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ANNALYN S. DA-ANOY , M.D. , R.M.T.

Azotemia vs. Uremia

 Biochemical  Azotemia
abnormality +
 Elevated BUN
clinical signs &
 Elevated creatinine symptoms
Nephrotic Syndrome

1. Massive proteinuria (3.5 gms or


more/day)

2. Hypoalbuminemia (less than 3 gm/dl)

3. Generalized edema

4. Hyperlipidemia & lipiduria


Nephritic vs.
Nephrotic
 Hematuria  Heavy proteinuria
 Mild to moderate  Hypoalbuminemia
proteinuria  Severe edema
 Hypertension  Hyperlipidemia
 Lipiduria
Diabetes Mellitus

1. Capillary basement membrane thickening


2. Diffuse mesangial sclerosis
- diffuse increase in mesangial matrix
1. Nodular glomerulosclerosis Syn:
intercapillary glomerulosclerosis
Kimmelsteil-Wilson lesion
- ball-like deposits of laminated matrix 
enlarge & compress capillaries  renal ischemia &
tubular atrophy
4. Renal atherosclerosis/arteriosclerosis
5. Pyelonephritis, necrotizing papillitis
DM: Nodular Glomerulosclerosis
ADPKD

 Bilateral; adults
 Mutations in:
 PKD1 (polycystin-1)
 PKD2 (polycystin-2)

 Cysts & anomalies in other organs:


 Liver, spleen, pancreas
 Intracranial berry aneurysm
 Mitral valve prolapse
ADPKD

 Enlarged kidneys made up of cysts


 PKD1 mutation more common, with
earlier onset of renal failure
Slide# 81 Polycystic Kidney Disease
(Adult type)
Tubulointerstitial
Nephritis
 ACUTE  CHRONIC
- Rapid clinical onset - Mononuclear leukocytes
- Interstitial edema - Interstitial fibrosis
- Neutrophils & eos - Widespread tubular
in interstitium & atrophy
tubules
- Focal tubular
necrosis
Pyelonephritis & UTI

 Gram-neg bacilli (>85%)


 E. coli, Proteus, Klebsiella, Enterobacter
 from fecal flora in most patients

 Routes of Infection
1. Hematogenous
2. Ascending (more common)
Papillary Necrosis
Acute Pyelonephritis -
Complications
1. Papillary necrosis
 In diabetics & those with urinary tract
obstruction
 Usually bilateral
 Necrosis of tips or distal 2/3 of the pyramids
1. Pyonephrosis
 Pus is not drained & fills the renal pelvis,
calyces & ureters

1. Perinephric abscess
 Suppurative inflammation extends through
the renal capsule into the perinephric tissue
Chronic Pyelonephritis

 Chronic tubulointerstitial inflammation &


scarring with involvement of the pelvis &
calyces

 2 types:
1. Reflux nephropathy
- Renal involvement occurs during childhood
1. Chronic obstructive pyelonephritis
- Effects are due to infection and
obstruction
Chronic Pyelonephritis -
Morphology
 Gross:
 Asymmetric involvement
 Irregular scars – coarse, discrete, corticomedullary
scars overlying blunted or deformed calyces

 Microscopic:
 Tubular atrophy with dilatation & hypertrophy in
others
 Thyroidization
 Chronic interstitial inflammation
 fibrosis
Slide#161 Acute and Chronic
Pyelonephritis
RIGHT LEFT 70 GRAMS
60 GRAMS
Slide# 61 Hydronephrosis with severe
acute
and chronic pyelonephritis
Slide#172 Tuberculous
Pyelonephritis
Slide#172 Tuberculous
Pyelonephritis
Diseases of the Blood
Vessels
1. Benign nephrosclerosis
2. Malignant nephrosclerosis
3. Renal artery stenosis
4. Thrombotic microangiopathies
5. Others
Benign Nephrosclerosis

 Medial & intimal thickening

 Hyaline deposition (protein extravasation


& increased deposition of basement
membrane matrix)

 Vascular narrowing  patchy ischemic


atrophy
HYALINE ARTERIOLOSCLEROSIS
HYALINE ATHEROLOSCLEROSIS
Slide#214 Chronic Pyelonephritis
with arterio and
arteriolonephrosclerosis
AKI

 Destruction of tubular epithelial


cells

 Acute diminution or loss of renal


function

 Most common cause of ARF


ACUTE TUBULAR
NECROSIS

Necrotic & detached tubular


epithelial cells

Swollen, vacuolated epithelial cells


SLIDE 62 Renal
infarction
Slide#62 Renal
Infarction

Infarcted area
Slide# 34 Wilm’s Tumor
(Nephroblastoma)
Slide# 34 Wilm’s Tumor
(Nephroblastoma)
Slide# 34 Wilm’s Tumor
(Nephroblastoma)
Tumors – Malignant

1. Renal cell carcinoma


- adenocarcinoma of the kidneys
- hypernephroma

2. Urothelial Carcinoma
Renal Cell Carcinoma:
Risk Factors
1. Cigarette-smoking
2. Obesity
3. Hypertension
4. Unopposed estrogen therapy
5. Exposure to asbestos, petroleum
products & heavy metals
Renal Cell Carcinoma:
Major Types

1. Clear cell carcinoma (70% - 90%)


2. Papillary carcinoma (10% - 15%)
3. Chromophobe renal cell carcinoma
(5%)
4. Collecting duct carcinoma (<1%)
Renal Cell Carcinoma:
Morphology
 Gross:
 Poles (upper > lower)
 Solitary, spherical mass
 Bright yellow to gray-white
 Areas of ischemic necrosis, hemorrhagic
discoloration, and softening
 Tendency to invade renal vein
 Papillary Carcinoma:
 Multifocal
Hemorrhagic & cystic
Slide# 27 Clear cell Carcinoma,
Kidney
Renal Cell Carcinoma:
Clinical Features
 costovertebral pain, palpable mass,
hematuria (10%)
 paraneoplastic syndromes – mimic
 Tends to metastasize widely before
giving rise to local s/sx
 Lungs (>50%)
 Bones (33%)
 5 yr SR = 45%
Urothelial Carcinoma

 From the urothelium of the renal


pelvis
 May be multiple (pelvis, ureter,
bladder)
Urothelial
Carcinoma
 Histology of the normal
bladder.
•The lumen of the
bladder (L) is on the left.
•Lining the bladder wall
is the epithelium (Ep).
•The loose connective
tissue beneath the
epithelium is the lamina
propria (LP).
•The bladder
musculature is labeled
(Mus).
NORMAL UROTHELIUM
 a resected bladder
which has been
opened to reveal the
mucosal surface.
 There is a large ,
irregular, nodular, and
hemorrhagic surface
 contrasts with the
normal smooth,
glistening tan mucosa
with regular folds seen
in the center of the
specimen
Slide#181 Urothelial Carcinoma,
Low grade
Slide#181 Urothelial
Carcinoma, Low grade
HIGH GRADE UROTHELIAL
CARCINOMA , BLADDER
Slide# 248 Urothelial Cell
Carcinoma, High Grade
High grade papillary
urothelial carcinoma. At
low magnification there is
focal necrosis, a feature
not seen with lower grade
lesions.
Slide# 248 Urothelial Cell
Carcinoma, High Grade
 This acute renal infarction
is pale, typical of
coagulative necrosis. It is
roughly wedge-shaped.
Renal infarctions usually
result from embolization
of cardiac valvular
vegetations or a portion
of cardiac mural
thrombus. Sometimes a
renal arterial vasculitis
can lead to infarction.
 This gross photograph is of
a resected bladder which
has been opened to reveal
the mucosal surface. There
is a large invasive
transitional cell carcinoma
which can be recognised by
its irregular, nodular, and
hemorrhagic surface which
contrasts with the normal
smooth, glistening tan
mucosa with regular folds
seen in the center of the
specimen
High grade papillary
urothelial carcinoma. At
low magnification there is
focal necrosis, a feature
not seen with lower grade
lesions.
 Urothelium: formerly
called transitional
epithelium since
intermediate between
nonkeratinizing
squamous and
pseudostratified
columnar epithelium; 5-7
cell layers thick in
contracted bladder, 2-3
cells thick in distended
bladder; lines renal
pelvis, ureters, bladder,
most of urethra but not
terminal urethra
 Histology of the normal
bladder.
•The lumen of the
bladder (L) is on the left.
•Lining the bladder wall
is the epithelium (Ep).
•The loose connective
tissue beneath the
epithelium is the lamina
propria (LP).
•The bladder
musculature is labeled
(Mus).
 The enlarged prostate gland
seen here not only has
enlarged lateral lobes, but
also a greatly enlarged
median lobe that obstructs
the prostatic urethra. This
led to obstruction with
bladder hypertrophy, as
evidenced by the prominent
trabeculation of the bladder
wall seen here from the
mucosal surface.
Obstruction with stasis also
led to the formation of the
yellow-brown calculus
(stone).
 Obstruction from nodular
prostatic hyperplasia has
led to prominent
trabeculation seen on the
mucosal surface of this
bladder with hypertrophy.
The stasis from
obstruction predisposes
to infection. The
obstruction can also lead
to bilateral hydroureter
and hydronephrosis.
NORMAL UROTHELIUM
 This gross photograph
shows the cut surface of a
kidney which has been
longitudinally bisected.
There is a large renal cell
carcinoma in the upper
pole with a typical
variegated appearance
with bright yellow areas,
areas of hemorrhage, and
tan and white areas. The
bright yellow color is
related to the lipid content
in these tumors.
 The typical "clear cell"
appearance of many
renal cell carcinomas is
illustrated in this
photomicrograph. The
malignant cells have
abundant clear or empty
appearing cytoplasm, and
the delicate lobular
growth pattern is a result
of the numerous
capillaries between
clusters of cancer cells.
RENAL PRE-LAB ACTIVITY
1 A. AND B.

 DEFINE AZOTEMIA AND UREMIA


2. A AND B.

2A.GIVE THE
DIAGNOSIS
2B.GIVE THE
MOST COMMON
HISTOLOGIC
SUBTYPE OF
THIS TUMOR.
3A. AND 3.B.
3.A.GIVE THE
DIAGNOSIS.

3.B. TRUE OR
FALSE
This tumor
produce noticeable
hematuria.
4.A and B.
CASE OF A 1 YO INFANT
,RENAL MASS
4.A and B.

 A. GIVE THE DIAGNOSIS


 B. TRUE OR FALSE
THIS TUMOR HAS A GOOD
PROGNOSIS.
5.A AND B.
5. A AND B.

A. GIVE THE DIAGNOSIS


B. GIVE THE MOST COMMON ROUTE
OF INFECTION.
6. A AND B.

 DIFFERENTIATE NEPHRITIC AND


NEPHROTIC SYNDROME?