KIDNEY DISEASE
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
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What is Cancer?
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Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

Kidney and Lower Urinary
Photo Library of Pathology
U. of Tokushima

Kidney
Taiwanese pathology site
Good place to go to practice

UNC Nephropathology
Great site -- start here
if you're truly hard-core

Atlas of Renal Pathology
Vanderbilt / National Kidney Foundation
Agnes Fogo MD -- thank you!

Kidney Images
University of Washington
Pictures and comments

Urinary Tract
Iowa Virtual Microscopy
Have fun

Nephrology
Utah cases for path students
Juliana Szakacs MD

Urinary System
First Section
Chaing Mi, Thailand

Pathology of GU infections
Great site
Yutaka Tsutsumi MD

Urinary System
Second Section
Chaing Mi, Thailand

Urinary System
Third Section
Chaing Mi, Thailand

Urinary System
Fourth Section
Chaing Mi, Thailand

Urinary System
Fifth Section
Chaing Mi, Thailand

Kidney Exhibit
Virtual Pathology Museum
University of Connecticut

Kidney Transplant Pictures
Great site
Transplant Pathology Internet Services

Kidney Transplant
From Chile
In Spanish

The Kidney in Systemic Disease I
From Chile
In Spanish

The Kidney in Systemic Disease II
From Chile
In Spanish

Primary Nephropathies I
From Chile
In Spanish

Primary Nephropathies II
From Chile
In Spanish

Primary Nephropathies III
From Chile
In Spanish

Primary Nephropathies IV
From Chile
In Spanish

Renal
Photos, explanations, and quiz
Indiana U.

Kidney & Urinary Tract
Brown Digital Pathology
Some nice cases

Kidney and Male Pathology
Photomicrograph collection
In Portuguese

Atlas of Diseases of the Kidney
Robert W. Schrier
Classic photo series
Highly recommended

Kidney Histology
Ed's Histology Notes

Kidney
"Pathology Outlines"
Nat Pernick MD

Learning Objectives

Describe what the kidneys do in health. Describe the different parts of the nephron, what each does, and what things are likely to happen when each malfunctions.

Recognize the causes of acute renal shutdown and of irreversible renal failure. Describe the many clinical and anatomic consequences of uremia.

Recall the clinical, gross, and microscopic pictures, when applicable, for each of the following:

Describe what is happening in each of the following syndromes. Tell what you might see clinically, grossly (when applicable) and microscopically (when applicable), and mention its common causes.

Explain how casts form. Mention the various casts that may appear in the urine in health and disease, and what they mean.

NOTE: For changes in blood chemistry (blood urea nitrogen, creatinine, creatinine clearance, etc.), see my unit on renal function testing I also have a unit on urinalysis.

KCUMB Students
"Big Robbins" -- Kidney
Lectures follow Textbook

QUIZBANK... Metabolic #'s 82-92; Kidney (all)

What's the difference between beer and urine?
About twenty minutes!

What's the difference between a nephrologist and a neurologist?
The 'p'!

VOCABULARY

One thing that makes kidney pathology so hard is that many of the words sound alike. Here are the most troublesome words:

Collagenized glomeruli: These glomeruli have been obliterated by dense type I collagen. Most often, the collagen has been laid down concentrically on the inner surface of Bowman's capsule, as in longstanding arterial/arteriolar disease. Collagenized glomeruli are more often called hyalinized or obsolescent, despite the fact that these terms are less specific.

Diffuse: As applied to glomerular disease, all the glomeruli are involved.

Endothelialitis: Lymphocytes under the endothelium in the arterioles and venules; one hallmark of T-cell-mediated transplant rejection, but not diagnostic

Fibrosis: Dense, type I collagen deposited in the glomeruli and/or interstitium and/or vessels.

Focal: As applied to glomerular disease, some glomeruli are involved and some are not.

Global: As applied to glomerular disease, if a glomerulus is involved, all portions of it are involved.

Glomerulonephritis: As usually used, this implies that the glomeruli are sufficiently inflamed to cause at least a few of them to lose blood into the tubules.

Glomerulopathy: Any primary problem with the glomeruli.

Glomerulosclerosis, diffuse: Thickening of the basement membrane as a result of diabetes mellitus.

Glomerulosclerosis, focal/segmental: A pattern of injury with foot process fusion and hyalinization of some lobules in some glomeruli. It has nothing to do with diabetes mellitus.

Glomerulosclerosis, nodular: Diabetes mellitus with Kimmelstiel-Wilson disease. Always superimposed on diffuse glomerulosclerosis.

* Hyalinosis: A distinctive, homogeneous pink blob seen in certain sick glomeruli, notably those damaged by FSGS, diabetes, or other causes of hyperfiltration.

Hyalinized glomeruli: A term that can mean collagenized or sclerotic glomeruli.

Hypernephroma: Obsolete term for renal cell carcinoma.

Nephritis: Used by itself, this means "glomerulonephritis".

Nephritis, interstitial: Inflammation of the kidney that spares the glomeruli. Includes cases formerly diagnosed as "chronic pyelonephritis". Causes U-shaped cortical scars.

Nephroblastoma: The common childhood cancer of the kidney -- Wilms tumor.

Nephrocalcinosis: Calcification of the basement membranes of the tubules in the medullae. It has nothing to do with calcium stones. A little calcification here is common, especially in older people. Extensive calcification suggests hypercalcemia and/or hyperphosphatemia ("metastatic calcification").

Nephrolithiasis: Stones (calculi) in the pelvis of a kidney

Nephropathy: Anything wrong with the kidney -- glomeruli, tubules, or vessels.

Nephrotic syndrome: The sequelae of heavy protein leakage at the glomerular capillaries.

Nephrosclerosis: Disease of the renal arteries and/or arterioles.

Nephrosclerosis, arterial: Multiple small infarcts destroying scattered groups of glomeruli. Causes V-shaped cortical scars. Usually caused by atheroembolization.

Nephrosclerosis, arteriolar: Vascular disease that destroys scattered individual nephrons. Causes pitted or sandpaper-surface kidney. "Benign nephrosclerosis". Caused by high blood pressure and/or diabetes.

Nephrosclerosis, benign: Arteriolar nephrosclerosis due to "benign essential hypertension".

Obsolescent glomeruli: Another term that can mean collagenized or sclerotic glomeruli.

Pyelonephritis: Inflammation of the interstitium of the kidney. Current usage mostly limits this to bacterial infection.

(Glomerulo)Sclerosis: As applied to kidney, this means increased basement membrane/mesangial matrix material obliterating loops of a glomerulus.

Sclerotic glomeruli: These glomeruli are fully replaced by basement membrane/mesangial matrix material, as in advanced diffuse, nodular, or focal-segmental glomerulosclerosis. They are also called hyalinized or obsolescent.

Segmental: As applied to glomerular disease, some portions of some glomeruli are involved and some other portions of the same glomeruli are spared.

IMMUNE DEPOSITS

Here is a list of the more important entities that are likely to be caused by a particular pattern:

Subepithelial, large, irregularly-spaced ("coarse granules"; "humps")

    Diffuse proliferative GN (especially post-streptococcal)
    Membranoproliferative GN type I
    Lupus, class IV

Subepithelial, uniform, evenly-spaced ("fine granules evenly spaced")

    Membranous glomerulopathy (any cause) Lupus, class V

Anti-GBM diseases ("smooth linear" -- don't expect to see these on EM)

    Goodpasture's, others

Subendothelial (various descriptions, you will only need to recognize on EM)

    Membranoproliferative GN type I
    Lupus, especially class IV ("wire loops")
    Cryoglobulinemia
    Hemolytic-uremic syndrome ("fluff")

    Also look here for amyloid deposits.

Intramembranous (various descriptions, depends on the disease)

    Dense deposit disease (membranoproliferative GN type II)
    Late membranous glomerulopathy
    Late stages of any other progressive immune complex disease

Mesangial ("mesangial pattern")

    IgA nephropathy
    IgM mesangial-proliferative glomerulopathy
    Membranoproliferative GN type I
    Lupus, any class
    Also look here for amyloid deposits.

{11850} kidney, model
{11851} kidney, model, close-up

INTRODUCTION TO KIDNEY DISEASE

To review:

Kidney disease is prevalent and usually serious.

Hantavirus in the kidney
Korean hemorrhagic fever
Yutaka Tsutsumi MD

Adenovirus of the kidney
Advanced students
Yutaka Tsutsumi MD

Acute transplant rejection
Vessel changes
KU Collection

Kidney transplant

WebPath Photo

REVIEW OF NORMAL ANATOMY AND PHYSIOLOGY

Normal kidney
Uncut
WebPath Photo

Normal kidney
Cut section
WebPath Photo

Baby kidneys

WebPath Photo

Baby kidneys

WebPath Photo

Glomeruli forming
in newborn
ERF/KCUMB

{46463} scanning electron micrograph of podocytes

{17244} red cell cast

SYNDROMES OF KIDNEY DISEASE: Am. J. Kid. Dis. 10: 181, 1987 (still good)

{16764} nephrotic syndrome
{16857} kidney, yellow cortex of nephrotic syndrome
{16800} lipid in tubule, nephrotic syndrome, oil red O (lipid is red)

UREMIA: The clinical signs and symptoms of renal failure; especially, the clinical problems associated with chronic renal failure. Today, the definition excludes electrolyte, calcium, blood pressure, and vitamin D problems. Update NEJM 357: 1316, 2007.

{24577} uremic frost

{05904} peritoneal dialysis guy
{05905} peritoneal dialysis, how-to
{05913} hemodialysis, fistula
{05914} hemodialysis machine

KIDNEY BIOPSY (standards J. Clin. Path. 49: 233, 1996; J. Clin. Path. 53: 433, 2000)

Remember: Hyaline casts in the urine are normal. Other casts in the urine indicate disease in the nephron.

INTRODUCTION TO GLOMERULAR DISEASE (update for clinicians Arch. Int. Med. 161: 25, 2001; pathologists Med. Clin. N.A. 81: 653, 1997)

HISTOLOGIC ALTERATIONS IN GLOMERULAR DISEASE

Great fibrin cap (hyalinosis in diabetes)
Slide from Andrea McCollum MD
Cuyahoga County Coroner's Office

Normal glomerulus

WebPath Photo

Normal glomerulus
PAS stain
WebPath Photo

Normal glomerulus
EM -- Sketch
WebPath Photo

Normal glomerulus
EM
WebPath Photo

MECHANISMS OF GLOMERULAR INJURY

DIFFUSE PROLIFERATIVE GLOMERULONEPHRITIS

{13388} diffuse proliferative glomerulonephritis, fatal case, flea-bitten cortex
{16814} diffuse proliferative glomerulonephritis, H&E
{08261} diffuse proliferative glomerulonephritis
{08264} diffuse proliferative glomerulonephritis, low power
{09709} diffuse proliferative glomerulonephritis (this was a mild case of post-streptococcal disease)
{17020} diffuse proliferate glomerulonephritis (this was a case of post-streptococcal disease)
{24845} diffuse proliferative glomerulonephritis (this was a case of post-streptococcal disease)
{24846} diffuse proliferative glomerulonephritis (this was a case of post-streptococcal disease)
{24847} diffuse proliferative glomerulonephritis, immunofluorescence (this was a case of post-streptococcal disease)
{17024} diffuse proliferative glomerulonephritis, immunofluorescence
{09718} diffuse proliferative glomerulonephritis, coarsely-granular immunofluorescence (this was a case of post-streptococcal disease)
{09721} diffuse proliferative glomerulonephritis, electron micrograph (this was a case of post-streptococcal disease)
{16769} diffuse proliferative glomerulonephritis, red cell cast
{08267} diffuse proliferative glomerulonephritis, coarsely-granular immunofluorescence pattern
{08270} diffuse proliferative glomerulonephritis, electron- micrograph showing large subepithelial deposits
{16817} diffuse proliferative glomerulonephritis, EM

Flea-bitten kidney
This was bad lupus
Wikimedia Commons

Post-streptococcal glomerulonephritis
Great labels
Romanian Pathology Atlas

Post-strep GN

WebPath Photo

Post-strep GN

WebPath Photo

Post-strep GN
Fluorescence
WebPath Photo

Post-strep GN
EM
WebPath Photo

RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS (RPGN, "crescentic glomerulonephritis"):

{08907} rapidly progressive glomerulonephritis, H&E
{16837} rapidly progressive glomerulonephritis, trichrome
{16838} rapidly progressive glomerulonephritis, IF for fibrin
{16839} rapidly progressive glomerulonephritis, PAS stain
{34228} rapidly-progressive glomerulonephritis with crescent

Crescentic glomerulonephritis
Great labels
Romanian Pathology Atlas

RPGN
Crescent
WebPath Photo

RPGN
Fibrin stain
WebPath Photo

{16842} Goodpasture's, IF
{16843} Goodpasture's, IF
{16847} Goodpasture's, IF
{16851} Goodpasture's, silver stain
{17073} Goodpasture's, IF
{17074} Goodpasture's, IF for fibrin
{34234} Goodpasture's, IF

Goodpasture's disease
Linear fluorescence
WebPath photo

Goodpasture's
Fluorescence
WebPath Photo

{16832} segmental necrotizing RPGN, probably Wegener's
{16917} polyarteritis ("nodosa"???) in kidney, H&E
{16918} polyarteritis ("nodosa"???) , elastic stain
{16920} polyarteritis nodosa, angiogram
{16922} old polyarteritis ("nodosa"???), elastic stain

Vasculitis
Kidney biopsy
WebPath Photo

Vasculitis
This was Wegener's
WebPath Photo

Wegener's granulomatosis
Nice photo of renal lesion
Dr. Warnock's Collection

Vasculitis
This was polyarteritis ("nodosa"?)
WebPath Photo

MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS ("mesangioproliferative GN", etc.)

Mesangial proliferative lupus
WHO II
KU Collection

MEMBRANOUS GLOMERULOPATHY ("MGN", "membranous glomerulonephritis"; now it's"nephrotic idiopathic membranous nephropathy")

{16811} membranous glomerulopathy
{24849} membranous glomerulopathy, silver stain showing spikes
{00077} membranous glomerulopathy, H&E
{10565} membranous glomerulopathy
{16809} membranous glomerulopathy
{16807} membranous glomerulopathy, electron micrograph
{16808} membranous glomerulopathy, electron micrograph
{34237} membranous glomerulopathy, finely-granular immunofluorescence
{17015} membranous glomerulopathy, early
{17016} membranous glomerulopathy, early
{17017} membranous glomerulopathy, early, immunofluorescence
{17018} membranous glomerulopathy, early, electron micrograph

Membranous glomerulopathy
Electron micrograph
KU Collection

Membranous GN

WebPath Photo

Membranous GN
Silver stain -- Spikes
WebPath Photo

Membranous GN
Immunofluorescence
WebPath Photo

Membranous GN
EM
WebPath Photo

MINIMAL CHANGE GLOMERULOPATHY ("minimal change disease", "foot process disease", "lipoid nephrosis", "nil lesion", "nil disease")

{10566} foot process fusion, electron micrograph
{17032} foot process fusion, electron micrograph
{34294} foot process fusion, electron micrograph

Minimal change disease
Looks normal
KU Collection

FOCAL-SEGMENTAL GLOMERULOSCLEROSIS ("focal sclerosing nephropathy," "focal sclerosis")

{16802} focal-segmental glomerulosclerosis
{17035} focal-segmental glomerulosclerosis
{17036} focal-segmental glomerulosclerosis
{21028} focal-segmental glomerulosclerosis, with nice * hyalinosis lesion

"Chronic glomerulonephritis"
I favor FSGS superimposed on
chronic pyelo. Romanian Pathology Atlas

Focal-segmental glomerulosclerosis

KU Collection

FSGS

WebPath Photo

FSGS
Trichrome stain
WebPath Photo

MEMBRANOPROLIFERATIVE "GLOMERULONEPHRITIS" (MPGN "type I", "mesangiocapillary glomerulonephritis type I", "cloverleaf disease", "membranoproliferative GN with immunoglobulin", etc.) Update MPGN I & MPGN II -- NEJM 366: 1119, 2012.

{08900} membranoproliferative glomerulonephritis, type I
{34264} membranoproliferative glomerulonephritis, type I
{17059} membranoproliferative glomerulonephritis, type I
{17060} membranoproliferative glomerulonephritis, type I
{16830} membranoproliferative glomerulonephritis, type I
{08902} membranoproliferative glomerulonephritis, type I
{16760} membranoproliferative glomerulonephritis, type I
{16761} membranoproliferative glomerulonephritis, type I

Membranoproliferative GN

WebPath Photo

Membranoproliferative GN
EM
WebPath Photo

{33331} good tram tracks

Membranoproliferative glomerulonephritis type I
Tramtrack disease
New England Journal of Medicine

BASEMENT MEMBRANE DENSE DEPOSIT DISEASE ("membranoproliferative glomerulonephritis type II", "membranoproliferative GN without immunoglobulin", etc.)

{10568} dense deposit disease, immunofluorescence for C3
{16831} dense deposit disease

Dense deposit disease
Pittsburgh Pathology Cases

Dense Deposit Disease
Pittsburgh Illustrated Case

Dense Deposit Disease
EM
WebPath Photo

IgA NEPHROPATHY (see Medicine 73: 79, 1994).

{16751} IgA nephropathy, mesangial proliferation
{34297} IgA nephropathy, segmental proliferation
{16746} IgA nephropathy, mesangial immunofluorescence for IgA

Berger's
You'd need fluorescence to be sure
WebPath Photo

Berger's
Fluorescence -- tree in winter / golf course?
WebPath Photo

Henoch-Schonlein
IgA stained brown
Wikimedia Commons

Henoch-Schonlein purpura
Pittsburgh Pathology Cases

"CHRONIC GLOMERULONEPHRITIS"

{13374} "chronic glomerulonephritis"

End-stage kidneys

WebPath Photo

End-stage kidney

WebPath Photo

SYSTEMIC LUPUS ERYTHEMATOSUS

{33195} wire loop
{16822} wire loop
{16824} wire loop, immunofluorescence
{16825} wire loop, fingerprints on EM

Lupus glomerulonephritis
Severe disease
KU Collection

Lupus RPGN
Wire loops
WebPath Photo

Membranous lupus
Bryan Lee

GLOMERULONEPHRITIS OF BACTERIAL ENDOCARDITIS

DIABETIC GLOMERULOSCLEROSIS (huge review for pathologists: J. Clin. Path. 60: 18, 2007) Still probably the most common cause of end-stage renal disease.

{08892} KW disease
{17159} diabetes with hyalinized arteriole
{16789} diabetic glomerulosclerosis, electron micrograph (thick GBM)
{16790} diabetic glomerulosclerosis, electron micrograph (thick GBM)
{16791} diabetic glomerulosclerosis, H&E
{16792} diabetic glomerulosclerosis, H&E
{16793} diabetic glomerulosclerosis, H&E
{08893} Kimmelstiel-Wilson diabetic nodular glomerulosclerosis
{08895} Kimmelstiel-Wilson diabetic nodular glomerulosclerosis, PAS
{09877} Kimmelstiel-Wilson diabetic nodular glomerulosclerosis
{17158} Kimmelstiel-Wilson diabetic nodular glomerulosclerosis
{17171} end-stage diabetic glomerulosclerosis

Diabetes in the Kidney
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Diabetic diffuse glomerulosclerosis
Great labels
Romanian Pathology Atlas

Nodular glomerulosclerosis
PAS stain
KU Collection

Nodular glomerulosclerosis

KU Collection

Diabetes
Kimmelstiel-Wilson
WebPath Photo

Diabetes
Kimmelstiel-Wilson, hyaline arteriolar sclerosis
WebPath Photo

RENAL AMYLOIDOSIS (grading / scoring system Arch. Path. Lab. Med. 134: 532, 2010)

Renal amyloidosis
Great labels
Romanian Pathology Atlas

Amyloidosis of the kidney
Pittsburgh Pathology Cases

Fibrillary glomerulopathy
Pittsburgh Pathology Cases

Immunotactoid glomerulonephritis
Pittsburgh Pathology Cases

Fibrillary Glomerulopathy
Pittsburgh Illustrated Case

Amyloidosis
Pittsburgh Illustrated Case

Amyloidosis

WebPath Photo

Amyloidosis

WebPath Photo

{10883} congo red stain of amyloid, polarized
{39804} amyloid in the glomeruli

THIN GBM DISEASE ("benign familial hematuria", "familial benign hematuria", "idiopathic essential hematuria, etc.")

CRYOGLOBULINEMIA... Worth knowing.

HEREDITARY GLOMERULONEPHRITIS (serious hereditary hematuria is generically called "Guthrie's disease")

{24844} * Alport's syndrome, nice foam cells on the left

Alport's
Trichrome
WebPath Photo

Remember:

KIDNEY MALFORMATIONS

{16972} horseshoe kidney

Kidney Malformations
From Chile
In Spanish

Horseshoe kidney

WebPath Photo

Double ureters
Common, and seldom a problem
WebPath Photo

Renal tubular dysgenesis
Potter's baby
Pittsburgh Pathology Cases

{10563} renal multicystic dysplasia (this is NOT polycystic kidney)
{10241} renal multicystic dysplasia
{39684} renal multicystic dysplasia; find the cartilage
{08453} renal multicystic dysplasia
{21006} renal multicystic dysplasia (this is NOT polycystic kidney or tumor)

Multicystic dysplastic kidney

WebPath Photo

Multicystic dysplastic kidney

WebPath Photo

Multicystic dysplastic kidney

WebPath Photo

{00056} adult, autosomal-dominant polycystic kidney (26 lb!)
{00059} adult, autosomal-dominant polycystic kidney (same case as 56)
{10553} adult, autosomal-dominant polycystic kidney
{05965} adult, autosomal-dominant polycystic kidney, histology

Adult polycystic kidneys

WebPath Photo

Adult polycystic kidneys
With transplant
WebPath Photo

Polycystic kidneys
Nice case
Pittsburgh Pathology Cases

Adult polycystic kidney

WebPath Photo

Polycystic Kidneys
Australian Pathology Museum
Hey, how about a ruler?

Adult Polycystic Kidney Disease
CDC
Wikimedia Commons

{16978} infantile, autosomal-recessive polycystic kidney disease
{17223} infantile, autosomal-recessive polycystic kidney disease
{15817} infantile, autosomal-recessive polycystic kidney disease (huge kidneys)
{15818} infantile, autosomal-recessive polycystic kidney disease
{17224} infantile, autosomal-recessive polycystic kidney disease, histology

Infantile polycystic kidneys

WebPath Photo

Infantile polycystic kidneys

WebPath Photo

Infantile polycystic kidney

WebPath Photo

Hepatic fibrosis
Seen with infantile polycystic kidney
WebPath Photo

Autosomal recessive PCKD
WebPath Photo

{25322} medullary sponge kidney, sketch

{16985} medullary cystic disease, the bad kind, gross; it has been in formalin for a long time and lost its color
{25323} medullary cystic disease, the bad kind, sketch
{25324} medullary cystic disease, the bad kind, gross

Uremic medullary cystic disease
Idiopathic case, missed in life
KCUMB Team

* Glomerulocystic disease, with dilated Bowman capsules, is secondary to some other illness, famously tuberous sclerosis; you will not be asked to recognize it.

* OTHER CYSTIC DISEASES

"ACQUIRED DIALYSIS CYSTIC DISEASE" ("trans-stygian kidney")

{38869} acquired dialysis cystic disease" (trans-stygian kidney)

Trans-stygian kidneys

WebPath Photo

Oxalate in trans-stygian kidney
Patient had uremic medullary cysts
KCUMB Team

Oxalate in trans-stygian kidney
Polarized light
KCUMB Team

SIMPLE CYSTS

Pathology of Kidney Cysts
WebPath Tutorial

Simple kidney cyst

WebPath Photo

Simple renal cysts

WebPath Photo

DISORDERS OF THE PROXIMAL TUBULE ("Fanconi" and so forth)

* GENETIC DISEASE OF THE TUBULES: Nat. Genet. 13: 183, 1996; Am. J. Med. Sci. 322: 316, 2001

ACUTE TUBULAR NECROSIS ("ATN", the usual cause of what clinicians call "acute renal failure", "renal shutdown", nowadays "acute renal injury", "acute kidney injury", etc.) NEJM 334: 1448, 1996; updates Chest 128: 2847, 2005; JAMA 294: 813, 2005, J. Clin. Inv. 121: 4210, 2011.

{07026} mercury coagulation necrosis of the proximal tubule (the dead cells have undergone dystrophic calcification)
{32072} mercury necrosis of the proximal tubule
{17106} acute tubular necrosis, mitotic figure
{10262} acute tubular necrosis

Toxic damage to proximal tubules
Great labels
Romanian Pathology Atlas

Mercury poisoning
Striking coagulation necrosis
of proximal tubules
KU Collection

Acute tubular necrosis
Pale cortex, dusky medulla
KU Collection

Acute tubular necrosis

WebPath Photo

Acute tubular necrosis
Pale cortex, dark medulla
Wikimedia Commons

{07201} he died of ethylene glycol drinking

Ethylene glycol poisoning
Kidney crystals
KU Collection

HEPATORENAL SYNDROME (Med. Clin. N.A. 93: 855, 2009; Dig. Dis. Sci. 57: 210, 2012 reaffirms its untreatability in the absence of liver transplantation as does Gut 62: 131, 2013).

Future pathologists: At autopsy, if a patient has received an osmotic diuretic, the proximal tubular cells are likely to contain little vacuoles. Abundant glycogen ("Armanni-Ebstein") means hyperglycemia before death. In hypokalemia, there may be big water-filled vacuoles.

PYELONEPHRITIS AND OTHER UPPER URINARY TRACT INFECTIONS

{39794} acute pyelonephritis, dilated and inflamed pelvis
{17177} acute pyelonephritis, histology; note the neutrophils, sparing the glomeruli
{10564} acute pyelonephritis, gross; little abscesses
{16868} acute pyelonephritis, gross
{08876} acute pyelonephritis, histology
{08877} acute pyelonephritis, histology
{16866} acute pyelonephritis, histology
{17574} acute pyelonephritis, gross
{17575} acute pyelonephritis and hydronephrosis
{25332} acute pyelonephritis with hydronephrosis
{25335} acute pyelonephritis, histology; tubule full of polys
{00071} renal abscess and kidney stones

Acute pyelonephritis
Great labels
Romanian Pathology Atlas

Acute pyelonephritis
Great labels
Romanian Pathology Atlas

Hematogenous pyelonephritis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Acute pyelonephritis
Low magnification
KU Collection

Kidney abscess

WebPath Photo

Acute pyelonephritis

WebPath Photo

Acute pyelonephritis

WebPath Photo

Acute pyelonephritis

WebPath Photo

Acute pyelonephritis
Neutrophils in tubules
KU Collection

E. coli infection of the kidney
with gas ("emphysematous pyelonephritis")
Yutaka Tsutsumi MD

{16950} papillary necrosis in phenacetin abuse; necrotic patches are greenish
{16894} papillary necrosis, same picture backwards! You need a laugh right about now.
{21015} papillary necrosis in pyelonephritis

{16883} "chronic pyelonephritis", gross
{08868} "chronic pyelonephritis", trichrome, blue is scar
{08881} "chronic pyelonephritis", lymphocytes
{08883} "chronic pyelonephritis", lymphocytes
{08884} chronic pyelonephritis", lymphocytes. I bet this is really chronic autoimmune interstitial nephritis because of all the lymphocytes.
{17185} "chronic pyelonephritis", thyroidization
{16871} "chronic pyelonephritis", old scars, gross
{08731} chronic pyelonephritis, old scarring
{16872} "chronic pyelonephritis", old scars
{21011} "chronic pyelonephritis", gross
{28934} "chronic pyelonephritis", gross
{28937} "chronic pyelonephritis", good example, glomeruli spared, tubules shot
{28940} "chronic pyelonephritis", severe tubular atrophy
{28946} "chronic pyelonephritis", periglomerular fibrosis

Chronic pyelonephritis
Typical gross appearance
KU Collection

Acute pyelonephritis

WebPath Photo

Chronic pyelonephritis

WebPath Photo

{24044} xanthogranulomatous pyelonephritis, gross, trust me
{11541} xanthogranulomatous pyelonephritis, good foam cells
{24045} xanthogranulomatous pyelonephritis, good inflammation and foam cells

{16892} anti-tubular basement membrane auto-antibody fluorescence

Polyoma viruses
Nice site
Pittsburgh

BK virus in the bladder

Yutaka Tsutsumi MD

TB of the kidney
From Chile
In Spanish

CHRONIC INTERSTITIAL NEPHRITIS (CIN) is scarring of the kidney from some process that is primarily interstitial (i.e., not some glomerular or vascular disease).

{25331} interstitial nephritis

Interstitial Nephritis
From Chile
In Spanish

Interstitial Nephritis
From Chile
In Spanish

Lymphocytic interstitial nephritis
Pittsburgh Pathology Cases

BK interstitial nephritis
Decoy cells
Pittsburgh

Tubular Nephropathies
From Chile
In Spanish

TUBULOINTERSTITIAL NEPHRITIS CAUSED BY DRUGS AND POISONS: "All drugs are poisons, and all poisons are (potential) drugs." There are several important patterns. All about drug-induced renal toxicity: Med. Clin. N.A. 74: 909, 1990.

Cyclosporine nephrotoxicity
Acute, proximal tubules have hydropic change
Nature Clin Pract Nephro, above

Cyclosporine nephrotoxicity
Acute, has turned to thrombotic microangiopathy / HUS
Nature Clin Pract Nephro, above

Cyclosporine nephrotoxicity
Chronic, string-of-beads hyaline
Nature Clin Pract Nephro, above

Cyclosporine nephrotoxicity
Chronic, electron micrograph showing string of beads
Nature Clin Pract Nephro, above

Hantavirus in the kidney
Korean hemorrhagic fever
Yutaka Tsutsumi MD

HYPERCALCEMIC NEPHROPATHY (Am. J. Kid. Dis. 19: 604, 1992)

HYPOKALEMIC NEPHROPATHY

PLASMA CELL MYELOMA KIDNEY (Arch. Path. Lab. Med. 128: 875, 2004; Blood 116: 1397, 2010)

{17274} plasma cell myeloma, cast; PAS stain shows magenta tubules

OXALATE NEPHROPATHY

RADIATION NEPHRITIS

* BALKAN NEPHROPATHY (update Am. J. Neph. 26: 1, 2006; Kid. Int. 69: 644, 2006)

* RENAL HYPERTROPHY

NEPHROGENIC DIABETES INSIPIDUS

GOUT: An Important Kidney Disease. Update Lancet 375: 318, 2010; JAMA 308: 2133, 2013.

{25521} gout, tophi
{25522} gout, tophi
{24641} gout, bone
{11559} gout, histology of tophi; uric acid crystals are pale and surrounded by granuloma
{24642} gout, uric acid crystals under polarized light
{24643} gout, uric acid crystals unpolarized; they are brown

Uric acid deposit
Kidney
KCUMB Team

Uric acid deposit
Kidney -- polarized
KCUMB Team

Gout
Photomicrograph of tophus
KU Collection

Gouty Arthritis
Australian Pathology Museum
High-tech gross photos

Tophus in kidney
Surprise at autopsy
KCUMB Team

Gout
Uric acid crystals
WebPath Tutorial

Gout

WebPath Tutorial

Gout
X-ray

WebPath Tutorial

Gout
Tophus
WebPath Tutorial

Renovascular I
From Chile
In Spanish

Renovascular II
From Chile
In Spanish

HIGH BLOOD PRESSURE ("hypertension")

BENIGN ESSENTIAL HYPERTENSION (common "high blood pressure", "the silent killer", etc.);

The molecular biology is only starting to be understood. Whatever is really happening, the kidneys of most hypertensives seem to have difficulty disposing of a sodium load. (And, of course, we in the US eat too much salt....). However, salt-loading will not cause high blood pressure in most people.

{21010} arteriolar nephrosclerosis with plenty of little cysts (gross)
{10575} arteriolar nephrosclerosis, sandpaper kidney
{11777} arteriolar nephrosclerosis, hyalinized artery
{40267} arteriolar nephrosclerosis, gross
{25760} hypertension, bad fibrous intimal proliferation
{08871} hypertension, intimal fibroplasia
{25764} hypertension, intimal fibroplasia

Hyaline arteriolar sclerosis, kidney
Great labels
Romanian Pathology Atlas

Arteriolar Nephrosclerosis
Dino Laporte's PathosWeb

Sandpaper kidney
Benign nephrosclerosis
WebPath Photo

{25763} hypertension
{25764} hypertension
{25765} hypertension; trichrome
{25766} hypertension; reticulin

MALIGNANT HYPERTENSION: High blood pressure causing papilledema (clinically) or necrosis of the vessels themselves (autopsy)

{25757} malignant hypertension, bleeding into the kidney
{25759} malignant hypertension, most of kidney is infarcted
{25761} malignant hypertension, intimal proliferation (trust me this was malignant hypertension)
{25762} malignant hypertension, fibrinoid necrosis
{25762} malignant hypertension

Malignant hypertension
Necrotic kidney arteries
KU Collection

Malignant hypertension
Necrotic kidney arteries
KU Collection

Fibrinoid in malignant hypertension
WebPath photo

Malignant hypertension

WebPath Photo

Malignant hypertension
Fibrinoid
WebPath Photo

Malignant hypertension
Onion skinning
WebPath Photo

RENAL VASCULAR HYPERTENSION:

HEMOLYTIC-UREMIC SYNDROME ("HUS"; review of the thrombopathy NEJM 346: 23, 2002):

THROMBOTIC MICROANGIOPATHY is now an umbrella term for a host of renal lesions that have in common damage to the endothelium.

{10570} diffuse cortical necrosis
{10574} diffuse cortical necrosis
{21026} diffuse cortical necrosis

ATHEROEMBOLIZATION (Lancet 375: 1650, 2010)

{16900} atheroembolus; scar has formed around it

Shrivelled kidney
Attributed to atherosclerosis
WebPath Photo

Kidney infarct

WebPath Photo

SICKLE CELL DISEASE NEPHROPATHY (South. Med. J. 104: 752, 2011)

OBSTRUCTIVE DISEASE OF THE KIDNEY

{10573} hydronephrosis
{10577} hydronephrosis

Hydronephrosis

WebPath Photo

KIDNEY STONES (renal calculi, "urolithiasis"; Am. Fam. Phys. 63: 1329, 2001; BMJ 334: 468, 2007)

{40264} kidney stone
{09786} staghorn kidney stone
{09789} kidney stone
{18787} staghorn stone
{49322} kidney stone

Hydronephrosis and stones
From Chile
In Spanish

Kidney stone
Animation
WebPath Photo

Kidney stone

WebPath Photo

Kidney Stones
Dino Laporte's PathosWeb

Staghorn kidney stone

WebPath Photo

KIDNEY TUMORS: Heidelberg classification J. Path. 183: 131, 1997.

Kidney Tumors
From Chile
In Spanish

Kidney
Nice case photos
Charam M. Ramnani MD

{25360} angiomyolipoma, gross; aorta is small because this is from a child
{25361} angiomyolipoma

Renal angiomyolipoma
H&E
Wikimedia Commons

{21021} renal cell carcinoma, gross
{21022} renal cell carcinoma invading the vein
{09754} renal cell carcinoma, gross
{09788} renal cell carcinoma, gross
{09823} renal cell carcinoma, gross
{17204} renal cell carcinoma, microscopic; the nuclei look deceptively benign
{17207} renal cell carcinoma, microscopic
{35582} renal cell carcinoma, microscopic
{00080} renal cell carcinoma, clear cells

Renal cell carcinoma
Great labels
Romanian Pathology Atlas

Kidney Adenocarcinoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Renal cell carcinoma

WebPath Photo

Renal cell carcinoma

WebPath Photo

Renal cell carcinoma
This one turned mostly to mush
WebPath Photo

Renal cell carcinoma
Invading the renal vein
WebPath Photo

Renal cell carcinoma
Clear cells
WebPath Photo

Renal cell carcinoma
Renin granules
Pittsburgh Pathology Cases

Renal Cell Carcinoma
CDC
Wikimedia Commons

Clear cell "sugar" lung adenocarcinoma
AFIP
Wikimedia Commons

Renal clear cell carcinoma
Low-grade
Wikimedia Commons

Renal Cell Carcinoma
Pittsburgh Illustrated Case

Renal cell carcinoma
Papillary type
Pittsburgh Pathology Cases

{25369} Wilms, histology
{25370} Wilms, histology
{25373} Wilms, some second-rate rhabdomyoblasts

Wilms tumor
Great labels
Romanian Pathology Atlas

Wilms tumor
WebPath Photo

Wilms tumor
WebPath Photo

Wilms tumor

WebPath Photo

Wilms tumor
Very primitive one
WebPath Photo

Wilms tumor
Makes tubules
WebPath Photo

Wilms tumor
AFIP
Wikimedia Commons

Renal Pelvis Exhibit
Virtual Pathology Museum
University of Connecticut

{09778} urothelial carcinoma of renal pelvis
{18790} urothelial carcinoma of renal pelvis
{39762} urothelial carcinoma of renal pelvis
{39844} urothelial carcinoma of renal pelvis -- this is invading the cortex

Metastases to the kidney
Lung cancer's the most common
WebPath Photo

Urothelial carcinoma
Renal pelvis
WebPath Photo

Urothelial carcinoma
Renal pelvis
WebPath Photo

TRANSPLANT PATHOLOGY

World Kidney Day is the second Thursday in March. (Good site -- and a good cause.)

Your lecturer believes that most people want to help strangers when they can and when it costs them nothing. When dialysis was instituted in the 1960's, it was with the expectation that most people would want to donate their deceased loved-one's kidneys and that no one would have to be on dialysis for long. Sadly, a mix of ideologues and tort lawyers (and perhaps third-party payers) has made this much more difficult than it should be. We look with hope to countries like Spain and Belgium, where the doctor will take the decedent's kidneys unless there's a previous opt-out (Lancet 378: 1356, 2011).

* SLICE OF LIFE REVIEW

{03184} renal tubules composite of micro, normal vs. cell swelling
{03184} renal tubules composite of micro, normal vs. cell swelling
{11813} kidney, normal cut surface
{14919} kidney, cortex & medulla
{14920} kidney, cortex & medulla
{14921} kidney, cortex & medulla
{14922} kidney, cortex & medulla
{14923} kidney, cortex
{14924} kidney, cortex
{14925} kidney cortex, (glomerulus)
{14926} kidney cortex, (glomerulus)
{14927} kidney, tubules (distal & proximal)
{14928} kidney, tubules (distal & proximal)
{14929} kidney, medulla (collecting tubules)
{14930} kidney, medulla (collecting tubules)
{14931} kidney, medulla collecting duct
{14932} kidney, medulla collecting duct
{14933} juxtaglomerular apparatus
{14934} juxtaglomerular apparatus, kidney
{14935} glomerulus, (vascular pole)
{14936} glomerulus, (vascular pole)
{15316} kidney, cortex
{15317} kidney, medulla
{15318} kidney, papilla
{15319} kidney, medullary ray
{15320} kidney, medulla
{15321} kidney, macula densa and distal tubule
{15322} kidney, area cribrosa
{15323} kidney, medullary ray
{15324} kidney, cortex
{15572} kidney, normal
{15573} kidney, normal
{15574} kidney, normal
{15834} kidney, normal neonatal
{16657} kidney, normal
{16658} kidney, normal
{16723} kidney, normal
{16724} kidney, almost normal -- the cortex is a bit pale, suggesting terminal ATN
{16729} glomerulus, normal
{16730} glomerulus, normal
{16732} glomerulus structure, normal
{16733} glomerulus structure, normal
{16735} glomerulus capillary structure, normal
{16738} glomerulus capillary structure, normal
{16739} glomerulus capillary structure, normal
{16740} glomerulus ultrastructure, normal
{16741} glomerulus ultrastructure, normal
{16744} glomerulus ultrastructure, normal
{16748} glomerulus, normal
{16762} glomerulus ultrastructure, normal
{16763} glomerulus, normal
{16859} kidney, normal
{17027} glomerulus, normal
{17028} glomerulus, normal
{17149} kidney, normal-1303
{17150} kidney, normal-1303
{17534} kidney, normal
{17576} kidney, normal
{17577} kidney, normal
{19798} kidney, normal
{19799} kidney, normal
{19800} kidney, normal
{19801} kidney, normal
{19802} kidney, normal
{19803} kidney, normal
{20924} kidney, papilla
{20925} kidney, medullary ray
{20926} kidney, collecting duct
{20927} kidney, distal tubule
{20928} thick loop of henle, kidney
{20929} kidney, collecting duct
{20932} kidney, macula densa
{20933} kidney, parietal cells
{20934} kidney, proximal tubule
{20935} kidney, distal tubule
{20936} kidney, collecting duct
{20937} kidney, proximal tubule
{20938} kidney, distal tubule
{29587} kidney, normal biopsy
{33307} glomerular disease, normal?
{34216} glomerulus, normal
{34282} glomerulus, normal
{34291} glomerulus, normal
{34306} glomerulus, normal
{39473} glomerulus, normal
{46462} cilia in collecting tubule of kidney, normal
{46463} glomerulus, normal
{46526} proximal tubules, normal
{46527} glomerular capillary, normal

I saw a man pursuing the horizon;
Round and round they sped.
I was disturbed at this;
I accosted the man.

"It is futile," I said, "You can never -- "

"You lie," he cried, And ran on.

BIBLIOGRAPHY / FURTHER READING

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reset Jan. 30, 2005:

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Teaching Pathology

Pathological Chess


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