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Renal Disease

Basic Anatomy Renal Microanatomy

Glomerular Microanatomy The Business End of the Kidney

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A Little Higher Please The Details

Renal Functions Amniotic Fluid


„ The Kidney does lots
of stuff
„ RBC production
„ Amniotic fluid is mostly urine produced by
„ Erythropoietin the developing fetus.
„ Calcium metabolism „ No urine, no kidneys or
By means of phosphate
„
elimination.
„ Major malconnections of lower urinary
„ Acid-
Acid-Base balance.
tract.
„ Na+ and K+ balance „ If the expectant mother is ‘small for
„ Processes Budweiser dates’, the fetus may have problems with
into urine renal development.

Big Ticket Items

„ Immunological injury
„ Glomerulus
„ Interstitial tissue
„ Vascular injury or compromise
„ Diabetes
„ Hypertension
„ Infections
„ Upper urinary tract
„ Lower urinary tract

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Nephritic Syndrome
Clinical Syndromes
„ Acute injury, multiple
possible causes
„ Nephritic syndrome „ Major, acute injury to
the glomerular
„ Nephrotic syndrome basement membrane.
Basic clinical pattern
„ Chronic renal failure „
„ RBCs in the urine
„ Localized pain „ RBC casts in urine
„ Decreased urine output
„ Increased protein
„ Increased B/P

Urinary Casts
Clinical Syndromes
„ Material cleared or shed
by a sick glomerulus.
„ Congeals within the
„ Convoluted tubules or „ Nephritic syndrome
„ Collecting ducts
„ Nephrotic syndrome
„ Creates a ‘cast’ of the
interior of the duct it „ Chronic renal failure
formed in. „ Localized pain
„ Is Cleared in urine.
„ Observed
microscopically

Nephrotic Syndrome Chronic Renal Failure


„ Many causes
Progressive loss
„ Chronic injury of „

the glomerulus. of renal function.


„ Many causes „ Anemia
„ Basic clinical pattern „ Bleeding
„ Proteinuria (>3.5 gm) „ Increased
„ High serum lipids infections
„ Lipiduria „ Accumulation of
„ Low serum albumen nitrogen wastes
„ Pericarditis
„ Edema
„ Uremic frost

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Glomerulonephritis General Features

„ Mesangial cell
proliferation
„ Leukocyte
infiltration
„ BM thickening
„ Regular
(linear)
„ Irregular
(lumpy)

Immunologic Injury Acute Glomerulonephritis

„ Follows Streptoccocal
infection
„ Antigen-
Antigen-antibody
complexes lodge
beneath the foot
processes.
„ Elicit a flaming
inflammatory reaction
„ Complement deposited
„ Huge holes in BM
„ Nephritic syndrome

Acute Glomerulonephritis Acute Glomerulonephritis


„ Large number of immune complexes all at once
„ Collect under foot processes because of charge
„ Fix C’
„ Focal destruction of BM
„ Leakage of RBCs

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Membranous Glomerulonephritis
Acute Glomerulonephritis
„ Slow accumulation of Ag-
Ag-Ab complexes
Anti- Small holes, but numerous
„ Anti-human IgG „

labeled with „ Tremendous protein loss


fluorescence.
„ Identifies the
immune complexes
„ Granular pattern
„ Irregular clumps
„ Fix C’
„ Membrane damage

Membranous Glomerulonephritis Goodpasture’s Syndrome

„ Anti-
Anti-human IgG „ Antibodies specifically
against BM
labeled with
„ Different from immune
fluorescence.
complex disease.
„ Identifies the „ Starts as a pulmonary
immune complexes infection (virus).
„ Linear pattern „ Make antibodies against
„ Smooth contours pulmonary BM
„ Smaller holes „ Cross reacts with
glomerular BM
„ Protein loss
„ No RBC loss

Membranoproliferative Glomerulonephritis Minimal Change Glomerulonephritis

„ Hybrid appearance „ Foot process disease


„ Split BM „ Children 2-
2-6 yrs
„ Train track „ Follows viral
„ C’ deposition infection
„ Alternate pathway „ T-cell mediated?
„ Several types based „ Tremendous loss of
on what starts it protein (nephrotic)
„ Steroids helpful

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Minimal Change Glomerulonephritis

Diabetic Nephropathy Diabetes is a Vascular Disease


„ Diabetes is a small
vessel disease.
„ Arterioles „ Atherosclerosis
„ All parts of the „ Accelerated
kidney are involved. „ Arterioles ->
„ Glomerulus most „ Retinal blindness
significantly „ Gangrene
„ Kimmelstiel-
Kimmelstiel-Wilson „ Renal failure
„ Non-
Non-enzymatic „ Neuropathy
glycosylation of
proteins

Non-
Non-Enzymatic Glycosylation IgA Nephropathy
„ Glucose sticks to, and
alters, all sorts of proteins.
„ No way of getting rid of the „ Mesangial deposits of
modified protein. IgA antibodies.
„ BMs especially „ Mid 20’s
„ Small vessels narrow „ Multiple episodes of
„ Glomerular BM hematuria.
„ Thickens
„ Becomes inefficient „ More common than
„ Loss of protein once thought
„ Renal failure „ Transplant

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Tubular and Interstitial Disease

„ Acute tubular necrosis


„ Pure tubular cell condition
„ Ischemia or toxic
„ Interstitial (Pyelonephritis)
„ Toxic
„ Infectious
„ Autoimmune (medications)

Acute Tubular Necrosis (ATN) Pyelonephritis


„ Ischemic or toxic „ Inflammation of the
death of epithelial interstitial tissue.
cells. „ Infectious
„ Toxic
„ Dead epithelial cells „ Immunologic
fall off the tubular „ Acute pyelonephritis.
BM. „ Bacteria ascend from the
urinary bladder.
„ They clog the
Gram neg rods
tubules.
„

„ Blood, pus and casts in the


„ No urine output. urine.

„ Loss of concentrating „ These folks are sick.


gradient.

Bacterial Pyelonephritis Ureteral Implant Angle


„ Actually two ways
„ Lack of sphincter
„ Blood borne
action.
„ Ascend from bladder
„ Direct infection of „ Reflux
renal tissue. „ Bugs go upstream
„ Predisposing factors „ Congenital
„ Ureteral reflux „ Problems for
Lower urinary tract
„
obstruction
children
„ Diabetes „ Surgically
„ Vascular disease correctable

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Chronic Pyelonephritis Renal Papillary Necrosis
„ Vascular
insufficiency. „ Death of the papillae
„ Arteriolar problem
„ Slough and obstruct
„ Chronic ureter
inflammation
„ Round cells „ Inflammatory and/or
„ Tissue destruction vascular causes
„ Fibrosis „ Diabetes
„ Diabetes „ Analgesic nephropathy
„ Hypertension „ Chronic pyelonephritis
„ Repeat infections
„ ‘Thyroidization’

Hypertension Hypertension and the Kidney

„ Arteriolar changes
„ Onion skinning
„ Loss of luminal size
„ Reduced blood flow
„ Release of renin
„ Higher blood pressure
„ Chronic pyelonephritis
„ In time renal failure

Additional Vascular Problems

„ Diabetes (small vessel disease)


„ Clotting related
„ Emboli
„ Sickle cell disease

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Cystic Disease Tumors of the kidney
„ Polycystic renal disease
„ Growth of tubular
„ Benign vs. malignant
epithelium causes cyst
formation. „ Primary vs. metastatic
„ Cysts accumulate fluid
and squeeze the rest of
the kidney out of
existence.
„ Adult and juvenile forms

Renal Cell Carcinoma Wilm’s Tumor

„ Arises from tubular „ Childhood tumor


epithelium
„ Embryonic appearing
„ Likes to spread by tissue
way of blood vessels.
„ Two cell types
„ Widely metastatic „ Stromal element
„ Painless hematuria „ Little tubules
„ Golden yellow with
areas of necrosis.

Lower Urinary Tract

„ Infections
„ Stones
„ Cancer

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Bladder Infections Kidney Stones

„ Most are formed of


„ Very common oxalate crystals.
„ Host bugs „ Contributing factors
„ E. coli „ Dehydration
„ Other gram negatives „ High protein diet
„ Genetics
„ Urethral trauma
„ Very painful
„ Catheterization „ Ureteral dilation
„ Paraplegics especially

Kidney Stones Papillary Transition Cell Carcinoma

„ Large calculus
„ Transition cell
„ Hydronephrotic kidney origin
„ Tobacco
„ Industrial
chemicals
„ Hematuria

Papillary Transition Cell Carcinoma

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