Altered Renal Function. Overview of Kidney Diseases. Classified by site or cause of disease Organization by site: Prerenal Intrarenal (Renal) Postrenal. Prerenal disease. Results from inadequate blood flow to the kidney Decreased intravascular volume Lesions in the renal arteries
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There was a large renal calculus (stone) that obstructed the calyces of the lower pole of this kidney, leading to a focal hydronephrosis (dilation of the collecting system). The stasis from the obstruction and dilation led to infection. The infection with inflammation is characterized by the pale yellowish-tan areas next to the dilated calyces with hyperemic mucosal surfaces. The upper pole is normal and shows good corticomedullary demarcations.
Here is a kidney with much more advanced hydronephrosis in which there is only a thin rim of remaining renal cortex. Such a kidney is non-functional and a source for ongoing infection. If this process is unilateral, then the problem originates from the ureteral orifice up to the pelvis. In this case, a large "staghorn" calculus (so named because the prominent projections of the stone into the calyces resemble deer antlers) was present that filled up the pelvis and calyceal system. If this process were bilateral, then the problem would originate in the bladder trigone or urethra (or the prostate around the urethra) or some process (such as a large neoplasm) that could impinge on both ureters
Complete obstruction →damage to tubules within hours, and irreversible damage within 4 weeks.
Calcium oxalate (or phosphate) 75%
Magnesium ammonium phosphate 12%
(struvite, or "triple phosphate")
Uric acid (Gout) 6%
gram negative bacteria of the intestinal tract
Escherichia coli – 80% of all uncomplicated infections. Can form pili allowing bacterium to adhere to bladder epithelium
Cranberry juice decreases bacterial adhesions by epicatechin
Staphylococcus saprophyticus 10-20%
Other entreobacter species (Klebsiella, Proteus) remaining 5%
At high magnification, many neutrophils are seen in the tubules and interstitium in a case of acute pyelonephritis.
This is an ascending bacterial infection leading to acute pyelonephritis. Numerous PMN's are seen filling renal tubules across the center and right of this picture.
Both lymphocytes and plasma cells are seen at high magnification in this case of chronic pyelonephritis. It is not uncommon to see lymphocytes accompany just about any chronic renal disease: glomerulonephritis, nephrosclerosis, pyelonephritis. However, the plasma cells are most characteristic for chronic pyelonephritis.
The large collection of chronic inflammatory cells here is in a patient with a history of multiple recurrent urinary tract infections. This is chronic pyelonephritis.
Post-streptococcal glomerulonephritis is immunologically mediated, and the immune deposits are distributed in the capillary loops in a granular, bumpy pattern because of the focal nature of the deposition process.
This glomerulus is hypercellular and capillary loops are poorly defined. This is a type of proliferative glomerulonephritis known as post-streptococcal glomerulonephritis.
Here is another glomerulus with epithelial crescents squashing the glomerular tufts from all sides. RPGN may be idiopathic or may result from SLE, post-infectious GN (as in some cases of post-streptococcal GN), from various types of vasculitis, and from Goodpasture's syndrome.
Seen here within the glomeruli are crescents composed of proliferating epithelial cells. Crescentic glomerulonephritis is known as rapidly progressive glomerulonephritis (RPGN) because this disease is very progressive. There are several causes, and in this case is due to SLE. Note in the lower left glomerulus that the capillary loops are markedly thickened (the so-called "wire loop" lesion of lupus nephritis).
This immunofluorescence micrograph of a glomerulus demonstrates positivity with antibody to fibrinogen. With a rapidly progressive GN, the glomerular damage is so severe that fibrinogen leaks into Bowman's space, leading to proliferation of the epithelial cells and formation of a crescent.
This immunofluorescence micrograph shows positivity with antibody to IgG has a smooth, diffuse, linear pattern that is characteristic for glomerular basement membrane antibody with Goodpasture's syndrome.
Here is the light microscopic appearance of membranous glomerulonephritis in which the capillary loops are thickened and prominent, but the cellularity is not increased. Membranous GN is the most common cause for nephrotic syndrome in adults. Some cases of membranous GN can be linked to a chronic infectious disease such as hepatitis B, a carcinoma, or SLE, but many cases are idiopathic.
The tubular vacuolization and dilation here is a result of ethylene glycol poisoning. This is representative of acute tubular necrosis (ATN), which has many causes. ATN resulting from toxins usually has diffuse tubular involvement, whereas ATN resulting from ischemia (as in profound hypotension from cardiac failure) has patchy tubular involvement.
↓urine vol.about 25 % of normal to anuria
can last 1-3 weeks↑BUN, plasma creatinine
↑ K+ (hyperkalemia) and electrolyte imbalance
fluid retention and edema
congestive heart failure
3-4 L/day of urine
Tubules still damaged, but recovering
Can lose too much Na+ and K+May see extracellular volume depletion
Stage 3 Recovery
May take 3-12 months for plasma creatinine to return to normal
About 30 % never regain normal kidney function.
The microscopic appearance of the "end stage kidney" is similar regardless of cause, which is why a biopsy in a patient with chronic renal failure yields little useful information. The cortex is fibrotic, the glomeruli are sclerotic, there are scattered chronic inflammatory cell infiltrates, and the arteries are thickened. Tubules are often dilated and filled with pink casts and give an appearance of "thyroidization."
There is a relatively normal kidney at the left with only a few scattered, shallow cortical scars and one fairly large pale tan-yellow scar in the upper pole. The left kidney is atrophic because of renal arterial occlusion. Such a situation can lead to hypertension (Goldblatt kidney).