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63 Cards in this Set
- Front
- Back
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What is the term for inflammation of renal tubules and interstitium?
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Acute Interstitial Nephritis
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What are the causes of Acute Interstitial Nephritis?
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- Hypersensitivity reaction to *DRUGS* (PCN derivatives, NSAIDs, sulfonamides, rifampin) --> usually reversible
- Infections - Autoimmune dz (SLE, Sjogren's) |
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What can clue you in that it is a drug reaction / hypersensitivity causing the Acute Interstitial Nephritis?
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- Fever
- Arthralgias - Maculopapular rash - Peripheral blood eosinophilia - EOSINOPHILS in urine - UA can show WBCs, WBC cats, and RBCs |
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How do you treat Acute Interstitial Nephritis?
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- Most drug-related causes will resolve when drug is discontinued
- Corticosteroids can be used - Treat associated infections - Treat underlying disorders in autoimmune disorders |
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What are the morphological features of Acute Interstitial Nephritis?
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- Inflammation and edema of interstitium
- Involves tubules (tubulitis) but spares glomeruli and vessels - Presence of lymphocytes, plasma cells, and EOSINOPHILS (red) - May see granulomas |
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What is the term for acute inflammation of kidney d/t bacterial infection?
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Acute Pyelonephritis
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How can you get Acute Pyelonephritis?
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- Urinary route (*ascending UTI*)
- Hematogenous route |
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What are the typical urinary tract pathogens?
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Usually G- bacilli
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What bacteria can cause Acute Pyelonephritis from hematogenous infection?
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- Staphylococcus
- E. coli |
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What bacteria can cause Acute Pyelonephritis from ascending infection?
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- E. coli
- Proteus - Enterobacter (G- bacilli usually) |
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What conditions predispose to Acute Pyelonephritis?
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- Urinary obstruction (congenital or acquired)
- Urinary Tract Instrumentation - Vesicoureteral Reflux - Pregnancy - Diabetes |
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What are the morphological features of Acute Pyelonephritis?
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- Looks like Interstitial Nephritis, but contains NEUTROPHILS (=infection) instead of eosinophils
- Also can grow bacteria on urine culture |
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How common is renal failure in Multiple Myeloma?
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25%
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What causes chronic renal failure in Multiple Myeloma?
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- Direct tubular toxicity of light chains
- Tubular obstruction by casts - Interstitial inflammation |
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What causes cast nephropathy in Multiple Myeloma?
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D/t excessive production and urinary excretion of light chains (lambda or kappa)
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What factors favor intratubular precipitation and cast formation of light chains in Multiple Myeloma?
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- Hypercalcemia
- Volume depletion - Nephrotoxins |
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What are the presenting features / diagnostic characteristics of Multiple Myeloma?
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- Older (>40)
- Renal insufficiency and proteinuria - Hx of bone pain, fractures - Hypercalcemia - Monoclonal light chains in blood or urine - Renal biopsy helpful for diagnosis |
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What are the morphological features of a renal biopsy for Multiple Myeloma?
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Fractured casts on LM (= precipitated light chain)
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What disease presents with fractured red casts on LM? What do these fractures represent?
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Multiple Myeloma - casts w/ fractures = precipitated light chains
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How do you treat Multiple Myeloma?
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- Acutely: hydration and urinary alkalization (prevent tubular obstruction by casts)
- Chemotherapy or stem cell transplant |
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What are the Renal Vascular Diseases?
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- HTN nephrosclerosis
- Renovascular HTN (renal artery atherosclerosis or fibromuscular dysplasia) - Atheroembolic disease - Thrombotic Microangiopathy |
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What happens to the kidneys in CKD w/ long-standing, poorly controlled HTN?
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HTN Nephrosclerosis
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What are the features of HTN Nephrosclerosis?
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- Patient w/ CKD and long-standing, poorly controlled HTN
- Evidence of other organ damage - Proteinuria |
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What are the morphologic features of HTN Nephrosclerosis?
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- Gross: finely granular subcapsular surface
- LM: subcapsular glomerular sclerosis, tubular atrophy, interstitial fibrosis, arteriolar hyaline |
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What are the morphologic features of Malignant HTN?
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- Mucoid intimal thickening (arteries)
- Glomerular capillary wrinkling - GBM duplication (onion-skinning) |
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What causes renal artery stenosis? What can this lead to?
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** Main Causes: atherosclerosis or fibromuscular dysplasia
- Secondary cause of HTN - Other causes: trauma, dissection, extrinsic compression (eg, tumor) |
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What is the mechanism of causing HTN in renal artery stenosis?
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Renin-Angiotensin-Aldosterone system
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When should you suspect Renal Artery Stenosis?
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- Early or late onset HTN
- Difficult to control HTN - Abdominal or flank bruit - Renal failure after starting ACE-Inhibitor |
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Where does atherosclerosis cause stenosis of renal artery?
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Proximal renal artery
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What are the features of the atherosclerosis in renal artery stenosis?
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- Eccentric plaque w/ intimal fibrosis
- Cell debris - Lipid and foam cells |
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What happens in younger women w/ renal artery stenosis?
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Fibromuscular Dysplasia (FMD)
- Intimal, medial, and adventitial forms |
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What arteries are affected by Fibromuscular Dysplasia (FMD)?
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- Renal artery (60-75%) (bilateral 35%)
- Cervicocranial arteries (25-30%) - Visceral arteries (9%) - Extremity arteries (5%) - Two vascular beds involved in up to 28% |
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What kind of Fibromuscular Dysplasia (FMD) has alternating thinned media and thickened fibromuscular ridges? What is this called?
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- Fibromuscular Dysplasia (FMD) Medial Fibroplasia
- "String of beads" - Beading is larger than caliber of artery |
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What abnormality has the characteristic "string of beads" appearance?
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Fibromuscular Dysplasia (FMD) Medial Fibroplasia
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How do you treat Renal Artery Stenosis?
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- Surgical revascularization
- Angioplasty and stenting - Medical management only |
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What are the thromboemoblic diseases of the kidney?
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- Cortical infarcts
- Renal cholesterol micro-embolism syndrome - Thrombotic microangiopathy |
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What are the features of a cortical renal infarct?
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Renal Artery occlusion:
- Extensive parenchymal infarction Smaller branch: - Wedge-shaped infarct - Pale w/ hyperemic border - Coagulative necrosis - Hemorrhage and acute inflammation at edge Later becomes fibrotic |
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What can happen if you disrupt the atherosclerotic plaques? What can cause this?
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- Can cause acute and subacute renal failure
- Occurs after procedures that disrupt the plaques in the aorta, leading to a shower of cholesterol emboli that lodge in renal microvasculature |
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What What are some other potential manifestations of atheroembolic disease outside of the kidney?
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- Bowel infarction
- Digital infarction - Stroke |
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What do you find in the blood or urine in atheroembolic disease?
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Eosinophils
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What size arteries do cholesterol atheroemboli affect?
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Any size arteries
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What are the features of cholesterol atheroemboli?
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- Cholesterol clefts in artery lumen
- Usually see cellular reaction - May see parenchymal infarct distally - Eosinophilia may be related to activation of C5a which is chemotactic for eosinophils |
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What causes eosinophils to flock in cholesterol atheroemboli?
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Activation of C5a - chemotactic for eosinophils
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What do cholesterol atheroemboli look like on a slide?
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Slivers / clefts where cholesterol crystals used to be (looks like shards of glass)
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What are the outcomes of cholesterol atheroemboli?
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- Stabilized or normal renal function in mild, isolated cases
- Chronic, progressive deterioration in renal function in subacute cases - ESRD in severe cases |
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What may be required to treat cholesterol atheroemboli?
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Permanent dialysis or kidney transplant
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What is characterized by thrombosis in capillaries and arterioles?
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Thrombotic Microangiopathy
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What is caused by Thrombotic Microangiopathy?
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- Microangiopathic hemolytic anemia
- Thrombocytopenia - Renal failure - Hemolytic uremic syndrome - TTP: thrombotic thrombocytopenic purpura |
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What causes Thrombotic Microangiopathy?
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- Endothelial injury and activation (intravascular thrombosis)
- Platelet aggregation (vascular obstruction or vasoconstriction) |
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What can preceed Thrombotic Microangiopathy?
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Often occurs after intestinal infection w/ E. coli O157:H7
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What is the definition of CKD?
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- Progressive, irreversible renal insufficiency
- Develops over months to years - May lead to ESRD (GFR < 10 ml/min) |
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What are the main causes of CKD?
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1. Diabetes
2. HTN 3. Glomerulonephritis 4. Cystic disease |
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How does the size of a kidney in CKD change?
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- Kidney size usually reduced
- Normal or large kidneys may be seen w/ diabetes, amyloidosis, HIV, or CKD |
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What are the consequences of CKD?
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- Anemia (decreased EPO production)
- HTN (increased Na/H2O retention) - Secondary Hyper-PTH (decreased vitamin D3 synthesis) |
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Why do you get anemia in CKD?
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- Decreased EPO production
- Occurs below GFR of 60 ml/min |
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Why do you get HTN in CKD?
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Increased Na/H2O retention
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Why do you get Secondary Hyper-PTH in CKD?
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- Decreased renal synthesis of 1,25-dihdyroxy-D3
- Decreased phosphate excretion - Contributes to hypocalcemia, hyperphosphatemia, and renal osteodystrophy |
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What acid-base disturbance do you get in CKD?
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Metabolic Acidosis (d/t decrease secretion of ammonium and retention of phosphates and sulfates)
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What extra-renal findings do you get in CKD?
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- Metabolic Acidosis
- Hyperkalemia - Inability to maintain Na/H2O balance - Coagulopathy (platelet dysfunction) - Sensorimotor neuropathy |
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What are the physical symptoms of chronic uremia?
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- Lethargy, fatigue
- Day-night sleep reversal - Anorexia, nausea, and vomiting - Pruritus - Restless leg syndrome - Uremic pericarditis |
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What are the management goals in CKD?
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- Preserve renal function
- Delay progression to ESRD - Prevent / minimize side effects - Institute renal replacement therapy when necessary - Dietary restrictions (Na, K, PO4, protein?) - Control hyperlipidemia - Correct anemia - Correct acidosis - Dialysis or kidney transplant (GFR <10 ml/min) |
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How can you slow progression of CKD to ESRD?
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- Control HTN (ACE-I or ARB)
- Reduce proteinuria - Control blood sugar - Smoking cessation - Disease specific therapy as indicated |
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How do you treat ESRD?
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- Dialysis
- Kidney transplant |
