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Flashcards in Histopathology Renal Pathology Deck (84):
1

Functions of the kidney

• Excretion of waste products
• Regulation of water/salt
• Maintenance of acid/base balance
Secretion of hormones

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Nephrotic syndrome – chronic

• Massive proteinuria (selective albumin)
• Hypoalbuminaemia
• Oedema
• Hyperlipidaemia/ - uria

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Nephritic Syndrome acute

• Variable proteinuria (not selective)
• Haematuria
• Mild oedema
• Oliguria
• Azotaemia
• Hypertension

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Nephrotic Syndrome: Definition

Damage to the filtration of the glomerulus not accompanied by inflammation or proliferative response

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Nephrotic Syndrome: Histological damage

Loss of foot processes

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Nephrotic Syndrome: Triad

Hypoproteinaemia (hypoalbuminaemia)
Oedema
Hyperlipidaemia

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Nephrotic Syndrome: Massive proteinuria

>3.5 g/day
Hypoalbuminaemia

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Nephrotic Syndrome: Children

Minimal damage disease

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Nephrotic Syndrome: Adults

Systemic disease (diabetes)

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Nephrotic Syndrome: Nephrotic disease type?

Minimal change disease
Focal segmental glomerulosclerosis
Membranous glomerulonephritis

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Nephrotic Syndrome: Minimal change disease/glomerulopathy

• Commonest cause of nephrotic syndrome in childhood
• No detectable immune deposit but has, nonetheless an immune basis
• Strong association with resp. infection and immunization

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Nephrotic Syndrome: Minimal change disease/ glomerulopathy histological

Diffuse effacement of foot processes (fused)

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Nephrotic Syndrome: Focal segmental glomerulosclerosis

• Primary or Secondary
• Some (focal) glomeruli show partial (segmental) hyalinization
• Unknown pathogenesis
• Poor prognosis

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Nephrotic Syndrome: Membranous glomerulonephritis

• Deposition of anti-glomerular basal membrane antibodies
• Thickened GBM and sub epithelial deposits/spikes

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Nephrotic Syndrome: Membranous glomerulonephritis epi

• Commonest causes of nephrotic syndrome in adults
• 85% idiopathic, 15% association with malignant tumours, SLE, drugs, chronic infection.

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Nephritic Syndrome: Description



Expression of acute glomerular injury
• Inflammation
• Vascular and epithelial damage
• Plus or minus proliferation of glomerular cells

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Nephritic Syndrome: Triad

• Haematuria
• Azotemia
• Oliguria
• Mild oedema (facial puffiness)
• Variable proteinuria
• Mild to moderate Hypertension

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Nephritic Syndrome: Membranoproliferative (mesangiocapillary) glomerulonephritis

• Diffuse mesangioproliferative glomerulonephritis
• Crescentric glomerulonephritis
• Lupus nephritis

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Nephritic Syndrome: Glomerulonephritis

• Primary or secondary to systemic disease
• Immunological aetiology (+++ deposition of immune complex in the glomerular/capillary wall).

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Nephritic Syndrome: Glomerulonephritis features

• Local deposition of circulating immune complexes
• Anti-glomerular basal membrane antibodies
• Antibodies against glomerular component

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Nephritic Syndrome: Prognosis

• Benign outcome in children
• Permanent compromised of renal function in adults

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Nephritic Syndrome: The Major cause of acute nephritis in childhood

Acute proliferative Glomerulonephritis

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Nephritic Syndrome: Acute proliferative Glomerulonephritis arises

Arises following a group A beta-haemolytic streptococcal infection

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Nephritic Syndrome: Acute proliferative Glomerulonephritis features

• Endocapillary hypercellularity with numerous neutrophils and closure of glomerular vessels
• The glomeruli are increased in size and cellularity

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Nephritic Syndrome: Glomerulonephritis – antibodies against glomerular component

• Usually presents with a combined nephritis – nephrotic picture
• Cresentic or rapidly progressing glomerulonephritis

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Nephritic Syndrome: Glomerulonephritis – antibodies against glomerular component

Increase in mesangial substance. Localized capillary wall thickenings, increased cellularity and pronounced lobulation.

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Diseases affecting tubules and interstitium: types

Acute tubular necrosis
Tubulointerstitial nephritis

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Acute tubular necrosis epi

Most common cause of ARF
Reversible tubular injury

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Causes of acute tubular necrosis

Ischemia (shock)
Toxic (Drugs)

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Prognosis Acute tubular necrosis

Most patients recover

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Acute tubular necrosis histology

There is focal necrosis and desquamation of the cells into the tubular lumen.

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Tubulointersitial nephritis

Acute pyelonephritis
Chronic pyelonephritis: and reflux nephropathy
Drugs and toxins – analgesic nephropathy

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Urinary tract infections and Reflux nephropathy

Women, elderly
Patients with catheters or malformations
Dysuria, frequency

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Urinary tract infections and Reflux nephropathy organisms

E. coli
Proteus

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Acute pyelonephritis

Acute pyelonephritis in a patient presenting with fever and elevated creatinine. There is an acute inflammatory infiltrate in the interstitium and tubular lamina.

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Chronic pyelonephritis

• The surface of the kidney is irregular/ or geographically, depressed in the scarred area with pseudo bulging of the remaining intact parenchyma.
• Chronic pyelonephritis can affect both kidneys simultaneously; however, the scarring is asymmetrical.
• The cut surface would reveal dilated, blunted or deformed calyces.

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Chronic pyelonephritis features

• Many dilated “colloid” filled tubules are present – ‘thyroidisation of the kidney’.

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Diseases of the blood vessels:

Hypertensive kidney disease
Benign nephrosclerosis

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Hypertensive kidney disease

Benign nephrosclerosis

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Benign nephrosclerosis

• Focal sclerosis of renal arterioles and small arteries > focal ischemia > cortical scarring.
• Some degree of nephroscleosis is present at autopsy with increased age.
• HTN and DM increased the severity of the lesion.

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More severe

Malignant HTN and accelerated nephrosclerosis

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Cystic Disease of the Kidney: Types

Malformative/congenital
Acquired

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Cystic Disease of the Kidney: Malformative/congenital

Multicystic renal dysplasia (most common causes of abdominal mass in newborn)
Medullary sponge kidney

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Cystic Disease of the Kidney: Acquired

Acquired renal cystic disease (mostly post dialysis)
Simple cysts (most common abnormality of the kidney)

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Cystic Disease of the Kidney:Hereditary

Autosomal dominant (adult) polycystic kidney disease (ADPKD)
Autosomal recessive (infantile) polycystic kidney disease
Nephronophthisis – medullary cystic kidney disease complex

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Cystic Disease of the Kidney:Adult polycystic disease epi

Occurs in 1/500 people
AD inheritance:
• Bilateral
• Presents middle age

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Cystic Disease of the Kidney: Clinically

Haematuria
UTI
Abdo mass
HTN

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Cystic Disease of the Kidney: Associated with CRF

Cerebral aneurysms
Subarachnoid haem
Cysts in other organs (liver, pancreas, lung)

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Cystic Disease of the Kidney: Complications

CRF

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Cystic Disease of the Kidney: Management

Supportive
Treat HTN
Some will need dialysis/transplant

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Infantile polycystic disease: Epi

1/20000
AR inheritance

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Infantile polycystic disease: Clinically

Large abdominal masses (both kidneys affected) at birth

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Infantile polycystic disease: Possible

“Potter” phenotype

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Infantile polycystic disease: Associated with

Liver abnormalities (congenital hepatic fibrosis, biliary dysgenesia, bile duct ectasia).

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Infantile polycystic disease: Evolves into

Death shortly after birth in severe forms
Renal failure
Hypertension
Portal Hypertension

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Simple renal cysts

Common autopsy findings. No clinical significance.

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Other cysts

Dialysis associated cystic disease

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Chronic Renal Disease: Description

Abnormal kidney function/ structure –end result of a number different renal diseases.
• Frequently unrecognised and/or coexisting with other conditions
• Can be asymptomatic till it progresses into end stage renal disease.

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Chronic Renal Disease: Causes

Diabetes
Hyperternsion

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Glomerulonephritis 40%

Chronic Pyelonephritis (20%)

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Polycystic disease 9%

Multisystem diseases 9%

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Acute Renal Failure → Description

Rapid reduction of in renal excretory function ( within 48 hr)

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Acute Renal Failure → Clinically

Absolute increase in serum creatinine >=m0.3 mg/dl serum urea, CR, K with anuria/ oliguria (<15ml/hr)
Reduction urine output (oliguria) less than 0.5 ml/kg per hour for more than 6 hr

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Acute Renal Failure → Clinical presentations

Oliguric phase – metabolic acidosis, increased Urea]Recovery pahse – polyuria

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Acute Renal Failure → Prerenal (renal perfusion)

Shock, Renal artery stenosis

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Acute Renal Failure → Renal causes (parenchyml structures)

ATN
Acute GN
Acute inst nephritis
CRF

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Acute Renal Failure → Post Renal (urine output)

Obstructive lesions
Stones
Tumours

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Nephrolithiasis: Description

Stone formation either in the kidney or renal tract

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Nephrolithiasis: Epi

• 20-30 yrs M>F
• 5% of population
• Reoccurrence - 40 to 70%
• Symptomatic – 50% will cause some problem with 5 years of discovery

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Nephrolithiasis: Stone types

• Calcium oxalate
• Triple phosphate (magnesium ammonium calcium phosphate)
• Urate
• Cystine

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Nephrolithiasis: Calcium oxalate

Hypercalcaemia/Idiopathic hypercalciuria 75%

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Nephrolithiasis: Triple phosphate (magnesium ammonium calcium phosphate)

Proteus infection which splits urea into ammonium (Staghorn calculus) 15%

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Nephrolithiasis: Urate

Hyperuricaemia (GOUT) 6%

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Nephrolithiasis: Cystine

In born error of metabolism 1%

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Nephrolithiasis:Predisposition to conditions

Dehydration
Sarcoidosis hypercalcaemia (Granuomas produce VitD)
Cushing disease hypercalcemi
Oxalate rich food broccoli, celery
Bladder obstruction urine stasis, stagnant urine
Polycystic disease congenital disorder
Medullary sponge kidney congenital disorder
Calycael diverticula congenital disorder
Urinary diversions crystallation on exposed metallic surgical clips
Stents, catheters crystallisation on foreign substances

76

Renal Tumours: Types

Childhood –Wilm’s tumour

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Renal Tumours: Benign

Papillary adenomas. Fund at autopsy (<5mm), Fibroma

78

Renal Tumours:Malignant -

Renal cell Carcinoma (80%) TCC (20%)

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Renal Tumours: Renal cell carcinoma risk factors

Smoking
HTN
Obesity
Heavy Metals

80

Renal Tumours:Von Hippel Lindau syndrome

Haemangioblastoma of cerebellum
Retina
Renal cyst
Bilateral RCC

81

Renal Tumours:Clinical presentation of Renal tumours

Paraneoplastic conditions
e.g.
• Polycythemia
• Hypercalcaemia
• Liver
• Dysfunction
• Cushing syndrome
• Amyloidosis
Palpable mass
Haematuria
Backpain

82

Renal Tumours: Histotypes

Clear cell
Papillary and chromophobe

83

Renal Tumours:Survival

5 yrs 70% if no mets, 45% if mets

84

Renal Tumours: Microscopic findings

Clear cytoplasm and sharply outlined cell membrane

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