Renal Pathology CASE 1 Final

Renal Pathology Case 1
Med 2 Section C Srikirin, Ruangruj Kaewnil, Kaewwalee Virattayanon, Nantiwat Sindhupreechapong, Russarin Movaliya, Ghanshyam Kathiriya, Yogesh Patel, Pinakin Dave, Nischay
Patient History and Chief Complaint

65-year-old woman
Complaint of hematuria (gross) for the past
6 months with right flank pain

No fever, dysuria, and oliguria
Laboratory Results
Urinalysis results
Numerous red blood cells (no red cell
casts) Few white blood cells

Normal range: CBC, Creatinine, and BUN
Differential Diagnosis/ Pxs Contd.

Hematuria Flank Pain No Fever No Dysuria No Oliguria Urinalysis Numerous RBCs (no red cell casts) Few white cells Normal CBC, Creatinine, BUN
Renal Trauma
Renal Cell Carcinoma (with mass) (fever + NAV) (urine retention)
Lower Urinary Track Infection
Nephro lithiasis
Pyelo nephritis (Acute)
(maybe with mass)
(complication = infection) (w/ imparied renal function)
(w/ impaired renal function)
(increased creatinine)
Final Diagnosis Nephrolithiasis

Kidney stones result when urine becomes too
concentrated and substances in the urine crystallize to form stones the ureter causing intense pain.
Symptoms arise when the stones begin to move down Often as small as grains of sand and pass out of the
body in urine without causing discomfort. or even larger.
If deposited, the size can be pea sized, marble sized,
Possible Causes and Risk Factors

Low fluid intake
High animal protein diet Sodium / Calcium supplements
Fluoridation of water
Alcohol consumption The most important cause is an increased urinary
concentration of the stones' constituents, such that it exceeds their solubility (supersaturation).
Clinical Manifestations and their Mechanisms

Stones may not produce symptoms until they begin to move
down the ureter, causing pain.

The pain is severe and often starts in the flank region and
moves down to the groin.

The most characteristic symptoms of nephrolithiasis are pain
often associated with hematuria, nausea, and vomiting.

Red blood cells in the urine can come from the kidney or
anywhere in the urinary tract. When kidney stones travel through the urinary tract, it can damage the inner lining of the tract and may cause hematuria.
Additional Studies and the Possible Results

A stone chemical composition analysis should be performed whenever
possible, and information should be provided to motivated patients about possible 24-hour urine testing for long-term nephrolithiasis prophylaxis.
This is particularly important in patients with only 1 functioning kidney,
those with medical risk factors, and children.

The size of the stone is an important predictor of spontaneous
passage.
A stone less than 4 mm in diameter has an 80% chance of spontaneous
passage; this falls to 20% for stones larger than 8 mm in diameter. However, stone passage also depends on the exact shape and location
of the stone and the specific anatomy of the upper urinary tract in the particular individual.
Morphologic Findings (Gross)
Nephrolithiasis. A large stone impacted in the renal pelvis
Morphologic Findings (Microscopic)

(A) Extensive pelvic
nephrolithiasis (between arrows) due to uric acid stone formation. of renal tissue showing partly amorphous, partly rectangular and birefringent crystals (marked with *).
(B) Light microscopy
(C) Interstitial
infiltrates of myeloid cells in the kidney at autopsy.
Complications
Complications include:
Kidney failure Obstructed kidney: May cause kidney damage or an infection
(pyelonephritis)
Pyelonephritis Sepsis
Prognosis
Kidney stones are painful but usually are excreted without
causing permanent damage.
It is a lifelong disease process. The rate of recurrence of
nephrolithiasis in first-time stone formers is 50% at 5 years and 80% at 10 years. compliant with medical therapy and dietary/lifestyle modifications, or where underlying metabolic abnormalities exist. spontaneously pass as long as their size is <4 mm.
The patients at highest risk for recurrence are those who are not
Residual stone fragments from surgery will usually
Management/ Treatment
90% of stones 4 mm or less in size usually will pass
spontaneously, however 99% of stones larger than 6 mm will require some form of intervention, based on clinical history.
Hydration (at least 2.53 L/day ) and diuretics to
encourage urine flow and prevent further stone formation

Caution in food with high concentrations of oxalate
(e.g. starfruit)
Management/ Treatment
Extracorporeal Shock Wave Lithotripsy (ESWL) (non
surgical)
The shockwaves are focused on the calculus, and the energy
released as the shockwave impacts the stone produces fragmentation. The resulting small fragments pass in the urine.
Percutaneous nephrolithotomy (surgical)
Done by nephroscope through skin in flank area May ultimately be necessary for large or complicated stones or stones which fail other less invasive attempts at treatment
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Renal Pathology Case 1

Patient History and Chief Complaint

6 months with right flank pain

casts) Few white blood cells

Differential Diagnosis/ Pxs Contd.

Renal Cell Carcinoma (with mass) (fever + NAV) (urine retention)

Lower Urinary Track Infection

Pyelo nephritis (Acute)

(maybe with mass)

(complication = infection) (w/ imparied renal function)

(w/ impaired renal function)

Final Diagnosis Nephrolithiasis

body in urine without causing discomfort. or even larger.

If deposited, the size can be pea sized, marble sized,

Possible Causes and Risk Factors

Clinical Manifestations and their Mechanisms

down the ureter, causing pain.

moves down to the groin.

often associated with hematuria, nausea, and vomiting.

Additional Studies and the Possible Results

those with medical risk factors, and children.

Morphologic Findings (Gross)

Nephrolithiasis. A large stone impacted in the renal pelvis

Morphologic Findings (Microscopic)

(B) Light microscopy

infiltrates of myeloid cells in the kidney at autopsy.

causing permanent damage.

It is a lifelong disease process. The rate of recurrence of

Residual stone fragments from surgery will usually

encourage urine flow and prevent further stone formation

Percutaneous nephrolithotomy (surgical)

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