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Kidney pathology 2010.1 Tubular & interstitial diseases.

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  • Slide 1
  • Kidney pathology 2010.1 Tubular & interstitial diseases
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  • 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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  • Malpighi and Malpighian corpuscles (glomeruli)
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  • Glomerular structure Arterioles Capillaries Mesangium (between capillaries) Urinary space surrounds glomerulus within Bowmans capsule Urin sp -> prox tubule
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  • Normal renal tubules
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  • 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)
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  • Acute pyelonephritis
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  • 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
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  • 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
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  • 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
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  • Complications of Acute Pyelo Perinephric abscess Pyonephrosis *Papillary necrosis Fibrous scars, chronic pyelonephritis
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  • Chronic pyelonephritis Scars overlying distended calyces Chronic inflammation and fibrosis involving tubules and interstitium Two types Reflux nephropathy Chronic obstructive pyelonephritis
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  • Reflux nephropathy Commoner VUR pressure threshold Organisms Refluxing papillae at upper, lower poles Hypertension at 15-25 yrs
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  • Chronic pyelonephritis (reflux)
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  • Chronic pyelonephritis - reflux type
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  • Chronic pyelonephritis, obstructive Older patients Strictures, calculi in ureter, renal pelvis BPH Tumours
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  • 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
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  • TB (L) & Xanthogranulomatous PN (R)
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  • 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
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  • Acute interstitial nephritis
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  • Eosinophils in drug induced interstitial nephritis
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  • Acute renal transplant rejection
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  • Acute renal failure Sudden onset of oliguria (
  • 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)
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  • Normal tubules (L) and drug-induced ATN* (R) *
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  • ATN, drug-induced
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  • ATN due to toxin
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  • ATN due to Sepsis/Ischaemia
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  • Interstitial fibrosis and tubular atrophy in chronic renal disease correlate with progressive loss of renal function
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  • 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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