulosclerosis
F. Minimal change disease

Membranous glomerulopathy is one of the most common causes of nephrotic syndrome in adults. It can occur secondary to underlying malignant tumors, infections, and certain medications. Diffuse increased thickness of the glomerular basement membrane on light microscopy (without increased cellularity), "spike and dome" appearance on methenamine silver stain, and granular deposits on
immunofluorescence are diagnostic.

A 13-year-old Caucasian female presents to your office with urine discoloration. She had been treated for facial impetigo three weeks ago. Urinalysis shows hematuria, mild proteinuria and occasional red blood cell casts. Renal biopsy is most likely to demonstrate:

A. Basement membrane splitting on light microscopy
B. Diffuse capillary wall thickening on light microscopy
C. Linear IgG and C3 deposits on immunofluorescent microscopy
D. Glomerular basement membrane disruptions and fibrin deposition on electron microscopy
E. Discrete subepithelial humps on electron microscopy