URINARY URINARY PATHOLOGYPATHOLOGY

Mary E. MartinMary E. Martin

Biology 120Biology 120

Wilm’s tumorWilm’s tumor

Wilms' tumor is a rare kidney cancer Wilms' tumor is a rare kidney cancer that primarily affects children. Also that primarily affects children. Also known as nephroblastoma, it's the known as nephroblastoma, it's the most common malignant tumor of most common malignant tumor of the kidneys in children. The peak the kidneys in children. The peak time of Wilms' tumor occurrence is time of Wilms' tumor occurrence is around ages 3 to 4, and it occurs around ages 3 to 4, and it occurs only rarely after age 6.only rarely after age 6.

Wilms' tumor may also go undetected early on, Wilms' tumor may also go undetected early on, because the tumors can grow large without because the tumors can grow large without causing pain. However, even when they're large, causing pain. However, even when they're large, most of these tumors are found before they have most of these tumors are found before they have a chance to spread (metastasize) to other parts a chance to spread (metastasize) to other parts of the body. Your child may appear healthy or of the body. Your child may appear healthy or may have:may have:

Abdominal swelling Abdominal swelling An abdominal mass you can feel An abdominal mass you can feel Fever Fever Blood in the urine Blood in the urine Reduced appetite Reduced appetite High blood pressure High blood pressure Constipation Constipation Stomach pain Stomach pain NauseaNausea

Although the exact cause remains Although the exact cause remains unknown, it's believed that this unknown, it's believed that this cancer arises when your child is still cancer arises when your child is still developing in the womb and some of developing in the womb and some of the cells that are supposed to form the cells that are supposed to form the kidneys fail to develop properly. the kidneys fail to develop properly. Instead, they multiply in their Instead, they multiply in their primitive state, becoming a tumor primitive state, becoming a tumor that often becomes evident around that often becomes evident around the time a child is 3 or 4 years old.the time a child is 3 or 4 years old.

Standard treatment for Wilms' tumor is surgery Standard treatment for Wilms' tumor is surgery and chemotherapy. The stage of the tumor and and chemotherapy. The stage of the tumor and appearance of the cancer cells under a appearance of the cancer cells under a microscope help determine whether your child microscope help determine whether your child also needs radiation therapy. At this point, your also needs radiation therapy. At this point, your doctor may tell you the tumor appears to be doctor may tell you the tumor appears to be either favorable or unfavorable (anaplastic) — either favorable or unfavorable (anaplastic) — the histology of the tissue. Children whose the histology of the tissue. Children whose tumors have a favorable histology have better tumors have a favorable histology have better survival rates. However, many children with survival rates. However, many children with unfavorable histology also have good outcomes.unfavorable histology also have good outcomes.

Polycystic kidneysPolycystic kidneysPKDPKD

Polycystic kidney disease (PKD) is a Polycystic kidney disease (PKD) is a disorder in which clusters of cysts disorder in which clusters of cysts develop primarily within your develop primarily within your kidneys. Cysts are noncancerous kidneys. Cysts are noncancerous round sacs containing water-like round sacs containing water-like fluid.fluid.

The greatest risk for people with The greatest risk for people with polycystic kidney disease is polycystic kidney disease is developing high blood pressure. developing high blood pressure. Kidney failure is another common Kidney failure is another common problem for people with polycystic problem for people with polycystic kidney disease.kidney disease.

Polycystic kidney disease symptoms may Polycystic kidney disease symptoms may include:include:

High blood pressure High blood pressure Back or side pain related to enlarged kidneys Back or side pain related to enlarged kidneys Headache Headache Increase in the size of your abdomen Increase in the size of your abdomen Blood in your urine Blood in your urine Frequent urination Frequent urination Kidney stones Kidney stones Kidney failure Kidney failure Urinary tract or kidney infectionsUrinary tract or kidney infections

A healthy kidney (left) eliminates A healthy kidney (left) eliminates waste from the blood and maintains waste from the blood and maintains the body's normal chemical balance. the body's normal chemical balance. Fluid-filled sacs (right), called cysts, Fluid-filled sacs (right), called cysts, characterize polycystic kidney characterize polycystic kidney disease.disease.

Abnormal genes cause polycystic Abnormal genes cause polycystic kidney disease, and the genetic kidney disease, and the genetic defects mean the disease runs in defects mean the disease runs in families. There are two types of families. There are two types of polycystic kidney disease, caused by polycystic kidney disease, caused by different genetic flaws:different genetic flaws:

Autosomal dominant polycystic Autosomal dominant polycystic kidney diseasekidney disease

Autosomal dominant polycystic kidney Autosomal dominant polycystic kidney disease (ADPKD).disease (ADPKD). Signs and symptoms of Signs and symptoms of ADPKD often develop between the ages of 30 ADPKD often develop between the ages of 30 and 40. In the past, this type was called adult and 40. In the past, this type was called adult polycystic kidney disease, but children can polycystic kidney disease, but children can develop the disorder. Only one parent needs to develop the disorder. Only one parent needs to have the disease in order for it to pass along to have the disease in order for it to pass along to the children. If one parent has ADPKD, each the children. If one parent has ADPKD, each child has a 50 percent chance of getting the child has a 50 percent chance of getting the disease. This form accounts for about 90 disease. This form accounts for about 90 percent of cases of polycystic kidney disease. percent of cases of polycystic kidney disease.

Autosomal recessive polycystic Autosomal recessive polycystic kidney diseasekidney disease

Autosomal recessive polycystic Autosomal recessive polycystic kidney disease (ARPKD).kidney disease (ARPKD). This type is This type is far less common than ADPKD. The signs far less common than ADPKD. The signs and symptoms often appear shortly after and symptoms often appear shortly after birth. Sometimes, symptoms don't birth. Sometimes, symptoms don't appear until later in childhood or during appear until later in childhood or during adolescence. Both parents must have adolescence. Both parents must have abnormal genes to pass on this form of abnormal genes to pass on this form of the disease. If both parents carry the the disease. If both parents carry the genes for this disorder, each child has a genes for this disorder, each child has a 25 percent chance of getting the disease. 25 percent chance of getting the disease.

There are numerous complications There are numerous complications associated with polycystic kidney disease associated with polycystic kidney disease including:including:

High blood pressureHigh blood pressure Loss of kidney functionLoss of kidney function Pregnancy complicationsPregnancy complications Growth of cysts in your liverGrowth of cysts in your liver Development of an aneurysm in your Development of an aneurysm in your

brainbrain Heart valve abnormalitiesHeart valve abnormalities Colon problemsColon problems Chronic painChronic pain

Several diagnostic methods are Several diagnostic methods are available to detect the size and available to detect the size and number of cysts as well as to number of cysts as well as to evaluate the amount of healthy evaluate the amount of healthy kidney tissue.kidney tissue.

Ultrasound examinationUltrasound examination Computerized tomography (CT) Computerized tomography (CT)

scanscan Magnetic resonance imaging Magnetic resonance imaging

(MRI) scan(MRI) scan Genetic testingGenetic testing

NephrolithiasisNephrolithiasis

Also known as kidney stonesAlso known as kidney stones

Kidney stones (renal lithiasis) are Kidney stones (renal lithiasis) are small, hard deposits that form inside small, hard deposits that form inside your kidneys. Kidney stones are your kidneys. Kidney stones are made of mineral and acid salts. made of mineral and acid salts. Kidney stones have many causes. In Kidney stones have many causes. In one common scenario, kidney stones one common scenario, kidney stones form when the urine becomes form when the urine becomes concentrated, allowing minerals to concentrated, allowing minerals to crystallize and stick together.crystallize and stick together.

A kidney stone may or may not cause signs and A kidney stone may or may not cause signs and symptoms until it has moved into the ureter — symptoms until it has moved into the ureter — the tube connecting the kidney and bladder. At the tube connecting the kidney and bladder. At that point, these signs and symptoms may occur:that point, these signs and symptoms may occur:

Severe pain in the side and back, below the ribs Severe pain in the side and back, below the ribs Pain that spreads to the lower abdomen and Pain that spreads to the lower abdomen and

groin groin Pain on urination Pain on urination Pink, red or brown urine Pink, red or brown urine Nausea and vomiting Nausea and vomiting Persistent urge to urinate Persistent urge to urinate Fever and chills if an infection is presentFever and chills if an infection is present

Kidney stones often have no definite, Kidney stones often have no definite, single cause. A number of factors, single cause. A number of factors, often in combination, create the often in combination, create the conditions in which susceptible conditions in which susceptible people develop kidney stones people develop kidney stones

Most kidney stones contain crystals Most kidney stones contain crystals of more than one type. Types of of more than one type. Types of kidney stones include: kidney stones include:

Calcium stonesCalcium stones Struvite stonesStruvite stones Uric acid stonesUric acid stones Cystine stonesCystine stones Other stones.Other stones. Other, rarer types of Other, rarer types of

kidney stones can occur kidney stones can occur

Kidney stones form in your kidneys. Kidney stones form in your kidneys. As stones move into your ureters — As stones move into your ureters — the thin tubes that allow urine to the thin tubes that allow urine to pass from your kidneys to your pass from your kidneys to your bladder — signs and symptoms can bladder — signs and symptoms can result. Signs and symptoms of result. Signs and symptoms of kidney stones can include severe kidney stones can include severe pain, nausea and vomiting.pain, nausea and vomiting.

If your doctor suspects you have a If your doctor suspects you have a kidney stone, you may undergo tests kidney stone, you may undergo tests and procedures to diagnose your and procedures to diagnose your condition, such as:condition, such as:

Blood testsBlood tests Urine testsUrine tests Imaging testsImaging tests Analysis of passed stonesAnalysis of passed stones

Treatment for small stones with Treatment for small stones with minimal symptomsminimal symptoms Most kidney stones won't require Most kidney stones won't require invasive treatment. You may be able invasive treatment. You may be able to pass a small stone by:to pass a small stone by:

Drinking waterDrinking water Pain relieversPain relievers

Treatment for larger stones and those Treatment for larger stones and those that cause symptomsthat cause symptoms Kidney stones that can't be treated with Kidney stones that can't be treated with conservative measures — either because conservative measures — either because they're too large to pass on their own or they're too large to pass on their own or because they cause bleeding, kidney because they cause bleeding, kidney damage or ongoing urinary tract damage or ongoing urinary tract infections — may require more invasive infections — may require more invasive treatment. Procedures include:treatment. Procedures include:

Using sound waves to break up stonesUsing sound waves to break up stones Surgery to remove very large stones in Surgery to remove very large stones in

the kidneythe kidney Using a scope to remove stonesUsing a scope to remove stones Parathyroid gland surgeryParathyroid gland surgery

HydronephrosisHydronephrosis

HydronephrosisHydronephrosis is is distensiondistension and and dilationdilation of the of the renal pelvisrenal pelvis calycescalyces, , usually caused by usually caused by obstructionobstruction of the of the free flow of free flow of urineurine from the from the kidneykidney, , leading to progressive leading to progressive atrophyatrophy of the of the kidney. In cases of kidney. In cases of hydroureteronephrosishydroureteronephrosis, there is , there is distention of both the ureter and the distention of both the ureter and the renal pelvis and calices.renal pelvis and calices.

There are numerous causes of There are numerous causes of hydronephrosis that are categorized hydronephrosis that are categorized based upon the location of the based upon the location of the swelling and whether the cause is swelling and whether the cause is intrinsic (located within the urinary intrinsic (located within the urinary collecting system), extrinsic (outside collecting system), extrinsic (outside of the collecting system) or if it due of the collecting system) or if it due to an alteration in function.to an alteration in function.

There may or may not be direct There may or may not be direct symptoms of hydronephrosis symptoms of hydronephrosis depending upon the underlying depending upon the underlying cause. cause.

Individuals with acute hydronephrosis, Individuals with acute hydronephrosis, for example symptoms from renal colic for example symptoms from renal colic due to a kidney stone begin with an due to a kidney stone begin with an acute onset of intense flank or acute onset of intense flank or back painback pain radiating to the groin, radiating to the groin, associated with associated with nauseanausea, , vomitingvomiting, and , and sweating. Colicky pain comes and goes sweating. Colicky pain comes and goes and its intensity may cause the person and its intensity may cause the person to writhe or roll around or pace in to writhe or roll around or pace in pain. There may be pain. There may be blood seen in the urineblood seen in the urine..

Chronic hydronephrosis develops over time Chronic hydronephrosis develops over time and there may be no specific symptoms. and there may be no specific symptoms. Tumors in the pelvis or bladder obstruction Tumors in the pelvis or bladder obstruction may develop silently and the person may may develop silently and the person may have symptoms of have symptoms of kidney failurekidney failure. These are . These are very non specific and may include very non specific and may include weaknessweakness, malaise, , malaise, nausea and vomitingnausea and vomiting. If . If electrolyte abnormalitieselectrolyte abnormalities occur because the occur because the kidneys are unable to regulate sodium, kidneys are unable to regulate sodium, potassium, and calcium, there may be potassium, and calcium, there may be heart rhythm disturbancesheart rhythm disturbances and and muscle spasmsmuscle spasms..

The following laboratory tests may be The following laboratory tests may be ordered depending upon what potential ordered depending upon what potential diagnosis is being considered. diagnosis is being considered.

UrinalysisUrinalysis Complete blood countComplete blood count ElectrolyteElectrolyte BUNBUN (blood urea nitrogen), (blood urea nitrogen),

creatinine and glomerular filtration ratecreatinine and glomerular filtration rate Imaging StudiesImaging Studies CT scanCT scan UltrasoundUltrasound Intravenous pyelographyIntravenous pyelography KUB X-raysKUB X-rays

Imaging Studies

If hydronephrosis remains If hydronephrosis remains untreated, the increased pressure untreated, the increased pressure within the kidney may decrease the within the kidney may decrease the ability of the kidney to filter blood, ability of the kidney to filter blood, remove waste products, and make remove waste products, and make urine as well as regulate the urine as well as regulate the electrolytes in the body. electrolytes in the body.

Hydronephrosis can lead to kidney Hydronephrosis can lead to kidney infections (pyelonephrosis), infections (pyelonephrosis), sepsissepsis, , and in some cases, complete kidney and in some cases, complete kidney function loss or death. Kidney function loss or death. Kidney function will begin decreasing function will begin decreasing almost immediately with the onset of almost immediately with the onset of hydronephrosis but is reversible if hydronephrosis but is reversible if the swelling resolves. Usually the swelling resolves. Usually kidneys recover well even if there is kidneys recover well even if there is an obstruction lasting up to 6 weeks. an obstruction lasting up to 6 weeks.

calyxcalyx

structural components of the structural components of the mammalian kidney mammalian kidney

Major calyxMajor calyx Minor calyxMinor calyx

Structures of the KidneyStructures of the Kidney1. Renal pyramid 1. Renal pyramid 2. Interlobar artery 2. Interlobar artery 3. Renal artery 3. Renal artery 4. Renal vein 4. Renal vein 5. Renal hylum 5. Renal hylum 6. Renal pelvis 6. Renal pelvis 7. Ureter 7. Ureter 8. Minor calyx 8. Minor calyx 9. Renal capsule 9. Renal capsule 10. Inferior extremity 10. Inferior extremity 11. Superior extremity 11. Superior extremity 12. Interlobar vein 12. Interlobar vein 13. Nephron 13. Nephron 14. Renal sinus 14. Renal sinus 15. Major calyx 15. Major calyx 16. Renal papilla 16. Renal papilla 17. Renal column17. Renal column

Major CalyxMajor Calyx

Two or three minor calyces converge Two or three minor calyces converge to form a major calyx. The to form a major calyx. The major major calyxcalyx, in the kidney, surrounds the , in the kidney, surrounds the apex of the apex of the renal pyramidsrenal pyramids. . UrineUrine formed in the formed in the kidneykidney passes through passes through a a renal papillarenal papilla at the apex into a at the apex into a minor calyxminor calyx then into major calyx then into major calyx before passing through the before passing through the renal pelvisrenal pelvis into the into the ureterureter..

Peristalsis of the smooth muscle Peristalsis of the smooth muscle originating in pace-maker cells originating in pace-maker cells originating in the walls of the originating in the walls of the calyces propels urine through the calyces propels urine through the renal pelvis and ureters to the renal pelvis and ureters to the bladder.bladder.

Minor CalyxMinor Calyx The The minor calyxminor calyx, in the kidney, , in the kidney,

surrounds the apex of the renal surrounds the apex of the renal pyramids. Urine formed in the pyramids. Urine formed in the kidney passes through a papilla at kidney passes through a papilla at the apex into the minor calyx then the apex into the minor calyx then into the major calyx.into the major calyx.