Renal pathology..at glance

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  • Pitting geographic “scars” is the hallmark of chronic pyelonephritis.
  • THYROIDIZATION is another common hallmark of chronic pyelonephritis
  • Renal pathology..at glance

    1. 1. KIDNEY www.freelivedoctor.com
    2. 2. RENAL PATHOLOGY <ul><li>NORMAL </li></ul><ul><li>CONGENITAL </li></ul><ul><li>“ CYSTS” </li></ul><ul><li>GLOMERULAR </li></ul><ul><li>TUBULAR/INTERSTITIAL </li></ul><ul><li>BLOOD VESSELS </li></ul><ul><li>OBSTRUCTION </li></ul><ul><li>TUMORS </li></ul>www.freelivedoctor.com
    3. 3. www.freelivedoctor.com
    4. 4. www.freelivedoctor.com
    5. 5. 1. Renal Vein 2. Renal Artery 3. Renal Calyx 4. Medullary Pyramid 5. Renal Cortex 6. Segmental Artery 7. InterlobAR Artery 8. Arcuate Artery  interlobULAR 9. Arcuate Vein 10. Interlobar Vein 11. Segmental Vein 12. Renal Column 13. Renal Papillae 14. Renal Pelvis 15. Ureter www.freelivedoctor.com
    6. 6. www.freelivedoctor.com
    7. 7. S.E.M. T.E.M. www.freelivedoctor.com
    8. 8. www.freelivedoctor.com
    9. 9. Fluid and Electrolytes: Dehydration, Edema, Hyperkalemia, Metabolic acidosis Calcium Phosphate and Bone: Hyperphosphatemia, Hypocalcemia, Secondary hyperparathyroidism, Renal osteodystrophy Hematologic: Anemia, Bleeding diathesis Cardiopulmonary: Hypertension, Congestive heart failure, Pulmonary edema, Uremic pericarditis Gastrointestinal: Nausea and vomiting, Bleeding, Esophagitis, gastritis, colitis Neuromuscular: Myopathy, Peripheral neuropathy, Encephalopathy Dermatologic: Sallow (greenish-yellow) color, Pruritus, Dermatitis CHRONIC RENAL FAILURE www.freelivedoctor.com
    10. 10. CONGENITAL <ul><li>AGENESIS </li></ul><ul><li>HYPOPLASIA </li></ul><ul><li>ECTOPIC </li></ul><ul><li>HORSESHOE </li></ul>www.freelivedoctor.com
    11. 11. AGENESIS www.freelivedoctor.com
    12. 12. HYPOPLASIA www.freelivedoctor.com
    13. 13. ECTOPIC (usually PELVIC) www.freelivedoctor.com
    14. 14. HORSESHOE www.freelivedoctor.com
    15. 15. CYSTIC DISEASES <ul><li>CYSTIC RENAL “DYSPLASIA” </li></ul><ul><li>A utosomal D OMINANT ( AD -ULTS) </li></ul><ul><li>Autosomal RECESSIVE (CHILDREN) </li></ul><ul><li>MEDULLARY </li></ul><ul><ul><li>Medullary Sponge Kidney (MSK) </li></ul></ul><ul><ul><li>Nephronopththisis-Medullary </li></ul></ul><ul><li>ACQUIRED </li></ul><ul><li>SIMPLE </li></ul>www.freelivedoctor.com
    16. 16. CYSTIC RENAL “DYSPLASIA” <ul><li>ENLARGED </li></ul><ul><li>UNILATERAL or BILATERAL </li></ul><ul><li>CYSTIC </li></ul><ul><li>Have “MESENCHYME” </li></ul><ul><li>NEWBORNS </li></ul>www.freelivedoctor.com
    17. 17. A UTOSOMAL D OMINANT <ul><li>HEREDITARY, PKD1, PKD2 </li></ul><ul><li>FOLLOWS AUTOSOMAL DOMINANT PEDIGREE </li></ul><ul><li>COMPLEX GENETICS </li></ul><ul><li>RENAL FAILURE in 50’s </li></ul>www.freelivedoctor.com
    18. 18. A UTOSOMAL R ECESSIVE <ul><li>CHILDHOOD </li></ul><ul><li>KIDNEYS LOOK EXACTLY LIKE THE ADULT TYPE </li></ul><ul><li>PKHD1 </li></ul><ul><li>PATIENTS WHO SURVIVE CHILDHOOD OFTEN DEVELOP HEPATIC FIBROSIS </li></ul>www.freelivedoctor.com
    19. 19. MEDULLARY CYSTS <ul><li>MEDULLARY SPONGE KIDNEY (MSK), usually an incidental finding on CT or US </li></ul><ul><li>. NEPHRONOPHTHISIS, cysts @ CMJ, hereditary, progressive </li></ul>www.freelivedoctor.com
    20. 20. ACQUIRED (DIALYSIS) www.freelivedoctor.com
    21. 21. “ SIMPLE” CYSTS <ul><li>Cortical </li></ul><ul><li>Also called “retention” cysts </li></ul><ul><li>Also “acquired” </li></ul><ul><li>Incidental </li></ul><ul><li>VERY very very common </li></ul>www.freelivedoctor.com
    22. 22. GLOMERULAR DISEASES www.freelivedoctor.com
    23. 23. CLINICAL MANIFESTATIONS <ul><li>ACUTE NEPHROTIC SYNDROME </li></ul><ul><li>RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS </li></ul><ul><li>NEPHROTIC SYNDROME </li></ul><ul><li>CHRONIC RENAL FAILURE </li></ul><ul><li>ASYMPTOMATIC HEMATURIA or PROTEINURIA </li></ul>www.freelivedoctor.com
    24. 24. PATHOLOGIC MANIFESTATIONS <ul><li>CELLULAR PROLIFERATION </li></ul><ul><ul><li>Mesangial </li></ul></ul><ul><ul><li>Endothelial </li></ul></ul><ul><li>LEUKOCYTE INFILTRATION </li></ul><ul><li>CRESCENTS (RAPIDLY progressive) </li></ul><ul><li>BASEMENT MEMBRANE THICKENING </li></ul><ul><li>HYALINIZATION </li></ul><ul><li>SCLEROSIS </li></ul>www.freelivedoctor.com
    25. 25. PATHOGENESIS <ul><li>Antibodies against inherent GBM </li></ul><ul><li>Antibodies against “planted” antigens </li></ul><ul><li>Trapping of Ag-Ab complexes </li></ul><ul><li>Antibodies against glomerular cells, e.g., mesangial cells, podocytes, etc. </li></ul><ul><li>Cell mediated immunity, i.e., sensitized T-cells as in TB </li></ul>www.freelivedoctor.com
    26. 26. www.freelivedoctor.com
    27. 27. MEDIATORS <ul><li>NEUTROPHILS, MONOCYTES </li></ul><ul><li>MACROPHAGES, T-CELLS, NK CELLS </li></ul><ul><li>PLATELETS </li></ul><ul><li>MESANGIAL CELLS </li></ul><ul><li>SOLUBLE: CYTOKINES, CHEMOKINES, COAGULATION FACTORS </li></ul>www.freelivedoctor.com
    28. 28. ACUTE GLOMERULONEPHRITIS <ul><li>Hematuria, Azotemia, Oliguria, in children following a strep infection </li></ul><ul><li>POSTSTREPTOCOCCAL (old term) </li></ul><ul><li>HYPERCELLULAR GLOMERULI </li></ul><ul><li>INCREASED ENDOTHELIUM AND MESANGIUM </li></ul><ul><li>IgG, IgM, C3 along GMB FOCALLY </li></ul><ul><li>95% full recovery </li></ul>www.freelivedoctor.com
    29. 29. www.freelivedoctor.com
    30. 30. RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS <ul><li>Clinical definition, NOT a specific pathologic one </li></ul><ul><li>“ CRESCENTIC” </li></ul><ul><li>Anti-GBM Ab </li></ul><ul><li>IMMUN CPLX </li></ul><ul><li>Anti-Neut. Ab </li></ul>www.freelivedoctor.com
    31. 31. NEPHROTIC SYNDROME <ul><li>MASSIVE PROTEINURIA </li></ul><ul><li>HYPOALBUMINEMIA </li></ul><ul><li>EDEMA </li></ul><ul><li>LIPIDEMIA/LIPIDURIA </li></ul><ul><li>NUMEROUS CAUSES: </li></ul><ul><ul><li>MEMBRANOUS, MINIMAL CHANGE, FOCAL SEGMTL. </li></ul></ul><ul><ul><li>DIABETES, AMYLOID, SLE, DRUGS </li></ul></ul>www.freelivedoctor.com
    32. 32. MEMBRANOUS GLOMERULONEPHRITIS <ul><li>Drugs, Tumors, SLE, Infections </li></ul><ul><li>Deposition of Ag-Ab complexes </li></ul><ul><li>Indolent, but >60% persistent proteinuria </li></ul><ul><li>15% go on to nephrotic syndrome </li></ul>www.freelivedoctor.com
    33. 33. www.freelivedoctor.com
    34. 34. MINIMAL CHANGE GLOM. (LIPOID NEPHROSIS) <ul><li>MOST COMMON CAUSE of NEPHROTIC SYNDROME in CHILDREN </li></ul><ul><li>EFFACEMENT of FOOT PROCESSES </li></ul>www.freelivedoctor.com
    35. 35. FOCAL SEGMENTAL GLOMERULO-SCLEROSIS <ul><li>Just like its name </li></ul><ul><ul><li>Focal </li></ul></ul><ul><ul><li>Segmental </li></ul></ul><ul><ul><li>Glomerulo-SCLEROSIS (NOT –itis) </li></ul></ul><ul><li>HIV, Heroine, Sickle Cell, Obesity </li></ul><ul><li>Most common cause of ADULT nephrotic syndrome </li></ul>www.freelivedoctor.com
    36. 36. MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS <ul><li>MPGN can be idiopathic or 2 º to chronic immune diseases Hep-C, alpha-1-antitrypsin, HIV, Malignancies </li></ul><ul><li>GBM alterations, subendo. </li></ul><ul><li>Leukocyte infiltrations </li></ul><ul><li>Predominant MESANGIAL involvement </li></ul>www.freelivedoctor.com
    37. 37. IgA NEPHROPATHY (BERGER DISEASE) <ul><li>Mild hematuria </li></ul><ul><li>Mild proteinuria </li></ul><ul><li>IgA deposits in mesangium </li></ul>www.freelivedoctor.com
    38. 38. HEREDITARY HEMATURIA SYNDROMES <ul><li>ALPORT SYNDROME </li></ul><ul><ul><li>Progressive Renal Failure </li></ul></ul><ul><ul><li>Nerve Deafness </li></ul></ul><ul><ul><li>VARIOUS eye disorder </li></ul></ul><ul><ul><li>DEFECTIVE COLLAGEN TYPE IV </li></ul></ul><ul><li>THIN GBM (Glomerular Basement Membrane) Disease, i.e., about HALF as uniformly thin as it should be </li></ul>www.freelivedoctor.com
    39. 39. CHRONIC GLOMERULONEPHRITIS <ul><li>Can result from just about ANY of the previously described acute ones </li></ul><ul><ul><li>THIN CORTEX </li></ul></ul><ul><ul><li>HYALINIZED (fibrotic) GLOMERULI </li></ul></ul><ul><ul><li>OFTEN SEEN IN DIALYSIS PATIENTS </li></ul></ul>www.freelivedoctor.com
    40. 40. SECONDARY (2 º) GLUMERULONEPHROPATHIES <ul><li>SLE </li></ul><ul><li>Henoch-Schonlein Purpura (IgA-NEPH) </li></ul><ul><li>BACTERIAL ENDOCARDITIS </li></ul><ul><li>DIABETES (Nodular Glomerulosclerosis, or K-W Kidney) </li></ul><ul><li>AMYLOIDOSIS </li></ul><ul><li>GOODPASTURE </li></ul><ul><li>WEGENER </li></ul><ul><li>MYELOMA </li></ul>www.freelivedoctor.com
    41. 41. www.freelivedoctor.com
    42. 42. TUBULES INTERSTITIUM BLOOD VESSELS OBSTRUCTION TUMORS www.freelivedoctor.com
    43. 43. TUBULAR DISEASES <ul><li>ACUTE TUBULAR NECROSIS </li></ul><ul><li>TUBULOINTERSTITIAL NEPHRITIS </li></ul><ul><ul><li>PYELONEPHRITIS </li></ul></ul><ul><ul><ul><li>ACUTE </li></ul></ul></ul><ul><ul><ul><li>CHRONIC </li></ul></ul></ul><ul><ul><li>DRUGS </li></ul></ul><ul><ul><li>TOXINS </li></ul></ul><ul><li>URATE NEPHROPATHY </li></ul><ul><li>HYPERCALCEMIA/NEPHROCALCINOSIS </li></ul><ul><li>MULTIPLE MYELOMA </li></ul>www.freelivedoctor.com
    44. 44. ACUTE TUBULAR NECROSIS <ul><li>Destruction of renal TUBULAR epithelium </li></ul><ul><li>Loss of renal function </li></ul><ul><li>50% of ACUTE renal failure </li></ul><ul><li>Two types: </li></ul><ul><li>ISCHEMIC </li></ul><ul><li>NEPHROTOXIC </li></ul><ul><li>- AMINOGLYCOSIDES </li></ul><ul><li>- AMPHOTERICIN B </li></ul><ul><li>- CONTRAST AGENTS </li></ul>www.freelivedoctor.com
    45. 45. ATN PATHOGENESIS <ul><li>BLOOD FLOW DISTURBANCES (ISCHEMIC) </li></ul><ul><li>TUBULAR INJURY (NEPHROTOXIC) </li></ul>www.freelivedoctor.com
    46. 46. CLINICAL COURSE <ul><li>INITIATION (36 hours) </li></ul><ul><ul><li>Mild OLIGURIA </li></ul></ul><ul><ul><li>Mild AZOTEMIA </li></ul></ul><ul><li>MAINTENANCE </li></ul><ul><ul><li>More OLIGURIA </li></ul></ul><ul><ul><li>More AZOTEMIA </li></ul></ul><ul><ul><li>DIALYSIS NEEDED </li></ul></ul><ul><li>RECOVERY </li></ul><ul><ul><li>HYPOKALEMIA main problem </li></ul></ul><ul><ul><li>BUN, CREATININE return to normal </li></ul></ul>www.freelivedoctor.com
    47. 47. TUBULO/INTERSTITIAL NEPHRITIS <ul><li>INFECTIONS, i.e., pyelonephritis </li></ul><ul><li>TOXINS, heavy metals, chemo, NSAIDS </li></ul><ul><li>METABOLIC, urates, Ca++, Oxalates </li></ul><ul><li>PHYSICAL, obstruction, radiation </li></ul><ul><li>IMMUNOLOGIC, esp. transplant rejection </li></ul>www.freelivedoctor.com
    48. 48. PYELONEPHRITIS <ul><li>GI Gram NEGATIVES: E. COLI, Proteus, Klebsiella, Enterobacter, Strep. faecalis, usually “NORMAL” flora </li></ul><ul><li>ASCENDING, by FAR, the most common, i.e., reflux, obstruction </li></ul><ul><li>HEMATOGENOUS too </li></ul><ul><li>ACUTE PYELONEPHRITIS, neutrophils </li></ul><ul><li>CHRONIC PYELONEPHRITIS, lymphocytes, scars </li></ul>www.freelivedoctor.com
    49. 49. ACUTE or CHRONIC PYELONEPHRITIS? www.freelivedoctor.com
    50. 50. ACUTE or CHRONIC PYELONEPHRITIS? www.freelivedoctor.com
    51. 51. ACUTE or CHRONIC PYELONEPHRITIS? www.freelivedoctor.com
    52. 52. FACTORS <ul><li>OBSTRUCTION: Congenital or Acquired </li></ul><ul><li>INSTRUMENTATION </li></ul><ul><li>VESICOURETERAL REFLUX </li></ul><ul><li>PREGNANCY </li></ul><ul><li>AGE, SEX, why sex? F>>>M </li></ul><ul><li>PREVIOUS LESIONS </li></ul><ul><li>IMMUNOSUPPRESION or IMMUNODEFICIENCY </li></ul>www.freelivedoctor.com
    53. 53. DRUGS/TOXINS causing INTERSTITIAL NEPHRITIS <ul><li>Synthetic Penicillins </li></ul><ul><li>Rifampin </li></ul><ul><li>Thiazides </li></ul><ul><li>2 weeks later: Fever, eosinophilia, rash, and an acute renal failure type of picture </li></ul>www.freelivedoctor.com
    54. 54. ANALGESIC NEPHROPATHY <ul><li>ASPIRIN, TYLENOL, NSAIDS </li></ul><ul><ul><li>TUBULOINTERSTITIAL NEPHRITIS </li></ul></ul><ul><ul><li>PAPILLARY NECROSIS (also Dm & HbS) </li></ul></ul>www.freelivedoctor.com
    55. 55. URATE NEPHROPATHY <ul><li>Precipitation of Uric Acid Crystals in the TUBULES, especially in a LOWER than usual PH situation (mini-TOPHUS) </li></ul>H & E alcohol fixed POLARIZED LIGHT MICROSCOPY www.freelivedoctor.com
    56. 56. HYPERCALCEMIA NEPHROCALCINOSIS PRINCIPLE: In extreme or uncontrolled or chronic HYPERCALCEMIA, calcium stones form in the tubulo-interstitium of the kidney, which can eventually lead to tubular obstruction and loss of function www.freelivedoctor.com
    57. 57. MULTIPLE MYELOMA <ul><li>Bence Jones proteinuria (immunoglobulin light chains) </li></ul><ul><li>AMYLOIDOSIS </li></ul>www.freelivedoctor.com
    58. 58. VASCULAR DISEASES <ul><li>BENIGN NEPHROSCLEROSIS </li></ul><ul><li>MALIGNANT NEPHROSCLEROSIS (i.e., malignant hypertension) </li></ul><ul><li>RENAL ARTERY STENOSIS </li></ul><ul><li>THROMBOTIC MICROANGIOPATHIES </li></ul><ul><ul><li>Hemolytic-Uremic Syndromes, Child, Adult, TTP </li></ul></ul><ul><li>THROMBI, EMBOLI, INFARCTS </li></ul><ul><ul><li>SICKLE CELL </li></ul></ul><ul><ul><li>DIFFUSE CORTICAL NECROSIS </li></ul></ul>www.freelivedoctor.com
    59. 59. BENIGN NEPHROSCLEROSIS <ul><li>Sclerosis, i.e., “hyalinization” of arterioles and small arteries, i.e., arterio-, arteriolo- </li></ul><ul><li>Is this part of “routine” atherosclerosis???? </li></ul><ul><li>VERY VERY VERY common </li></ul>www.freelivedoctor.com
    60. 60. MALIGNANT NEPHROSCLEROSIS (i.e., malignant hypertension) <ul><li>NOT a part of “routine” atherosclerosis </li></ul><ul><li>By definition, associated with rapidly progressive hypertension (1-2% of HTN) </li></ul><ul><li>VASCULAR DAMAGE </li></ul><ul><li>FIBRINOID NECROSIS </li></ul><ul><li>“ ONION SKINNING” </li></ul><ul><li>SIGNIFICANT LUMENAL NARROWING </li></ul>www.freelivedoctor.com
    61. 61. Renal Artery Stenosis <ul><li>Rare cause of HTN </li></ul><ul><li>SMALL Kidney </li></ul><ul><li>1) Plaque type is usual cause, yes regular old atherosclerosis </li></ul><ul><li>2) Fibromuscular “dysplasia” type: </li></ul><ul><ul><li>INTIMAL HYPERPLASIA </li></ul></ul><ul><ul><li>MEDIAL HYPERPLASIA </li></ul></ul><ul><ul><li>ADVENTITIAL HYPERPLASIA </li></ul></ul><ul><ul><li>In younger women </li></ul></ul>www.freelivedoctor.com
    62. 62. PLAQUE , i.e., ATHEROSCLEROSIS FIBROMUSCULAR DYSPLASIA www.freelivedoctor.com
    63. 63. MICROANGIOPATHIES (thrombotic) <ul><li>Hemolytic-Uremic Syndrome </li></ul><ul><ul><li>Familial </li></ul></ul><ul><ul><li>Childhood </li></ul></ul><ul><ul><li>Adult </li></ul></ul><ul><li>TTP ( T hrombotic T hrombocytopenic P urpura), IDIOPATHIC </li></ul>www.freelivedoctor.com
    64. 64. MICROANGIOPATHIES <ul><li>COMMON PROCESSES </li></ul><ul><ul><li>Hemolysis </li></ul></ul><ul><ul><li>Thromboses in renal capillaries </li></ul></ul><ul><ul><li>Thrombocytopenia (a “consumption” coagulopathy) </li></ul></ul><ul><ul><li>FIBRIN PLUGS </li></ul></ul>www.freelivedoctor.com
    65. 65. OTHER VASCULAR <ul><li>Atherosclerosis </li></ul><ul><li>Atheroemboli </li></ul><ul><li>Sickle Cell </li></ul><ul><li>Diffuse Cortical Necrosis </li></ul>www.freelivedoctor.com
    66. 66. RENAL INFARCTS <ul><li>WEDGE SHAPED </li></ul><ul><li>WELL DELINEATED </li></ul><ul><li>“ WHITE” (anemic) INFARCT </li></ul><ul><li>Perhaps a little “YELLOW” </li></ul><ul><li>HEAL WITH A SCAR </li></ul>www.freelivedoctor.com
    67. 67. www.freelivedoctor.com
    68. 68. OBSTRUCTIONS <ul><li>UROLITHIASIS </li></ul><ul><li>CONGENITAL </li></ul><ul><li>PROSTATE ENLARGEMENT </li></ul><ul><li>TUMORS </li></ul><ul><li>INFLAMMATION </li></ul><ul><li>SLOUGHED CLOTS, PAPILLAE </li></ul><ul><li>PREGNANCY </li></ul><ul><li>NEUROGENIC </li></ul>www.freelivedoctor.com
    69. 69. UROLITHIASIS <ul><li>CALCIUM (OXALATE or PHOSPHATE) 70% </li></ul><ul><li>MAGNESIUM AMMONIUM PHOSPHATE 20% </li></ul><ul><li>URIC ACID 10% </li></ul>CA ↑↑↑ Bact. U.A. ↑↑↑ www.freelivedoctor.com
    70. 70. TUMORS <ul><li>BENIGN </li></ul><ul><ul><li>Papillary Adenoma </li></ul></ul><ul><ul><li>Fibroma/Hamartoma </li></ul></ul><ul><ul><li>Angiomyolipoma </li></ul></ul><ul><ul><li>Oncocytoma </li></ul></ul><ul><li>MALIGNANT </li></ul><ul><ul><li>Renal Cell Carcinoma (Clear Cell Carcinoma, Adenocarcinoma, Hypernephroma) </li></ul></ul><ul><ul><li>Urothelial (Transitional) </li></ul></ul>www.freelivedoctor.com
    71. 71. RENAL CELL CARCINOMA <ul><li>TOBACCO RELATED, STRONGLY </li></ul><ul><li>SOME HEREDITARY/FAMILIAL </li></ul><ul><li>MOST are “CLEAR CELL” , a few PAPILLARY </li></ul><ul><li>YELLOW grossly, “CLEAR” cells microscopically </li></ul><ul><li>STRONGLY tend to invade the renal VEIN early, in preference to lymphatics. Does the kidney have lymphatics? </li></ul>www.freelivedoctor.com
    72. 72. UROTHELIAL (TRANSITIONAL) RENAL CARCINOMAS <ul><li>In renal pelvis. Why? </li></ul><ul><li>1/10 as common as renal cell carcinomas </li></ul><ul><li>EXACTLY the same appearance as lower urinary tract carcinomas. Why? </li></ul><ul><li>MUCH more likely to obstruct the kidney than renal cell carcinomas. Why? </li></ul><ul><li>Associated with ureter and bladder carcinomas. Why? </li></ul>www.freelivedoctor.com

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