Normal kidney

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Normal kidney
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Ultrasructure of normal kidney
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Clinical presentations

• Azotemia
• Uremia
• Nephritic syndrome
• Nephrotic syndrome
• Hematuria
• Proteinuria
• Acute renal failure
• Chronic renal failure

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Nephrotic syndrome

• S/S
• Heavy proteinuria (3.5 gm) and hypoalbuminemia
• Edema
• Infections
• Thrombosis
• Hyperlipidemia and lipiduria.
• Disorders with thickening of BM and mesangium.
• Associated common glomerular diseases
• Membranoproliferative glomerulonephritis
• Membranous glomerulonephritis
• Minimal change

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Nephritic syndrome

• Sudden onset
• S/S
• Hematuria, RBC casts.
• Proteinuria, mild to moderate, not nephrotic
  range.
• Hypertension
• Glomerular diseases with cellular proliferation.
• Hallmark disease post streptococcal
  glomerulonephritis

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Acute Renal failure

• Kidney stops working.
• Oliguria to anuria.
• Reversible
• Common cause- acute perfusion failure
• Gross and M/E Renal cortical necrosis
• Lab Data increased BUN and Serum Cr
• Hyperkalemia, metabolic acidosis, urinary sodium
  loss, same plasma and urine osmolality.

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Chronic renal failure

• Irreversible
• Slow progression
• S/S Uremia, polyuria, bone disease, anemia.
  Metabolic compensation.
• Common causes hypertension and diabetes.
• Leads to end-stage renal disease.

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End stage renal disease

• Small, shrunken and granular
• Misnomer-chronic glomerulonephritis
• D/D Chronic pyelonephritis
• M/E hyalanized glomeruli, tubular atrophy and
  interstitial fibrosis.

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Congenital Disorders

• Renal agenesis- usually unilateral
• Hypoplasia
• Ectopic Kidneys
• Horseshoe kidney

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Double ureter
Horse shoe kidney
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Cystic diseases of kidney

• Simple cyst
• Adult polycystic kidney disease
• Childhood polycystic kidney disease

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Adult Polycystic kidney
Simple renal cyst
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Adult polycystic kidney disease

• Autosomal dominant
• Bilateral
• Does not produce symptoms until the 4th decade
• Slowly progressive
• Associated findings
• Liver cysts
• berry aneurysms.

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Autosomal recessive kidney disease
Autosomal recessive Presents early Bilateral Liver
cysts with proliferation of bile ducts
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Renal pathology

• Diseases of the following
• Glomeruli- glomerulonephritis
• ( classified on the basis of histopathology)
• Vessels
• Interstitium
• Tubules

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Pathogenesis of glomerular diseases

• Immunological
• Antibodies reacting with glomerular antigens
• Trapped circulating agent (Membranous)
• Anti GBM antibodies (Good pasture's disease)
• Circulating immune complexes (Post streptococcal
• Vascular
• Hypertension
• Diabetes
• Foreign material
• Amyloidosis

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Glomerular response to damageHistological changes

• Hypercellularity
• BM thickening
• Hyalinization and sclerosis
• Terminology
• Diffuse/focal
• Global/segmental

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Acute glomerulonephritis

• Acute proliferative(poststreptococcal)
  glomerulonephritis
• Rapidly progressive (crescentric)
  glomerulonephritis.
• Reaction to severe glomerular damage
• Leakage of fibrin, leading to epithelial cell
  proliferation and crescent formation
• Poor prognosis

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Acute diffuse proliferative glomerulonephritis

• 1-2 wks post streptococcal
• Usually in children
• Usually mild and transient
• Clinical presentation- nephritic syndrome
• Diagnosis
• Histology- increased cellularity
• IF IgG and C3
• EM- granular subepithelial deposits
• Rx supportive

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Crescentric glomerulonephritis
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Minimal change disease

• In children
• CP -Nephrotic syndrome
• Histology
• H and E Normal
• EM Fusion of foot process
• IF
• Rx steroids

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Membranous nephropathy

• Usually adults
• CP- nephrotic syndrome
• Etiology- idiopathic/ secondary to multiple
  causes
• Infective
• Drugs
• Tumors
• SLE
• Diagnosis
• H and E- diffuse and global, BM and mesangial
  thickening
• IF- IgG and complement
• EM- Subepithelial deposits (spikes)

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Membranoproliferative glomerulonephritis

• Children and adults
• CP- mixed nephrotic and nephritic
• Etiology- idiopathic or secondary e.g. SLE
• Histology- Type 1 and Type 2
• Type I- increased lobularity of the glomeruli,
  because of mesangial proliferation ( mesangial
  interposition-tram track appearance)
• EM Subendothelial deposits
• IF IgG/ IgM and C3
• Type II- mesangial proliferation not that
  prominent
• EM dense deposit disease
• IF C3
• Course progressive, poor prognosis

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Focal glomerulosclerosis

• Children and adults
• CP- nephrotic syndrome
• Etiology- Idiopathic/ secondary e.g. HIV.
• Poor prognosis

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Kidney and vascular disease

• Central perfusion failure
• Large vessel disease e.g. atherosclerosis-thromboe
  mbolic, renal artery stenosis
• Small vessel disease e.g. hypertension, diabetes
  and vasculitis
• Pathogenesis- affects glomerular infiltration and
  ischemic tubular atrophy
• Course- usually chronic

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Renal infarcts

• Causes
• accelerated hypertension
• Vasculitis
• Emboli

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Hypertension and kidney

• Benign hypertensive nephrosclerosis
• Granular kidney
• Arteriolar hyalinization
• Malignant hypertension
• Flea bitten kidney
• Fibrinoid necrosis of the vessels

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Hyalanized arterioles
Granular kidney
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Malignant Hypertension
Fibrinoid necrosis Hyperplastic arteriopathy
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Diabetes and kidney

• Diabetes most common cause of end stage renal
  failure.
• Diabetic vascular disease- AS/hyaline
  arteriosclerosis.
• Diabetic glomerulosclerosis
• Mesangial matrix formation
• Diffuse glomerulosclerosis
• Nodular glomerulosclerosis (Kimmelstiel-wilson
  disease)
• BM thickening
• Exudative lesions- fibrin cap
• Increased infection- Pyelonephritis
• Papillary necrosis

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Diseases of renal tubules and interstitium

• Pyelonephritis- acute and chronic
• Acute tubular necrosis
• Interstitial nephritis
• acute and chronic
• interstitial inflammation
• Drugs like analgesics and antibiotics
• Metabolic damage to tubules for eg calcium and
  urate
• Functional tubular abnormality

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Acute tubular necrosis

• Reversible acute renal failure.
• Causes
• Ischemia
• Drugs
• Clinical stages
• Initiating- oliguria
• Maintenance- polyuria
• Recovery

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Acute Pyelonephritis

• Bacterial infection
• Routes ascending infection and hematogenous
• Predisposing factors pregnancy, DM, stones,
  tumor, vesicoureteral reflux
• S/S pain, fever, often with lower urinary
  symptoms.
• Gross small cortical abscess
• M/E neutrophils present
• Course septicemia, papillary necrosis, peri and
  pyonephrosis.

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Chronic Pyelonephritis

• Reflux associated/ obstructive.
• Gross irregular cortical scarring, distorted
  renal calyx
• M/E chronic inflammation, fibrosis and tubular
  atrophy.
• Specific Tuberculous pyelonephritis

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Chronic pyelonephritis
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HYDRONEPHROSIS

• Dilatation of renal pelvis and calyces and
  parenchymal atrophy due to urinary tract
  obstruction.

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Renal stones

• Factors
• Increased conc. of solutes
• change in urinary Ph
• decreased urinary volume
• infection
• Types
• Calcium (hypercalcinuria, hypercalcemia, excess)
• Magnesium ammonium phosphate stones (alkaline
  urine due to infection)
• Uric acid stones ( gout, leukemias, acidic urine)
  

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Renal tumors

• Benign tumors common.
• Common malignant tumors
• Renal adenocarcinoma in adults (90)
• Wilms tumor in children.
• CP- hematuria, pain, mass, metastasis,
  paraneoplastic.
• Prognosis depends on the stage.
• Etiology - cytogenetic abnormalities

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Renal Cell Carcinoma

• 6th to 7th decade
• Male predominance 31
• Yellow round mass, 3-15 cm
• Often invade renal vein and extend into the
  inferior vena cava
• Chromosome 13

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Wilms tumor

• Childhood tumor composed of primitive tissue.
• Chromosome 1-loss of cancer suppression gene WT-1
• Combination of radiotherapy, nephrectomy and
  chemotherapy good results

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