2013 URINARY TRACT

SUMMER REVIEW
Barbara D. Bosch, M.D.

References for USMLE Step 1-format questions (with modifications):

Cataiano E. Appleton & Lanqe Review of General Pathology, 4th ed. McGraw Hill Medical, 2003.

Fenderson BA, Strayer DS, Rubin R, Rubin E. Illustrated Q&A Review of Rubin's Pathology, 2nd
ed. Lippincott Williams & Wilkins, 201 1.
Goldberg J. Lanqe Practice Tests USMLE Step 1, 2nd ed. McGraw Hill Medical, 2006.
Kettering JD, Fletcher HM. PreTest Microbiology,

12th ed.

McGraw Hill Medical, 2007.

King MW. Lanoe Q&A USMLE Step 1. 6th ed. McGraw Hill Medical, 2008.

Klatt EC, Kumar V. Robbins and Cotran Review of Pathology, 3rd ed. Saunders Elsevier, 2010.
Klein RM, Enders GC. PreTest Anatomy. Histology & Cell Biology, 3rd ed. McGraw Hill Medical,
2007.

Le T, Klein J, Shivaram A. First Aid Q&A for the USMLE Step 1. McGraw Hill Medical, 2007.
Le T, Krause K, Klein J, Shivaram A. First Aid Cases for the USMLE Step 1. McGraw Hill Medical,
2006.

Mufson M. PreTest Pathophysiology, 3rd ed. McGraw Hill Medical, 2005.

PreTest Clinical Vignettes for the USMLE Step 1. 4th ed. McGraw Hill Medical, 2008.

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 2

A 59 year-old man complains of periorbital edema and ankle swelling which have gradually been
getting worse over the past few months. His blood pressure is 120/80 mm Hg. Urinalysis shows 4+
proteinuria, but no cells or casts. Serum albumin is moderately decreased, but blood urea nitrogen
(BUN) and creatinine are normal. Which of the following is the most likely diagnosis?
A. acute proliferative glomerulonephritis
B. diabetic nephropathy
C. IgA nephropathy
D. lupus nephritis
E. membranous glomerulopathy
F. minimal change disease
A 52 year-old woman who suffers from diabetes mellitus and frequent urinary tract infections presents
with a 3-day history of flank pain, undulating fever and general malaise. A CBC shows neutrophilic
leukocytosis (16,000/mL). Urine cultures reveal more than 100,000 bacterial colonies, composed
predominantly of gram-negative rods. Blood pressure is 170/100 mm Hg, BUN is 30 mg/dl_ (normal
7-18 mg/dL) and creatinine is 2.0 mg/dL (normal 0.6-1.2 mg/dL). Fasting serum glucose is 190 mg/dL
(normal 70-110 mg/dL). Urinalysis shows 2+ sugar and 1+ protein. Microscopic examination of the
urine sediment reveals neutrophils and occasional WBC casts. Which of the following is the best
diagnosis?
A. acute pyelonephritis
B. acute tubular necrosis
C. diabetic glomerulonephropathy
D. nephrolithiasis
E. postinfectious glomerulonephritis

A 7 year-old boy is recovering from impetigo. Physical exam shows a few honey-colored crusts on his
face. A culture of these crusts grows group A Streptococcus pyogenes. 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. chronic renal failure
B. complete recovery without treatment
C. development of rheumatic heart disease
D. lower urinary tract infection
E. progression to crescentic glomerulonephritis
A 72 year-old woman is hospitalized after becoming acutely ill.
Despite intervention, she dies 9 days later. One of the findings
at her autopsy is shown in the accompanying photomicrograph.
Which of the following conditions could have led to the changes
seen in this patient's kidney and was most likely the reason for
her hospitalization?
A. myocardial infarction
B. pyelonephritis
C. renal cell carcinoma
D. sepsis
E. shock

The mother of a 1 year-old boy palpates a mass on the right side of the infant's abdomen.
Microscopically, the lesion is composed of blastemal, stromal and epithelial tissues. Which of the
following is the most likely diagnosis?
A. angiomyolipoma
B. neuroblastoma
C. renal cell carcinoma

D. urothelial cell carcinoma

E. Wilms tumor

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 3

A 25 year-old man complains of intermittent hematuria over

the past 8 years. Urinalysis shows microscopic hematuria.
Urine cultures are negative. A renal biopsy (shown in the
image) displays mesangial proliferation within some glomeruli,
whereas others appear normal. Immunofluorescence staining
discloses mesangial deposition of IgA. Which of the following
is the appropriate pathologic diagnosis?
A. amyloid nephropathy
B. crescentic glomerulonephritis
C. focal proliferative glomerulonephritis
D. Kimmelstiel-Wilson disease
E. membranous glomerulonephropathy

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 exam, he has pitting edema to his
thighs. Lab studies show an elevated total serum protein with a normal albumin level; creatinine, 3.1
mg/dL (normal 0.6-1 .2 mg/dL); and glucose, 79 mg/dL (normal 70-110 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
the glomeruli, interstitium and arteries with an H&E stain. Which of the following diseases is most
likely?
A. analgesic nephropathy
B. diabetes mellitus
C. membranous glomerulonephropathy
D. multiple myeloma
E. Wegener granulomatosis
A 25 year-old man presents to his doctor with a 2-day history of hemoptysis and blood in his urine. A
kidney biopsy is obtained. When the tissue is stained with fluorescent anti-IgG, the staining reveals a
linear pattern. Which of the following is the most likely diagnosis?
A. acute poststreptococcal glomerulonephritis
B. Alport syndrome
C. Goodpasture syndrome
D. IgA nephropathy
E. membranous glomerulonephritis
A 46 year-old woman presents with a 6-month history of vague upper abdominal pain after fatty
meals, some abdominal distention and frequent indigestion. Physical examination shows an obese
woman (BMI = 32 kg/m2) with right upper quadrant tenderness. A CT scan discloses gallstones and
an ectopic kidney. Which of the following is the most common location of an ectopic kidney?
A. adjacent to the gallbladder
B. attached to the left adrenal gland
C. fused laterally with the contralateral kidney
D. pelvis
E. posterior epigastrium

A 65 year-old man presents with a recent episode of painless hematuria. Vital signs are normal. All
blood tests and urinalysis are normal, except for the presence of erythrocytes in the urine. The
patient smokes cigarettes but does not drink alcoholic beverages. Which of the following is the most
likely cause of hematuria in this patient?
A. acute cystitis
B. acute pyelonephritis
C. bladder calculi
D. carcinoma of the bladder
E. prostatic carcinoma

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 4

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A 30 year-old man with a history of drug addiction presents with a 6-month

history of progressive swelling in his ankles and abdomen. Urinalysis shows
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A 6 year-old child develops fever, abdominal pain and bloody diarrhea. Several other children in the
neighborhood have similar symptoms. The common feature is traced to eating hamburgers at a fast
food restaurant. The clinical course is complicated by the development of acute renal failure. Which
of the following is the most likely diagnosis?
A. acute postinfectious glomerulonephritis
B. Churg-Strauss syndrome
C. hemolytic uremic syndrome
D. Henoch-Schonlein purpura
E. malignant hypertension
F. polyarteritis nodosa

Which of the following microscopic findings on urinalysis indicates that hematuria in a patient is
caused by a renal process, rather than bleeding from another site in the urinary tract?
A. blood clots
B. hemoglobin crystals
C. numerous free erythrocytes
D. phagocytosed hemoglobin
E. red blood cell casts
A 46 year-old man with no past medical history presents with excruciating episodic (colicky) right flank
pain. A renal stone is passed. In the U.S., this stone is most likely composed of which of the
following?
A. calcium oxalate
B. calcium phosphate
C. cystine
D. magnesium ammonium phosphate
E. uric acid
A 54 year-old woman with squamous cell carcinoma of the lung develops bilateral pitting edema of the
lower extremities. Laboratory studies show hyperlipidemia, hypoalbuminemia and 4+ proteinuria.
Urinalysis reveals no inflammatory cells or RBCs. Renal biopsy in this patient would most likely show
which of the following abnormalities?
A. Goodpasture syndrome
B. IgA nephropathy (Berger disease)
C. membranous glomerulonephropathy
D. minimal change disease
E. nodular glomerulosclerosis

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 5

The mother of a 2 month-old child palpates a mass on the left side

of the child's abdomen. Vital signs are normal. The mass is
removed (shown in the image) and displays variably-sized cysts
surrounded by primitive mesenchyme, smooth muscle and islands
of cartilage. Which of the following is the most likely diagnosis for
this child's flank mass?
A. autosomal dominant polycystic kidney disease
B. autosomal recessive polycystic kidney disease
C. medullary sponge kidney
D. multicystic renal dysplasia
E. Wilms tumor
A 56 year-old man is diagnosed with urothelial cell carcinoma of the renal pelvis. Which of the
following risk factors most likely led to this patient's cancer?
A. alcohol use
B. exposure to asbestos
C. exposure to phenacetin
D. hypertension
E. previous pyelonephritis
A 38 year-old woman sees her physician because she has been feeling tired and lethargic for several
months. On physical exam, she is afebrile with a blood pressure of 140/90. Laboratory findings show
Hgb, 10.3 g/dL (normal 12.0-16.0 g/dL); serum creatinine, 5.8 mg/dl_ (normal 0.6-1.2 mg/dL). C3
nephritic factor is present in the serum, and the ANA is negative. Urinalysis shows 2+ proteinuria. A
renal biopsy reveals hypercellular glomeruli and prominent electron-dense deposits along the lamina
densa of the glomerular basement membrane. Which of the following is the most likely diagnosis?
A. chronic glomerulonephritis
B. membranoproliferative glomerulonephritis
C. membranous glomerulonephropathy
D. postinfectious glomerulonephritis
E. rapidly progressive glomerulonephritis

A 12 year-old girl complains of headaches and blurred vision. She has a history of high blood
pressure, but is not currently taking medication. Her blood pressure is 160/95 mm Hg and pulse is 95
per minute. Fundoscopic examination reveals small retinal microaneurysms and zones of retinal
edema and necrosis. She is hospitalized for further evaluation. Renal arteriography shows
segmental stenoses forming multiple ridges that project into the lumen. What is the most likely cause
of secondary hypertension in this young patient?
A. Buerger disease
B. Churg-Strauss syndrome
C. fibromuscular dysplasia
D. Kawasaki disease
E. Takayasu arteritis
A 49 year-old man with a history of heavy smoking presents with a 5-year history of shortness of
breath and cough with the production of abundant foul-smelling sputum. A pulmonary work-up
demonstrates chronic bronchiectasis. Laboratory studies reveal hypoalbuminemia and
hyperlipidemia. Urinalysis shows heavy proteinuria (> 4 g/day). Which of the following is the most
likely diagnosis?
A. amyloid nephropathy
B. IgA nephropathy (Berger disease)
C. minimal change disease
D. post-infectious glomerulonephritis
E. Wegener granulomatosis

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 6

A 75 year-old homeless man is brought to the emergency room in a coma. Upon

admission to the hospital, the BUN is 74 mg/dL (normal 7-18 mg/dL) and the
creatinine is 6.5 mg/dL (normal 0.6-1.2 mg/dL). He dies thereafter, and an autopsy
reveals abnormal kidneys (one of which is shown in the image). The pathogenesis
of this disease is most likely related to which of the following?
A. acute pyelonephritis

B. amyloidosis
C. polycystic kidney disease
D. systemic hypertension
E. urinary tract obstruction

A 50 year-old man is found to have blood in his urine during a routine checkup.
He is otherwise in excellent health, except for a mild microcytic, hypochromic
anemia. An enlarged right kidney is found on X-ray examination, and CT scan
reveals a renal mass of irregular shape measuring 6 cm in diameter. A fineneedle aspiration biopsy of this lesion shows glycogen-rich tumor cells.
Molecular studies would most likely identify mutations in which of the following
growth regulatory genes?
A. ADPKD
B. IGF-2
C. PAX6
D. VHL
E. WT1

A 32 year-old man complains of recurrent hematuria since adolescence. The hematuria typically
occurs following upper respiratory tract infections. Vital signs are normal. Urinalysis shows
proteinuria, hematuria and a few red blood cell casts. Laboratory studies disclose normal levels of
BUN and creatinine. The ANA and ANCA tests are negative. Which of the following is the most likely
diagnosis?
A. amyloid nephropathy
B. hereditary nephritis (Alport syndrome)
C. IgA nephropathy (Berger disease)
D. membranous glomerulonephropathy
E. Wegener granulomatosis

For the patient described above, which of the following patterns of immunofluorescence would be
expected in the renal biopsy?
A. granular capillary membrane deposition
B. linear basement membrane staining
C. mesangial deposition
D. perivascular location
E. staining would be negative
A 56 year-old woman presents with acute renal failure. A renal biopsy demonstrates birefringent,
intratubular deposits of uric acid crystals. This finding suggests that the patient most likely has been
treated recently for which of the following underlying conditions?
A. chronic hepatitis B
B. leukemia
C. porphyria
D. rheumatoid arthritis
E. ulcerative colitis

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 7

A 62 year-old man presents for a follow-up of a renal

malignancy. Cystoscopy reveals multiple, red, velvety, flat ,
patches in the bladder mucosa. A biopsy is shown in the
image. Which of the following is the appropriate diagnosis?!
A. chronic interstitial cystitis
B. invasive urothelial cell carcinoma
C. malakoplakia
D. urothelial cell carcinoma in situ
E. urothelial cell papilloma

The parents of a 6 year-old girl notice that she has become increasingly lethargic over the past 2
weeks. On exam, she has puffiness around her eyes as well as swelling of her legs and ankles.
Laboratory findings show normal serum creatinine and BUN levels. Urinalysis shows 4+ proteinuria.
The urinary sediment contains no inflammatory cells or red blood cells. The 24-hour urine protein
level is 3.8 g. The child recovers completely after a course of corticosteroids. Which of the following
pathologic findings would most likely have been found in the urine prior to her treatment?
A. amyloid casts
B. eosinophils
C. lipid droplets
D. red blood cell casts
E. white blood cell casts

For the patient described above, electron microscopy of a renal biopsy specimen prior to her
treatment would most likely have demonstrated which of the following abnormalities?
A. electron-dense immune deposits in the mesangium
B. fusion of the podocyte foot processes
C. loss of microvilli by the tubular lining cells
D. reduplication of the glomerular basement membrane
E. subepithelial electron-dense humps
A 34 year-old man undergoing cisplatin-based chemotherapy complains of a 1-week history of
increasing fatigue and headaches. He also reports seeing blood in his urine. Blood pressure is
150/100 mm Hg. Physical examination reveals diffuse purpura over his upper trunk and arms.
Laboratory studies show elevated levels of BUN and creatinine, and 24-hour urinalysis reveals
hematuria and oliguria. Urine cultures are negative. A CBC demonstrates severe anemia and
thrombocytopenia. The direct Coombs test is negative. A peripheral blood smear reveals
schistocytes. Which of the following is the most likely cause of acute renal failure in this patient?
A. ANCA-positive glomerulonephritis
B. Henoch-Schonlein purpura
C. nephrotoxic acute tubular necrosis
D. polyarteritis nodosa
E. thrombotic microangiopathy

The parents of a 6 month-old girl palpate a mass on the left side of the child's abdomen. Urinalysis
shows high levels of vanillylmandelic acid. A CT scan reveals an abdominal tumor and bony
metastases. Which of the following is the most likely diagnosis?
A. dysgerminoma
B. ganglioneuroma
C. immature teratoma
D. neuroblastoma
E. Wilms tumor

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 8

An 8 year-old boy presents with headaches, dizziness and malaise

approximately 2 weeks after a severe sore throat. His mother describes
puffiness of his face and darkening of his urine. She also notes that her son
is passing less urine, and that he is becoming increasingly short of breath.
On physical examination, there is anasarca, hypertension (BP 190/130 mm
Hg) and tachycardia. The urine is scanty and brownish red. Urinalysis shows
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3+ proteinuria. Microscopic examination of the urine discloses numerous
RBCs, as well as occasional granular and red blood cell casts. A renal biopsy 4
is stained by direct immunofluorescence microscopy for complement C3, and -V
the results are shown. Which of the following is the most likely outcome in
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A. bilateral cortical necrosis
B. membranoproliferative glomerulonephritis
C. recovery without serious consequences
D. slow progression to chronic kidney disease
E. transition into crescentic glomerulonephritis

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A 15 year-old black girl with sickle cell anemia presents to the emergency room because she is
experiencing severe bone pain. An abdominal CT scan shows evidence of splenic infarcts. Which of
the following renal diseases is a direct complication of this patient's vaso-occlusive disease?
A. acute pyelonephritis
B. papillary necrosis
C. polycystic kidney disease
D. urate nephropathy
E. urolithiasis
A 30 year-old man with a history of smoking suddenly develops
oliguria, hematuria and hemoptysis. Serologic studies reveal
antibodies to the glomerular basement membrane (GBM). A renal
biopsy is shown. Which of the following pathologic changes is
visible by light microscopy in this biopsy specimen?
A. crescent in the urinary space
B. leukocytic infiltrates in the glomerulus
C. mesangial cell proliferation
D. thickening of the GBM
E. thrombi in the glomerular capillaries

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A 5 year-old girl presents with the sudden onset of diffuse arthralgias and a skin rash. Physical
examination shows a violaceous maculopapular rash on the lower torso. Urinalysis discloses oliguria
and 2+ hematuria. Urine cultures are negative. This child's clinical presentation is most consistent
with which of the following diseases?
A. Berger disease
B. Goodpasture syndrome
C. hemolytic uremic syndrome
D. Henoch-Schonlein purpura
E. polyarteritis nodosa

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 9

A 40 year-old Egyptian fisherman presents with painless hematuria. The patient's past medical
history is significant for chronic schistosomiasis, which is endemic in his country of origin. Urinalysis
shows malignant cells, and cystoscopy reveals a mass in the wall of the urinary bladder. Which of the
following is the most likely diagnosis in this individual?
A. adenocarcinoma
B. leiomyosarcoma
C. papillary urothelial cell carcinoma
D. squamous cell carcinoma
E. urothelial cell carcinoma in situ
A 44 year-old man complains of swelling of his legs and puffiness around his
eyes. His abdomen has become protuberant, and he feels short of breath.
Physical examination reveals generalized edema and ascites. His total serum
protein is 5.2 g/dL (normal 5.5-8.0 g/dL), and albumin is 1.9 g/dL (normal 3.55.5 g/dL). Serum cholesterol is elevated at 530 mg/dL. There are 5 g of
protein in a 24-hour urine collection. The urinary sediment contains many
hyaline casts but no RBCs or inflammatory cells. A renal biopsy stained by
direct immunofluorescence for IgG is shown in the image. Which of the
following is the most likely diagnosis?
A. amyloid nephropathy
B. Berger disease
C. focal segmental glomerulosclerosis
D. Goodpasture disease
E. membranous glomerulonephropathy
F. minimal change disease
The pathogenesis of the nephrotic syndrome in the patient described above is
best characterized by which of the following mechanisms of disease?
A. deposition of antiglomerular basement membrane antibody
B. deposition of immune complexes primarily in the mesangium
C. expansion of the glomerular basement membrane by PAS-positive glycoproteins
D. subendothelial deposits of immune complexes
E. subepithelial deposits of immune complexes

The glomerular changes shown in the above patient can also be seen in individuals with which of the
following systemic diseases?
A. amyloidosis
B. diabetes mellitus
C. scleroderma
D. systemic lupus erythematosus
E. Wegener granulomatosis
A 55 year-old man dies of chronic kidney disease. Examination
of his kidneys at autopsy reveals a "staghorn" calculus (illustrated
in the image). Which of the following best describes the
pathogenesis of this renal stone?
A. gout
B. hereditary cystinuria
C. hypercalcemia
D. hyperparathyroidism
E. urinary tract infection

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 10

A 64 year-old man presents to his family physician with hematuria

and flank pain. Radiographic imaging reveals a renal mass. A
photomicrograph of this lesion is provided. Which of the following
is the most likely diagnosis?
A. angiomyolipoma
B. oncocytoma
C. renal cell carcinoma
D. urothelial cell carcinoma
E. Wilms tumor

A 28 year-old man complains of nasal obstruction, bloody nose,

cough, and bloody sputum. A chest X-ray displays cavitary lesions
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and multiple nodules within both lung fields. Urinalysis reveals 3+
hematuria and red blood cell casts. Laboratory studies show anemia and elevated serum levels of cANCA (antineutrophil cytoplasmic antibody). Peripheral eosinophils are not increased. A renal biopsy
exhibits focal glomerular necrosis with crescents and vasculitis affecting arterioles and venules. What
is the appropriate diagnosis?
A. Churg-Strauss syndrome
B. Goodpasture syndrome
C. hypersensitivity vasculitis
D. polyarteritis nodosa
E. Wegener granulomatosis
A 32 year-old male cyclist is struck at night by a hit-and-run motorist. He is unconscious and severely
injured, and isn't discovered until a pedestrian walks by a few hours later. When he arrives at the
emergency room, he is in shock and his BP is 80/30 mm Hg. He is transfused, and a large wound on
his right leg is cleaned and sutured. However, by the next day his urine output has decreased to less
than 20 mL/hr. Which of the following microscopic descriptions best describes his kidneys at this
time?
A. fibrinoid necrosis of arterioles
B. interstitial mononuclear inflammatory cell infiltrate with "thyroidization"
C. neutrophilic infiltration of the tubules and interstitium
D. tubular necrosis with pigmented cellular casts
E. wedge-shaped areas of coagulative necrosis

A 60 year-old man complains of chronic back pain and fatigue, excessive

urination, and increased thirst. X-ray examination reveals numerous lytic
lesions in the lumbar vertebral bodies. Laboratory studies show hypoalbuminemia, mild anemia and thrombocytopenia. Urinalysis displays 4+
proteinuria. A monoclonal immunoglobulin light-chain peak is demonstrated
by serum electrophoresis. A bone marrow biopsy discloses foci of plasma
cells, which account for 20% of all nucleated hematopoietic cells. A kidney
biopsy is obtained (shown in the image). Which of the following is the most
likely cause of nephrotic syndrome in this patient?
A. amyloid nephropathy
B. crescentic glomerulonephritis
C. IgA nephropathy (Berger disease)
D. membranous glomerulonephropathy
E. nodular glomerulosclerosis (Kimmelstiel-Wilson disease)

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2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 11

A 42 year-old woman had a catheter temporarily placed in her urethra. One week later she is
experiencing suprapubic and flank pain with urinary urgency and frequency. She also has chills and
fever. After examining the patient and evaluating the sediment of her centrifuged urine, she is
informed by her physician that she has acute pyelonephritis. If the diagnosis is accurate and the
patient's urine is cultured, which of the following organisms will most likely be isolated?
A. Clostridium difficile
B. Escherichia coli
C. Pseudomonas aeruginosa
D. Staphylococcus aureus
E. Streptococcus agalactiae
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. There are no remarkable findings on physical
exam. Urinalysis shows 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 this patient is most likely to show which of the following
glomerular alterations?
A. diffuse proliferation and basement membrane thickening
B. granular staining of the basement membrane by anti-IgG antibodies
C. mesangial IgA staining by immunofluorescence
D. subepithelial electron-dense deposits
E. thrombosis in the glomerular capillaries
A 43 year-old man has had type 1 diabetes mellitus for 30 years. He uses insulin to treat his
diabetes, but his blood glucose levels have been poorly controlled. Over the years, he has developed
painful peripheral neuropathy and a non-healing diabetic foot ulcer. Which of the following glomerular
changes would most likely be found on a biopsy of this man's kidney?
A. crescent-shaped lesions in Bowman space
B. hypercellularity of the glomerular tufts
C. nodular glomerulosclerosis
D. proliferation of the mesangium
E. tram-track appearance of the glomerular basement membrane
A 68 year-old man presents with a 4-week history of painless hematuria.
'Cystoscopy reveals a large exophytic papillary tumor in the bladder. The
cystectomy specimen is shown in the image. In addition to cigarette
smoking, exposure to which of the following is the most significant risk
factor for the development of this patient's malignant neoplasm?
A. aflatoxin
B. aromatic amines and azo dyes
C. arsenic
D. lead
E. vinyl chloride
A 10 year-old boy is brought to a pediatric clinic by his mother, who states that he has been voiding
brown-colored urine for the past 2 days. The child's history is negative except for a sore throat about
2 weeks ago. Physical examination reveals moderate periorbital edema and mild hypertension.
Urinalysis demonstrates red blood cells, red blood cell casts and 2+ protein. If a renal biopsy were
obtained, what would be the characteristic light &/or electron microscopic findings in the glomeruli?
A. hypercellularity with duplication of the basement membrane
B. hypercellularity with subepithelial "humps"
C. hypercellularity with "wire loop" lesions
D. normocellularity with effacement of epithelial cell foot processes
E. normocellularity with segmental sclerosis
F. normocellularity with thickening of the basement membrane

2013 Urinary Tract Summer Review; Barbara D. Bosch, M.D. page 12

A 42 year-old woman comes to her physician because she noticed

blood in her urine and has been having some low back pain.
Physical examination reveals bilateral palpable flank masses, as
well as mild hypertension. Based on the clinical findings, the
physician orders a CT scan to aid in the diagnosis. The
accompanying image illustrates the gross pathologic changes that
would be seen in both of her kidneys. Which of the following central
nervous system conditions is also associated with this disorder?
A. berry aneurysm
B. cerebral cortical hamartomas
C. communicating hydrocephalus
D. optic nerve degeneration
E. vestibular schwannoma
A 5 year-old boy is brought to a pediatrician by his mother for progressive abdominal girth and poor
appetite. His mother is concerned over a "growing lump" she has felt in his abdomen, and physical
examination confirms the presence of a large palpable mass in the left upper quadrant. Abdominal
ultrasound demonstrates an 18-cm solid mass in the upper pole of the left kidney. A renal biopsy is
taken. Which of the following is the pathologist most likely to see on microscopic examination of the
biopsy?
A. a mixture of proliferating smooth muscle cells, mature fat cells and blood vessels
B. numerous cysts lined by uniform cuboidal cells with little normal parenchyma
C. primitive embryonic cells with minimal tubular and glomerular differentiation
D. sheets of large cells with abundant clear cytoplasm and small, regular nuclei
E. well-formed papillary frond structures lined by slightly atypical, thickened epithelium

Autopsy findings from a 54 year-old woman who died secondary to chronic kidney disease revealed
shrunken, asymmetrical kidneys with extensive corticomedullary scars and dilated, blunted calyces.
Microscopically, patchy atrophic tubules were seen interspersed with dilated tubules containing
acellular casts. Extensive glomerular and interstitial fibrosis and chronic tubulointerstitial
inflammation were present. Based on these findings, what was the most likely underlying cause of
this patient's renal failure?
A. analgesic nephropathy
B. chronic pyelonephritis
C. diabetic glomerulosclerosis
D. focal segmental glomerulosclerosis
E. membranous nephropathy
A 35 year-old man with a history of smoking presents with hematuria and
bloody sputum. Over the next 2 days, he develops oliguria and renal failure,
after which he is placed on dialysis. A renal biopsy is stained with fluoresceinconjugated goat antihuman IgG, and the results are shown. Which of the
following best describes the pattern of direct immunofluorescence observed
on this photomicrograph?
A. discontinuous and peripheral
B. finely granular along the perimesangial reflections
C. linear along the glomerular basement membrane
D. mesangial with a stalk predominance
E. peripheral granular humps