Hassan Professor of...
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Hassan Hassan ArganiArgani MD.MD.
Professor of NephrologyProfessor of NephrologyProfessor of NephrologyProfessor of Nephrology
Shahidbeheshti university of Medical Sciences
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Normal kidneyy
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Normal renal vasculature
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Clinical signs of kidney disease
• Symptoms of associated disease• Renal colic and painRenal colic and pain• Hematuria
F i ( ibl t i i )• Foamy urine (possibly proteinuria)• Volume overload• Uremic syndrome: CNS, GI, CV, skin
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Clinical assessment of extracellular volume
• BP and heart rate• Skin turgorg• Mucous membrane moisture• Jugular venous pressureg p• Pulmonary crackles• Third heart soundThird heart sound• Edema
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CKDCKDCKDCKD
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Cocesh etal. J Am Soc Nephrol 2005,16(1):180-8
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Toxins retained in uremia:Low molecular weights (MW<300 D)Urea Creatinine Guanidines LipidsUrea, Creatinine, Guanidines, Lipids,Hipporic acid, indoxil sulfate, p-cresol O l t H P 4 H+ N + K+ tOxalate,Hcy, Po4, H+, Na+, K+, waterMiddle mollecules (MW=300-12000 D)Middle mollecules (MW 300 12000 D)PTH, B2 microglobuline, AGE,
High molecules (MW >12000 D)Cystatin C, Clara cell Protein,Cystatin C, Clara cell Protein, Retinol Binding Protein, Leptin
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R.F AnemiaAVF }COHyperlipidemia AVF }
Fl idU id tifi d
PTH
Alteredvasopressor/NO
Fluidoverload
P i di l
Unidentifiedtoxins
HypertensionPericardialdiseases
K+
Cardiovascular Damageg
V l d l it dBioincompatibility
DialysisVolume and osmolarity and electrolyte changesAir emboli& hemolysis
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E d t l diEnd-stage renal disease
Diabetic nephrosclerosisDiabetic nephrosclerosisHypertensive nephrosclerosisChronic glomerulonephritisChronic glomerulonephritisChronic interstitial nephritisPolycystic kidney diseasePolycystic kidney disease
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Urine analysis
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PROXIMAL TUBULAR CELL
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DISTAL TUBULAR CELL
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COLLECTING DUCT CELL
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INTRACELLULAR LIPIDS
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“OVAL FAT BODY”
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FATTY CAST
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CHOLESTEROL CRYSTAL
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LEUKOCYTE CAST
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BACTERIAL CAST
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YEAST CAST
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CALCIUM OXALATE BYHYDRATED (U-pH <5.4-6.7)
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CALCIUM PHOSPHATE (U-pH ≥7.0)
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TRIPLE PHOSPHATE (U-pH ≥7.0)
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CYSTINE
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Qualitative identification of C ti tCystine stone
Sodium Nitroprosside
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2,8-HYDROXYADENINE (BF)
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2,8-HYDROXYADENINE (POL)
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SULPHADIAZINE (POL)
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AMOXYCILLIN (BF)
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INDINAVIR
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ACYCLOVIR
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EGG OF SCHISTOSOMA HAEMATOBIUM (120-150 μm)
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Normal glomerulusg
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Presentation of renal diseasesPresentation of renal diseases
Glomerulopathies proteinuria/hematuriaNephrotic syndrome
Acute glomerulonephritis
Hemolytic uremic syndrome
Tubulointerstitial diseasesTubulointerstitial diseases
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Nephrotic syndromeNephrotic syndrome
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Negative charges on glomerular capillariescapillaries
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Loss of negative chargesg g
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Minimal change disease
Diffuse effacement of foot proces
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PROTEINURICPROTEINURIC GLOMERULUS
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Nephrotic s ndromeNephrotic syndromeDefinition:Definition:
Always presentProteinuriaHypoalbuminemia
Usually presentEdemaEdemaHyperlipidemia
Sometimes presentH t iHematuriaAzotemiaHypertension
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Li id iLipiduria
Maltese cross
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Pi t f hild ith h ti dPicture of a child with nephrotic syndrome
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Sequence of events in nephrotic dsyndrome
Pathophysiology Clinical manifestationsPathophysiology Clinical manifestationsGlomerular injury
Increased permeability of the Heavy proteinuriaIncreased permeability of theglomerular basement membrane
Albuminuria
(foamy urine)Occasional hematuria
HypoproteinemiaDecreased serum albumin
Decreased peripheral Increased renal
Decreased plasma oncotic pressure
Decreased urine sodium
Peripheral and periorbital edema
capillary return Na reabsorption
Increased interstitial fluid
Decreased urine sodium
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Distribution of histologic lesions in children and adults
Children AdultsMinimal 80% 20%Minimal change
80% 20%
Proliferative 15% 25%Proliferative 15% 25%
Membranous <1% 30%
Focal sclerosis 5% 25%
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GlomerulonephritisGlomerulonephritis
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Mesangial cell architectureg
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M i l f tiMesangial function
Structural supportModulation of circulation
Matrix production and remodelinMC contractionModulation of circulation
Immune/inflammatory modulationFiltration and clearing
MC contraction Cytokine productionEndocytosisFiltration and clearing EndocytosisProtease secretion
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Mesangial proliferative glomerulonephritisglomerulonephritis
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Mesangial deposition of immunoglobulinimmunoglobulin
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Mesangial depositsMesangial deposits
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Sequence of events in acute l l h itiglomerulonephritis
Pathophysiology Clinical manifestationsPathophysiology Clinical manifestationsGlomerular injury
Inflammation of glomerular capillary bedRBC castsHematuriaInflammation of glomerular capillary bed
Decreased glomerular capillary perfusion
HematuriaProteinuria
Decreased GFR AzotemiaIncreased urine osmolalityDecreased urine sodium
Increased Na and water reabsorption
Decreased tubular fluidIncreased ECF volume Decreased urine volume- oliguria
Hypertension- CHF, encephalopathyEdema formationEdema formation
AnemiaRenal failure
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RBC cast is the typical feature in iurine
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Immunologic mechanisms f l l i jof glomerular injury
A tib di i t fi d l l tiAntibodies against fixed glomerular antigens- Planted antigens
Autoantigens- AutoantigensCirculating antigen-antibody complexes- Antigens unrelated to the kidney- Antigens unrelated to the kidney- Autoantigens unrelated to the kidney
T cell cytokine mediatedT cell cytokine mediated
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Anti-basement membrane antibodies
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Anti-GBM crescentic glomerulonephritisg p
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Linear deposition of anti-GBM tib diantibodies
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Circulating complexesCirculating complexes
“Single shot” serum sicknessChronic serum sicknessChronic serum sicknessTitered immune complex pformation
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Immune complex nephritisp p
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Acute proliferative glomerulonephritis
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Immune complex depositsp p
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Subendothelial depositsp
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Membranous glomerulonephritisg p
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Membranous pattern of immunoglobulin depositionimmunoglobulin deposition
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Subepithelial deposits deposits
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M di t f l l i jMediators of glomerular injury
ComplementAntibody mediated cellular cytotoxicityActivation of coagulationApoptotic signalsT cell cytokines
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Antibody deposition T cell immune reaction
Immune complexes
Complement activationComplement activation
C5b-9 C5a
Mesangial cellsMacrophagesPlateletsNeutrophils
EpithelialEndothelial
OxidantsC t ki
ProteasesG h f
EicosanoidsNit i idEndothelial
MesangialCytokines Growth factors Nitric oxide
Others
Proteinuria Proteinuria, decreased GFR, inflammation.
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Criteria for diagnosis of acute post streptococcal glomerulonephritispost-streptococcal glomerulonephritis
L t t i t l ti f i f ti t t1. Latent interval- time from infection to symptoms1. Not less than 5 days and not more than 28 days 2. Usually 10-21 days.
2. Documentation of preceding streptococcal infectiona) Culture of throat or skinb) Serologic changes in strep titers
3. Evidence of immunologic involvementa) Appropriate complement profile or low serum C3
4. Clinical course characteristic of post-streptococcal GNp pa) Lack of nephrotic syndrome at onsetb) Oliguria followed by a diuresis in 10-30 daysc) Edema formation and hypertension proportional to decrease in renal ) yp p p
functiond) Return of C3 to normal levels in 6-12 weeks
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Non streptococcal GNNon-streptococcal GNPrimary renal disease
F l ild lif ti GNPrimary hematuriaHypocomplementemic nephritisChronic (non-specific) GN
Focal or mild proliferative GNMesangiocapillary GNFocal or diffuse irreversible GN( p )
Rapidly progressive GNHereditary nephritis
S t i di ith l
Severe proliferative GN with crescentsChronic non-specific changesSystemic disease with renal
involvementAnaphylactoid nephritis
p g
Focal or diffuse proliferative lesionFocal or diffuse proliferative lesion
Lupus nephritis
Hemolytic uremic syndrome
Membranous lesionMicrothrombi in capillary loopsFocal areas of necrosisHemolytic uremic syndrome
Hypersensitivity angiitisPolyarteritis
Focal areas of necrosisPerivascular infiltrate
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Renal diseases associated with a low Clow C3
Post-infectious glomerulonephritisPost-streptococcal GNSBEShunt nephritis
SLE nephritisDiffuse proliferative type
M i l ill h i iMesangial capillary nephritisA.K.A. membranoproliferative GNP ti l li d t h dPartial lipodystrophy syndrome
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THROMBOTICMICROANGIOPATHY
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H l ti i dHemolytic uremic syndromeDefinitionDefinition
Microangiopathic hemolytic anemiaThrombocytopeniaAzotemia
Frequently associated findings
Abdominal painBloody diarrheaOli iOliguriaHypertension
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Mechanisms of Vascular InjuryMechanisms of Vascular InjuryEndothelial Activation Smooth Muscle _ Endothelial Activation
_ Stretch / Shear Forces_ Inflammation
_ Smooth Muscle Activation_ Contraction
_ Immune Response_ Activation of
Coagulation
_ Ischemia_ Hyalinosis
Autocrine g_ Platelets_ Tissue Factor
F t X
_ Autocrine regulation_ Renin - Angiotensin
_ Factor X _ g_ Cytokines, Growth
Factors
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Sequence of events in hemolytic uremic syndrome
Pathophysiology Clinical manifestationsGl l i jGlomerular injury
Endothelial damage in arterioles and capillary loops
Microangiopathic hemolytic anemiaFormation of fibrin strands
Platelet consumption and utilization Thrombocytopenia
g p yHematuria and proteinuria
Formation of fibrin strandsIntravascular thrombosis
Decreased glomerular capillary perfusion
Decreased GFR Increased Na and water reabsorption Decreased urine osmolality
AzotemiaDecreased urine sodium
Oligo-anuria
Decreased urine formation Decreased urine sodium
Renal failure
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Typical features of microangiopathic hemolytic anemia
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Tubulo-interstitial disorders
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Interstitial nephritisInterstitial nephritis
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Mechanisms of tubulointerstitial i jinjury
Infectious agentsInfectious agentsToxinsImmunologic responsesImmunologic responsesObstructionIschemiaIschemia
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Comparison of the clinical presentation of l l t b l di dglomerular vs tubular disorders
Gl l T b lGlomerular Tubular
Proteinuria > 1.0 gm/day < 1.0 gm/day
Urine sediment Active many RBC & Inactive few cellsUrine sediment Active many RBC & WBC casts
Inactive few cells
Urine Na FENa Low (<1%) High (>2%)
Urine osm High (>500 mosm/L) Low (<300 mosm/L)
Acid excretion Large anion gap Hyperchloremic acidosis
O COliguria Common Unusual
Edema Common Unusual
Hypertension Common UnusualHypertension Common Unusual
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Chronic glomerulosclerosis
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Gl l L i fGl l L i fGlomerular Lesions of Glomerular Lesions of Systemic DiseasesSystemic DiseasesSystemic DiseasesSystemic Diseases
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Nonimmunologic causes of gincreased glomerular permeability
Diabetic nephropathyAmyloid
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P h l f di b i h hPathology of diabetic nephropathyThickening of GBMThickening of GBMNodular mesangial sclerosis Kimmelsteil Wilson lesionKimmelsteil-Wilson lesionMesangial widening with an increase in matrixVm/VgArteriolar hyalinizationLinear fluorescenceGlomerular hypertrophy
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Diabetic nephropathyDiabetic nephropathy
Normal
K-W nodules
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Diabetic nephropathy
Diffuse linear deposition of IgG and albumin
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Diabetic nephropathyp p y
Diffusely thickened GBM Nodular sclerosis
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Natural history of diabetic nephropathyStage 1- Time of initial diagnosis
Increased GFRIncreased GFRIncreased kidney size
Stage II- The first decade (years 1-10)Stage II The first decade (years 1 10)Early structural changes (GBM, mesangium)
Stage III- MicroalbuminuriaStage III MicroalbuminuriaStage IV- Onset of clinical disease (years 10-20))
ProteinuriaHypertensionDeclining GFR
Stage V- End-stage renal disease
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Potential mechanismsPotential mechanisms
HyperfiltrationHypertensionypAldose-reductase
Excess glucose polyolExcess glucose polyolIncreased sorbitol/ decreased myoinositolmyoinositol
Toxicity of high glucoseNon enzymatic glycationNon-enzymatic glycation
Advanced glycation end products
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AmyloidosisAmyloidosis
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Crescentic glomerulonephritisCrescentic glomerulonephritis
Lightmicroscopy
IFmicroscopy
Possiblepathogenesis
Association
Crescents/ Linear IgG Anti GBM PulmonaryCrescents/necrosis
Linear IgGFibrinogen
Anti-GBMantibodies
Pulmonaryhemorrhage
Crescents/proliferation
Granular IgGComplement
Immunecomplexes
Bacterialinfectionsproliferation Complement
Fibrinogencomplexes infections
Crescents/necrosis
NegativeFibrinogen (?)
ANCA SystemicSymptoms
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Cresentic Glomerulonephritis
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Anti-Glomerular Basement Membrane Disease
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Anti-neutrophil cytoplasmic antibodiesC-ANCA- antiproteinase 3
90% sensitivity for extended Wegener’s granulomatosis
P-ANCAVariety of antigens
MyeloperoxidaseWegener s granulomatosisGranulomatous respiratory lesionSystemic vasculitis
MyeloperoxidaseElastaseCathepsin GLysozymey
Necrotizing glomerulonephritis75% sensitivity for limited Wegener’s granulomatosis
LysozymeLactoferrinB-glucuronidaseEnolaseWege e s g a u o atos s
With or without renal involvement
Potential false positives
EnolaseBroader reactivity
MPA, NCGN, C-S, 10-20% PAN, 20% KAW IgA ANCA in HSPp
AmebiasisPropylthiouracil induced vasculitis
20% KAW, IgA, ANCA in HSPOther diseases
Inflammatory bowel diseaseA t i li diTiter varies with activity Autoimmune liver diseaseSepsisNeoplasia
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Systemic Vasculitis
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Pauci Immune Glomerulonephritis
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RPGN- crescents
Fibrin deposition (immunofluorescence)
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WHO Classification of Lupus Neprhitis, RevisedRevised
Class I Minimal mesangial lupus glomerulonephritis -mesangial deposits
Class II Mesangial proliferative LGN-with immune deposits
Class III Focal LGN (less than 50% of glomeruli) subendothelial depositsdeposits,
Class III (A) Purely active focal proliferative LGN Class III (A/C) Active and chronic lesions focal LGN:Class III (C) Chronic inactive sclerotic focal LGN( )
Class IV Diffuse segmental (IV-S) or global (IV-G) LGN - SE deposits,
Class IV (A) Active lesions: diffuse proliferative LGNClass IV (A) Active lesions: diffuse proliferative LGNClass IV (A/C) Active and chronic lesions: proliferative and
sclerotic LGNClass IV (C) Inactive with glomerular scars: diffuse sclerotic LGN
Class V Membranous LGN - subepithelial immune deposits
Class VIAdvanced sclerotic LGN
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Lupus nephritis WHO Class I
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Lupus nephritis WHO Class I
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Lupus nephritis WHO Class II
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Lupus nephritis WHO Class II
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Lupus nephritis WHO Class III
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Hereditary diseasesHereditary diseasesyy
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Polycystic kidney disease
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Alport: Molecular Genetics• 1 in 50,000 live births • X-linked form is most common (no father-son
transmission, females are carriers)transmission, females are carriers)o responsible gene is COL4α5
• X-linked form associated with esophageal leiomyomatosisleiomyomatosiso contiguous gene syndrome involving COL4α5
and COL4α6 l i f li k d h 2• autosomal recessive form linked to chromosome 2
o mutations in COL4α3 and COL4α4
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Renal TransplantationRenal Transplantation
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Technique of pancreas-kidney transplant with systemic drainage. The pancreas is i i i i f i i i iplaced in the right iliac fossa. The donor portal vein is anastomosed to the recipient
iliac vein, resulting in systemic drainage of pancreatic veins.
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BK Virus Nephropathyp p y
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DECOY CELLS BY PHASE CONTRAST
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Thank youThank you