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Kidney

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Childhood & Adult Hemolytic-Uremic Syndrome (HUS) ... Acetaminophen (Tylenol) directly damages cells. Aspirin -vasoconstriction ischemia ... – PowerPoint PPT presentation

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Title: Kidney


1
Kidney
2
  • Vascular diseases of Kidney
  • 1.Hypertensive Renal Disease
  • Nephrosclerosis-Benign Malignant
  • 2.Thrombotic Microangiopathies
  • Childhood Adult Hemolytic-Uremic Syndrome (HUS)
  • Adult (female) Thrombotic Thrombocytopenic
    Purpura (TTP)
  • Autoimmune Diseases
  • Toxemia of pregnancy
  • Severe bacterial infections.
  • 3.Renal Artery Stenosis (RAS)
  • Atherosclerotic or Fibromuscular dysplasia
  • reversible hypertension
  • 4.Renal Infarcts
  • Embolic or Thrombotic.

3
  • 1. Hypertension
  • Most renal diseases cause HTN
  • HTN has marked effects on the kidneys
  • Benign Nephrosclerosis hyaline arteriosclerosis
  • Most are at risk for developing malignant
    hypertension
  • Malignant Nephrosclerosis Hyperplastic
    arteriolosclerosis
  • Fibrinoid necrosis of arterioles
  • Thrombotic Microangiopathy (Necrotizing
    Glomerulitis)
  • ? renal blood flow therefore, ? renin
    -angiotensin system ? ?BP ? hypertension.
  • Clinical
  • Neurological Disoriented ? coma
  • Eyes Papilledema
  • Renal proteinuria, Hematuria RF

4
Benign Nephrosclerosis
  • Fine leathery granularity,

5
Benign Nephrosclerosis
  • Hyaline change in small blood vessels

6
Malignant Nephrosclerosis
  • Hyperplastic arteriolosclerosis (onion-skinning)
  • Blood vessels have collagen deposits making the
    onion skinning appearance
  • Notice how lumen gets very small

7
  • 2. Thrombotic Microangiopathies
  • Common findings
  • Thrombosis in small vessels
  • Microangiopathic hemolytic anemia (MHA)
  • Thrombocytopenia
  • Pathogenesis
  • Endothelial injury ? platelet aggregation?
    thrombosis
  • Vasoconstriction ? ischemia ? necrosis
  • A) Childhood Hemolytic Uremic Syndrome (HUS)
  • E. coli (infected Hamburgers)
  • Clinical renal failure is prominent
  • Intestinal bleeding, oliguria, Hematuria, MHA,
    HTN
  • B) TTP young females with High mortality

8
Fibrin Thrombi (Childhood HUS)
  • Caused by DIC, HUS (E. coli 0157H7)

9
3. RENAL ARTERY STENOSIS (RAS)
10
Fibromuscular Dysplasia
  • Fibromuscular dysplasia

11
  • 4. Renal infarcts
  • Branches of Renal artery - End arteries.
  • MCC MI and thromboembolism from Atrial
    Fibrillation
  • Clinical
  • Asymptomatic or
  • Large unilateral -May cause HTN
  • Extensive bilateral -May cause RF

12
Renal Infarcts
13
Renal Infarcts
14
Kidney
15
  • Tubulo Interstitial diseases
  • 1. Acute Tubular Necrosis (ATN)
  • 2. Pyelonephritis (PN)
  • Acute
  • Chronic
  • 3. Acute drug-induced Interstitial Nephritis
  • 4. Analgesic Abuse Nephropathy
  • 5. Metabolic Tubulointerstitial Disease
  • Urate
  • Hypercalcemia
  • Multiple Myeloma

16
  • 1. Acute Tubular Necrosis (ATN)
  • Most serious but reversible kidney disease,
  • Causes next slide
  • Pathology destruction of tubular epithelial
    cells ?Acute suppression of renal function,
    urinary output lt400 ml/day
  • ATN ?ARF by mechanisms
  • Tubular cell injury? Tubulo glomerular feed back
  • Tubular obstruction by Hyaline or pigmented
    granular casts (Tamm-Horsfall proteins secreted
    by tubular epithelium)
  • Back-leak of tubular fluid into the interstitial
    space (due to death of tubular cells)
  • The outcome of all the above three is ?GFR
    (oliguria)
  • Clinical Course Three phases
  • Initial phase (first 36 hrs.), Dominated by the
    cause
  • Maintenance phase Oliguria acute uremia
  • Salt water retention
  • Hyperkalemia and metabolic acidosis.
  • Rx fluid Electrolyte balance, dialysis
  • Recovery phasePolyuria electrolyte loss
  • Hypokalemia (give lots of fluids K sparing
    diuretics)
  • ?risk of infections
  • BUN creatinine levels return to normal

17
ATN- Causes
18
ATN
  • Necrotic Regenerating tubular epithelial cells

19
  • 2. Pyelonephritis (PN) Bacterial infection of
    kidney
  • Causes? chronic urinary tract infection
  • Routes of bacterial entry into kidneys
  • 1.Ascending Infection (MCC)
  • by vesico-ureteral reflux (VUR)
  • 2. Hematogenous Infection (septicemia)
  • Helped by lower UT obstruction
  • Pathology Inflammation - renal parenchyma
    pelvis
  • Clinical asymptomatic or cause severe flank pain
    fever
  • Lab Bacteria, leukocytes Casts
  • High risk pts DM, pregnancy UT obstruction
  • Complications Necrotizing papillitis or
    papillary necrosis
  • (papillary necrosis is seen in 4
    conditions????)
  • ( CT scan - best investigation)
  • Pathologic types Acute PN, Chronic PN

20
  • Acute Pyelonephritis Neutrophilic exudate
    within tubules and renal substance
  • kidney is almost unrecognizable
  • Complications papillary necrosis, Perinephric
    abscesses, Pyonephrosis, Scarring (Chronic
    Pyelonephritis)
  • Chronic Pyelonephritis (CPN) Chronic
    tubulointerstitial inflammation
  • Characterized by CRF HTN
  • Pathology corticomedullary scars overlying
    dilated blunted calyces.
  • Forms of CPN
  • 1 Reflux nephropathy-associated type
  • MCC of CPN
  • MCC of reflux Congenital intra-renal reflux With
    superimposed bacterial infection (E. coli).
  • 2.Obstructive type
  • predisposes to recurrent bacterial infections (E.
    coli)
  • Course Glomeruli undergo ischemic atrophy, total
    sclerosis with fine leathery granularity,
    shrunken.
  • Finally Glomeruli disappears

21
Acute Pyelonephritis
  • Neutrophilic exudate within tubules and renal
    substance kidney is almost unrecognizable

22
Chronic Pyelonephritis (CPN)
Thyroidization of renal tubules MOST Important
23
Chronic Pyelonephritis (CPN)
obstruction
24
  • 3 . Acute drug-induced interstitial nephritis
  • Manifests 2-40 days after the start of Rx
    (methicillin, ampicillin, rifampicin, thiazides,
    NSAID, cimetidine, .... )
  • Clinical Presents with fever, skin rash,
    hematuria, proteinuria, sterile pyuria,
    Eosinophilia (allergic, parasitic and Drug
    reactions), azotemia, and acute RF
  • Pathology Eosinophils and mononuclear
    infiltrates Patchy tubular necrosis
  • Withdrawal of drug ? recovery
  • 4. Analgesic Abuse Nephropathy Chronic
    tubulointerstitial nephritis with papillary
    necrosis
  • Caused by Habitual intake of large doses
  • Acetaminophen (Tylenol) ? directly damages cells
  • Aspirin -vasoconstriction ? ischemia
  • Pathology papillary necrosis ( other causes???)
  • Clinical Presents with Polyuria, Nocturia, HTN,
    headache, GI symptoms, anemia, may develop UTI,
    may develop CRF
  • Complications ? risk for TCC (Transitional cell
    Carcinoma) - renal pelvis

25
Drug-induced interstitial nephritis
Numerous Eosinophils
26
Analgesic Abuse Nephropathy
  • Papillary necrosis

27
Analgesic Abuse Nephropathy
  • Can slough off and obstruct urinary tract

28
  • 5. Metabolic Tubulointerstitial Disease
  • Urate Nephropathy form of
  • Acute RF (with cancer chemotherapy).
  • Chronic RF (with gout chronic lead poisoning).
  • Hypercalcemia cause RF by
  • Nephrolithiasis (causing UT obstruction).
  • Nephrocalcinosis (causing renal atrophy).
  • Multiple Myeloma
  • Acute or chronic RF
  • result of Bence - Jones Tamm-Horsfall
    proteinuria,
  • Hypercalcemia Nephrotoxic drugs
  • Cast nephropathy
  • Amyloid deposits- Light-chain nephropathy -AL

29
MULTIPLE MYELOMA (plasma cells)
  • Note tubular casts

30
Kidney
31
  • OBSTRUCTIVE UROPATHY (HYDRONEPHROSIS)
  • Characterized by
  • Unrelieved UT obstruction
  • Leads to renal atrophy, with dilatation of the
    renal pelvis and calyses ? Hydronephrosis all
    widened due to obstruction and distension in
    pelvis.
  • Still have glomerular filtration ? increase in
    urine load ? distension
  • If Bilateral ? CRF

32
HYDRONEPHROSIS
  • Causes are
  • Congenital anomalies
  • (vesicoureteral reflux, urethral valves, meatal
    stenosis)
  • Urinary calculi
  • Benign prostatic hypertrophy
  • Tumors
  • Pregnancy
  • Neurogenic bladder
  • Inflammatory strictures (including
    retroperitoneal fibromatosis).

33
HYDRONEPHROSIS
  • Hydronephrosis all widened due to obstruction
    and distension in pelvis

34
Kidney
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