Renal
Pathology
Kristine Krafts, M.D.
October 26, 2009
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Diseases involving blood vessels
• Cystic diseases
• Tumors
Renal Pathology Outline
• Introductory stuff
Introductory Stuff
• Functions of the kidney:
• excretion of waste products
• regulation of water/salt
• maintenance of acid/base balance
• secretion of hormones
• Diseases of the kidney
• glomeruli
• tubules
• interstitium
• vessels
Introductory Stuff
• Azotemia: BUN, creatinine
• Uremia: azotemia + more problems
• Acute renal failure: oliguria
• Chronic renal failure: prolonged uremia
Introductory Stuff
Nephrotic syndrome Nephritic syndrome
• Massive proteinuria • Hematuria
• Hypoalbuminemia • Oliguria
• Edema • Azotemia
• Hyperlipidemia/-uria • Hypertension
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
• Focal segmental glomerulosclerosis
• Membranous nephropathy
• Nephritic syndrome
• Postinfectious GN
• IgA nephropathy
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
Nephrotic Syndrome
• Massive proteinuria
• Hypoalbuminemia
• Edema
• Hyperlipidemia, lipiduria
Nephrotic Syndrome
Causes
• Adults: systemic disease (diabetes)
• Children: minimal change disease
• Characterized by loss of foot processes
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
Minimal Change Disease
Things you must know
• #1 cause of nephrotic syndrome in children
• Loss of foot processes
• Pathogenesis unknown
• Good prognosis
Minimal change disease
Normal glomerulus
Minimal change disease
Minimal change disease
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
• Focal segmental glomerulosclerosis
Focal Segmental Glomerulosclerosis
Things you must know
• Primary or secondary
• Some (focal) glomeruli show partial
(segmental) hyalinization
• Unknown pathogenesis
• Poor prognosis
Focal segmental glomerulosclerosis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
• Focal segmental glomerulosclerosis
• Membranous glomerulonephritis
Membranous Glomerulonephritis
Things you must know
• Autoimmune reaction against
unknown renal antigen
• Immune complexes
• Thickened GBM
• Subepithelial deposits/spikes
Membranous glomerulonephritis
Membranous glomerulonephritis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
• Focal segmental glomerulosclerosis
• Membranous glomerulonephritis
• Nephritic syndrome
Nephritic Syndrome
• Hematuria
• Oliguria, azotemia
• Hypertension
Nephritic Syndrome
Causes
• Post-infectious GN, IgA nephropathy
• Immunologically-mediated
• Characterized by proliferative changes
and inflammation
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
• Focal segmental glomerulosclerosis
• Membranous glomerulonephritis
• Nephritic syndrome
• Postinfectious GN
Post-Infectious Glomerulonephritis
Things you must know
• Child after strep throat
• Immune complexes
• Hypercellular glomeruli
• Subepithelial humps
Post-Infectious Glomerulonephritis
Mnemonic
“Sore throat, face bloat, pee coke”
Post-infectious glomerulonephritis
Post-infectious glomerulonephritis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Nephrotic syndrome
• Minimal change disease
• Focal segmental glomerulosclerosis
• Membranous glomerulonephritis
• Nephritic syndrome
• Postinfectious GN
• IgA nephropathy
IgA Nephropathy
Things you must know
• Common!
• Child with hematuria after URI
• IgA in mesangium
• Variable prognosis
IgA nephropathy
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Inflammatory lesions
• pyelonephritis
• drug-induced interstitial nephritis
• Toxic/ischemic lesions
• Acute tubular necrosis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Inflammatory lesions
• pyelonephritis
Pyelonephritis
Things you must know
• Invasive kidney infection
• Usually ascends from UTI
• Fever, flank pain
• Organisms: E. coli, Proteus
Acute pyelonephritis with abscesses
Pyelonephritis
Pyelonephritis
Cellular cast
Pyelonephritis
Urinary Tract Infection
• Women, elderly
• Patients with catheters or malformations
• Dysuria, frequency
• Organisms: E. coli, Proteus
Pyelonephritis
UTI: Causative Organisms
E. coli
uncomplicated complicated
Urinary catheter colonized by Proteus
Chronic pyelonephritis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Inflammatory lesions
• pyelonephritis
• drug-induced interstitial nephritis
Drug-Induced Interstitial Nephritis
Things you must know
• Antibiotics, NSAIDS
• IgE and T-cell-mediated immune reaction
• Fever, eosinophilia, hematuria
• Patient usually recovers
• Analgesic nephritis is different (bad)
Drug-induced interstitial nephritis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Inflammatory lesions
• pyelonephritis
• drug-induced interstitial nephritis
• Toxic/ischemic lesions
• Acute tubular necrosis
Acute Tubular Necrosis
Things you must know
• The most common cause of ARF!
• Reversible tubular injury
• Many causes: ischemic (shock), toxic (drugs)
• Most patients recover
Acute tubular necrosis
Acute tubular necrosis
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Diseases involving blood vessels
• Benign nephrosclerosis
• Malignant nephrosclerosis
Benign Nephrosclerosis
Things you must know
• Found in patients with benign hypertension
• Hyaline thickening of arterial walls
• Leads to mild functional impairment
• Rarely fatal
Benign nephrosclerosis
Malignant nephrosclerosis
Things you must know
• Arises in malignant hypertension
• Hyperplastic vessels
• Ischemia of kidney
• Medical emergency
Malignant nephrosclerosis
Malignant Hypertension
• 5% of cases of hypertension
• Super-high blood pressure, encephalopathy, heart abnormalities
• First sign often headache, scotomas
• Decreased blood flow to kidney leads to increased renin, which
leads to increased BP!
• 5y survival: 50%
Malignant hypertension
Malignant hypertension
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Diseases involving blood vessels
• Cystic diseases
• Adult polycystic kidney disease
• Childhood polycystic kidney disease
• Medullary cystic disease
Adult Polycystic Kidney Disease
Things you must know
• Autosomal dominant
• Huge kidneys full of cysts
• Usually no symptoms until 30s
• Associated with brain aneurysms
Adult polycystic kidney disease
Childhood Polycystic Kidney Disease
Things you must know
• Autosomal recessive
• Numerous small cortical cysts
• Associated with liver cysts
• Patients often die in infancy
Childhood polycystic kidney disease
Medullary Cystic Kidney Disease
Things you must know
• Chronic renal failure in children
• Complex inheritance
• Kidneys contracted, with many cysts
• Progresses to end-stage renal disease
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Diseases involving blood vessels
• Cystic diseases
• Tumors
• Renal cell carcinoma
• Bladder carcinoma
Renal Cell Carcinoma
Things you must know
• Derived from tubular epithelium
• Smoking, hypertension, cadmium exposure
• Hematuria, abdominal mass, flank pain
• If metastatic, 5y survival = 5%
Renal cell carcinoma
Renal cell carcinoma
Renal cell carcinoma
Bladder Carcinoma
Things you must know
• Derived from transitional epithelium
• Presents with painless hematuria
• Prognosis depends on grade and depth of invasion
• Overall 5y survival = 50%
Bladder carcinoma
Renal Pathology Outline
• Introductory stuff
• Glomerular diseases
• Tubular and interstitial diseases
• Diseases involving blood vessels
• Cystic diseases
• Tumors
