Difference between revisions of "Medical kidney diseases"

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Medical kidney diseases (view source)

Revision as of 03:51, 23 November 2011

2,943 bytes added ,  03:51, 23 November 2011
light microscopy pattern
(re-work)
(light microscopy pattern)
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*Endothelial cell.
*Endothelial cell.
*Mesangial cell.
*Mesangial cell.
====Obsolete glomeruli====
*Completely sclerosed glomeruli are not important - unless present in larger numbers than expected for the age of the patient.
:Percent of sclerosed glomeruli = (age in years)/2 - 10%.<ref name=Ref_DARP16>{{Ref DARP|16}}</ref>
Example:
*It is normal for an 80 year-old to have 30% sclerosed glomeruli.
====Glomerular disease terms====
Number of glomeruli involved:<ref name=DARP7>{{Ref DARP|7}}</ref>
*Focal = some of the glomeruli.
**In practical terms, defined as: <50% of glomeruli.
*Diffuse = most of glomeruli.
How much of the glomerulus is involved:<ref name=DARP7>{{Ref DARP|7}}</ref>
*Global = most of the glomerulus.
**In practical terms, defined as: >80% of glomerulus.<ref>{{Cite journal  | last1 = Berden | first1 = AE. | last2 = Ferrario | first2 = F. | last3 = Hagen | first3 = EC. | last4 = Jayne | first4 = DR. | last5 = Jennette | first5 = JC. | last6 = Joh | first6 = K. | last7 = Neumann | first7 = I. | last8 = Noël | first8 = LH. | last9 = Pusey | first9 = CD. | title = Histopathologic classification of ANCA-associated glomerulonephritis. | journal = J Am Soc Nephrol | volume = 21 | issue = 10 | pages = 1628-36 | month = Oct | year = 2010 | doi = 10.1681/ASN.2010050477 | PMID = 20616173 |url=http://jasn.asnjournals.org/content/21/10/1628/T1.expansion.html}}</ref>
*Segmental = part of the glomerulus.


===Vessels===
===Vessels===
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*Cholesterol emboli?
*Cholesterol emboli?


===Tubules & interstitium===
====Arteriolar hyalinosis====
Microscopic:
*Small vessels (afferent +/- efferent arteriole) with:
**Glassy eosinophilic material in arteriolar wall.
***[[PAS stain]] +ve.
 
DDx:
*Aging.
*[[Diabetes mellitus]].
*[[Hypertension]].
*Drugs - [[calcineurin inhibitor toxicity|calcineurin inhibitors]] (tacrolimus, cyclosporine).
 
Note:
*Arteriolar hyalinosis - involves ''afferent'' and ''efferent'' arterioles in diabetes, in others it is only the afferent.
 
Memory device ''ADHD'':
*'''A'''ging, '''D'''iabetes, '''H'''ypertension, '''D'''rugs.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_he_-_very_high_mag.jpg Arterial hyaline - HE - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_pas_-_very_high_mag.jpg Arterial hyaline - PAS - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_hps_-_very_high_mag.jpg Arterial hyaline - HPS - very high mag. (WC)].
 
====Atherosclerosis====
{{Main|Atherosclerosis}}
Microscopic:
*Intimal thickening of medium-sized vessels.
**Where is the intima/media interface?
***Internal elastic lamina - wavy band of eosinophilic material on H&E that is 1-2 micrometres thick.
 
Grading - based on the thickness of the media and intima:
*Mild: (tunica) media > (tunica) intima.
*Moderate: media = intima.
*Severe: media < intima.
 
===Tubules===
Tubules - proximal portion is the most important.
Tubules - proximal portion is the most important.
Consider:
*Casts?
*Casts?
*Degeneration, i.e. apoptosis.
*Degeneration, i.e. apoptosis.
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*Regeneration, e.g. mitoses.
*Regeneration, e.g. mitoses.


===Interstitium===
Interstitium
Interstitium
*Fibrosis - prognostically important.
*Fibrosis - prognostically important.
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==Important terms/process related==
==Important terms/process related==
===Obsolete glomeruli===
*Completely sclerosed glomeruli are not important - unless present in larger numbers than expected for the age of the patient.
:Percent of sclerosed glomeruli = (age in years)/2 - 10%.<ref name=Ref_DARP16>{{Ref DARP|16}}</ref>
Example:
*It is normal for an 80 year-old to have 30% sclerosed glomeruli.
===Glomerular disease terms===
Number of glomeruli involved:<ref name=DARP7>{{Ref DARP|7}}</ref>
*Focal = some of the glomeruli.
**In practical terms, defined as: <50% of glomeruli.
*Diffuse = most of glomeruli.
How much of the glomerulus is involved:<ref name=DARP7>{{Ref DARP|7}}</ref>
*Global = most of the glomerulus.
**In practical terms, defined as: >80% of glomerulus.<ref>{{Cite journal  | last1 = Berden | first1 = AE. | last2 = Ferrario | first2 = F. | last3 = Hagen | first3 = EC. | last4 = Jayne | first4 = DR. | last5 = Jennette | first5 = JC. | last6 = Joh | first6 = K. | last7 = Neumann | first7 = I. | last8 = Noël | first8 = LH. | last9 = Pusey | first9 = CD. | title = Histopathologic classification of ANCA-associated glomerulonephritis. | journal = J Am Soc Nephrol | volume = 21 | issue = 10 | pages = 1628-36 | month = Oct | year = 2010 | doi = 10.1681/ASN.2010050477 | PMID = 20616173 |url=http://jasn.asnjournals.org/content/21/10/1628/T1.expansion.html}}</ref>
*Segmental = part of the glomerulus.
===Staining===
===Staining===
The standard [[stain]] in kidney pathology is ''PAS''.
The standard [[stain]] in kidney pathology is ''PAS''.
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*Linear C3 with mesangial rings; IgG -ve, IgA -ve.
*Linear C3 with mesangial rings; IgG -ve, IgA -ve.
**[[Dense deposit disease]] (DDD).
**[[Dense deposit disease]] (DDD).


Notes:
Notes:
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*Subendothelial - proximal to BM, closer to the glomerular capillary.
*Subendothelial - proximal to BM, closer to the glomerular capillary.


==Pathologic differential diagnosis==
===Tram-tracking of BM===
===Tram-tracking of BM===
DDx:<ref>AH. 17 July 2009.</ref>
DDx:<ref>AH. 17 July 2009.</ref>
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#[[Transplant glomerulopathy]] (TG).
#[[Transplant glomerulopathy]] (TG).


===Arteriolar hyalinosis===
Microscopic:
*Small vessels (afferent +/- efferent arteriole) with:
**Glassy eosinophilic material in arteriolar wall.
***[[PAS stain]] +ve.
DDx:
*Aging.
*[[Diabetes mellitus]].
*[[Hypertension]].
*Drugs - [[calcineurin inhibitor toxicity|calcineurin inhibitors]] (tacrolimus, cyclosporine).
Note:
*Arteriolar hyalinosis - involves ''afferent'' and ''efferent'' arterioles in diabetes, in others it is only the afferent.
Memory device ''ADHD'':
*'''A'''ging, '''D'''iabetes, '''H'''ypertension, '''D'''rugs.
Image:
*[http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_he_-_very_high_mag.jpg Arterial hyaline - HE - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_pas_-_very_high_mag.jpg Arterial hyaline - PAS - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_hps_-_very_high_mag.jpg Arterial hyaline - HPS - very high mag. (WC)].
===Atherosclerosis===
{{Main|Atherosclerosis}}
Microscopic:
*Intimal thickening of medium-sized vessels.
**Where is the intima/media interface?
***Internal elastic lamina - wavy band of eosinophilic material on H&E that is 1-2 micrometres thick.
Grading - based on the thickness of the media and intima:
*Mild: (tunica) media > (tunica) intima.
*Moderate: media = intima.
*Severe: media < intima.
==Pathologic differential diagnosis==
===Mesangial hypercellularity===
===Mesangial hypercellularity===
DDx:
DDx:
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Diseases with crescents - is a long list.<ref>URL: [http://path.upmc.edu/cases/case51/dx.html http://path.upmc.edu/cases/case51/dx.html]. Accessed on: 9 November 2010.</ref>
Diseases with crescents - is a long list.<ref>URL: [http://path.upmc.edu/cases/case51/dx.html http://path.upmc.edu/cases/case51/dx.html]. Accessed on: 9 November 2010.</ref>
===Light microscopy pattern===
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
| '''Pattern'''
| '''Key feature'''
| '''Other findings'''
| '''DDx of the pattern'''
| '''DDx'''
| '''Image'''
|-
|[[Nodular glomerulosclerosis]]
| nodular mesangial matrix expansion
| GBM thickening, both afferent and efferent arteriole hyalinized
| Membranous nephropathy
| [[diabetic nephropathy]], [[idiopathic nodular glomerularsclerosis]], [[amyloidosis]]
| [http://commons.wikimedia.org/wiki/File:Nodular_glomerulosclerosis.jpeg (WC)]
|-
|Normal light microscopy
| Normal histology
| none
| [[membranous nephropathy]]
| normal kidney, [[minimal change disease]], [[thin glomerular basement membrane disease]], [[Alport syndrome]], early [[membranous nephropathy]]
| Image?
|-
|[[Membranous nephropathy]]
| GBM spikes or pinholes with silver stain, GBM thickening on PAS
| +/-mesangial hypercellularity +/-tram-tracking/wireloop GBM
| normal light microscopy
| [[hepatitis B]], [[hepatitis C]], carcinoma, NSAID toxicity, SLE, idiopathic
| Image
|-
|[[Focal segmental glomerulosclerosis]]
| glomerularsclerosis = mesangial expansion with collagen
| +/-glomerular enlargement, +/- tuft-capsule adhesions
| [[rapidly progressive glomerularnephritis]], [[nodular glomerulosclerosis]]
| primary FSGS, secondary FSGS ([[HIV]], [[IVDU]], obesity, [[parvovirus B19]], [[Alport syndrome]]
| [http://commons.wikimedia.org/wiki/File:Focal_segmental_glomerulosclerosis_-_high_mag.jpg (WC)]
|-
|[[Diffuse proliferative glomerulonephritis]]
| mesangial hypercellularity
| +/-mesangial expansion, +/-interstitial inflammation
| nodular glomerulosclerosis
| [[post-infectious glomerulonephritis]], [[MPGN]], [[dense deposits disease]], diffuse proliferative [[lupus nephritis]] (class IV), cryoglobulinemic GN
| Image
|-
|Tubular injury
| tubular degeneration (loss of cilia in proximal tubule, apoptosis, necrosis), regeneration (mitosis, nucleoli)
| +/-interstitial fibrosis
| normal light microscopy
| [[acute tubular necrosis]], [[chronic allograft nephropathy]]
| [http://commons.wikimedia.org/wiki/File:Chronic_allograft_nephropathy_-_intermed_mag.jpg (WC)]
|-
|Small vessel pathology
| luminal narrowing; +/-thrombosis, +/-hyalinosis
| +/-onion-skinning
| none
| [[thrombotic microangiopathy]] (malignant hypertension, scleroderma renal crisis, DIC, HUS, TTP,
| [http://commons.wikimedia.org/wiki/File:Renal_arterial_hyalinosis_-_pas_-_very_high_mag.jpg hyalinosis (WC)], [http://commons.wikimedia.org/wiki/File:Thrombotic_microangiopathy_-_very_high_mag.jpg TMA (WC)]
|-
|Large vessel pathology
| luminal narrowing; +/-intimal thickening; +/-embolization
| +/-medial thinning
| none
| [[atherosclerosis]], embolization
| Image
|- <!--
| Pattern
| Key feature
| Other findings
| DDx of the pattern
| Pathol. DDx
| Image -->
|}




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| primary FSGS, secondary FSGS ([[HIV]], [[IVDU]], obesity, [[parvovirus B19]], [[Alport syndrome]]); unresponsive to steroids, worse prognosis than MCD
| primary FSGS, secondary FSGS ([[HIV]], [[IVDU]], obesity, [[parvovirus B19]], [[Alport syndrome]]); unresponsive to steroids, worse prognosis than MCD
| [[minimal change disease]]
| [[minimal change disease]]
| Image?
| [http://commons.wikimedia.org/wiki/File:Focal_segmental_glomerulosclerosis_-_high_mag.jpg (WC)]
|-
|-
|[[Membranous nephropathy]]<br>(AKA membranous GN)
|[[Membranous nephropathy]]<br>(AKA membranous GN)
Michael
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