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Renal I > Pathology 4, 5, 6 > Flashcards

Pathology 4, 5, 6 Flashcards

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
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2
Q

What is the most common cause of acute renal failure?

A

AKI/ATN

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3
Q

What are the 4 causes of AKI/ATN?

A
  1. Ischemia
  2. Direct toxic injury to tubules (Drugs, radiocontrast dyes, myoglobin, hemoglobin, radiation)
  3. Acute tubulointerstitial nephritis (HS rxn to drug)
  4. Urinary obstruction (tumors, prostate hypertrophy, blood clots)
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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

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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

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6
Q

Where are Tamm-Horsfall proteins normalls secreted?

A

The cells of the ascending thick limb and distal tubules

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7
Q

What does toxic AKI result in?

A

Acute tubular injury to the proximal convoluted tubules

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8
Q

What 3 toxins can cause Toxic AKI?

A
  1. Mercuric chloride
  2. Carbon tetrochloride
  3. Ethylene Glycol
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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

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10
Q

Which toxin causes accumulation of neutral lipids in injured cells followed by necrosis?

A

Carbon tetrachloride

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11
Q

What type of crystals are seen in the tubular lumen with ethylene glycol toxicity?

A

Calcium oxalate

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12
Q

What is characteristic for ethylene glycol toxicity?

A

Marked ballooning and hydropic or vacuolar degeneration of PCT (this also happens in immunosuppression

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13
Q

What are 2 forms of the group of renal diseases called tubulointersitial nephritis?

A

Acute or Chronic

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14
Q

4 Characteristics for acute tubulointerstitial nephritis?

A
  1. Rapid clinical onset
  2. Interstitial edema * (not in tubular epithelial cells)
  3. Leukocytic infiltration of the interstitium and tubules
  4. Focal tubular necrosis
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15
Q

What is seen in chronic interstitial nephritis?

A
  1. Infiltration with mononuclear leukocytes
  2. Interstitial fibrosis
  3. Tubular atrophy
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16
Q

What is acute suppurative inflammation of the kidney?

A

Acute pyelonephritis

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17
Q

What cn cause acute pyelonephritis?

A

Bacterial and viral (polyomavirus) infection

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18
Q

What are the 3 morphological hallmarks of acute pyelonephritis?

A
  1. Patchy interstitial suppurative inflammation
  2. Intratubular aggregates of neutrophils
  3. Tubular necrosis
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19
Q

What 3 things are associated with yellow?

A
  1. Fat
  2. Necrosis
  3. Granulomas
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20
Q

What are the 3 complications seen with acute pyelonephritis?

A
  1. Papillary necrosis
  2. Pyonephrosis
  3. Perinephric Abscess
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21
Q

What is pyonephrosis?

A

Suppurative destruction of the renal parenchyma, with total or almost complete loss of kidney function

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22
Q

What are the symptoms associated with pyonephrosis?

A

Fever, chills, and flank pain

but some can be asymptomatic

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23
Q

What can cause pyonephrosis?

A
  1. Ascending infection of the urinary tract

2. Hematogenous spread of a bacterial pathogen

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24
Q

What is a collection of suppurative material in the perinephric space?

A

Perinephric abscess

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25
Q

What is a pyelonephritic scar?

A

Inflammation, fibrosis, and deformation of the underlying calyx and pelvis

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26
Q

This is chronic tubulointerstitial inflammation and renal scarring associated with pathologic involvement of the calyces and pelvis.

A

Chronic pyelonephritis

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27
Q

What is the association between chronic pyelonephritis and kids?

A

Chronic pyelonephritis is an important cause of kidney destruction in children with severe lower urinary tract abnormalities

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28
Q

What are the 2 forms of Chronic Pyelonephritis?

A
  1. Chronic reflux-associated

2. Chronic obstructive

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29
Q

What are the 2 hallmarks of chronic pyelonephritis?

A
  1. Coarse, discrete, corticomedullary scars overlying dilated, blunted, or deformed calyces
  2. Flattening of the papillae
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30
Q

Are the kidneys scarred in chronic pyelonephritis?

A

YES- Irregularly scarred

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31
Q

What is seen in the tubules with chronic pyelonephritis?

A
  1. Tubular atrophy in some areas and hypertrophy or dilation in others
  2. Dilated tubules with flattened epithelium filled with colloid casts (thyroidization)
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32
Q

What is seen in the cortex and medulla for chronic pyelonephritis?

A

Chronic interstitial inflammation and fibrosis

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33
Q

Are the glomeruli normal in chronic pyelonephritis?

A

Maybe… except for periglomerular fibrosis

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34
Q

What causes analgesic nephropathy (a form of chronic renal disease)?

A

Excessive intake of analgesic mixtures

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35
Q

What nephropathy is associated with tubulointersitial nephritis and renal papillary necrosis?

A

Analgesic nephropathy

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36
Q

5 Morphological features of analgesic nephropathy?

A
  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
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37
Q

Patient profile for analgesic nephropathy?

A

CRAZY WOMAN

-Or someone with recurrent HA and muscle pain, factory workers

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38
Q

What other clinical symptoms are seen with analgesic nephropathy?

A

-HA, anemia, GI symptoms, and HTN

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39
Q

What happens to the papillae in analgesic nephropathy?

A

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

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40
Q

If you stop taking the drugs that cause analgesic nephropahty, do you get better?

A

Kinda.. the renal function with either stabilize or get better

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41
Q

What is urate nephropathy and how many types are there?

A

Nephropathy in persons with hyperuricemic disorders..3 types

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42
Q

What are the 3 types of urate nephropathy?

A
  1. Acute uric acid nephropathy
  2. Chronic urate nephropathy (gouty nephropathy)
  3. Nephrolithiasis
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43
Q

What type of crystals are found in acute uric acid nephropathy and where?

A

Uric acid crystals in the renal tubules, principally in the collecting ducts

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44
Q

What happens from the precipitation of uric acid crystals in acute uric acid nepropathy?

A

Get obstruction of nephrons and the development of acute renal failure

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45
Q

What conditions are associtaed with acute uric acid nephropathy?

A

Leukemias and lymphomas, undergoing chemo

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46
Q

What types of crystals are deposited in chronic urate nephropathy and where?

A

Monosodium urate crystals in the distal tubules, collecting ducts, and interstitium

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47
Q

Describe the crystals seen in chronic urate nephropathy

A

Variably birefringent needle-like crystals in the tubular lumens or interstitium

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48
Q

What is trophus and what is it seen in?

A

Foreign-body giant cells, other mononuclear cells, and a fibrotic reaction … seen in chronic urate nephropathy

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49
Q

Uric acid stones are seen in what % of people with gout?

A

22%

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50
Q

Uric acid stones are seen in what % of people with secondary hyperuricemia?

A

42%

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51
Q

Does urolithiasis affect more men or women?

A

Men more often

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52
Q

What is the peak age of onset for urolithiasis?

A

20-30 years

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53
Q

Does urolithiasis have a familial and hereditary predisposition to stone formation?

A

YES

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54
Q

What are the 4 main types of calculi in urolithiasis?

A
  1. Calcium stones (70%)
  2. Triple Stones or Struvite stones (15%)
  3. Uric acid stones (5% to 10%)
  4. Cystine (1% to 2%)
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55
Q

What are calcium stones composed of?

A

Calcium oxalate or calcium oxalate mixed with calcium phosphate

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56
Q

What are triple/struvite stones made of?

A

Magnesium ammonium phosphate

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57
Q

Which stone is the biggest (staghorn calculi)?

A

Triple stones or struvite stones

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58
Q

What are triple/struvite stones associated with ?

A

Infections by bacteria *Proteus (and some staphylococci)

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59
Q

True or False: Uric acid stones are radioopaque

A

FALSE… those suckers and radiolucent

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60
Q

When do you see uric acid stones?

A

Hyperuricemia (gout)

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61
Q

What is multicystic renal dysplasia?

A

A sporadic disorder resulting in an abnormality in metanephric differentiation

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62
Q

What are the characteristic histological findings of multicystic renal dysplasia?

A

Persistence of abnormal structures in the kidney…cartilage, undifferentiated mesenchyme, and immature collecting ductules

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63
Q

What are the 3 associations of multicystic renal dysplasia?

A
  1. Ureteropelvic Obstruction
  2. Ureteral agenesis or atresia
  3. Anomalies of the lower urinary tract
64
Q

Is the dysplasia seen in multicystic renal dysplasia unilateral or bilateral?

A

Either

65
Q

What does the kidney look like in multicystic renal dysplasia?

A

It is enlarged, irregulat and multicystic

66
Q

What type of cells line the cysts and are the cysts big or small?

A

Flattened epithelium and they vary in size

67
Q

What is the histologic hallmark of multicystic renal dysplasia?

A

Presence of islands of undifferentiated mesenchyme with cartilage** and immature collecting ducts

68
Q

What are the 3 cystic diseases discussed?

A
  1. Autosomal-Dominant Polycystic Kidney Disease
  2. Autosomal-Recessive Polycystic Kidney Disease
  3. Medullary Sponge Kidney
69
Q

Does autosomal-dominant polycystic kidney disease (ADPKD) affect adults or kids?

A

ADULTS

70
Q

Is ADPKD hereditary?

A

YES

71
Q

What happens in ADPKD?

A

You get multiple expanding cysts of both kidneys that destroy the renal parenchyma and cause renal failure

72
Q

What is the pattern of inheritance in ADPKD?

A

AUTOSOMAL DOMINANT (shocker) with high penetrance

73
Q

Tell me about the kidneys in ADPKD?

A

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
Q

What’s in the cysts in ADPKD?

A

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
Q

Does autosoma-recessive polycystic kidney disease (ARPKD) affect kids or adults?

A

KIDS
Perinatal, neonatal ,infantile, and juvenile subcategories (based on time of presentation and presence of associated hepatic lesions)

76
Q

What mutation causes ARPKD?

A

Mutation in the PKHD1 gene

77
Q

What is the morphology of ARPKD?

A
  1. Enlarged kidneys with a smooth external appearance

2. Numerous small cysts in the cortex and medulla (Looks like a sponge

78
Q

In ARPKD what cells line the cysts and where are they from?

A

Cuboidal cells that originate from the collecting ducts

79
Q

What other organ has cysts in ARPKD?

A

The liver

80
Q

What is a result of liver cysts seen in ARPKD?

A
  • Portal Fibrosis

- Proliferation of portal bile ducts

81
Q

What is medullary Sponge Kidney?

A

A sporadic cystic disease involving bilateral cystic dilations of medullary collecting ducts with normal cortex

82
Q

What diseases are associated with Medullary Sponge Kidney?

A

Marfans, Carolis, Ehlers-Danlos

83
Q

When does medullary sponge kidney present?

A

Adulthood

84
Q

What is the prognosis of medullary sponge kidney?

A

Patients are usually asymptomatic with normal renal function… this does not progress to end stage renal disease

85
Q

How is medullary sponge kidney diagnosed?

A

Intravenous pyelography

86
Q

Are the kidneys normal sized in Medullary Sponge Kidney?

A

YES

87
Q

What is seen in the kidneys in medullary sponge kidney?

A

Multiple, small cysts in the medullary pyramids and papillae…gives a sponge-like appearance of the medulla and is most often bilateral

88
Q

What is seen microscopically in medullary sponge kidney ?

A
  1. Medullary cysts lined by cuboidal epithelium or urothelium
  2. Severe inflammation and scarring in the interstitium
  3. Tubular atrophy near papillary tips
89
Q

What are the 3 benign tumors of the kidney discussed?

A
  1. Renal Papillary Adenoma
  2. Angiomyolipoma
  3. Oncocytoma
90
Q

Which tumor type arises from renal tubular epithelium?

A

Renal Papillary Adenoma

91
Q

Describe renal papillary adenomas

A

Small and discrete with complex, branching papillomatous structures

92
Q

What is used as a prognostic feature in renal papillary adenoma?

A

SIZE

-Over 3cm, metastasize, under 3cm, just chill

93
Q

What are angiomyolipomas made of?

A

Vessels, smooth muscle, and fat

94
Q

What is the clinical association with angiomyolipomas?

A

20%-50% of patients with tuberous sclerosis

95
Q

Which tumor type do we need to worry about spontaneous hemorrhage?

A

Angiomyolipomas

96
Q

What is an oncocytoma compoase of?

A

Large eosinophilic cells

97
Q

Which tumor arises from the intercalated cells of the collecting ducts?

A

Oncocytomas

98
Q

Describe oncocytomas

A

Small, round, benign-appearing nuclei with LARGE NUCLEOLI (like they are staring at you)

99
Q

Which tumor is mahogany brown and well encapsulated?

A

Oncocytomas

100
Q

What is seen on EM for an oncocytoma?

A

Eosinophilic cells have numerous mitochondria

101
Q

What are the malignant tumors in the kidneys called?

A

Renal cell carcinomas or adenocarcinoma of the kidney

102
Q

What age and gender are renal cell carcinomas associated with?

A

6th-7th decade and males (2:1)

103
Q

Smoking is a risk factor for what tumor?

A

Renal cell carcinoma

104
Q

Which cells do renal cell carcinomas arise from?

A

Tubular epithelium

105
Q

What color are adenocarcinomas (renal cell carcinomas)?

A

YELLOW

106
Q

What are the 4 types of renal cell carcinomas?

A
  1. Clear cell carcinoma
  2. Papillary carcinoma
  3. Chromophobe renal cell carcinoma
  4. Collecting duct (Bellini duct) carcinoma
107
Q

What % of renal cell cancers is clear cell carcinoma?

A

70-80%

108
Q

In clear cell carcinoma, where do the tumor cells derive from?

A

Proximal convoluted tubule

109
Q

What color are clear cell carinomas?

A

Oragne/Yellow (LIPID)

110
Q

Which tumor is commonly found in the upper pole, is well circumscribed, has hemorrhage, necrosis, and calcification?

A

Clear Cell Carcinoma

111
Q

What other structures are frequently involved in clear cell carcinoma?

A

Renal vein and renal sinus (especially if its BIG)

112
Q

If a clear cell carcinoma is bilateral, what conditions are associated with it?

A
  1. von Hippel Lindau

2. Tuberous Sclerosis

113
Q

What are the microscopic findings for clear cell carcinoma?

A
  1. Compact, tubulocystic, alveolar patterns
  2. Clear/granular cytoplasm (glycogen/lipid)
  3. Cell size is 2x normal epithelial tubule cell
114
Q

What mutation is associated with clear cell carcinoma?

A

-Loss of sequences on the short arm of chromosome 3 (3p deletion)

115
Q

10-15% of renal cancers are caused by what?

A

Papillary carcinoma

116
Q

Where do papillary carcinomas originate from?

A

Proximal or distal convoluted tubule

117
Q

What is the size that papillary carcinomas are over to distinguish them from papillary adenomas?

A

5cm

118
Q

What is papillary carcinoma also called?

A

Chromophil renal carcinoma

119
Q

What are the microscopic findings associated with papillary carcinoma?

A
  1. Well-circumscribed, often with distinct fibrou capsule
  2. Papillary growth patter
  3. Foamy macrophages and intracellular hemosiderin
120
Q

Which mutations is the sporadic form of papillary carcinoma associated with?

A

Trisomies 7, 16, 16

Loss of Y in male patients

121
Q

Which mutations is the familial form of papillary carcinoma associated with?

A

Trisomy 7

122
Q

What % of renal cell cancers is made up of by chromophobe renal carcinoma?

A

5%

123
Q

Where do chromophobe renal carcinomas arise from?

A

Intercalated cells of the collecting ducts

124
Q

Gross findings for Chromophobe renal carcinoma?

A
  1. Well-circumscribed, tan brown
  2. Geographic necrosis
  3. 8cm
125
Q

What cancer is positive for Hale’s colloidal iron stain?

A

Chromophobe renal carcinoma

126
Q

What is seen microscopically in chromophobe renal carcinoma?

A
  1. Compact architecture of nests or broad alveoli/trabeculae

2. Cell membranes and prominent and have pale eosinophilic cytoplasm

127
Q

Which tumors show halos around their nuclei?

A

Chromophobe renal carcinoma

128
Q

What types of mutations cause chromophobe renal carcinoma?

A

Multiple chromosome losses and extreme hypodiploidy

129
Q

True or false: Chromophobe renal carcinoma has a poor prognosis

A

FALSE… it has an excellent prognosis

130
Q

What tumor accounts for 1% of less the renal cell cancers?

A

Collecting duct (Bellini duct) Carcinoma

131
Q

Where does collecting duct (Bellini duct) carcinoma arise from?

A

Collecting duct cells in the medulla

132
Q

What are the gross findings for Collecting duct (Bellini duct) carcinoma?

A
  1. Infiltrative, firm, gray-white, 5cm

2. May have intrarenal metastases

133
Q

Which tumor has irregular channels lined by high grade hobnail cells?

A

Bellini duct/Collecting duct carcinoma

134
Q

What will you find in a Collecting duct (Bellini Duct) carcinoma?

A

Neutrophilic infilatrate and mucin production

135
Q

Where are collecting duct (Bellini duct) carcinomas commonly found?

A

Medullary location

136
Q

Describe some microscopic findings for Bellini Duct (Collecting duct) carcinoma?

A
  1. Poorly circumscribed tubulopapillary tumor with infiltrative borders
  2. Nests of malignant cells within a prominent fibrotic stroma
  3. Marked desmoplastic response
137
Q

What is the prognosis for Bellini Duct (Collecting duct) carcinoma?

A

Really bad…death within weeks to months

138
Q

When does hyperacute rejection occur?

A

Within minutes or the first few hours after transplantation

139
Q

In hyperacute rejection, where does the initial injury occur?

A

The endothelium of the arterial and capillaries of the renal parenchyma

140
Q

What causes hyperacute rejection?

A

Recipient pre-sensitization to donor-incompatible blood groups or HLA antigens (from prior transplantation, blood transfusions, or pregnancies)

141
Q

In hyperacute rejection, what does endothelial injury lead to?

A

Complement activation

142
Q

What is the result of hyperacute rejection?

A

Vascular thrombosis and ischemic necrosis of the allograft (happens within few hours or days after transplantation)

143
Q

What is a desmoplastic response?

A

Mucin and collaginous deposition that can happen around any tumor cells

144
Q

What is the time-frame for acute rejection?

A

First 5-7 post-transplant days

145
Q

What type of injury causes acute rejection?

A

Cell-mediated immune injury: Delayed hypersensitivity and cytotoxicity mechanisms are involved

146
Q

What is the immune injury directed against in acute rejection?

A

HLA expressed by the tubular epithelium and vascular endothelium

147
Q

What type of antigens are expressed in acute rejection?

A

Class I and Class II HLA antigens

148
Q

What is seen in Banff Schema acute rejection?

A

Presence of tubulitis and intimal arteritis

149
Q

What is tubulitis?

A

Infiltration of the tubular epithelium by lymphocytes

150
Q

What is infiltration of the arterial intima?

A

Intimal arteritis

151
Q

What are the classificaions for acute rejection?

A

Mild, moderate, and severe

152
Q

What features allow us to categorize acute rejection into mild, moderate, or severe?

A

Intensity of the infiltrate and severeity of tubulitis and intimal arteritis

153
Q

Why do we categorize acute rejection?

A

It is a useful way of indicating how urgently and intensively a particular episode of rejection needs to be treatesd

154
Q

What type of infiltrate do you see attacking the kidney in acute rejection?

A

Lymphocytes

155
Q

When would you see neutrophils in rejection?

A

Only if its severe (person not taking medication, ect.)

156
Q

What 4 diseases cause papillary necrosis?

A
  1. Sickle cell
  2. Obstructive pyelonephritis
  3. Diabetes
  4. Analgesics
    SODA
157
Q

In acute lung injury caused by ischemia, what type of necrosis will you see?

A

COAGULATIVE

Renal I (8 decks)

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