Medical kidney diseases

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This article describes medical renal disease or the medical kidney. Much in medical kidney depends on the clinical information. Most of the disease seen by pathologists is... glomerular disease. If in doubt... the answer to most questions is diabetes mellitus or systemic lupus erythematosus. Medical kidney is niche area in pathology. It is one of the few areas that routinely requires electron microscopy.

Kidney tumours are dealt with in the kidney tumours article, and pediatric kidney tumours article.

Clinical

Creatinine

  • The standard screening test for renal function.
  • 300 mmol/L is the general cut-point for referral to a nephrologist.[1]

Notes:

  • Dinosaurs use the units mg/dL; normal with these units is: 0.8 to 1.4 mg/dL.[2]
  • Conversion: 1.0 mg/dL = 88.4 umol/L.[3][4]

Glomerular filtration rate

  • Abbreviated GFR.
  • Ultimate measure of renal function - usually estimated from the serum creatinine using a formula.
  • Declines with age.
  • Normal range (dependent on age): 116-75 mL/min/1.73m2.[5]

Urine protein to creatinine ratio

  • Indicator of proteinuria.
  • Predictor of glomerular filtration rate.[6]

Cut points:[7]

  • Normal (2 years and older): <0.2 g protein / g Creatinine
  • Nephrotic range: >3.5 g protein / g Creatinine.

Complement

C3, C4 levels:[8]

ANCA

Types:[12]

C4d

  • Suggests humoral immunity (antibody-mediated immunity) at play.
  • Important in monitoring of renal transplant recipients.
  • Immunostain also available - see below.

Other blood work

Renal ultrasound

  • Normal adult kidney size ~10.8+/-0.8 cm.[13]
  • Good for assessing the major vessels, drainage system and parenchymal lesions.
    • Renal artery stenosis?
    • Hydronephrosis?
    • Pelviectasis?
    • Renal cyst?
    • Renal mass?

Urine dip

Findings:[14]

  • RBC casts = acute bleed, e.g. nephritic syndrome.
  • WBC casts = interstitial nephritis, e.g. pylonephritis, parenchymal infection.
  • Hemegranular casts = acute tubular necrosis, transplant rejection.

Notes:

  • "Active sediment" = RBCs, RBC casts;[15] implies glomerulonephritis.
    • Some include the above (RBCs, RBC casts) + WBCs & protein.[16]

Urine crystals

Main article: Crystals in body fluids

Clinical presentations

Nephrotic syndrome

Features:

  • Anasarca (whole body - edema).
  • Proteinuria (>3.5 g/24h).
  • Hypercholesterolemia.
  • Hypoalbuminemia.

Nephritic syndrome

Features - mnemonic PHAROH:[17]

  • Proteinuria.
  • Hypertension.
  • Azotemia.
  • RBC casts.
  • Oliguria.
  • Hematuria.

Mixed

  • Features of nephritic syndrome and nephrotic syndrome.

Normal

Cells of the glomerulus

  • Podocytes.
  • Mesangial cells.
  • Endothelium.

Epithelium

Features:[18]

  • The glomeruli visceral epithelium is part of the capillary wall (part of the glomerular tuft).
  • The parietal epithelium is part of Bowman's capsule.

Remember: visceral has vessels.

Glomerulus

  • A large autopsy series suggest it is: 223-292 micrometers.[19]
    • Another autopsy series suggests the mean diameter is: 225 micrometers.[20]

Glomerular basement membrane

The glomerular basement membrane (GBM) should be thinner than the tubular basement membrane.

Basic approach to renal biopsy

Basic components

  • Glomeruli.
  • Tubules.
  • Interstitium.
  • Vessels.

Glomeruli

  1. Mesangium
    • Matrix should be: "one cell thick" (expanded in diabetes mellitus).
    • Cellularity of the mesangium - normal = upto 3 cells (don't count cell abutting the capillary lumen, don't count at the hilum).
  2. Capillary loops "open"
    • Lumina patent? If not patent is it due to matrix or cells (endocapillary hypercellularity).
    • Capillary wall morphology - wavy thin is normal; hulla-hoop/wire-like abnormal (suggestive of immune complex deposition).
  3. Bowman's space (urinary space) - crescents present?
  • Count the number of glomeruli.
  • Count number of the obsolete glomeruli.

Components of the glomeruli (anatomical)

  • Podocyte - rarely affect by disease
    • One notable disease is collapsing glomerulopathy in HIV.[21]
  • Endothelial cell.
  • Mesangial cell.

Vessels

  1. Arteriolar hyalinosis - too much pink stuff?
  2. Intimal hyperplasia.

Consider:

  • Vasculitis? - inflammatory cells in vessel wall.
  • Amyloid? - pink.
  • Rejection? - PMNs.

Tubules & interstitium

Tubules - proximal portion is the most important.

  • Casts?
  • Necrosis?

Interstitium

  • Fibrosis - prognostically important.
    • Grading: mild = <25%, moderate 25-50%, severe >50%.

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%.[22]

Example:

  • It is normal for an 80 year-old to have 30% sclerosed glomeruli.

Glomerular disease terms

Number of glomeruli involved:[23]

  • Focal = some of the glomeruli.
    • In practical terms, defined as: <50% of glomeruli.
  • Diffuse = most of glomeruli.

How much of the glomerulus is involved:[23]

  • Global = most of the glomerulus.
    • In practical terms, defined as: >80% of glomerulus.[24]
  • Segmental = part of the glomerulus.

Staining

The standard stain in kidney pathology is PAS. Section are usually 1-2 micrometers, as opposed to 4-5 micrometers seen in rountine section of other organs.

Interpretation of medical renal disease more difficult or even impossible if the sections are thicker, as one does not see the glomerular structures well.

In kidney that is cut thick the glomeruli look more nodular and it is more difficult to find open capillary loops.

Immunofluorescence

Routinue (mnemonic GAM CF):

  • IgG.
  • IgA.
  • IgM.
  • C1q
  • C3.
  • Fibrinogen.
  • Albumin.

Optional:

  • Kappa.
  • Lambda.
  • C4d.
    • Positive staining = peri-tubular capillaries stain.

Negative immunofluorescence

  • Excludes all immune complex associated disease.

Seen in:

Positive immunofluorescence

  • Positive immunofluorescence is usually diagnostic.

Basic patterns:

  1. Linear.
  2. Granular.
  3. Ring-like.

Examples:


Notes:

Immune complex-related disease

Can be:

  • Subepithelial - distal to basement membrane (BM), closer to the urinary space.
  • Subendothelial - proximal to BM, closer to the glomerular capillary.

Tram-tracking of BM

DDx:[25]

  1. MPGN.
  2. Thrombotic microangiopathy (TMA).
  3. Transplant glomerulopathy (TG).

Arteriolar hyalinosis

Microscopic:

  • Small vessels (afferent +/- efferent arteriole) with:
    • Glassy eosinophilic material in arteriolar wall.

DDx:

Note:

  • Arteriolar hyalinosis - involves afferent and efferent arterioles in diabetes, in others it is only the afferent.

Memory device ADHD:

  • Aging, Diabetes, Hypertension, Drugs.

Image:

Atherosclerosis

Main article: 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.

Mesangial hypercellularity

DDx:

  1. Lupus nephritis.
  2. IgA nephropathy.

Mesangial expansion

Glomerular crescents

General

  • Indicates a rapidly progressive disease.
  • Etiology/definition: break in the glomerular basement membrane (GBM).

Microscopic

  • Crescentic-shaped lesion in the urinary space of a glomerulus.
    • Crescent = looks like the moon shortly after new moon.
  • Break in the glomerular basement membrane - key feature.
  • Fibrin.
    • Described as orange on HPS.
  • Urinary space cellular debris.
  • Inflammatory cells (lymphocytes, plasma cells, eosinophils, macrophages) - extravascular - low power feature.

DDx:

  • Glomerular sclerosis:
    • Usu. no significant inflammation.
    • No fibrin.
    • Collagen deposition within the glomerular tuft.

Bland necrotic crescents

DDx:

  • ANCA-related glomerulonephritis.
  • Anti-GBM disease.

Diseases with crescents - is a long list.[27]

Pathologic DDx

The clinical presentations suggest a pathologic DDx.[28]

Nephritic

  • Post-infectious glomerulonephritis.
    • Classically streptococcal.
  • Crescentic glomerulonephritis (AKA rapidly progressive glomerulonephritis (RPGN)).

RPGN

Classification:[29]

  1. Linear immune deposits.
  2. Granular immune deposits.
  3. Pauci-immune.

Nephrotic

Mixed presentation


Diagnoses - Table

Pattern Key feature Other findings IF & EM Presentation Clinical Pathol. DDx Image
Nodular glomerulosclerosis nodular mesangial matrix expansion GBM thickening, both afferent and efferent arteriole hyalinized EM? nephrotic (???) diabetes mellitus (DM) amyloidosis, idiopathic nodular glomerulosclerosis (nodular GS without DM) (WC)
Focal segmental glomerulosclerosis (FSGS) focal sclerosis of gloms +/-interstitial fibrosis IF: negative; EM: foot process loss nephrotic syndrome primary FSGS, secondary FSGS (HIV, IVDU, obesity, parvovirus B19, Alport syndrome); unresponsive to steroids, worse prognosis than MCD minimal change disease Image?
Membranous nephropathy
(AKA membranous GN) 		spikes or pinholes with silver stain mesangial hypercellularity; +/-tram-tracking/wireloop GBM IF: diffuse granular capillary loop IgG, C3, kappa, lambda; EM: diffuse subepithelial deposits - spike forming nephrotic syndrome hepatitis B, hepatitis C, carcinoma, NSAID toxicity, SLE, idiopathic Nodular glomerulosclerosis (?) silver stain (flickr.com)
Minimal change disease (MCD) foot process loss on EM usu. none EM: foot process loss nephrotic syndrome primary vs. secondary (lymphoproliferative disorder, NSAIDs); idiopathic responds to steroids FSGS, thin glomerular basement membrane disease (histologic DDx) Image?
IgA nephropathy IgA branching pattern +/-mesangial hypercellularity, +/-crescents IF: IgA +ve (branching pattern); EM: dense mesangial deposits mixed nephrotic/nephritic primary vs. secondary (Henoch-Schoenlein purpura) RPGN (WC)
Membranoproliferative glomerulonephritis (MPGN) thick GBM Other findings? subepithelial deposits mixed nephrotic/nephritic SLE, cryoglobulinemia, hepatitis B, hepatitis C Pathol. DDx? Image?
Focal proliferative
glomerosclerosis (FPGS) 		<50% of glomeruli partially sclerosis Other findings? EM? mixed nephrotic/nephritic Clinical? Pathol. DDx? Image?
Rapidly progressive GN (RPGN) crescents Other findings? EM? nephritic syndrome AGBM, ANCA-vasculitis IgA nephropathy with crescents Image?
Dense deposit disease linear C3 with rings +/-thick GBM EM: GBM lamina densa thickening Presentation? mixed nephrotic/nephritic (???) MPGN (nature.com)

Diffuse proliferative glomerulonephritis

Pattern Key feature Clinical
Post-infectious glomerulonephritis IF: capillary loop +/- mesangial IgG/C3; EM: large infreq. hump-like subepithelial deposits post-infection
Membranoproliferative glomerulonephritis (MPGN) low C3, normal C4; primary vs. secondary (often hepatitis C)
Dense deposit disease
Cryoglobulinemic glomerulonephritis
Diffuse proliferative lupus glomerulonephritis systemic lupus erythematosus; low C3, low C4
Diffuse proliferative IgA nephropathy IF: IgA +ve (branching pattern)

Common diseases

Diabetic nephropathy

General

Microscopic

Features:[30]

  • Thick glomerular basement membrane (GBM).
  • Thickened (eosinophilic) tunica media in both the afferent and efferent arterioles.[31]
  • Mesangial matrix expansion - leads to nodule formation Kimmelstiel-Wilson nodules (nodular glomerulosclerosis).

Other:

  • Armanni-Ebstein change - cytoplasmic vacuolization of tubular cells (usu. loop of Henle) -- innermost cortex, outer medulla;[32] not specific to diabetes mellitus.[33]

Other - with weak evidence:

  • Extra efferent vessels.[34]

Memory device:

  • GBM = thick GBM, both afferent & efferent artiole thickened, mesangial matrix expansion.

Images:

Notes:

  • Hypertensive kidneys have changes only in the afferent arteriole, i.e. the efferent arteriole is spared (see hypertension).

IF

  • Negative.
  • +/-Nonspecific linear IgG.

EM

  • Severe thickening of GBM.
  • Mesangial sclerosis.

Lupus nephritis

  • Abbreviated LN.

General

Main article: Systemic lupus erythematosus
  • Bread & butter of nephropathology.
  • The biopsy done to determine treatment, i.e. how much immunosuppression is needed.

Immunofluorescence

  • "Full house" = all of 'em light up.

Classification

International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification:[35][36]

  • Class I - minimal mesangial LN.
  • Class II - mesangial proliferative LN.
  • Class III - focal lupus nephritis; <50% of glomeruli.
  • Class VI-S - diffuse segmental LN; >50% of glomeruli.
  • Class VI-G - global LN; >50% of glomeruli.
  • Class V - Membranous lupus nephritis.
  • Class IV - Advanced sclerosing LN; essentially end-stage kidney.

Notes:

  • Most of the action is in Class III and Class IV.
    • Class I is near normal - doesn't get biopsied.
    • Class IV is essentially a dead kidney - doesn't get biopsied.

Images:

Nephrotic syndrome

Main article: Nephrotic syndrome

This includes the following:

Mixed nephrotic and nephritic

IgA nephropathy

  • AKA Berger disease.

General

Microscopic

Features:

  • Variable:
    • Mesangial hypercellularity - may be only light microscopy finding.

Note:

  • Diagnosis based on immunofluorescence (IgA+).

Image: IgA nephropathy (med.utah.edu).

Scoring

IgA nephropathy can be scored using an assessment of mesangial proliferation, endocapillary proliferation, glomerulosclerosis and tubular atrophy and interstitial fibrosis (abbreviated MEST).[38]

IF

  • IgA +ve -- branching pattern.

EM

  • Mesangial deposits.
    • These are electron dense, ergo dark on EM images.

Membranoproliferative glomerulonephritis

  • Abbreviated MPGN.
  • Old name MPGN type 1.

General

  • In adults most common cause: hepatitis C.

Microscopic

Features:

  • Endothelial cell proliferation.
  • Basement membrane double layering (tram-tracking).
  • Mesangial hypercellularity.

Dense deposit disease

  • Abbreviated DDD.
  • AKA MPGN type 2 (old name).

General

  • Usually children and young adults.
  • No longer considered a type of MPGN.[39]

Microscopic

Features:

  • Variable - may be like MPGN.
    • Four patterns:[39]
      1. Hypercellularity and lobular (membranoproliferative-like).
      2. Mesangial proliferative.
      3. Crescentic.
      4. Acute proliferative and exudative.

Images:

IF

  • Linear C3 with mesangial rings (donut-like).
  • IgG negative.
  • IgA negative

EM

  • Electron dense transformation of GBM lamina densa - key feature.
    • Dense = darker.

Images:

Nephritic syndrome

Rapidly progressive glomerulonephritis

  • Abbreviated RPGN.
  • AKA crescentic glomerulonephritis.

General

  • Acute renal dysfunction.
  • Nephritic syndrome.

DDx:

  1. Linear immunofluorescence.
  2. Granular immunofluorescence
  3. Pauci-immune.

Microscopic

Features:

Image:

Post-infectious glomerulonephritis

General

  • Post-streptococcal infection.
    • Lab test: Antistreptolysin O titer (ASOT) +ve.

Microscopic

Features:

  • +/-Neutrophils - in glomerulus.

Image:

Rare diseases

Antiglomerular basement membrane disease

  • Abbreviated AGBM.

General

  • Known as Goodpasture disease (AKA Goodpasture syndrome), if renal failure is accompanied by pulmonary hemorrhage.[40]
  • Rare - estimated incidence 1/1-2 million.[41]
  • Antibody mediated hypersensitivity.
  • Thought to occur in genetically susceptible individuals.[41]
    • Associated with a specific HLA type (HLA-DRB1*1501) and two gene families.
    • Antibodies directed against COL4A3,[42] which is not mutated.

Tx:

  • Immune suppression & plasma exchange.[43]

Clinical DDx:

Microscopic

Features:

  • RPGN.
    • Crescentic glomerulonephritis.

IF

  • Linear IgG deposits - diagnostic.

DDx:

  • Goodpasture syndrome with the pulmonary hemorrhage.

Thin glomerular basement membrane disease

General

Clinical:

  • Hematuria.
  • FHx.
  • Nonprogressive.

Microscopic

  • Normal.

IF

  • Normal.

EM

  • GBM thin <200-250 - key feature.

Note:

  • Normal GBM: 300-350 nm.

Alport syndrome

General

Clinical:

  • Hearing loss (sensorineural).
  • Hematuria - usually preceeds hearing loss.[45]

Etiology:

  • Genetic defect - collagen type IV.

Inheritance:[45]

  • X-linked - 80%.
  • Autosomal recessive - 15%.
  • Autosomal dominant - 5%.

Microscopic

Features:[47]

  • Normal.

IF

  • Negative.

EM

Features:[47]

  • Abnormal glomerular basement membrane (GBM); thinning or thickening.
    • Classically thinning with thick lamellation (splitting/multi-layering).

Idiopathic nodular glomerulosclerosis

General

Associations:[48]

Microscopic

Features:[48]

  • Looks like diabetic nodular glomerulosclerosis.

IF

Nonspecific.

EM

Nonspecific.

Fabry disease

General

  • Rare X-linked genetic disease.
    • Caused by defect in alpha-galactosidase A gene.
    • Women partially affected
  • Lysosomal storage disorder -- 2nd in prevalence only to Gaucher disease.
  • Multisystem disease affecting small vessels and kidney.

Presentation

Tx

  • Symptomatic treatment.
  • Enzyme replacement - agalsidase alpha (Replagal) or agalsidase beta (Fabrazyme).

Microscopic

LM:[50]

  • Foamy podocyte inclusions, best visualized with toluidine blue.
  • Mild mesangial hypercellularity.

EM:[50]

  • Myelin-like inclusions.
    • Concentric bodies with an onion-skin-like appearance.
  • Zebra bodies.
    • Ovoid inclusions with striped pattern.

Note:

  • Myelin-like inclusion are not pathognomonic for Fabry disease; they may result from drug use:[50]
    • Amiodarone,
    • Aminoglycosides,
    • Chloroquine.

Myeloma

See: Haematopathology.
  • AKA myeloma kidney.

Myeloma cast nephropathy

General

  • Renal failure.

Microscopic

Features:[51]

  • Crap in tubules.
    • Refractile.
  • Cast with cellular reaction.
    • Macrophages (CD68 +ve).

Image:

Stains

  • Myeloma casts = PAS -ve.
    • Hyaline casts = PAS +ve.

Amyloidosis

Main article: Amyloidosis
  • Usually associated with lambda clone.

Light chain deposition

  • Usually associated with kappa clone.

Cystic kidney diseases

Main article: Cystic kidney diseases

These are discussed in a separate article and include:

  • Autosomal dominant polycystic kidney disease (ADPKD).
  • Adult-onset medullary cystic disease.
  • Acquired renal cystic disease.
  • Autosomal recessive polycystic kidney disease (ARPKD).
  • Medullary sponge kidney.
  • Nephronophthisis.
  • Cystic renal cell carcinoma.

Disease that does not get biopsied

Malignant hypertension

See: hyperplastic arteriolosclerosis.
See: thrombotic microangiopathy.

Pyelonephritis

General

  • Usually diagnosed clinically: urine C&S, urine R&M, +/-CT abdomen.
  • May be associated with vesicoureteral reflux.
  • Chronic pyelonephritis may be a reason for nephrectomy.[52]

Gross

Features:[53]

Microscopic

Features:

  • Interstitial nephritis.

Acute tubular necrosis

General

  • Best diagnosed clinically (using urine R&M) - hemegranular casts are diagnostic.
  • Often abbreviated ATN.

Microscopic

Features:[54]

  • Hemegranular casts in the lumen.
  • Regenerative activity (mitoses).

Hepatorenal syndrome

General

  • Acute renal failure secondary to liver failure (e.g. fulminant liver failure, cirrhosis with marginal liver function).

Clinical:

  • Urine sodium is low,[55] unlike in ATN (the main DDx).

Pathophysiology:

  • Renal vasoconstriction.[56]

Treatment: Medical and surgical:[57]

  • Vasoconstrictors (e.g. midodrine, terlipressin (counteracts splanchnic vasodilation), norepinephrine).
  • Albumin.
  • TIPS (transjugular intrahepatic portosystemic shunt).
  • Liver transplantation.

Note:

  • I suspect a portal vein pump would work... it reduces portal pressure and would likely increase hepatic function.

Microscopic

Features (kidney):

  • Normal.

Renal transplant pathology

Main article: Renal transplant pathology

See also

References

  1. ↑ Mendelssohn DC, Barrett BJ, Brownscombe LM, et al. (August 1999). "Elevated levels of serum creatinine: recommendations for management and referral". CMAJ 161 (4): 413–7. PMC 1230545. PMID 10478168. http://www.cmaj.ca/cgi/content/full/161/4/413.
  2. ↑ URL: http://www.nlm.nih.gov/medlineplus/ency/article/003475.htm. Accessed on: 8 November 2010.
  3. ↑ URL: http://www.sydpath.stvincents.com.au/other/Conversions/ConversionMasterF3.htm. Accessed on: 8 November 2010.
  4. ↑ URL: http://www.unc.edu/~rowlett/units/scales/clinical_data.html. Accessed on: 8 November 2010.
  5. ↑ URL: http://www.kidney.org/professionals/KLS/gfr.cfm. Accessed on: 8 November 2010.
  6. ↑ Ruggenenti P, Gaspari F, Perna A, Remuzzi G (February 1998). "Cross sectional longitudinal study of spot morning urine protein:creatinine ratio, 24 hour urine protein excretion rate, glomerular filtration rate, and end stage renal failure in chronic renal disease in patients without diabetes". BMJ 316 (7130): 504–9. PMC 2665663. PMID 9501711. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2665663/pdf/9501711.pdf.
  7. ↑ URL: http://www.fpnotebook.com/urology/lab/urnprtntcrtnrt.htm. Accessed on: 8 November 2010.
  8. ↑ Levo Y, Pick AI (1974). "The significance of C3 and C4 complement levels in lupus nephritis". Int Urol Nephrol 6 (3-4): 233–8. PMID 4549215. http://www.springerlink.com/content/l1657797661468g1/fulltext.pdf.
  9. ↑ 9.0 9.1 Nusinow SR, Zuraw BL, Curd JG (May 1985). "The hereditary and acquired deficiencies of complement". Med. Clin. North Am. 69 (3): 487–504. PMID 3892188.
  10. ↑ URL: beckmancoulter.com. Accessed on: 9 November 2010.
  11. ↑ URL: beckmancoulter.com. Accessed on: 9 November 2010.
  12. ↑ Kallenberg, CG. (Mar 2011). "Pathogenesis of ANCA-associated vasculitides.". Ann Rheum Dis 70 Suppl 1: i59-63. doi:10.1136/ard.2010.138024. PMID 21339221.
  13. ↑ Guzman, RP.; Zierler, RE.; Isaacson, JA.; Bergelin, RO.; Strandness, DE. (Mar 1994). "Renal atrophy and arterial stenosis. A prospective study with duplex ultrasound.". Hypertension 23 (3): 346-50. PMID 8125561.
  14. ↑ URL: http://www.nlm.nih.gov/medlineplus/ency/article/003586.htm. Accessed on: 20 September 2010.
  15. ↑ URL: http://emedicine.medscape.com/article/238158-overview. Accessed on: 9 November 2010.
  16. ↑ URL: http://www.nephrologychannel.com/agn/index.shtml. Accessed on: 9 November 2010.
  17. ↑ URL: http://books.google.com/books?id=5bmg8xiLxkMC&pg=PA249&lpg=PA249&dq=Nephritic+syndrome+PHAROH#v=onepage&q=Nephritic%20syndrome%20PHAROH&f=false. Accessed on: 9 December 2009.
  18. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 956. ISBN 0-7216-0187-1.
  19. ↑ Hoy, WE.; Douglas-Denton, RN.; Hughson, MD.; Cass, A.; Johnson, K.; Bertram, JF. (Feb 2003). "A stereological study of glomerular number and volume: preliminary findings in a multiracial study of kidneys at autopsy.". Kidney Int Suppl (83): S31-7. PMID 12864872. http://www.nature.com/ki/journal/v63/n83s/fig_tab/4493733t2.html#figure-title.
  20. ↑ Nyengaard, JR.; Bendtsen, TF. (Feb 1992). "Glomerular number and size in relation to age, kidney weight, and body surface in normal man.". Anat Rec 232 (2): 194-201. doi:10.1002/ar.1092320205. PMID 1546799.
  21. ↑ AH. 13 August 2009.
  22. ↑ Fogo, Agnes B.; Kashgarian, Michael (2005). Diagnostic Atlas of Renal Pathology: A Companion to Brenner and Rector's The Kidney 7E (1st ed.). Saunders. pp. 16. ISBN 978-1416028710.
  23. ↑ 23.0 23.1 Fogo, Agnes B.; Kashgarian, Michael (2005). Diagnostic Atlas of Renal Pathology: A Companion to Brenner and Rector's The Kidney 7E (1st ed.). Saunders. pp. 7. ISBN 978-1416028710.
  24. ↑ Berden, AE.; Ferrario, F.; Hagen, EC.; Jayne, DR.; Jennette, JC.; Joh, K.; Neumann, I.; Noël, LH. et al. (Oct 2010). "Histopathologic classification of ANCA-associated glomerulonephritis.". J Am Soc Nephrol 21 (10): 1628-36. doi:10.1681/ASN.2010050477. PMID 20616173. http://jasn.asnjournals.org/content/21/10/1628/T1.expansion.html.
  25. ↑ AH. 17 July 2009.
  26. ↑ Fioretto P, Mauer M (March 2007). "Histopathology of diabetic nephropathy". Semin. Nephrol. 27 (2): 195-207. doi:10.1016/j.semnephrol.2007.01.012. PMID 17418688.
  27. ↑ URL: http://path.upmc.edu/cases/case51/dx.html. Accessed on: 9 November 2010.
  28. ↑ URL: http://www.emedicine.com/med/topic886.htm and http://www.emedicine.com/ped/topic1564.htm. Accessed on: 8 November 2010.
  29. ↑ URL: http://bestpractice.bmj.com/best-practice/monograph/207/basics/classification.html. Accessed on: 17 November 2011.
  30. ↑ Zelmanovitz T, Gerchman F, Balthazar AP, Thomazelli FC, Matos JD, Canani LH (2009). "Diabetic nephropathy". Diabetol Metab Syndr 1 (1): 10. doi:10.1186/1758-5996-1-10. PMC 2761852. PMID 19825147. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761852/.
  31. ↑ Østerby R, Hartmann A, Bangstad HJ (April 2002). "Structural changes in renal arterioles in Type I diabetic patients". Diabetologia 45 (4): 542–9. doi:10.1007/s00125-002-0780-2. PMID 12032631.
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  49. ↑ Costa, AF.; Gomes dos Santos, WA.; Filho, MA.; Farias, FT.; Modesto dos Santos, V.. "Nodular glomerulosclerosis in a non-diabetic hypertensive smoker with dyslipidemia.". An Sist Sanit Navar 34 (2): 301-8. PMID 21904413.
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  51. ↑ URL: http://www.kidneypathology.com/English_version/Amyloidosis_and_others.html. Accessed on: 9 November 2010.
  52. ↑ URL: https://secure.health.utas.edu.au/intranet/cds/pathprac/Files/Cases/Renal/Case44/Case44.htm. Accessed on: 26 July 2011.
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  54. ↑ PS. April 2009.
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