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Kidney pathology 2010.1

Kidney pathology 2010.1. Tubular & interstitial diseases. Kidney - cut surface. Outer cortex (Co) Inner medulla composed of pyramids * Cortical columns of Bertini (B) between pyramids* Urine first collects in calyces, pelvis. Co. *. *. B. Calyx. Pelvis.

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Kidney pathology 2010.1

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  1. Kidney pathology 2010.1 Tubular & interstitial diseases

  2. Kidney - cut surface • Outer cortex (Co) • Inner medulla composed of pyramids * • Cortical columns of Bertini (B) between pyramids* • Urine first collects in calyces, pelvis Co * * B Calyx Pelvis

  3. Malpighi and Malpighian “corpuscles” (glomeruli)

  4. Glomerular structure • Arterioles • Capillaries • Mesangium (“between capillaries”) • Urinary space surrounds glomerulus within Bowman’s capsule • Urin sp -> prox tubule

  5. Normal renal tubules

  6. Acute pyelonephritis • Most severe end of spectrum of UTI • Acute bacterial inflammation of kidney • E coli, Proteus, Enterobacter, Klebsiella … • Abscesses in cortex, medulla • Polymorphs in tubules; glomeruli spared • (CMV, polyoma virus in immunocompromised)

  7. Acute pyelonephritis

  8. Acute pyelonephritis

  9. Acute pyelonephritis - clinical • M < 1yr and over 40 yrs; F 1 - 40 yrs • Sudden onset tenderness in costo-phrenic angle • Temp, rigors, cystitis • Most resolve quickly • May recur, become chronic • Complications

  10. Pathogenesis of acute pyelonephritis • (Haematogenous spread) • Bacterial adhesins, colonisation, ascending infection • Cystitis • Vesico-Ureteric Reflux & Intrarenal Reflux, congenital or acquired • VUR: Urine, bacteria -> ureter • Inrarenal reflux: Urine enters kidney papillae

  11. Predisposing factors • Short female urethra • Obstruction (pregnancy, congenital, stones, tumours, BPH) • Bladder dysfunction • Diabetes • Catheters, cystoscopy, other • Vesico-Ureteric Reflux & Intrarenal Reflux • If no reflux, infection only in bladder

  12. Complications of Acute Pyelo • Perinephric abscess • Pyonephrosis • *Papillary necrosis • Fibrous scars, chronic pyelonephritis

  13. Chronic pyelonephritis • Scars overlying distended calyces • Chronic inflammation and fibrosis involving tubules and interstitium • Two types • Reflux nephropathy • Chronic obstructive pyelonephritis

  14. Reflux nephropathy • Commoner • VUR pressure threshold • Organisms • Refluxing papillae at upper, lower poles • Hypertension at 15-25 yrs

  15. Chronic pyelonephritis (reflux)

  16. Chronic pyelonephritis - reflux type

  17. Chronic pyelonephritis, obstructive • Older patients • Strictures, calculi in ureter, renal pelvis • BPH • Tumours

  18. Chronic pyelonephritis - clinical • Chronic renal failure, hypertension • UTI (but often negative urine cultures) • Interstitial fibrosis, tubular atrophy, thyroidization of tubules, thick arteries, FSGS • Accounts for 10 - 20% of patients on dialysis • Other types of pyelonephritis

  19. TB (L) & Xanthogranulomatous PN (R)

  20. Non-bacterial inflammation of renal tubules, interstitium • Drugs/toxins: penicillins, rifampicin, NSAIDs….. • Immune injury (types I, IV); direct, unknown • Fever, oliguria in 50%, rash • Micro; inflammatory cells, inc eosinophils • Analgesic nephropathy - phenacetin, +/- aspirin, codeine • Assoc with glomerular disease e.g. SLE, renal vasculitis • Gout, multiple myeloma • Renal allograft rejection

  21. Acute interstitial nephritis

  22. Eosinophils in drug induced interstitial nephritis

  23. Acute renal transplant rejection

  24. Acute renal failure • Sudden onset of oliguria (<400ml) • Raised serum Creatinine • Cause determines symptoms, prognosis • Overall mortality is 40% • Drugs, toxins • Crescentic glomerulonephritis e.g. ANCA+ vasculitis • Genitourinary obstruction • Shock, ischaemia

  25. Acute renal failure - pathology • Most patients have a microscopic lesion - Acute Tubular Necrosis (necrosis of tubular epithelial cells is a “marker” of acute loss of renal function) • Renal tubular epithelium sensitive to toxins, ischaemia • Vasoconstriction -> hypoxia in outer medulla • Two types of ATN: • ATN due to drugs, toxins - PCT cells (95% survival) • ATN due to ischaemia, shock or sepsis - granular casts (20-50% survival)

  26. Normal tubules (L) and drug-induced ATN* (R) *

  27. ATN, drug-induced

  28. ATN due to toxin

  29. ATN due to Sepsis/Ischaemia

  30. Interstitial fibrosis and tubular atrophy in chronic renal disease correlate with progressive loss of renal function

  31. Chronic renal failure • Progressive and irreversible loss of renal tissue • Chronic GN, chronic PN, hypertensive nephrosclerosis, diabetes, adult type PCKD • Symptoms - anaemia, dehydration, nausea, metabolic bone disease, etc • Asymptomatic renal insufficiency present prior to this while kidneys’ intact nephrons compensate • Dialysis, transplant or death within 1 year of onset of CRF

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