CASE 1

History:

This was a 27 week gestational age stillborn. Severe oligohydramnios was present. A fetal ultrasound was difficult to interpret because of the lack of amniotic fluid, but enlarged, cystic kidneys were thought to be present. At autopsy, the kidneys were symmetrically enlarged and on sectioning displayed numerous 0.1 to 0.2 cm cysts. Other findings included pulmonary hypoplasia, prominent infraorbital creases with flattened nose on the face, and varus deformities of both feet.

Image 1.1

Image 1.2

Image 1.3

Image 1.4

Questions:

1. What is the diagnosis?
2. What are the consequences of this disease?
3. How would you counsel the family regarding the recurrence risk for this disease?
4. How does this case differ from the other forms of cystic disease of the kidney?

An adult form of polycystic kidney disease is shown in image 1.5, and the inheritance pattern in image 1.6.

Image 1.5

Image 1.6

Multicystic renal dysplasia is shown grossly in images 1.7 and 1.8 and microscopically in image 1.9.

Image 1.7

Image 1.8

Image 1.9

The normal external appearance of fetal kidney is shown in image 1.10 and the cut surface in image 1.11.

Image 1.10

Image 1.11

CASE 2

History:

This is a 56-year-old woman who has had a history of episodes of dysuria in the past. She has had another episode for the past four days, but in the past day she has developed decreased urine output with fever to 38.9 C (102 F). On physical examination, she has costophrenic angle tenderness on the right.

Image 2.1

Image 2.2

Image 2.3

Image 2.4

Questions:

1. What is the diagnosis?
2. How does an infectious agent reach the kidney?
3. How do you explain the findings present on urinalysis?
4. How do you treat this condition?

CASE 3

History:

A 52-year-old woman had a long history of essential hypertension which was poorly controlled despite therapy with multiple anti-hypertensive regimens. On the day of admission to hospital, she had suffered a seizure. Prior to this, she had severe headaches for several days. Physical examination revealed a blood pressure of 230/140. The skin of her fingers appeared taut. A urinalysis revealed both proteinuria and hematuria. Laboratory data revealed a serum BUN of 81 mg/dL and creatinine of 4.8 mg/dL.

Image 3.1

Image 3.2

Image 3.3

Image 3.4

Questions:

1. What is the diagnosis?
2. What additional laboratory findings would you suspect?
3. What other organs may be affected by this disease?
4. What is the course of this disease?
5. If persons with renal disease develop chronic renal failure, what are treatment options?
6. In cases where renal transplantation is considered, who provides the allograft, and what are ethical issues related to this decision?

CASE 4

History:

The mother of a five-year-old child noted that the child's abdomen seemed to be getting larger. She took the child to a pediatrician who found a large, firm abdominal mass on physical examination. Urinalysis dipstick and microscopic examination was normal. An abdominal CT scan revealed a 10 cm solid mass involving the right kidney. The right kidney was removed at surgery.

Image 4.1

Image 4.2

Image 4.3

Image 4.4

Questions:

1. What is the diagnosis?
2. What is the peak age incidence of this tumor?
3. What is the survival of patients with this tumor today?
4. How do you deal with poor outcomes?

CASE 5

History:

A 54-year-old man noted dull left flank pain that was becoming more constant over the past few weeks. He had constant dull left flank pain. A urinalysis dipstick examination showed 4+ blood and microscopic examination showed 50-75 RBC's/hpf. A CT scan of the abdomen revealed a large left renal mass that appeared solid. A left radical nephrectomy was performed.

Image 5.1

Image 5.2

Image 5.3

Image 5.4

Questions:

1. What the diagnosis of the neoplasm?
2. Name some paraneoplastic syndromes associated with this lesion.
3. What is the natural history of this lesion? What does the size of the tumor tell you?
4. What is the lesion in the adjacent kidney and what caused it?

CASE 6

History:

A 64-year-old man with a 50 pack/year history of smoking and who worked for many years in a printing shop noted that for the past week there was blood in his urine when he first urinated in the morning. He went to a urologist who did cystoscopy but did not see a lesion in the bladder. Biopsies and urine cytology specimens were sent to the laboratory. The biopsies of the bladder showed benign transitional epithelium, but the cytology specimens showed atypical cells present. The urologist then did another cystoscopy and took separate urine cytology samples from each ureter. The atypical cells were present on the left. An intravenous pyelogram showed a filling defect of the left renal pelvis. A left nephrectomy was performed.

Image 6.1

Image 6.2

Image 6.3

Questions:

1. What is the diagnosis?
2. Where do these tumors occur?
3. Are there any risk factors or environmental causes of this tumor?
4. What must be remembered about the origin of these tumors?

CASE 7

History:

This 46-year-old homeless man was found in a stuporous condition one morning by the owner of an auto parts store. Apparently the man had broken into the store. A half empty container of antifreeze was found next to him (go to any store that sells automobile antifreeze to view the container warning label). The owner called paramedics, who transported him to a local hospital, where he was admitted. It was soon noted that he had no urine output. His serum BUN and creatinine, which were 25 mg/dL and 1.5 mg/dL respectively on admission, continued to rise. He died a week later.

Image 7.1

Questions:

1. What is the diagnosis?
2. What histopathologic findings are present in the kidney?
3. What are potential ethical concerns in treating a patient who had premeditated this event and willfully consumed the antifreeze?