Pathology 4, 5, 6 Flashcards
(157 cards)
1
Q
What is needed to diagnose Acute Kidney Injury (AKI) / Acute Tubular Necrosis (ATN)
A
CLINICAL AND PATHOLOGY
- Acute diminution of renal function
- Evidence of tubular injury
2
Q
What is the most common cause of acute renal failure?
A
AKI/ATN
3
Q
What are the 4 causes of AKI/ATN?
A
- Ischemia
- Direct toxic injury to tubules (Drugs, radiocontrast dyes, myoglobin, hemoglobin, radiation)
- Acute tubulointerstitial nephritis (HS rxn to drug)
- Urinary obstruction (tumors, prostate hypertrophy, blood clots)
4
Q
What is characterized morphologically by focal tubular epithelial necrosis at multiple points along the nephron, rupture of BM and occlusion of tubular lumens by casts, and interstitial edema and accumulations of leukocytes within dilated vasa recta?
A
Ischemic AKI
5
Q
What type of casts are seem in tubular lumens in ischemic AKI?
A
Eosiniphilic hyaline casts and pigmented granular casts –> Tamm-Horsfall protein
6
Q
Where are Tamm-Horsfall proteins normalls secreted?
A
The cells of the ascending thick limb and distal tubules
7
Q
What does toxic AKI result in?
A
Acute tubular injury to the proximal convoluted tubules
8
Q
What 3 toxins can cause Toxic AKI?
A
- Mercuric chloride
- Carbon tetrochloride
- Ethylene Glycol
9
Q
What is seen in cells affected by mercuric chloride?
A
- Contain large acidophilic inclusions
- . Cells become necrotic, are sloughed into lumen, and undergo calcification
10
Q
Which toxin causes accumulation of neutral lipids in injured cells followed by necrosis?
A
Carbon tetrachloride
11
Q
What type of crystals are seen in the tubular lumen with ethylene glycol toxicity?
A
Calcium oxalate
12
Q
What is characteristic for ethylene glycol toxicity?
A
Marked ballooning and hydropic or vacuolar degeneration of PCT (this also happens in immunosuppression
13
Q
What are 2 forms of the group of renal diseases called tubulointersitial nephritis?
A
Acute or Chronic
14
Q
4 Characteristics for acute tubulointerstitial nephritis?
A
- Rapid clinical onset
- Interstitial edema * (not in tubular epithelial cells)
- Leukocytic infiltration of the interstitium and tubules
- Focal tubular necrosis
15
Q
What is seen in chronic interstitial nephritis?
A
- Infiltration with mononuclear leukocytes
- Interstitial fibrosis
- Tubular atrophy
16
Q
What is acute suppurative inflammation of the kidney?
A
Acute pyelonephritis
17
Q
What cn cause acute pyelonephritis?
A
Bacterial and viral (polyomavirus) infection
18
Q
What are the 3 morphological hallmarks of acute pyelonephritis?
A
- Patchy interstitial suppurative inflammation
- Intratubular aggregates of neutrophils
- Tubular necrosis
19
Q
What 3 things are associated with yellow?
A
- Fat
- Necrosis
- Granulomas
20
Q
What are the 3 complications seen with acute pyelonephritis?
A
- Papillary necrosis
- Pyonephrosis
- Perinephric Abscess
21
Q
What is pyonephrosis?
A
Suppurative destruction of the renal parenchyma, with total or almost complete loss of kidney function
22
Q
What are the symptoms associated with pyonephrosis?
A
Fever, chills, and flank pain
but some can be asymptomatic
23
Q
What can cause pyonephrosis?
A
- Ascending infection of the urinary tract
2. Hematogenous spread of a bacterial pathogen
24
Q
What is a collection of suppurative material in the perinephric space?
A
Perinephric abscess
25
What is a pyelonephritic scar?
Inflammation, fibrosis, and deformation of the underlying calyx and pelvis
26
This is chronic tubulointerstitial inflammation and renal scarring associated with pathologic involvement of the calyces and pelvis.
Chronic pyelonephritis
27
What is the association between chronic pyelonephritis and kids?
Chronic pyelonephritis is an important cause of kidney destruction in children with severe lower urinary tract abnormalities
28
What are the 2 forms of Chronic Pyelonephritis?
1. Chronic reflux-associated
| 2. Chronic obstructive
29
What are the 2 hallmarks of chronic pyelonephritis?
1. Coarse, discrete, corticomedullary scars overlying dilated, blunted, or deformed calyces
2. Flattening of the papillae
30
Are the kidneys scarred in chronic pyelonephritis?
YES- Irregularly scarred
31
What is seen in the tubules with chronic pyelonephritis?
1. Tubular atrophy in some areas and hypertrophy or dilation in others
2. Dilated tubules with flattened epithelium filled with colloid casts (thyroidization)
32
What is seen in the cortex and medulla for chronic pyelonephritis?
Chronic interstitial inflammation and fibrosis
33
Are the glomeruli normal in chronic pyelonephritis?
Maybe... except for periglomerular fibrosis
34
What causes analgesic nephropathy (a form of chronic renal disease)?
Excessive intake of analgesic mixtures
35
What nephropathy is associated with tubulointersitial nephritis and renal papillary necrosis?
Analgesic nephropathy
36
5 Morphological features of analgesic nephropathy?
1. Kidneys are either normal or slightly reduced in size
2. Cortical atrophy overlying necrotic papillae
3. Papillae show various stages of necrosis, calcification, fragmentation, and sloughin
4. Cortical loss and atrophy of tubules
5. Intersitial fibrosis and inflammation
37
Patient profile for analgesic nephropathy?
CRAZY WOMAN
| -Or someone with recurrent HA and muscle pain, factory workers
38
What other clinical symptoms are seen with analgesic nephropathy?
-HA, anemia, GI symptoms, and HTN
39
What happens to the papillae in analgesic nephropathy?
They are necrotic and the tips are excreted causing gross hematuria or renal colic (this is secondary to obstruction of the ureter by necrotic fragments)
PAINFUL
40
If you stop taking the drugs that cause analgesic nephropahty, do you get better?
Kinda.. the renal function with either stabilize or get better
41
What is urate nephropathy and how many types are there?
Nephropathy in persons with hyperuricemic disorders..3 types
42
What are the 3 types of urate nephropathy?
1. Acute uric acid nephropathy
2. Chronic urate nephropathy (gouty nephropathy)
3. Nephrolithiasis
43
What type of crystals are found in acute uric acid nephropathy and where?
Uric acid crystals in the renal tubules, principally in the collecting ducts
44
What happens from the precipitation of uric acid crystals in acute uric acid nepropathy?
Get obstruction of nephrons and the development of acute renal failure
45
What conditions are associtaed with acute uric acid nephropathy?
Leukemias and lymphomas, undergoing chemo
46
What types of crystals are deposited in chronic urate nephropathy and where?
Monosodium urate crystals in the distal tubules, collecting ducts, and interstitium
47
Describe the crystals seen in chronic urate nephropathy
Variably birefringent needle-like crystals in the tubular lumens or interstitium
48
What is trophus and what is it seen in?
Foreign-body giant cells, other mononuclear cells, and a fibrotic reaction ... seen in chronic urate nephropathy
49
Uric acid stones are seen in what % of people with gout?
22%
50
Uric acid stones are seen in what % of people with secondary hyperuricemia?
42%
51
Does urolithiasis affect more men or women?
Men more often
52
What is the peak age of onset for urolithiasis?
20-30 years
53
Does urolithiasis have a familial and hereditary predisposition to stone formation?
YES
54
What are the 4 main types of calculi in urolithiasis?
1. Calcium stones (70%)
2. Triple Stones or Struvite stones (15%)
3. Uric acid stones (5% to 10%)
4. Cystine (1% to 2%)
55
What are calcium stones composed of?
Calcium oxalate or calcium oxalate mixed with calcium phosphate
56
What are triple/struvite stones made of?
Magnesium ammonium phosphate
57
Which stone is the biggest (staghorn calculi)?
Triple stones or struvite stones
58
What are triple/struvite stones associated with ?
Infections by bacteria *Proteus (and some staphylococci)
59
True or False: Uric acid stones are radioopaque
FALSE... those suckers and radiolucent
60
When do you see uric acid stones?
Hyperuricemia (gout)
61
What is multicystic renal dysplasia?
A sporadic disorder resulting in an abnormality in metanephric differentiation
62
What are the characteristic histological findings of multicystic renal dysplasia?
Persistence of abnormal structures in the kidney...cartilage, undifferentiated mesenchyme, and immature collecting ductules
63
What are the 3 associations of multicystic renal dysplasia?
1. Ureteropelvic Obstruction
2. Ureteral agenesis or atresia
3. Anomalies of the lower urinary tract
64
Is the dysplasia seen in multicystic renal dysplasia unilateral or bilateral?
Either
65
What does the kidney look like in multicystic renal dysplasia?
It is enlarged, irregulat and multicystic
66
What type of cells line the cysts and are the cysts big or small?
Flattened epithelium and they vary in size
67
What is the histologic hallmark of multicystic renal dysplasia?
Presence of islands of undifferentiated mesenchyme with cartilage** and immature collecting ducts
68
What are the 3 cystic diseases discussed?
1. Autosomal-Dominant Polycystic Kidney Disease
2. Autosomal-Recessive Polycystic Kidney Disease
3. Medullary Sponge Kidney
69
Does autosomal-dominant polycystic kidney disease (ADPKD) affect adults or kids?
ADULTS
70
Is ADPKD hereditary?
YES
71
What happens in ADPKD?
You get multiple expanding cysts of both kidneys that destroy the renal parenchyma and cause renal failure
72
What is the pattern of inheritance in ADPKD?
AUTOSOMAL DOMINANT (shocker) with high penetrance
73
Tell me about the kidneys in ADPKD?
They are both BIG (can weigh as much s 4kg per kidney) and the external surface is a mass of cysts (3-4cm in diameter) with no intervening parenchyma
74
What's in the cysts in ADPKD?
They are filled with a clear, serous fluid or with turbid, red to brown fluid
(They arise from the tubules throughout the nephron and have variable lining epithelia)
75
Does autosoma-recessive polycystic kidney disease (ARPKD) affect kids or adults?
KIDS
Perinatal, neonatal ,infantile, and juvenile subcategories (based on time of presentation and presence of associated hepatic lesions)
76
What mutation causes ARPKD?
Mutation in the PKHD1 gene
77
What is the morphology of ARPKD?
1. Enlarged kidneys with a smooth external appearance
| 2. Numerous small cysts in the cortex and medulla (Looks like a sponge
78
In ARPKD what cells line the cysts and where are they from?
Cuboidal cells that originate from the collecting ducts
79
What other organ has cysts in ARPKD?
The liver
80
What is a result of liver cysts seen in ARPKD?
- Portal Fibrosis
| - Proliferation of portal bile ducts
81
What is medullary Sponge Kidney?
A sporadic cystic disease involving bilateral cystic dilations of medullary collecting ducts with normal cortex
82
What diseases are associated with Medullary Sponge Kidney?
Marfans, Carolis, Ehlers-Danlos
83
When does medullary sponge kidney present?
Adulthood
84
What is the prognosis of medullary sponge kidney?
Patients are usually asymptomatic with normal renal function... this does not progress to end stage renal disease
85
How is medullary sponge kidney diagnosed?
Intravenous pyelography
86
Are the kidneys normal sized in Medullary Sponge Kidney?
YES
87
What is seen in the kidneys in medullary sponge kidney?
Multiple, small cysts in the medullary pyramids and papillae...gives a sponge-like appearance of the medulla and is most often bilateral
88
What is seen microscopically in medullary sponge kidney ?
1. Medullary cysts lined by cuboidal epithelium or urothelium
2. Severe inflammation and scarring in the interstitium
3. Tubular atrophy near papillary tips
89
What are the 3 benign tumors of the kidney discussed?
1. Renal Papillary Adenoma
2. Angiomyolipoma
3. Oncocytoma
90
Which tumor type arises from renal tubular epithelium?
Renal Papillary Adenoma
91
Describe renal papillary adenomas
Small and discrete with complex, branching papillomatous structures
92
What is used as a prognostic feature in renal papillary adenoma?
SIZE
| -Over 3cm, metastasize, under 3cm, just chill
93
What are angiomyolipomas made of?
Vessels, smooth muscle, and fat
94
What is the clinical association with angiomyolipomas?
20%-50% of patients with tuberous sclerosis
95
Which tumor type do we need to worry about spontaneous hemorrhage?
Angiomyolipomas
96
What is an oncocytoma compoase of?
Large eosinophilic cells
97
Which tumor arises from the intercalated cells of the collecting ducts?
Oncocytomas
98
Describe oncocytomas
Small, round, benign-appearing nuclei with LARGE NUCLEOLI (like they are staring at you)
99
Which tumor is mahogany brown and well encapsulated?
Oncocytomas
100
What is seen on EM for an oncocytoma?
Eosinophilic cells have numerous mitochondria
101
What are the malignant tumors in the kidneys called?
Renal cell carcinomas or adenocarcinoma of the kidney
102
What age and gender are renal cell carcinomas associated with?
6th-7th decade and males (2:1)
103
Smoking is a risk factor for what tumor?
Renal cell carcinoma
104
Which cells do renal cell carcinomas arise from?
Tubular epithelium
105
What color are adenocarcinomas (renal cell carcinomas)?
YELLOW
106
What are the 4 types of renal cell carcinomas?
1. Clear cell carcinoma
2. Papillary carcinoma
3. Chromophobe renal cell carcinoma
4. Collecting duct (Bellini duct) carcinoma
107
What % of renal cell cancers is clear cell carcinoma?
70-80%
108
In clear cell carcinoma, where do the tumor cells derive from?
Proximal convoluted tubule
109
What color are clear cell carinomas?
Oragne/Yellow (LIPID)
110
Which tumor is commonly found in the upper pole, is well circumscribed, has hemorrhage, necrosis, and calcification?
Clear Cell Carcinoma
111
What other structures are frequently involved in clear cell carcinoma?
Renal vein and renal sinus (especially if its BIG)
112
If a clear cell carcinoma is bilateral, what conditions are associated with it?
1. von Hippel Lindau
| 2. Tuberous Sclerosis
113
What are the microscopic findings for clear cell carcinoma?
1. Compact, tubulocystic, alveolar patterns
2. Clear/granular cytoplasm (glycogen/lipid)
3. Cell size is 2x normal epithelial tubule cell
114
What mutation is associated with clear cell carcinoma?
-Loss of sequences on the short arm of chromosome 3 (3p deletion)
115
10-15% of renal cancers are caused by what?
Papillary carcinoma
116
Where do papillary carcinomas originate from?
Proximal or distal convoluted tubule
117
What is the size that papillary carcinomas are over to distinguish them from papillary adenomas?
5cm
118
What is papillary carcinoma also called?
Chromophil renal carcinoma
119
What are the microscopic findings associated with papillary carcinoma?
1. Well-circumscribed, often with distinct fibrou capsule
2. Papillary growth patter
3. Foamy macrophages and intracellular hemosiderin
120
Which mutations is the sporadic form of papillary carcinoma associated with?
Trisomies 7, 16, 16
| Loss of Y in male patients
121
Which mutations is the familial form of papillary carcinoma associated with?
Trisomy 7
122
What % of renal cell cancers is made up of by chromophobe renal carcinoma?
5%
123
Where do chromophobe renal carcinomas arise from?
Intercalated cells of the collecting ducts
124
Gross findings for Chromophobe renal carcinoma?
1. Well-circumscribed, tan brown
2. Geographic necrosis
3. 8cm
125
What cancer is positive for Hale's colloidal iron stain?
Chromophobe renal carcinoma
126
What is seen microscopically in chromophobe renal carcinoma?
1. Compact architecture of nests or broad alveoli/trabeculae
| 2. Cell membranes and prominent and have pale eosinophilic cytoplasm
127
Which tumors show halos around their nuclei?
Chromophobe renal carcinoma
128
What types of mutations cause chromophobe renal carcinoma?
Multiple chromosome losses and extreme hypodiploidy
129
True or false: Chromophobe renal carcinoma has a poor prognosis
FALSE... it has an excellent prognosis
130
What tumor accounts for 1% of less the renal cell cancers?
Collecting duct (Bellini duct) Carcinoma
131
Where does collecting duct (Bellini duct) carcinoma arise from?
Collecting duct cells in the medulla
132
What are the gross findings for Collecting duct (Bellini duct) carcinoma?
1. Infiltrative, firm, gray-white, 5cm
| 2. May have intrarenal metastases
133
Which tumor has irregular channels lined by high grade hobnail cells?
Bellini duct/Collecting duct carcinoma
134
What will you find in a Collecting duct (Bellini Duct) carcinoma?
Neutrophilic infilatrate and mucin production
135
Where are collecting duct (Bellini duct) carcinomas commonly found?
Medullary location
136
Describe some microscopic findings for Bellini Duct (Collecting duct) carcinoma?
1. Poorly circumscribed tubulopapillary tumor with infiltrative borders
2. Nests of malignant cells within a prominent fibrotic stroma
3. Marked desmoplastic response
137
What is the prognosis for Bellini Duct (Collecting duct) carcinoma?
Really bad...death within weeks to months
138
When does hyperacute rejection occur?
Within minutes or the first few hours after transplantation
139
In hyperacute rejection, where does the initial injury occur?
The endothelium of the arterial and capillaries of the renal parenchyma
140
What causes hyperacute rejection?
Recipient pre-sensitization to donor-incompatible blood groups or HLA antigens (from prior transplantation, blood transfusions, or pregnancies)
141
In hyperacute rejection, what does endothelial injury lead to?
Complement activation
142
What is the result of hyperacute rejection?
Vascular thrombosis and ischemic necrosis of the allograft (happens within few hours or days after transplantation)
143
What is a desmoplastic response?
Mucin and collaginous deposition that can happen around any tumor cells
144
What is the time-frame for acute rejection?
First 5-7 post-transplant days
145
What type of injury causes acute rejection?
Cell-mediated immune injury: Delayed hypersensitivity and cytotoxicity mechanisms are involved
146
What is the immune injury directed against in acute rejection?
HLA expressed by the tubular epithelium and vascular endothelium
147
What type of antigens are expressed in acute rejection?
Class I and Class II HLA antigens
148
What is seen in Banff Schema acute rejection?
Presence of tubulitis and intimal arteritis
149
What is tubulitis?
Infiltration of the tubular epithelium by lymphocytes
150
What is infiltration of the arterial intima?
Intimal arteritis
151
What are the classificaions for acute rejection?
Mild, moderate, and severe
152
What features allow us to categorize acute rejection into mild, moderate, or severe?
Intensity of the infiltrate and severeity of tubulitis and intimal arteritis
153
Why do we categorize acute rejection?
It is a useful way of indicating how urgently and intensively a particular episode of rejection needs to be treatesd
154
What type of infiltrate do you see attacking the kidney in acute rejection?
Lymphocytes
155
When would you see neutrophils in rejection?
Only if its severe (person not taking medication, ect.)
156
What 4 diseases cause papillary necrosis?
1. Sickle cell
2. Obstructive pyelonephritis
3. Diabetes
4. Analgesics
SODA
157
In acute lung injury caused by ischemia, what type of necrosis will you see?
COAGULATIVE
