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Y2 Clinical Pathology > Medical Renal Pathology > Flashcards

Medical Renal Pathology Flashcards

1
Q

What are the 4 main functions of the kidney?

A
  1. elimination of metabolic waste products
  2. regulation of fluid / electrolyte balance
  3. regulation of acid-base balance
  4. production of hormones
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2
Q

What are the 2 main hormones produced by the kidney?

What are their functions?

A

Renin:

  • involved in fluid balance (RAAS)

Erythropoietin:

  • stimulates erythrocyte production
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3
Q

What is the treatment for acute renal failure and the associated mortality?

A

acute renal failure accounts for 15% of hospital admissions

most patients recover

around 10,000 out of 26,000 annually need dialysis

this has a 50% mortality

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4
Q

What are the treatments for the patients that develop chronic renal failure?

A

50% will have a transplant at some point

40% will have haemodialysis

10% will have peritoneal dialysis

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5
Q

Approximately how many renal transplants are performed each year?

What are the sources?

A

2300 transplants per year

28% are living donor renal transplants

most are deceased donor transplants

5000 patients are still on the renal transplant waiting list

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6
Q

How will someone with acute renal failure present?

A

unwell

rapid rise in creatinine and urea

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7
Q

How would someone with nephrotic syndrome present?

A

oedema

proteinuria

hypoalbuminaemia

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8
Q

How would someone with acute nephritis (nephritic syndrome) present?

A

oedema

proteinuria

haematuria

hypertension

renal failure

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9
Q

How would someone with chronic renal failure present?

A

there would be a slow decline in renal function

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10
Q

What are 2 common presentations of renal disease?

A

haematuria and proteinuria

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11
Q

What biochemical tests are used to assess renal function?

A

blood tests:

  • urea
  • creatinine

urine analysis:

  • protein
  • blood
  • electrolytes
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12
Q

How would a renal biopsy be analysed?

A
  • light microscopy
  • immunofluoresence
  • electron microscopy
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13
Q

What procedure might a urologist perform in diagnosing a renal impairment?

Why?

A

cystoscopy

to look for obstruction and haematuria

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14
Q

What would be looked for in renal pathology from a radiological point of view?

A
  • obstruction
  • kidney size
  • structural abnormalities
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15
Q

What is shown in this image?

A

the renal cortex

this consists of glomeruli and tubules

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16
Q

What types of cells cover the glomerulus?

How do they play a role in acting as a filter?

A

podocytes cover the glomerulus

the filter involves podocyte foot processes, endothelial cells and the basement membrane

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17
Q

Label the features of the nephron and the blood flow pathway

A
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18
Q

What 3 main conditions cause vascular damage that affects the kidneys?

A
  1. hypertension
  2. diabetes
  3. atheroma e.g. renal artery stenosis
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19
Q

What is vasculitis?

What can it cause in the kidney?

A

acute / chronic vessel wall inflammation with lumen obliteration

various types affect different calibre vessels

e.g. Wegener’s granulomatosis

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20
Q

What is thrombotic microangiopathy?

How can it affect the kidneys?

A

thrombi in capillaries / arterioles

endothelial damage by bacterial toxins, drugs, complement or clotting system abnormalities

can lead to haemolytic uraemic syndrome

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21
Q

What are the 3 immunological conditions which can cause basement membrane damage?

A
  1. circulating immune complexes deposit in the glomerulus
    e. g. SLE, IgA / membranous nephropathy
  2. circulating antigens deposit in the glomerulus
  3. antibodies to the basement membrane / glomerular components
    e. g. goodpasture’s syndrome
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22
Q

What can immunological basement membrane damage lead to?

A
  1. complement activation
  2. neutrophil activation
  3. reactive oxygen species
  4. clotting factors

these all cause glomerular damage

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23
Q

What are the 4 non-immunological processes that can cause direct glomerular damage?

A
  1. endothelial injury
    e. g. vasculitis, HTN, clotting disorders
  2. altered basement membrane
    e. g. DM hyperglycaemia
  3. abnormal basement membrane or podocytes due to inherited disease
    e. g. Alport disease
  4. Abnormal protein deposition (amyloid) impairs function
    e. g. myeloma, RA
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24
Q

How is the degree of renal tubule damage related to renal function?

A

the degree of renal tubule damage correlates with renal function

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25
Q

what are the ischaemic and toxic causes of tubular damage?

A

Ischaemic:

  • hypotension
  • vessel damage
  • glomerular damage

These cause reduced perfusion, leading to tubular damage

Toxic:

  • direct toxins
  • hypersensitivity reactions
  • crystal deposits
  • abnormal protein deposition

These cause direct tubular damage

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26
Q

What are examples of direct toxins?

A
  • drugs - NSAIDs, antibiotics, ACEi, diuretics
  • contrast medium
  • organic solvents
  • heavy metals
  • ethylene glycol
  • pesticides
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27
Q

What 3 components can cause reduced blood flow to the kidney?

A
  1. damage to glomerulus
  2. damage to tubule
  3. damage to blood vessels
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28
Q

What diseases are caused by damage to the glomerulus?

A

Immunological:

  • membranous anti-GBM disease
  • IgA nephropathy
  • lupus nephritis
  • post-infective

Non-immunological:

  • minimal change disease
  • FSGS
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29
Q

What types of diseases cause damage to blood vessels?

A

Inflammatory:

  • vasculitis

Endothelial damage:

  • hypertension
  • thrombotic microangiopathy

Abnormal deposits:

  • amyloid
  • diabetes
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30
Q

What kind of diseases cause damage to the tubule?

A

direct toxicity:

  • drugs and poisons
  • e.g. gentamicin

hypersensitivity:

  • drugs e.g. penicillins

abnormal deposits:

  • myeloma

inflammatory:

  • pyelonephritis
  • others e.g. sarcoid

ischaemic:

  • shock
  • glomerular damage
  • vascular disorders
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31
Q

What are the problems with diagnosing renal conditions based on histological appearance?

A
  • more than one disease may look the same
  • some diseases have variable histology
  • some names are both diseases (when idiopathic) and appearances (when secondary to known cause)

This means that aetiology and pathophysiology may be unclear

32
Q

What causes nephrotic syndrome?

What are the features and complications?

A

ALWAYS DUE TO DAMAGE TO GLOMERULUS

features:

  • oedema
  • proteinuria ( >3g in 24 hrs)
  • hypoalbuminaemia
  • +/- hypertension
  • +/- hyperlipidaemia

complications:

  • infection
  • thrombosis
33
Q

What are the 3 most common causes of nephrotic syndrome?

A

Membranous nephropathy:

  • most common
  • mostly in adults under 60
  • more common in men
  • 20-30% progress to end stage renal failure

focal segmental glomerulosclerosis (FSGS):

  • more common in males
  • usually idiopathic but also genetic, due to HIV or heroin use

minimal change disease:

  • normal histology
  • equally affects males and females

also caused by diabetes, lupus nephritis and amyloid

34
Q

What are the most common causes of nephrotic syndrome in children?

A
  • minimal change disease
  • focal segmental glomerulosclerosis (FSGS)
  • other causes are rare
35
Q

What are the symptoms of acute nephritis (nephritic sydrome)?

A
  1. oedema
  2. haematuria
  3. proteinuria
  4. hypertension
  5. acute renal failure
36
Q

What are the 4 most common causes of acute nephritis in adults?

A

post-infective glomerulonephritis:

  • weeks after streptococcal throat infection

IgA nephropathy:

  • common primary glomerular disease
  • usually in young adults
  • 20-50% develop renal failure over 20 years

Vasculitis:

  • unwell, fever, rash, myalgia, arthralgia

SLE:

  • autoimmune disease
  • usually affects young women
37
Q

What are the most common causes of acute nephritis in children?

A
  • post-infective glomerulonephritis
  • IgA nephropathy

Henoch-Schönlein purpura:

  • specific IgA nephropathy (systemic vasculitis) often follows throat infection
  • usually in boys
  • associated with arthralgia, abdominal pain, purpuric rash, proteinuria, haematuria and acute renal failure

Haemolytic-uraemic syndrome:

  • typically in children with E. coli 0157 enteritis
  • acute nephritis, haemolysis and thrombocytopenia
38
Q

What is acute renal failure associated with?

What are the 3 categories of causes?

A
  • anuria / oliguria (<400 ml / 24 hours) + raised creatinine and urea
  • malaise, fatigue, nausea, vomiting and arrhythmias

causes:

  • pre-renal, renal or post-renal

prognosis is usually good if there is no underlying renal disease

short term dialysis may be needed in some patients

39
Q

What are the pre-renal causes of acute renal failure?

A

reduced blood flow to the kidney

  • severe dehydration
  • hypotension (bleed, septic shock, LVF)
40
Q

What are the post-renal causes of acute renal failure?

A

urinary tract obstruction

  • urinary tract tumours
  • pelvic tumour
  • calculi
  • prostatic enlargement
41
Q

What are the renal causes of acute renal failure?

A

damage to the kidney

42
Q

When can a renal biopsy be useful in acute renal failure?

A

a renal biopsy is helpfyl in renal causes

a renal biopsy is unhelpful in pre-renal or post-renal causes

43
Q

What are the most common causes of acute tubular necrosis/injury/damage as part of acute renal failure?

A

adults:

  • vasculitis
  • acute interstitial nephritis / tubulointerstitial nephritis

children:

  • PIGN
  • Henoch-Schönlein purpura
  • haemolytic uraemic syndrome
  • acute interstitial nephritis
44
Q

What is tubulointerstitial nephritis?

A

tubular damage with inflammation

this is usually due to drugs

45
Q

What are the complications and treatments for acute renal failure?

A

complications:

  • cardiac failure (fluid overload)
  • arrhythmias (electrolyte imbalance)
  • GI bleeding (multifactorial)
  • jaundice (hepatic venous congestion)
  • infection - esp. lung and urinary tract

treatment:

  • depends on underlying cause
  • short term dialysis may be needed
46
Q

What does it mean if someone has a permanently reduced GFR?

A

there is a reduced number of functional nephrons

47
Q

What are the 5 stages of chronic renal failure?

A

stage 1:

  • normal / increased GFR
  • > 90 ml / min / 1.73m2

stage 2:

  • mild GFR reduction
  • 60 - 89 ml/min/1.73m2

stage 3:

  • moderate GFR reduction
  • 30 - 59 ml / min / 1.73 m2

stage 4:

  • severe GFR reduction
  • 15 - 29 ml / min / 1.73 m2

stage 5:

  • kidney failure
  • GFR < 15 or dialysis
48
Q

Why is a renal biopsy usually unhelpful in established chronic renal failure?

A

the kidney will show severe scarring with loss of glomeruli and tubules

end-stage renal disease due to any cause is similar

49
Q

What are the effects of chronic renal failure?

A
  • reduced excretion of water / electrolytes - oedema & hypertension
  • reduced excretion of toxic metabolites
  • reduced production of erythropoietin - anaemia
  • renal bone disease (phosphate / calcium)
50
Q

What chronic conditions can lead to chronic renal failure in adults and children?

A

adults:

  • diabetes

children:

  • developmental abnormalities / malformations

adults and children:

  • glomerulonephritis
  • reflux nephropathy (repeated infections and scarring)
51
Q

What is meant by isolated proteinuria?

A

proteinuria BUT less than the nephrotic range

there is no allied haematuria, renal failure or oedema

52
Q

What are the 2 causes of isolated proteinuria?

A

benign:

  • e.g. postural, related to pyrexia or exercise

renal disease:

  • adults - FSGS, DM, SLE
  • children - FSGS, HSP
53
Q

What is meant by isolated haematuria?

Which investigations must be conducted?

A

haematuria +/- proteinuria with normal renal function

cystoscopy / urological investigations need to exclude malignancy

54
Q

What are the usual causes of isolated haematuria?

A

IgA nephropathy

Thin basement membrane disease:

  • inherited condition causing abnormally thin glomerular basement membranes
  • renal function usually normal

Alport hereditary nephropathy:

  • inherited abnormalities of type IV collagen cause abnormal basement membrane
  • sometimes with eye and ear problems
  • leads to renal failure +/- deafness +/- occular problems
55
Q

What are the risk factors and complications associated with acute pyelonephritis?

A

risk factors:

  • female (ascending infection)
  • instrumentation
  • diabetes
  • urinary tract structural abnormalities

complications:

  • abscess formation
56
Q

What are the risk factors and complications associated with chronic pyelonephritis?

A

risk factors:

  • urinary tract obstruction /reflux

complications:

  • scarring
  • chronic renal failure
57
Q

What actually is pyelonephritis?

A

inflammation of the kidney, usually due to a bacterial infection

58
Q

What happens in renal artery stenosis?

What is it usually caused by and what does it lead to?

A

most commonly due to atheroma and arterial dysplasia

leads to ischaemic injury of the affected kidney

activation of renin-angiotensin-aldosterone system leads to hypertension

loss of renal tissue leads to reduced renal function

59
Q

What is renal artery stenosis?

A

narrowing of the arteries that lead to one or both of the kidneys

commonly due to atherosclerosis so can get worse over time

60
Q

What is shown in this image?

A
61
Q

What is the role of mesangial cells?

A

they maintain the glomerular structure

62
Q

What is vasculitis?

How can it affect the kidneys?

What kind of disease is it usually part of?

A

there are various types affecting different calibre vessels

inflammation in glomerular vessels can cause clotting, obliteration of capillary lumena and glomerulus destruction

inflammation of larger renal arterioles can cause tubule hypoxia

it is often part of systemic disease - rash, fever, myalgia, arthralgia, fever, weight loss

63
Q

What histological signs are seen in vasculitis?

A
  • fibrin indicates thrombosis in glomerulus once capillary lumena are obliterated
  • inflammatory cells surround the artery which has damaged walls
64
Q

How does hypertension affect the renal vessels and kidneys?

A

it damages the renal vessels through wall thickening and reduction in lumen size

this produces chronic hypoxia - loss of renal tubules and reduced renal function

reduced renal blood flow activates the RAAS, which exacerbates hypertension

65
Q

What histological signs would be seen in hypertension?

A

renal arterioles have a thickened wall and small lumen

66
Q

What is the commonest cause of end-stage renal failure in the developed world?

A

diabetes

67
Q

What are the 2 mechanisms of damage to the kidney in diabetes?

A

two mechanisms of damage are both due to hyperglycaemia

  1. damaged basement membrane thickens and the glomerulus produces excess extracellular matrix (nodules)
  2. small vessel damage causes ischaemia and tubular damage
68
Q

What is myeloma?

How does it affect renal function?

A

a plasma cell tumour

causes excess antibodies to deposit in the tubules and cause inflammation and fibrosis

renal tubule loss causes irreversible decline in renal function

69
Q

what are the histological features of myeloma?

A
  • artery walls with immunoglobulin deposits
  • fibrosis
  • tubules destroyed by Ig deposits
70
Q

What is membranous nephropathy?

A

thickened glomerular capillary walls

71
Q

What are the histological features of FSGS?

A

mostly normal except for a solid area with loss of capillary lumena

72
Q

What are the histological features of post-streptococcal GN and IgA nephropathy?

A

they both show glomeruli with increased cellularity and loss of capillary lumena

73
Q

What are the histological features of acute tubulointerstitial nephritis?

A

many lymphocytes / inflammatory cells in between renal tubules

74
Q

What are the histological features of anti-GBM disease?

A

crescents represent cells proliferating in Bowman’s capsule in response to any severe glomerular injury

e.g. vasculitis and post-infective glomerulonephritis

75
Q

What are the histological features of acute tubular necrosis/injury?

A

loss of nuclei from tubular cells due to cell death

76
Q

What are the histological features of chronic kidney damage?

A

interstitial fibrosis and tubular atrophy

shrunken (atrophic) tubules are surrounded by fibrosis

scarring is present in end-stage renal disease

Y2 Clinical Pathology (76 decks)

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