Annalyn s. Da-Anoy , m.d. , r.m.t

8/14/2019 Annalyn s. Da-Anoy , m.d. , r.m.t.

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


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Azotemia vs. Uremia

Biochemicalabnormality

Elevated BUN

Elevated creatinine

Azotemia

+

clinical signs &symptoms


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Nephrotic Syndrome

1. Massive proteinuria (3.5 gms ormore/day)

2. Hypoalbuminemia (less than 3 gm/dl)

3. Generalized edema

4. Hyperlipidemia & lipiduria


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Nephritic vs.

Nephrotic Hematuria Mild to moderate

proteinuria

Hypertension

Heavy proteinuria

Hypoalbuminemia

Severe edema

Hyperlipidemia

Lipiduria


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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


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DM: Nodular Glomerulosclerosis


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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


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ADPKD

Enlarged kidneys made up of cysts

PKD1 mutation more common, with

earlier onset of renal failure


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Slide# 81 Polycystic Kidney Disease(Adult type)


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Tubulointerstitial

Nephritis ACUTE

- Rapid clinical onset

- Interstitial edema

- Neutrophils & eosin interstitium &tubules

- Focal tubularnecrosis

CHRONIC- Mononuclear leukocytes

- Interstitial fibrosis

- Widespread tubularatrophy


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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)


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Papillary Necrosis


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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


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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 andobstruction


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Chronic Pyelonephritis -Morphology

Gross: Asymmetric involvement

Irregular scars coarse, discrete, corticomedullaryscars overlying blunted or deformed calyces

Microscopic: Tubular atrophy with dilatation & hypertrophy in

others

Thyroidization Chronic interstitial inflammation fibrosis

Slid 161 A d Ch i


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Slide#161 Acute and ChronicPyelonephritis


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60 GRAMS 70 GRAMSRIGHT LEFT


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Slide# 61 Hydronephrosis with severeacute

and chronic pyelonephritis


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Slide#172 TuberculousPyelonephritis

Slide#172 Tuberculous


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Slide#172 TuberculousPyelonephritis


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Benign Nephrosclerosis

Medial & intimal thickening

Hyaline deposition (protein extravasation& increased deposition of basementmembrane matrix)

Vascular narrowing

patchy ischemicatrophy


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HYALINE ARTERIOLOSCLEROSIS


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HYALINE ATHEROLOSCLEROSIS


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Slide#214 Chronic Pyelonephritiswith arterio and

arteriolonephrosclerosis


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AKI

Destruction of tubular epithelialcells

Acute diminution or loss of renalfunction

Most common cause of ARF


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ACUTE TUBULAR

NECROSIS

Necrotic & detached tubular

epithelial cells

Swollen, vacuolated epithelial cells


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SLIDE 62 Renal

infarction


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Slide#62 Renal

Infarction

Infarcted area


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Slide# 34 Wilms Tumor

(Nephroblastoma)


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Slide# 34 Wilms Tumor

(Nephroblastoma)


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Slide# 34 Wilms Tumor(Nephroblastoma)


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Tumors Malignant

1. Renal cell carcinoma- adenocarcinoma of the kidneys

- hypernephroma

2. Urothelial Carcinoma


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Renal Cell Carcinoma:Risk Factors

1. Cigarette-smoking

2. Obesity

3. Hypertension4. Unopposed estrogen therapy

5. Exposure to asbestos, petroleum

products & heavy metals


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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 (


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Renal Cell Carcinoma:Morphology

Gross: Poles (upper > lower)

Solitary, spherical mass

Bright yellow to gray-white

Areas of ischemic necrosis, hemorrhagicdiscoloration, and softening

Tendency to invade renal vein

Papillary Carcinoma:

MultifocalHemorrhagic & cystic

Slid # 27 Cl ll C i


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Slide# 27 Clear cell Carcinoma,Kidney


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Urothelial Carcinoma

From the urothelium of the renalpelvis

May be multiple (pelvis, ureter,bladder)


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Urothelial

Carcinoma


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Histology of the normalbladder.

The lumen of thebladder (L) is on the left.

Lining the bladder wallis the epithelium (Ep).

The loose connectivetissue beneath theepithelium is the laminapropria (LP).

The bladdermusculature is labeled(Mus).
http://radiology.uchc.edu/eAtlas/GU/1374b.htm


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NORMAL UROTHELIUM
http://162.129.103.34/cgi-win/bladtutor.exe/image2?1


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a resected bladderwhich has beenopened to reveal themucosal surface.

There is a large ,irregular, nodular, andhemorrhagic surface

contrasts with thenormal smooth,

glistening tan mucosawith regular folds seenin the center of thespecimen

Slid #181 U th li l C i


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Slide#181 Urothelial Carcinoma,Low grade

Slide#181 Urothelial


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Slide#181 UrothelialCarcinoma, Low grade


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HIGH GRADE UROTHELIALCARCINOMA , BLADDER

Slide# 248 Urothelial Cell


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Slide# 248 Urothelial CellCarcinoma, High Grade


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High grade papillaryurothelial carcinoma. Atlow magnification there isfocal necrosis, a featurenot seen with lower grade

lesions.

Slide# 248 Urothelial Cell


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Slide# 248 Urothelial CellCarcinoma, High Grade


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This acute renal infarctionis pale, typical ofcoagulative necrosis. It isroughly wedge-shaped.Renal infarctions usuallyresult from embolizationof cardiac valvularvegetations or a portionof cardiac muralthrombus. Sometimes a

renal arterial vasculitiscan lead to infarction.


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This gross photograph is ofa resected bladder whichhas been opened to revealthe mucosal surface. Thereis a large invasivetransitional cell carcinomawhich can be recognised byits irregular, nodular, andhemorrhagic surface whichcontrasts with the normalsmooth, glistening tanmucosa with regular folds

seen in the center of thespecimen


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High grade papillaryurothelial carcinoma. Atlow magnification there isfocal necrosis, a featurenot seen with lower grade

lesions.


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Urothelium: formerlycalled transitionalepithelium sinceintermediate betweennonkeratinizingsquamous andpseudostratifiedcolumnar epithelium; 5-7cell layers thick incontracted bladder, 2-3

cells thick in distendedbladder; lines renalpelvis, ureters, bladder,most of urethra but notterminal urethra


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Histology of the normalbladder.

The lumen of thebladder (L) is on the left.Lining the bladder wallis the epithelium (Ep).

The loose connectivetissue beneath theepithelium is the laminapropria (LP).

The bladdermusculature is labeled(Mus).
http://radiology.uchc.edu/eAtlas/GU/1374b.htm


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The enlarged prostate glandseen here not only hasenlarged lateral lobes, butalso a greatly enlargedmedian lobe that obstructsthe prostatic urethra. This

led to obstruction withbladder hypertrophy, asevidenced by the prominenttrabeculation of the bladderwall seen here from themucosal surface.Obstruction with stasis alsoled to the formation of theyellow-brown calculus(stone).


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Obstruction from nodularprostatic hyperplasia hasled to prominenttrabeculation seen on themucosal surface of thisbladder with hypertrophy.The stasis fromobstruction predisposesto infection. Theobstruction can also lead

to bilateral hydroureterand hydronephrosis.


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NORMAL UROTHELIUM


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This gross photographshows the cut surface of akidney which has beenlongitudinally bisected.There is a large renal cell

carcinoma in the upperpole with a typicalvariegated appearancewith bright yellow areas,areas of hemorrhage, andtan and white areas. The

bright yellow color isrelated to the lipid contentin these tumors.


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The typical "clear cell"appearance of manyrenal cell carcinomas isillustrated in thisphotomicrograph. Themalignant cells haveabundant clear or emptyappearing cytoplasm, andthe delicate lobulargrowth pattern is a result

of the numerouscapillaries betweenclusters of cancer cells.


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1 A. AND B.

DEFINE AZOTEMIA AND UREMIA


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2. A AND B.

2A.GIVE THEDIAGNOSIS

2B.GIVE THEMOST COMMONHISTOLOGIC

SUBTYPE OFTHIS TUMOR.


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3A. AND 3.B.

3.A.GIVE THEDIAGNOSIS.

3.B. TRUE ORFALSE

This tumorproduce noticeablehematuria.

4.A and B.


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4.A and B.CASE OF A 1 YO INFANT

,RENAL MASS

4 A d B


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4.A and B.

A. GIVE THE DIAGNOSIS

B. TRUE OR FALSE

THIS TUMOR HAS A GOODPROGNOSIS.

5 A AND B


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5.A AND B.


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6 A AND B


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6. A AND B.

DIFFERENTIATE NEPHRITIC ANDNEPHROTIC SYNDROME?

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Annalyn s. Da-Anoy , m.d. , r.m.t