Renal Flashcards
Horseshoe Kidney
- fusion of the lower poles of the kidney.
- trapped by the inferior mesenteric artery.
- predisposed for infections and stone formation.
- associated with Turner’s syndrome.
- large cystic structure at the upper portion (retention cyst)
Autosomal Recessive Polycyctis Renal disease
- autopsy from an infant
- bilateral markedly enlarged cystic kidneys
- palpable abdominal mass in a newborn
- large size may impede delivery of the infant.
- incompatible with life.
- oligohydramnios.
Potter’s Face
- low set ears,
- beak-like nose,
- receding chin.
- associated with:
- bilateral autosomal recessive polycystic renal disease
- renal dysplasia
- renal agenesis
adult polycystic kidney disease
bilaterally enlarged and cystic kidneys as well as cysts in the liver.
Autosomal dominant polycystic kidney disease
(adult polycystic renal disease)
- enlarged cystic kidney.
- most common inherited renal disease.
- aberrant gene on the short arm of chromosome 16.
- present in the fourth decade with hypertension and progress into renal failure within 10 years.
Normal Glomerulus
- normal glomerulus with the normal number of cells.
Remember that within the glomerulus there are endothelial cells and visceral epithelial cells with podocytes which share the basement membrane. These are mesangial cells and a small amount of mesangila matrix in a normal glomerulus. The cells lining Bowman’s space are called parietal epithelial cells.
Normal glomerulus-electron micrograph
- 2 capillary lumens (CL) and associated endothelial cells. These are podocytes on epithelial side of the basement membrane. M designates mesangial cell.
Normal glomerulus-electron micrograph
- demonstrates podocytes or foot processes of the visceral epithelial cell on the right side of the basement membrane.
- Lining the basement membrane on the opposite side of the basement membrane are endothelial cell cytoplasmic extensions.
Linear immunofluorescence in a patient with anti-GBM antibodies
Goodpasture’s syndrome. Type II hyper-sensitivity reaction
Lumpy bumpy (granular) immunofluorescence in immuno-complex type III glomerulonephritis.
Acute diffuse proliferative glomerulonephritis
- increase in the number of cells (hypercellularity).
- basement membranes are not thickened.
- proliferative glomerulonephritis-diffuse involved all of the glomeruli in the renal biopsy.
- from a patient with acute post-streptococcal glomerulonephritis (nephritic syndrome)
Acute diffuse proliferative glomerulonephritis
- electron micrograph
- electron dense deposits (look like balls) on the epithelial side of the basement membrane.
- subepithelial deposits of acute post streptococcal glomerulonephritis.
Immunofluorescent study (serum antinuclear antibody study)
- fluorescent antinuclear antibody
- Rim patterns correlate with anti-dsDNA and the presence of acute glomerulonephritis in SLE patients
Systemic lupus erythematosus
- light microscopic section of a glomerulus with thickening of the basement membranes
- prominent around capillaries.
- wire-looping of the capillaries
- depositions are immune complexes of DNA plus antibodies
- deposited in the subendothelial portion of the basement membrane.
Systemis Lupus Erythematosus
- subendothelial deposition of immune complexes in the basement membrane of the glomerulus.
- deposition is responsible for the wire-looping pattern
Rapidly progressive crescentic glomerulonephritis (nephritic)
- crescent shaped proliferation of parietal epithelial cells
- worst type of glomerulonephritis
- associated with Goodpasture’s syndrome.
Goodpasture’s Syndrome (nephritic)
- pulmonary parenchyma showing many red blood cells collected within alveolar spaces.
- hemorrhage is classic for Goodpasture’s diseas
- hemoptysis that is the first
- prior to their developing renal disease
Goodpasture’s Syndrome (nephritic)
- red blood cells contained within the tubules in the kidney.
- antibasement membrane antibodies
- glomerular and pulmonary capillary alpha-3 chains of type IV collagen in the basement membrane.
- Immunofluorescence shows a smooth linear pattern of IgG, C3 and fibrin
- Goodpasture’s normally young males
Lipoid nephrosis
- electron micrography from a case of nephrotic syndrome in a child.
- widespread fusion of the foot processes on the epithelial side of the GBM.
- most common cause of nephrotic syndrome in children.
- loss of the negative charge in the GBM
Focal segmental glomerulosclerosis (nephrotic)
- Note how only part of the glomerulus is sclerotic.
- VEC’s are destroyed, which destroys the GBM.
- MC type of glomerular disease in HIV patients and intravenous drug abusers.
Membranous glomerulonephritis-nephrotic syndrome (nephrotic)
- light microscopic glomerulus in the center portion of the slide.
- basement membranes are thickened throughout the glomerulus.
- no evidence of hypercellularity.
- most common cause of nephrotic syndrome in adults.
Membranous glomerulonephritis
- silver stain
- subepithelial immunocomplex deposits
- membranous GN.
- epithelial side of the basement membrane
Electron micrograph of type II membranoproliferative glomerulonephritis (nephrotic)
- dense deposit disease
- intramembrane deposition of the immunocomplexes
- autoantibody against C3 (C3 nephritic factor) continually activates C3
- very low complement levels in these patients
Diabetic nephropathy (nodular glomerulosclerosis
- nodular thickening of the glomerular mesangium
- (type IV collagen)
- hyalinization of the arteriolar wall of both afferent and efferent vessels
Renal amyloidosis-Congo red stain
- Congo red staining in a case of amyloidosis
- polarized = apple green birefringence pattern
- Amyloidosis is a reactive response where the light chains are converted into amyloid
Patient with chronic renal failure and uremic frost
- crystals representing urea that are deposited on the face of this patient.
- Since the kidneys cannot excrete urea, the urea is excreted in sweat.
Acute tubular necrosis
- acute tubular necrosis demonstrating
- collections of necrotic tubules within tubular lumina
- pigmented renal tubular casts are the classic finding in acute tubular necrosis.
- Both forms, ischemic and nephrotoxic type, produce tubular casts.
Acute tubular necrosis
- acute ischemic tubular necrosis.
- ghost-like outlines of many of the tubular cells (coaguation necrosis).
Acute pyelonephritis
- scattered grey-white areas representing collections of acute inflammatory cells.
- pelvis is dilated (hydronephrosis)
- most common pathogen- E. coli.
- Acute PN is secondary to an ascending infection
- Vesicoureteral reflux is the most common cause of acute pyelonephritis
Chronic pyelonephritis
- eosinophilic protein casts in the tubular lumina
- due to obstruction of the tubules
- thyroidization of the kidney (resemble thyroid acini)
Chronic pyelonephritis
In chronic pyelonephritis, blunt calyces underlie cortical scars.
Papillary necrosis
- necrosis of the renal papillae.
- Causes: analgesic abuse, sickle cell anemia, acute pyelonephritis and diabetes.
- medullary portion- ischemic insult because of the low oxygen tension.
- absent papilla in the middle of the kidney
- produces a ring defect on an IVP
Renal papillary necrosis
- necrotic renal papillae.
- large quantities of aspirin and acetaminophen for chronic pain
Benign nephrosclerosis
- fine granular change of benign nephrosclerosis
- most common renal disease associated with hypertension
- kidney resembles that of a football
- Hyaline arteriosclerosis = renal changes in hypertension
Malignant hypertension
- multiple hemorrhages on the surface of the kidney
- flea-bitten kidney
- associated with
- glomerular damage
- glomerulitis
- arteriolitis
- hemorrhage in a case of malignant hypertension.
Multiple pale renal infarcts
- white areas on the cortical surface
- Most infarcts occur from embolic disease from the left heart
Renal infarction
Renal infarct with classic coagulation necrosis of tubules and glomerulus
Diffuse cortical necrosis
- coagulation necrosis involving the cortex of the kidney
- disseminated intravascular coagulation-pregnant or has developed preeclampsia or eclampsia in the third trimester
Hydronephrotic kidney
- Note the dilated renal pelvis
- Urinary stones are the MCC of hydronephrosis
Staghorn calculus of the kidney
- large stone corresponding with the dilated renal pelvis
- magnesium ammonium phosphate
- due to chronic urinary tract infections from urease producing organisms (e.g., Proteus).
- The urine is alkaline and smells like ammonia.
- Triple phosphate crystals are present in the urine.
Renal cell carcinoma
- renal cell carcinoma in the upper pole
- well demarcated cystic and hemorrhagic mass
- Prognosis is related to the extent of involvement of the renal vein
- metastasize to the lungs as cannonball metastasis.
- 6th to 7th decade
- present with hematuria
- associated with von Hippel-Lindau syndrome
- Smoking is the most common cause
Renal cell carcinoma
- microscopic findings of a renal cell carcinoma.
- derived from the proximal tubule
- Tumore cells clear and vacuolated in appearance
Wilm’s tumor
- left is almost completely replaced by a yellow-white mass
- Wilm’s tumor
- Hypertension (due to renin) and a palpable flank mass are commonly present
Wilm’s tumor
- primitive mesenchyme
- abortive glomerulus to the left of the slide
Hyaline cast
- shadowy, acellular cast with round ends
- Normal afteer viral illness
- or it may be associated with proteinuria
Maltese cross-nephrotic syndrome
- polarized specimen of urine with a cast filled with free cholesterol,
- Maltese crosses.
- Fatty casts, oval fat bodies and Maltese crosses are all features of nephrotic syndrome
Red blood cell casts
- cast filled with red blood cells.
- classic for a nephritic syndrome
- Presetns with:
- hypertension,
- oliguria,
- red cell casts,
- red blood cells,
- mild to moderate proteinuria,
- and periorbital edema
Pigmented tubular cast
- acute tubular necrosis.
- necrotic tubules
- are sloughed off and form a cast
- appears in the urine and gives an appearance of a muddy or dirty urine
- accompanied by some red blood cells or white blood cells
White blood cell casts
- white blood cell cast i
- acute pyelonephritis and acute drug-induced tubulointerstitial disease
- the white blood cell cast separates cystitis from pyelonephritis
- accompanied by bacteruria, scattered white blood cells, and occasionally red blood cells.
Fatty casts
- refractile cast
- polarized would have the appearance of the Maltese crosses.
- Fatty casts or oval fat bodies are associated with nephrotic syndromes
- patient typically has hypercholesterolemia
Waxy casts
- pale cast with sharp margins.
- Waxy casts are the end stage of breakdown of coarse and finally granular casts
- classic for chronic renal failure
Broad cast in chronic renal failure
- The cast is broad owing to tubular dilatation from obstruction of the lumens by casts
Calcium oxalate crystals
- Calcium oxalate and/or phosphate crystals are the most common type of crystal found in the urine.
- independent of urine pH for formation
- unfolded envelope
- associated with hypercalcemia states and commonly accompany calcium oxalate stones.
- causes include Crohn’s disease, excessive intake of vitamin C, and ethylene glycol poisoning
Triple phosphate crystals
- scattered rhomboid shaped crystals that resemble coffin-lids
- crystals of magnesium ammonium phosphate (staghorn calculi)
- alkaline urine
- associated with infections caused by Protease spp
Uric acid crystals
- scattered stellate or star-shaped crystals
- classic for uric acid crystals
- acid urine
- high rate of turnover of cells as in leukemias or lymphomas or multiple myeloma
- can also be seen in gout
Cystine crystal
- Note the hexagonal shape.
- occurs in the AR disorder called cystinuria
- can be associated with cystine stones
Hematuria with dysmorphic RBCs
- Note the crenated appearing RBCs.
- Dysmorphic RBCs indicate acute glomerulonephritis.
Classic urine sediment in a lower urinary tract infection
- clump of neutrophils (+ leukocyte esterase).
- Round, slightly red biconcave discs representing RBCs are present (+ blood).
- The granular material in the background represent bacteria (+ nitrite)
Transitional cell carcinoma of the bladder
- white exophytic mass protruding into the lumen of the bladder
- tumors are typically found in the trigone
- may produce obstruction of the ureter and hydronephrosis
- transitional cell origin
Transitional cell carcinoma of the bladder (cytoscopy).
- Note the papillary nature of the tumor.
- Smoking is the MCC of TCC.
Nodular hyperplasia of the prostate (paper clip in urethra)
- prostate gland with multiple nodules
- encroached on the prostatic urethra
- associated with estrogen-enhanced sensitivity to dihydrotestosterone
- nodular areas arise in the periurethral areas
- leads to obstructive uropathy.
Nodular hyperplasia of the prostate, hypertrophy of the bladder, hemorrhagic cystitis
- bladder that has been opened with extension into the prostatic urethra.
- mucosa shows hemorrhage
- indwelling catheter.
- hypertrophied.
- prostate gland shows the nodularity which is characteristic of nodular hyperplasia.
- Small indentations are noted in the bladder mucosa representing the openings of diverticular sacs which developed from increased intravesical pressure
Carcinoma of the prostate
- prostate gland with scattered foci of yellow-tan areas
- represent the carcinoma.
- arises in the posterior lobe and produces a firm or hard prostate gland on rectal exam.
- PSA is increased
Carcinoma of the prostate
This slide is a microscopic section of a prostatic adenocarcinoma showing well-formed glands that are fairly monotonous in appearance
Adenocarcinoma of the prostate
This slide shows a nerve with perineural invasion by a carcinoma of the prostate. Notice the glandular structures in the area surrounding the nerve.
Torsion of the testicle with hemorrhagic infarction
Patients lose the cremasteric reflex. The testicle rides high in the inguinal canal from vessel torsion
Seminoma
Note the yellow-tan tumor that does not completely replace the testicle (usually they do, but not in this case)
Seminoma
- tumor shows collections of germ cells in nests or cords
- stroma that has scattered lymphocytes present
- histologic pattern that you would see in a dysgerminoma of the ovary.
