Renal System
Renal System
Renal System
Credits:
1st part = written by Assem “ THe AWesOme” Kalantan revised by
A.Z.K
Table of Contents
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Topic page
MEMBRANOUS GLOMERULONEPHRITIS 7
MEMBRANOPROLIFERATIVE 11
GLOMERULONEPHRITIS
Nephritic Syndrome 16
Acute Postinfectious GN 17
Crescentic GN 20
Chronic GN 21
RENAL STONES 23
HYDRONEPHROSIS 25
ACUTE POLYNEPHRITIS 27
CHRONIC PYELONEPHRITIS 30
Wilms'Tumor 37
Beckwith-Wiedemann syndrome 38
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part 1
THE NEPHROTIC SYNDROME
In the normal kidney - the glomerular capillary wall, with its endothelium,
basement membrane (GBM), and podocytes , acts as a barrier through which
the glomerular filtrate must pass.
Any increased in permeability allows protein to escape from the plasma into
the glomerular filtrate. Massive pruteinuria
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MINIMAL CHANGE DISEASE (LIPOID NEPHROSIS)
A benign disorder that is the most frequent cause of the nephrotic syndrome
in children
It is characterized by:
- normal appearance of glomeruli under the light microscope
- diffuse effacement of podocyte foot processes when viewed with the
electron microscope
It may develop at any age, but it is most common between ages 1 and 7 years.
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Pathogenesis :
Morphology :
The cells of the proximal convoluted tubules are often heavily laden with
lipids, but this is secondary to tubular reabsorption of the lipoproteins ( this
appearance of the proximal convoluted tubules is the basis for the older term
for this disease, lipoid nephrosis )
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Even with the electron microscope, the glomerular capillary wall appears
normal.
Clinical Course :
There is no hypertension.
Adults also respond to steroid therapy, but the response is slower and
relapses are more common.
(2) malignant tumors (carcinoma of the lung and colon and melanoma)
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Pathogenesis :
As the disease progresses, these spikes incorporate the deposits into the GBM
Later in the disease, the incorporated deposits are catabolized and eventually
disappear, leaving cavities within the GBM. These cavities are later filled in by
deposition of GBM-like material
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Clinical course :
Can be
(1) in association with HIV infection or heroin addiction
(2) as a secondary event in other forms of GN
(3) as a component of glomerular ablation nephropathy
(4) in an inherited congenital form (Abnormal podocytes)
(5) as a primary disease. (10% of all cases of the nephrotic syndrome)
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Pathogenesis :
Injury to the visceral epithelial cells and the resultant disruption of visceral
epithelial cells is thought to represent the hallmark of FSG
Morphology :
At first, it affects only some of the glomeruli (hence the term “focal”) and only
the juxtamedullary glomeruli, eventually all levels of the cortex are affected
Lesions occurring in some tufts within a glomerulus and sparing of the others
(hence the term “segmental”)
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Clinical course :
Non–selevtive proteinuria
MPGN is manifested by
- alterations in the basement membrane and mesangium
- proliferation of glomerular cells
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Pathogenesis :
Type I :
Circulating immune complexes, akin to chronic serum sickness
The inciting antigen is not known
occurs in association with:
- hepatitis B and C antigenemia
- SLE
- infected atrioventricular shunts
- secondary infections with antigenemia
Type II :
C3 nephritic factor (C3NeF) activate the alternative complement pathway
elaboration of biologically active complement fragments
Morphology :
- infiltrating leukocytes
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By electron microscopy :
- C3 is deposited
- IgG
(2) Type II
- C3 is present
Clinical course :
MPGN, usually type I, may occur in association with other known disorders
(secondary MPGN)
- SLE
- Hepatitis B & C
End of Part 1
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Additional figures :
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2nd part
Nephritic Syndrome
By TMA
Outline
1. General Characteristics of the Nephritic Syndrome
2. Primary Causes
a. The Nephritides
c. Chronic GN
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General Characteristics of the Nephritic Syndrome
1. Hematuria
a. Gross (may be a smoky brown urine)
b. Microscopic
2. Oliguria
3. Azotemia
a. Increased blood nitrogen
b. Increased creatinine
c. Decreased GFR
4. Some proteinuria (not as much as in nephrotic syndrome, but may come close)
5. Hypertension (b/c of decreased GFR and/or rennin released by ischemic kidney)
Primary glomerular disease affects the glomeruli first and last and rarely
affects anything else
During the active stage, look for IgG and complement deposits on the GBM
(the excess deposit of complements results in hypocomplementemia).
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Morphology:
Clinical course:
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an absence of complements C1q and C4 complements (suggesting activation of
the alternative complement pathway). There may be a genetic predisposition.
Morphology:
Clinical course:
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Rapidly Progressive GN (Crescentic GN or CrGN)
Deposits of IgG, often with C3, on the GBM. In some these also bind to
pulmonary capillaries producing pulmonary hemorrhages associated with renal
failure. When this occurs the condition is preferably called Goodpasture
Syndrome (if there is no pulmonary involvement it is a pure type I CrGN and is
considered idiopathic).
Morphology:
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Type II CrGN (Immune Complex-Mediated)
Pauci- refers to few or some. From the name you can imagine that there is
not as much immune interaction. There are no anti-GBM Ab’s or immune
complexes to be found. The causative agent is the Antineutrophil Cytoplasmic Ab
discussed in the vasculitides. So, type III CrGN may be a complication of
microscopic polyangiitis or Wegener granulomatosis, but in most cases it is
idiopathic (when its limited to the kidney).
Morphology:
Summary of RPGN
Chronic GN
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prior history of symptomatic renal disease, and are usually young or middle aged
adults.
Morphology:
The infiltrate seen here is lypho but very rarely plasma cells may also be
found in the fibrotic tissues. In most cases by the time the condition is discovered
it is impossible to tell where the lesion began in the kidney, lending the name of
“end-stage kidneys”.
Clinical course:
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Renal dialysis and transplantation prevent the inevitable progression to
uremia and death.
Part 3
PATHOGENESIS
Composition
Calcium oxalate
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o 5% to 10% of patients, there is hypercalcemia (due to
hyperparathyroidism, vitamin D intoxication or sarcoidosis) and
consequent hypercalciuria .
o Bacteria may serve as nidi for the formation of any kind of stone.
MORPHOLOGY
Unilateral in about 80%.
Tend to be small
Staghorn calculi.
CLININCAL COURSE
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Large stones may be present without producing symptoms or
significant renal damage.
Smaller stones may pass into the ureter, producing a typical intense
pain known as renal or ureteral colic.
Gross hematuria.
HYDRONEPHROSIS
Dilatation to the renal pelvis and calyces with accompanying atrophy of
the parenchyma, caused by obstruction to the outflow of urine.
The most sever effects are seen in papillae , because they are subject to
the greatest increase in pressure.
Causes:
Congenital Acquired
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Carcinoma of the prostate
Bladder tumors
Prostatitis
Ureteritis
Urethritis
Retroperitoneal fibrosis
Morphology (macroscopically):
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o Kidney may be massively enlarged and greatly distended
pelvicalyceal system.
Morphology (microscopically):
Clinical course:
o Bilateral:
o Unilateral hydronephrosis:
May remain completely silent for long periods unless the other
kidney is for some reason not functioning.
DEFINITION
It is Suppurative inflammation of the kidney and renal pelvis (UTI) involving
upper and lower tracts (majority).
PATHOGENESIS
Organisms:
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o Rare: Strep. Feacalis & staph.
Routes of infection:
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Predisponsing factors:
Reflux of urine into ureter (Vesicoureteral reflux, VUR) & into tip of
papillae (intrarenal reflux)
Morphology:
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Macroscopically:
Microscopically:
o Papillary necrosis.
COMPLICATIONS
Necrotizing papillitis
Pyonephrosis
Perinephric abscess
CLINICAL FEATURES:
Sudden onset of pain, fever, malaise.
Two forms :
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MORPHOLOGY
Macroscopically
o Unilateral or bilateral
o Asymmetrical scar
Microscopically:
o Vascular change.
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CLINICAL COURSE :
Gradual onset of:
o Renal insufficiency.
o Hypertension
Fever
rash
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renal abnormalities
End of part 3
Done by Abo Malik
Part 4
The most common malignant tumor of the kidney is renal cell carcinoma,
followed in frequency by nephroblastoma (wilms tumor). Tumors of the lower
urinary tract are about twice as common as renal cell carcinoma.
Benign tumors:
1) Renal papillary adenoma:
small, discrete (usually yellow) tumors are seen in 7% to 22% of autopsies.
Histologically, consist of vacuolated epithelial cells forming tubules and
branching papillary structures.
2) Angiomyolipoma:
often associated with tuberous sclerosis (25% - 50% of patients), these
tumors are considered to be hamartomas.
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Malignant tumors:
Most common from the sixth to seventh decades, and men are affected about
twice as commonly as women. Renal cell carcinoma represent 85% of all primary
malignant tumors of the kidney. It arises from the renal tubular epithelium, and
hence they are located in the cortex. About 40% of the patients die of the disease.
Risk factors:
-smocking
-hypertension
-obesity
-exposure to cadmium
Based on the molecular origins of these tumors, the three most common forms
are as follows:
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3)Chromophope Renal Carcinomas:
These are the least common, representing 5% of all renal cell carcinomas. They arise
from intercalated cells of collecting ducts. These tumors are unique in having
multiple losses of entire chromosomes including chromosomes 1, 2, 6, 10, 13, 17, 21.
In general, chromophope renal cancers have a good prognosis.
Morphology:
Clear cell cancers (the most common
form) are usually solitary and large when
symptomatic (spherical masses 3-15 cm
in diameter). They may arise anywhere in
the cortex. The cut surface is yellow to
orange to gray-white, with prominent
areas of cystic softening or of
hemorrhage, either fresh or old. The
margins of the tumor are well defined.
Frequently, the tumor invades the renal
vein and grows as a solid column within
this vessel, sometimes extending in
serpentine fashion as far as the inferior
vena cava and even into the right side of
the heart.
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The tumor cells of clear cell renal cell carcinoma may appear almost vacuolated
(full of lipid and glycogen) or may be solid. The classic vacuolated (lipid-laden), or
clear cells are demarcated only by their cell membranes. The nuclei are usually small
and round (see the figure). At the other extreme (i.e. solid) are granular cells,
resembling the tubular epithelium, which have small, round, regular nuclei enclosed
within granular pink cytoplasm. Between the extremes of clear cells and solid,
granular cells, all intergradations may be found. The stroma is usually scant but
highly vascularized.
Papillary renal cell carcinomas tend to be bilateral and multiple. They may also show
gross evidence of necrosis, hemorrhage, and cystic degeneration. The cells can have
clear or, more commonly, pink cytoplasm.
Chromophobe-type renal cell carcinoma tends to be grossly tan-brown. Having very
prominent, distinct cell membranes. The nuclei are surrounded by halos of cleared
cytoplasm.
Clinical course:
The prevalent locations for metastases are the lungs and the bones.
End of Part 4
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Part 5
Wilms' Tumor
Wilm's tumor is the most common primary kidney tumor in children. Most
cases occur between the ages of 2 to 5 years. Wilm's tumor illustrates three
important concepts of childhood tumors :
1- WAGR syndrome
NOTE : WAGR stands for Wilms tumor, Anridia, Genital malformation and
Retardation .
DDS is also associated with abnormalities in WT1 gene, but here the
abnormality is a mutation.
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NOTE: DDS is a DOMINANT NEGATIVE syndrome. This means that a
mutation in one gene (allele) will block the function of the other.
NOTE: WAGR syndrome and DDS both show abnormalities in the WT1
Gene but
in WAGR it is deletion while in DDS it is mutation.
3- Beckwith-Wiedemann syndrome :
This syndrome is characterized by enlargement of individual body organs
(e.g., tongue, kidneys, or liver) or entire body segments
(hemihypertrophy); enlargement of adrenal cortical cells (adrenal
cytomegaly) is a characteristic microscopic feature
The genetic locus that is involved in these patients is called "WT2" for
the second Wilms' tumor locus.
In addition to Wilms' tumors, patients with BWS are also at increased risk
for developing hepatoblastoma, adrenocortical tumors,
rhabdomyosarcomas, and pancreatic tumors
Morphology:
Grossly:
Microscopically:
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mixed). The classic triphasic combination of blastemal, stromal, and epithelial
cell types is observed in most lesions, although the percentage of each
component is variable.
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(Morphology continued)
Nephrogenic rests:
Are precursor lesions of Wilms' tumors and are sometimes present in the renal
parenchyma adjacent to the tumor. Nephrogenic rests have a spectrum of
histologic appearances, from expansile masses that resemble Wilms' tumors
(hyperplastic rests) to sclerotic rests consisting mostly of fibrous tissue with
occasional admixed immature tubules or glomeruli. It is important to document
the presence of nephrogenic rests in the resected specimen, since these
patients are at an increased risk of developing Wilms' tumors in the
contralateral kidney.
Clinical Course:
1. Paitent complaints
Commonly :
Palpable abdominal mass that may extend to the pelvis
Rarely:
Abdominal pain
Fever
Hematuria
Intestinal obstruction (due to tumor's large size)
2. Progonosis
generally very good, and excellent results are obtained with a
combination of nephrectomy and chemotherapy.
Anaplasia is a harbinger of adverse prognosis :
It could be either diffuse or focal
Focal: good prognosis
Diffuse: bad prognosis
The entire urinary collecting system from renal pelvis to urethra is lined with
transitional epithelium. so its epithelial tumors assume similar morphologic
patterns. Tumors in the collecting system above the bladder are relatively
uncommon; those in the bladder, however, are an even more frequent cause of
death than are kidney tumors.
Classification:
1) Benign papillomas ( rare )
2) Urothelial carcinomas
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Morphology:
1) Benign papillomas :
The very rare benign papillomas are 0.2- to 1.0-cm frondlike
structures having a delicate fibrovascular core covered by
multilayered, well-differentiated transitional epithelium
2) Urothelial carcinoma :
they range from papillary to flat, noninvasive to invasive, and low
grade to high grade.
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Clinical course:
Painless hematuria is the dominant clinical presentation of all these tumors.
But since tumors of the bladder are more common than those of the collecting
system , they are discusssed first
1) Urinary bladder tumors:
They affect men about three times as frequently as women
usually develop between the ages of 50 and 70 years
mutations involving several genes on chromosome 9 have
been documented, p53 is the most common
bladder tumors are 50 times more common in those exposed
to :
o B-Napthylamine
o Ciggarette smoking
o Chronic cystits
o Schistosomiasis of the bladder
o Certain drugs ( eg Cyclophosphamide )
The clinical significance of bladder tumors depends on their histologic grade and
differentiation and, most importantly, on the depth of invasion of the lesion. Except
for the benign papillomas, all tend to recur. Lesions that invade the ureteral or
urethral orifices cause urinary tract obstruction.
As for the prognosis :
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The over all 5-year survival rate for both types together is 57%.
End Of Part 5
Done by: The DuDe
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