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TUSM13 - Renal - Tubulointerstitial Disease
L16
41
Other
Graduate
09/08/2010

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Term
What are the components of the renal system that are typically involved in tubulointerstitial diseases?
Definition
1) tubules
2) interstitium
3) pelvocalyceal system
Term
What are the two major categories of tubulointertstitial disease?
Definition
1) acute tubular necrosis (ischemia and toxins)
2) tubulointerstitial nephritis (inflammation)
Term
What are the major categories of causes of acute kidney injury?
Definition
1) perfusion-related
2) intrinsic
3) obstructive
Term
What are the two major patterns of ATN?
Definition
1) ischemic ATN
2) toxic ATN
Term
Describe the pathogenesis of ATN (both ischemic and toxic)
Definition
- ischemic: vasoconstriction (dec. GFR) w/ epithelial dmg
- Toxic: direct epithelial damage
- dmgd cells undergo necrosis and detachment
- casts: raise intratubular pressure (dec GFR)
- dmgd tubules leak fluid
- edematous interstitium
- inflammatory cells
Term
Describe the necrosis seen in ATN w/ ischemic damage, toxic damage. What regions of the tubule are first to be affected?
Definition
1) ischemic dmg: patchy necrosis
2) toxic dmg: long segments
3) proximal tubule and loop of Henle
Term
Describe the morphology of the affected tubules with ATN
Definition
- dilated
- patchy loss vs. epithelial cell flattening
- granular casts
- interstitial edema
- regenerative changes
- specific toxin fingerprint (ethylene glycol w/ Ca oxalate)
Term
What are the components to granular casts?
Definition
- necrotic cells
- plasma proteins
- Tamm-Horsfall protein
Term
What are the three phases of ATN? What does each involve?
Definition
1) initiaion: precipitating event
2) Maintenance: kidney failure - oliguria, elevated BUN, metabolic acidosis, hyperkalemia
3) Recovery: inc. UVol, return of normal fxn
Term
What types of characteristics are found with tubulointerstitial nephritis?
Definition
1) injury to the tubules and inflammatory infiltrates in the interstitium
Term
What are the major etiologies of tubulointerstitial nephritis?
Definition
1) infections
2) toxins
3) metabolic diseases
4) neoplasms (of course...cancer)
5) physical factors
6) immunologic feactions
7) vascular disease
8) hereditatry
Term
Define: pyelonephritis
Definition
- inflammation of the pelvis, calyces, tubules, and interstitium
- may be acute or chronic
Term
Describe Acute Pyelonephritis
Definition
1) E.coli (most common), Proteus, Klebsiella, enterobacter, strep fecalis
2) ascending infection w/ sequential steps
3) typically predisposing factors present
4) yellow nodules w/ ring of red hyperemia
5) triad of Sx: CVA tenderness, fever, urinary sx
6) fibrous scarring w/ horseshoe depression
Term
Describe the sequential steps for the pathogenesis of acute pyelonephritis
Definition
1) colonization of urethra
2) extension to the bladder
3) multiplication of bacteria in the bladder
4) vesicoureteric reflux
5) intrarenal reflux
6) bacterial reach renal parenchyma, inflammation response
Term
What are major predisposing factors associated with acute pyelonephritis?
Definition
1) instrumentation
2) urinary obstruction and reflux
3) pregnancy
4) patient's gender (F:M::10:1)
5) diabetes
6) immunodeficiency/immunosuppression
7) pre-existing lesions such as scars or congenital abnormalities of the tract
Term
Describe the associated pathology of acute pyelonephritis
Definition
1) multiple subcapsular abscesses
2) yellow nodules w/ ring or red hyperemia
2) neutrophilic infiltrate
3) polyoma virus
Term
What are clinical features associated with acute pyelonephritis?
Definition
1) Hx of cystitis
2) predisposing factor present
3) Triad of Sx: CVA tenderness; fever; urinary Sx (dysuria, pyuria, leukocyte casts)
Term
What ist he significance of leukocyte casts in urine?
Definition
1) indicates that the inflammatory process is in the kidney, not the bladder
Term
What are the major complications of acute pyelonephritis?
Definition
1) perinephric abscess
2) pyonephrosis
3) papillary necrosis
Term
Define: chronic pyelonephritis
Definition
- chronic tubulointerstitial inflammation with renal scarring AND deformation of the pelvocalyceal system
Term
Describe teh pathogenesis of chronic pyelonephritis
Definition
- recurrent and persistent bacterial infections
- predisposing factors of obstruction and vesicoureteric reflux (more common)
Term
What are the major causes of obstructive uropathy in adults? Children?
Definition
1) adults: prostatic hyperplasia; urinary calculi; malignancy; pregnancy
2) posterior urethral valves in boys; ureterocele; meatal strictures; ureteropelvic jxn stenosis/atresia
Term
Describe the pathology associated with obstructive type chronic pyelonephritis
Definition
- calyces are dilated and distorted
- atrophic tubules
- eosinophilic casts ("thyroidization")
- spared glomeruli
- coarse corticomedullary scar over a dilated calyx (focal and irregular)
- yellow nodules (proteus infections)
Term
What are clinical features of chronic pyelonephritis?
Definition
1) insidious onset
- associated HTN in children
- polyuria
- nocturia
- pyuria and bacteriuria if persisting bacterial infection
Term
What is the pathogenesis of allergic interstitial nephritis (AIN)?
Definition
1) various drugs: NSAIDS, antibiotics (sulfonamides)
2) Type IV hypersensitivity; Type I hypersensitivity
Term
Describe the pathology associated with allergic interstitial nephritis (AIN)
Definition
- interstitial infiltrate (lymphocytes, macrophages, eosinophils***)
- granulomas
- tubules inflammatory infiltrates
Term
What is allergic interstitial nephritis?
Definition
1) hypersensitivity reaction to certain drugs and toxic agents involving kidney interstitium
Term
What are clinical features associated with allergic interstitial nephritis (AIN)
Definition
1) history of exposure
2) physical sx: fever; rash
3) peripheral blood eosinophilia
4) urine analysis: blood, low proteinuria, leukocytes, eosinophils
5) reversible if drug is withdrawn
Term
What is analgesic nephropathy?
Definition
1) chronic tubulointrstitial nephritis and/or papillary necrosis secondary to analgesic drug usage
Term
Describe the pathogenesis associated with analgesic nephropathy
Definition
1) phenacetin directly or in combination medications
2) acetaminophen (phenacetin metabolite) injures cells by covalent bonding and oxidation esp in papillae
Term
Describe the pathology seen with analgesic nephropathy
Definition
1) papillary necrosis
2) structureless and often calcified mass
Term
Descirbe the clinical features associated with analgesic nephropathy
Definition
- uncommon in USA
- urine concentration deficit
- metabolic acidosis
- chronic renal failure
- hematuria
- renal colic
- transiional cell carcinoma of the renal pelvis
Term
Describe urate nephropathy (acute and chronic)
Definition
1) acute: rapid metabolism of DNA to uric acid; urate crystals lead to obstruction and AKI
2) chronic: chronic gout; foreign body giant cell rxn; interstitial fibrosis
Term
Describe hypercalcemia and tubulointerstitial disease
Definition
1) caused by hperparathyroidism, metastatic tumors in bode, myeloma, increased calcium intake or absorption
2) calcium deposits (nephrocalcinosis)
- atubular atrophy; interstitial fibrosis
Term
How is the kidney affected by multiple myeloma
Definition
- proteinuria: Bence-Jones proteins, casts, foreign body giant cells
- light-chain nephropathy: kappa deposition
- amyloidosis: lambda deposition
- hypercalcemia
- hyperuricemia
Term
Describe renal tuberculosis
Definition
- part of systemic dissemination
- kidney is most frequently involved organ after lung
- interstitial necrotizing granulomas in miliary distribution
Term
Describe renal sarcoidosis
Definition
1) multpile non-necrotizing granulomas
2) inflammation
3) diagnosis of exclusion after TB and other granulomatous conditions
Term
What are the major sources of kidney complications in kidney transplantation
Definition
1) rejection
2) drug toxicity
3) infections
4) post-transpland lymphoproliferative d/o
5) glomerulonephritis
Term
Describe acute cellular rejection of kidney vs. acute antibody mediated rejection
Definition
1) acute cellular: T-cell response; usually suppressed by medication; days to weeks
2) acute antibody: antibodies against donor antigens (endothelial cells); shortly after t-plant; inflammatory cells in subendothelium; intimal arteritis B.
Term
What two drugs are associated with complications of kidney transplant?
Definition
1) cyclosporine and FK506
2) nephrotoxic
3) suppression of transplant reection
Term
What are the most common causes of recurrent kidney disease associated with transplanted kidneys?
Definition
1) FSGS
2) IgA Nephropathy
3) SLE
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