Classification
Morphological types of cirrhosis
1. Micronodular (the nodules are usually regular and small, less than 3 mm in diameter).
2. Macronodular (the nodules are of variable size and are generally large than 3 mm in diameter).
3. Mixed (some part of the liver show micronodular appearance while other parts show macronodular pattern).
Each of these forms may have an active and inactive form:
- Hepatocellular necrosis and inflammatory reaction, a process that closely resembles chronic active hepatosis characterizes an active form.
- An inactive form, vise verse, has no evidence of continuing hepatocellular necrosis and has sharply-defined nodules of surviving hepatic parenchyma without any significant inflammation.
Etiologic types of cirrhosis
Infectious (often viral).
Toxic and toxic-allergic (Alcoholic cirrhosis, the most common, 60-70%; allergen, drugs, etc.).
Biliary cirrhosis (5-10%).
Metabolic-alimentary (Cirrhosis in Wilson’s disease, Cirrhosis in α-l antitrypsin deficiency, Pigment cirrhosis in hemochromatosis (5%), etc.).
Cardiac cirrhosis.
Cryptogenic cirrhosis (10-15%).
Types according to morphogenesis
Postnecrotic cirrhosis.
Portal (septical) cirrhosis.
Mixed cirrhosis.
Morphological patterns of cirrhosis
Morphological changes of all types of cirrhosis are similar.
Macroscopically the liver is small, having distorted shape with irregular and coarse scars and nodules of varying size. The cut surface shows scars and nodules varying in diameter from 3 mm to a few centimetres.
Microscopically, the features are following:
Abnormal lobular architecture can be identified and central veins are hard to find.
The fibrous septa dividing the variable-sized nodules are generally thick.
Active liver cell necrosis is observed. Fibrous septa contain prominent mononuclear inflammatory cell infiltrate even with follicles. Often there is extensive proliferation of bile ductules derived from collapsed liver lobules.
Liver cells vary considerably in size and multiple large nuclei are common in regenerative nodules. Fatty degeneration may be present.
Postnecrotic cirrhosis
This pattern of cirrhosis is characterized by irregularly sized nodules separated by variable but mostly broad scars.
The most common known cause is previous viral infection; in about 20 to 25% of cases it evolves from chronic HBV infection; the contribution of chronic HCV may be even greater.
In a small number of instances, there is a well-documented history of acute liver damage caused by some hepatotoxin, such as phosphorus; carbon tetrachloride; mushroom poisoning; or a drug such as acetaminophen, oxyphenisatin, or alpha-methyldopa. Undoubtedly some cases represent end-stage alcoholic cirrhosis, readily misinterpreted as postnecrotic cirrhosis in the absence of a history of chronic alcoholism.
After all these possibilities have been excluded, there remains a large residual of uncertain origin.
A single attack of massive hepatic necrosis only infrequently gives rise to postnecrotic cirrhosis because either it is fatal, or regeneration of the liver cells permits survival with little or no residual scarring.
Morphology
Typically some time after an acute event or following years of chronic hepatitis, the liver exhibits nodules of varying size (some several centimeters in diameter) and broad bands or areas of depressed scarring.
Severe collapse may leave a shrunken liver less than 1 kg in size.
Microscopically tubular architecture may be completely lost in the developing nodules and scar.
Alternatively, progressive chronic hepatitis of any etiology inexorably transforms a more normalized liver into a patchwork of variably sized nodules alternating with broad septal scars.
Eventually active liver cell necrosis becomes inconspicuous.
Residua of portal tracts may be evident; bile stasis is variable.
Ultimately the diagnosis rests on excluding other bases for cirrhosis.
Biliary cirrhosis
Biliary cirrhosis is defined as a chronic disorder characterized by clinical, biochemical and morphological features of long-continued cholestasis of extrahepatic or intrahepatic origin. There is primary and secondary biliary cirrhosis.
Primary biliary cirrhosis (PBC)
Primary biliary cirrhosis (PBC) is autoimmune disorder focused on intralobular bile ducts and holangioles, this disease causes chronic inflammation of intrahepatic bile ducts, leading to their destruction and, in time, cirrhosis.
The primary feature of this disease is a nonsuppurative, granulomatous destruction of medium-sized intrahepatic bile ducts; cirrhosis appears only late in the course.
This is primarily a disease of middle-aged women, with a female-to-male predominance in excess of 6:1. Age of onset is between 20 and 80 years, with the peak incidence between 40 and 50 years.
The onset is insidious, usually presenting with pruritus. Jaundice develops late in the course.
Hepatomegaly is typical. Xanthomas and xanthelasmas arise as a result of cholesterol retention. Stigmata of chronic liver disease are late features.
The disease may be asymptomatic for years, running its course over two or more decades.
PBC is the prototype of all conditions leading to small-duct biliary fibrosis and cirrhosis.
Historically, four histologic stages have described:
The duct lesion (granulomatous destruction of interlobular bile ducts). There is random, focal destruction of interlobular and septal bile ducts by granulomatous inflammation, named the florid duct lesion. Affected portal tracts exhibit a dense infiltrate of lymphocytes (including lymphoid follicle formation), histiocytes, plasma cells, and a few eosinophils. Parenchymal holestasis may be present.
Ductular proliferation with periportal hepatitis. With more global hepatic involvement, normal interlobular bile ducts become infrequent, and secondary obstructive changes develop, similar to those seen in extrahepatic obstruction. Mallory bodies (alcoholic hyaline) may be present in hepatocytes adjacent to portal tracts. Initially portal tract inflammation may be marked and spill over into the parenchyma, causing destruction of adjacent hepatocytes (piecemeal necrosis).
Fibrosis. With time, inflammation decreases; granulomas and duct lesions become infrequent and are replaced by fibrous septa. Bile ducts are reduced; holestasis is prominent.
Cirrhosis. Hepatocyte loss, fibrosis, and nodular regeneration lead to the gradual development of true cirrhosis. Macroscopically the liver does not at first appear abnormal, but as the disease progresses, bile stasis stains the liver green. The capsule remains smooth and glistening until a fine granularity appears, culminating in a well developed, uniform micronodularity. Liver weight is at first normal to increased (owing to inflammation); ultimately liver weight is slightly decreased. In most cases, the end-stage picture may be difficult to distinguish from secondary biliary cirrhosis or the cirrhosis that follows chronic active hepatitis.
Secondary biliary cirrhosis
Develops with prolonged extrahepatic biliary tract obstruction.
The most common cause of obstruction is an impacted gallstone in the common bile duct; other conditions include biliary atresia, malignancies of the biliary tree and head of the pancreas, and strictures resulting from previous surgical procedures.
Retained bile leads to inflammation initiating periportal fibrosis and eventual cirrhosis.
Secondary bacterial infection ("ascending cholangitis") may contribute to the damage; enteric organisms such as coliforms and enterococci are common culprits.
Macroscopically, the liver is of yellow-green color and is accompanied by marked icteric discoloration of body tissues and fluids. On cut surface, the liver is hard, with a finely granular appearance.
Microscopically:
Large and small bile ducts are distended and frequently contain inspissated bile.
Portal tracts are interconnected by inflamed fibrous septa and appear edematous; there is frequently a narrow zone of edema and ductular proliferation at the junction of parenchyma and septa.
Cholestatic features may be severe, with cytoplasmic and canalicular accumulation of bile, extensive feathery degeneration of hepatocytes, and the formation of bile lakes (see earlier discussion of cholestasis).
Once the regenerative nodules of cirrhosis have formed, however, bile stasis may become less conspicuous.
Ascending bacterial infection incites a supervening robust neutrophilic infiltration of bile ducts and cholangitic abscesses.
Cardiac cirrhosis
Cardiac cirrhosis is uncommon complication of severe right-sided congestive heart failure of long-standing duration.
The common causes culminating in cardiac cirrhosis are “cor pulmonale”, tricuspid insufficiency or constrictive pericarditis.
Microscopically, the hepatic sinusoids are dilated and congested with hemorrhagic necrosis of centrolobular hepatocytes.
Then fibrous strands radiating from the central veins are observed.
Alcoholic liver disease
Alcohol abuse constitutes the major form of liver disease in many countries.
Chronic alcohol consumption has a variety of adverse effects. Of greatest impact, however, there are three distinctive, albeit overlapping, forms of liver disease:
1. Hepatic steatosis.
2. Alcoholic hepatitis.
3. Cirrhosis referred to as alcoholic liver disease.
Hepatic steatosis
Following even moderate intake of alcohol, small (microvesicular) lipid droplets accumulate in hepatocytes.
With chronic intake of alcohol, lipid accumulates to the point of creating large clear macrovesicular spaces, compressing and displacing the nucleus to the periphery of the hepatocyte.
This transformation is initially centrolobular, but in severe cases, it may involve the entire lobule.
The liver is often grossly enlarged, up to 4 to 6 kg, and is a soft, yellow, greasy organ.
Although there is little or no fibrosis at the outset, with continued alcohol abuse, fibrous tissue develops around the central veins and extends into the adjacent sinusoids.
Up to the time that fibrosis appears, the fatty change is completely reversible if there is further abstention from alcohol.
Alcoholic hepatitis
Alcoholic hepatitis exhibits the following:
Liver cell necrosis, single or scattered foci of cells undergo swelling (ballooning) and necrosis, more frequently in the centrolobular regions of the lobule.
Mallory bodies (alcoholic hyaline), scattered hepatocytes accumulate tangled skeins of cytokeratin intermediate filaments and other proteins, visible as eosinophilic cytoplasmic inclusions.
Neutrophilic reaction. Neutrophils permeate the lobule and accumulate around degenerating liver cells, particularly those having Mallory bodies. Lymphocytes and macrophages also enter portal tracts and spill into the lobule. Potentially reversible, this lesion may smaller on long after cessation of alcohol intake.
Fibrosis. Alcoholic hepatitis is almost always accompanied by a sinusoidal and perivenular fibrosis; occasionally periportal fibrosis may predominate, particularly with repeated bouts of heavy alcohol intake. Fat may be present or entirely absent. Deranged iron processing in the alcoholic typically leads to a modest accumulation of hemosiderin in hepatocytes and Kupffer’s cells. The outcome is unpredictable. The condition may resolve in the absence of further alcohol exposure or may lead to cirrhosis, but there is significant risk of death with each bout.
Alcoholic cirrhosis
The final and irreversible form of alcoholic liver disease usually evolves slowly and insidiously.
At first the cirrhotic liver is yellow-tan, fatty, and enlarged, usually weighing more than 2 kg.
Over the span of years, it is transformed into a brown, shrunken, nonfatty organ, and sometimes less than 1 kg in weight.
Cirrhosis may develop within 1 to 2 years in the setting of alcoholic hepatitis.
Initially the developing fibrous septa are delicate and extend from central vein to portal regions as well as from portal tract to portal tract.
Regenerative activity of the entrapped parenchymal acini generates fairly uniformly sized “micronodules”.
With time, the nodularity becomes more prominent; scattered nodules may become quite large, and occasionally nodules more than 2 cm in diameter may develop.
As fibrous septa dissect and surround nodules, the liver becomes more fibrotic, loses fat, and shrinks progressively in size.
Parenchymal islands are engulfed by ever wider bands of fibrous tissue, and the liver is converted into a mixed micronodular and macronodular pattern.
Further ischemic necrosis and fibrous obliteration of nodules eventually create broad expanses of tough, pate scar tissue, leaving residual parenchymal nodules that protrude like “hobnails” from the surface of the liver (“Laennec’s cirrhosis”).
By microscopy, the septa contain variable amounts of scattered lymphocytes and some reactive bile duct proliferation. Bile stasis often develops; Mallory bodies are only rarely evident at this stage.
Thus, end-stage alcoholic cirrhosis comes to resemble, both macroscopically and microscopically, postnecrotic cirrhosis.
Complications of cirrhosis
Complications of cirrhosis are subdivided into 2 groups: hepatic and non-hepatic
I. Hepatic complication:
Progressive hepatic insufficiency.
Development of hepatocellular carcinoma.
Steatorrhea due to reduced hepatic bile secretion.
Gall stones usually of pigment type, are seen twice more frequently in patients with cirrhosis than in general population.
II. Non-hepatic complication:
1. Portal hypertension (increased resistance to portal flow) and its effects such as
Ascites.
The formation of portosystemic venous shunts through variceal chanells in the esophagus, rectum, and periumbilical abdominal wall.
Congestive splenomegaly.
Hepatic ehcephalopathy.
2. Chronic relapsing pancreatitis, especially in alcoholic liver disease.
3. Infections are more frequent in patients with cirrhosis due to impaired phagocytic activity of reticuloendothelial system.
4. Hematological derangements such as bleeding disorders and anemia due to impaired hepatic synthesis of coagulation factors and hypoalbuminemia are present.
5. Cardiovascular complications such as atherosclerosis of coronaries and aorta and myocardial infarction are more frequent in these patients.
6. Hypertrophic osteoarthropathy.
7. Endocrine disorders such as gynecomastia, testicular atrophy and impotence, whereas in cirrhotic women amenorrhoe is a frequent abnormality.
8. Hepatorenal syndrome leading to renal failure may occur in late stages of cirrhosis.
Causes of death
1. Hepatic coma.
2. Massive gastrointestinal hemorrhage from esophageal varice.
3. Intercurrent infections.
4. Hepatorenal syndrome.
5. Development of hepatocellular carcinoma.
Cholelitiasis (Gallstones)
Gallstones are formed from constituents of the bile (viz. cholesterol, bile pigments and calcium salts) along with other organic components.
Accordingly, the gallstones commonly contain cholesterol, bile pigment and calcium salts in varying proportions.
They are usually formed in the gall bladder, but sometimes may develop within extrahepatic biliary passages, and rarely in the larger intrahepatic bile duct.
The incidence of gallstones varies markedly in different geographic areas, age, sex, diet and various other risk factors.
The mechanism of cholesterol gallstone formation or lithogenesis is determined by 3 major factors:
Namely supersaturation of bile with cholesterol.
Cholesterol nucleation.
The hyperfunction of gallbladder.
Types of gallstones. As stated before, gallstones contain cholesterol, bile pigment and calcium carbonate, either in pure form or in various combinations. Gallstones are of 3 major types:
Pure gallstones
Mixed gallstones
Combined gallstones.
In general, gallstones are formed most frequently in the gall bladder but may occur in exlrahepatic as well as intrahepatic biliary passages.
Numerous complications develop in cholelithiasis. They are cholecystitis, choledocholithiasis, mucocele or hydrops of the gallbladder, biliary fistula, gallstone ileus, and gallbladder cancer.
Cholecyscitis
Cholecyscitis or inflammation of the gallbladder may be acute, chronic, or acute superimposed on chronic.
Acute cholecystitis
In many ways, acute cholecystitis is similar to acute appendicitis. The condition usually begins with obstruction, followed by infection later.
Based on the initiating mechanisms, acute cholecystitis occurs in two types of situations - acute calculous and acute acalculous cholecystitis.
In majority of cases, acute cholecystitis is caused by obstruction in the neck of the gallbladder or in the cystic duct by a gallstone. The commonest location of impaction of a gallstone is in Hartman’s pouch. After that secondary bacterial infection, for instance E.coli and Streptococcus facialis, supervenes.
Acute calculous cholecystitis. The remaining 10% cases of acute cholecystitis do not contain gallstones. In such cases, a variety of causes have been assigned such as previous non-biliary surgery, multiple injuries, bums, severe sepsis, diabetes mellitus, etc.
Morphology
Except for the presence or absence of calculi, the two forms of acute cholecystitis are morphologically similar.
Macroscopically, the gall bladder is distended and tense. The serosal surface is coated with fibrinous exudate with congestion and hemorrhages. The mucosa is red. The lumen is filled with pus mixed with green bile. In calculous cholecystitis, a stone is generally impacted in the neck or in the cystic duct. When obstruction of the cystic duct is complete, the lumen is filled with purulent exudate and the condition is known as empyema of the gall bladder.
Microscopically, wall of the gall bladder shows marked inflammatory edema, congestion and neutrophilic exudate. There may be frank abscesses in the wall and gangrenous necrosis with rupture into the peritoneal cavity (gangrenous cholecystitis).
Chronic Cholecystitis
Chronic cholecystitis is the commonest type of clinical gallbladder disease.
The association of chronic cholecystitis with mixed and combined gallstones is virtually always present.
Macroscopically, the gall bladder is generally contracted but may be normal or enlarged. The wall of the gall bladder is thickened which on cut section is grey-white due to dense fibrosis or may be even calcified. The mucosal folds may be intact, thickened, or flattened and atrophied. The lumen commonly contains multiple mixed stones or a combined stone.
Microscopically, the following signs, may be observed: thickened and congested mucosa but occasionally mucosa may be totally destroyed; penetration of the mucosa deep into the wall of the gall bladder up td muscular layer to form Rokitansky-Aschoff sinuses; variable degree of chronic inflammatory reaction, consisting of lymphocytes, plasma cells and macrophages, present in the lamina propria and subserosal layer; variable degree of fibrosis in the subserosal and subepithelial layers.
Pancreatitis
Pancreatitis is inflammation of the pancreas with acinic cell injury. It is classified into acute and chronic forms both of which are two distinct entities.
Acute pancreatitis
Acute pancreatitis is an acute inflammation of the pancreas.
The severe form of the disease associated with macroscopic hemorrhages and fat necrosis in and around the pancreas is termed acute hemorrhage pancreatitis or acute pancreatic necrosis.
The condition occurs in adults between the age of 40 and 70 years and is commoner in females than in males.
The onset of acute pancreatitis is sudden, occurring after a bout of alcohol or a heavy meal. The patient presents with abdominal pain, vomiting and collapse and the condition must be differentiated from other diseases producing acute abdomen such as acute appendicitis, perforated peptic ulcer, and acute cholecystitis.
Etiology. The two leading causes associated with acute pancreatitis are alcoholism and cholelithiasis, both of which are implicated in more than 80% of cases. Less common causes of acute pancreatitis include trauma, ischemia, shock, extension of inflammation from the adjacent tissues, blood-borne bacterial infection, viral infections, certain drugs, etc.
Morphology
The morphology of acute pancreatic necrosis stems directly from the action of activated pancreatic enzymes that are released into the pancreatic substance.
The basic alterations are proteolytic destruction of pancreatic substance, necrosis of blood vessels with subsequent hemorrhage, necrosis of fat, and an accompanying inflammatory reaction.
Amorphous basophilic calcium precipitates may be visible within the necrotic focus.
Grossly, foci of pancreatic necrosis are blue-black hemorrhages and grey-white necrotic softening alternates with sprinkled foci of yellow-white, chalky fat necrosis.
Complications
A patient of acute pancreatitis who survives may develop a variety of systemic and local complications:
1. Systemic complications are chemical and bacterial peritonitis, endotoxic shock, and acute renal failure.
2. Local complications are pancreatic abscess, pancreatic pseudocyst, and duodenal obstruction.
Chronic pancreatitis
Chronic pancreatitis is the progressive destruction of the pancreas due to repeated mild and subclinical attack of acute pancreatitis.
Most patients present with recurrent attacks of severe abdominal pain at intervals of months to years.
Weight loss and jaundice are often associated. Later manifestations include associated diabetes mellitus and steatorrhea.
Etiology. Most cases of chronic pancreatitis are caused by the same factors as for acute pancreatitis.
Morphology
Chronic pancreatitis is distinguished by irregularly distributed fibrosis, reduced number and size of acini with relative sparing of the islets of Langerhans, and variable obstruction of pancreatic ducts of all sizes.
The lesions have a macroscopic lobular distribution and may involve portions or the entire pancreas.
A chronic inflammatory infiltrate around lobules and ducts is usually present.
The ductal epithelium may be atrophied or hyperplastic or may show squamous metaplasia.
Macroscopically, the gland is hard and exhibits foci of calcification and may developed pancreatic calculi. These concretions vary from calculi invisible to the naked eye, to stones 1 cm to several centimetres in diameter, giving rise to the term “chronic calcifying pancreatitis”.
With chronic ductal obstruction, the distribution of lesions is irregular, and the ductal epithelium generally is less severely damaged. Protein plugs and calcified stones are rare.
Complications
Last stage of chronic pancreatitis may be complicated by diabetes mellitus, pancreatic insufficiency with steatorrhea and malabsorption and formation of pancreatic pseudocysts.
DISEASES OF KIDNEY AND URINARY TRACT
Diseases of the kidney are characterized by the injury basic morphologic components: glomeruli, tubules, interstitium, and blood vessels. The clinical manifestations of renal diseases can be grouped into reasonably well-defined syndromes.
We can now turn to a brief description of the major renal syndromes:
Acute nephritic syndrome is a glomerular syndrome dominated by the acute inset of usually grossly visible hematuria (red blood cells in urine), mild to moderate proteinuria, and hypertension; it is the classic presentation of acute poststreptococcal glomerulonephritis (GN).
The nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminuria, severe edema, hyperlipidemia, and lipiduria.
Asymptomatic hematuria or proteinuria, or a combination of them, is usually manifestation of subtle or mild glomerular abnormalities.
Acute renal failure is dominated by oliguria or anuria, with recent onset of azotemia. It can result from glomerular injury, interstitial injury, or acute tubular necrosis.
Chronic renal failure, characterized by prolonged symptoms and signs of uremia, is the final result of all chronic renal diseases.
Renal tubular defects are dominated by polyuria, nocturia, and electrilyte disorders. They are the result of either diseases directly affecting tubular structure or defects in specific tubular infection. The latter may be inheridited or acquired.
Urinary tract infection is characterized by bacteriuria and pyuria. The infection may be symptomatic or asymptomatic, and it may affect the kidney or the bladder only.
Nephrolitiasis (renal stone) is manifested by renal colic, hematuria, and recurrent stone formation
Glomerular Diseases
Glomerular injury is a major cause of renal disease and may be primary and secondary.
Primary glomerular diseases are characterized by primary injury of the glomeruli (acute and chronic glomerulonephritis (GN), lipoid nephrosis, etc.).
In secondary glomerular diseases the kidney is one of many organs and systems damaged by a systemic disease ( Systemic lupus erythematous, diabetes mellitus, amyloidosis, etc.)
Pathogenesis of glomerular injury
The consequences of injury at different sites within the glomerulus can be assessed when compared with the normal physiologic role of the main cells involved, i.e. endothelial, mesangial, visceral epithelial, and parietal epithelial cells as well as of the GBM.
There are two basic mechanisms of glomerular injury: immune and nonimmune.
Immune mechanisms
A. Antibody-mediated glomerular injury
1. Immune complex disease.
The deposition of Ag-Ab complexes in glomeruli is a major mechanism of glomerular injury, whether they are formed “in situ” with glomerular antigens or are trapped circulating complexes.
Immunologic mechanisms underlying glomerular injury are primarily antibody-mediated (immune-complex disease). More recently there has been evidence to suggest that cell-mediated immune reactions in the form of delayed type hypersensitivity can cause glomerular injury.
Glomerular deposits are formed by one of the following two mechanisms:
Local immune complex deposits. Formation of glomerular deposits of immune complex “in situ” occurs as a result of combination of antibodies with autologous non-basement membrane antigens or nonglomerular antigens planted on glomeruli. Classic experimental model of “in situ” immune complex GN is Heymann nephritis. The examples of planted nonglomerular antigens are cationic proteins, lectins, DNA, bacterial products (e.g. a protein of group A streptococci), viral and parasitic products and drugs.
Circulating immune complex deposits. Circulating immune complexes cause glomerular damage under certain circumstances, e.g. their presence in high concentrations for prolonged periods, or when they possess properties that cause their binding to glomeruli, or when host mechanisms fail to eliminate immune complexes. The antigen-antibody complexes are trapped in the glomeruli where they produce glomerular injury after combining with complement.
Immune complex GN is observed in the following diseases:
1. Primary GN, e.g. acute diffuse proliferative GN, membranous GN, membranoproliferative GN, IgA nephropathy and some cases of rapidly progressive GN and focal GN.
2. Systemic diseases, e.g. glomerular disease in SLE, malaria, syphilis, hepatitis, Henoch-Schonlein purpura and idiopathic mixed cryoglobulinemia.
2. Anti- GBM disease.
Less than 5% cases of human GN are associated with anti-GBM antibodies. The component of GBM acting as antigen appears to component of collagen IV of the basement membrane.
Anti-GBM disease is classically characterized by homogeneous linear deposits of anti-GBM antibodies (mostly IgG; rarely IgA and IgM) and complement (mainly C3) along the glomerular basement membrane.
Anti-GBM disease is characteristically exemplified by glomerular injury in Goodpasture’s syndrome. About half to two-third of the patients with renal lesions in Goodpasture’s syndrome have pulmonary hemorrhage mediated by cross-reacting autoantibodies against alveolar basement membrane.
3. Alternative pathway disease.
The complement system, in particular C3, contributes to glomerular injury in the majority of forms of GN.
The deposits in alternate pathway of the disease are characteristically electron-dense, glomerular lesions in such cases are referred to as dense-deposit disease.
Alternate pathway disease occurs in most cases of type II membranoproliferative GN, some patients of rapidly progressive GN, acute diffuse proliferative GN, IgA nephropathy and in SLE.
4. Other mechanisms of antibody-mediated injury.
A few autoantibodies have been implicated in some patients of glomerulonephritis:
Anti-neutrophil cytoplasmic antibodies (ANCA). About 40% cases of rapidly progressive GN are deficient in immunoglobulins in glomeruli and are positive for ANCA against neutrophil cytoplasmic antigens in their circulation. ANCA causes endothelial injury by generation of reactive oxygen radicals.
Anti-endothelial cell antibodies (AECA). Autoantibodies against endothelial antigens have been detected in circulation are several inflammatory vasculitis and glomerulonephritis.
B. Cell-mediated Glomerular Injury
Recent evidence suggests that cell-mediated immune reactions in the form of delayed hypersensitivity may be involved in causing glomerular injury, particularly in cases with deficient immunoglobulins.
C. Secondary pathogenetic mechanisms
Secondary pathogenetic mechanisms are a number of mediators of immunologic glomerular injury, such as: neutrophils, mononuclear phagocytes, complement system, platelets, mesangial cells, and coagulation system.
Nonimmune mechanisms
Though most forms of GN are immunologically mediated, a few examples by non-immunologic mechanisms are found:
1. Metabolic glomerular injury, e.g. diabetic nephropathy.
2. Hemodynamic glomerular injury, e.g. systemic hypertension.
3. Deposition diseases, e.g. cryoglobulinaemia, amyloidosis.
4. Infectious diseases, e.g. HBV, HCV, HIV.
5. Inherited glomerular diseases, e.g. Alport’s syndrome, nail-patella syndrome.
These diseases destroy sufficient functioning nephrons. Adaptive changes in glomeruli to the increased workload cause epithelial and endothelial injury and resulten proteinuria. The mesangial response, involving mesangial cell proliferation and matrix deposition, and intraglomerular coagulationcause the glomerulosclerosis.
Acute Glomerulonephritis
The first group of glomerular diseases are characterized anatomically by inflammatory alterations in the glomeruli and clinically by a complex of findings classically reffered to as the syndrome of acute nephritis.
Nonrenal features, such as: arterial hypertension, hypotrophy of right heart, disproteinemia, edema, hypernitrogenemia and uremia are presence.
It is infectious-allergic or unknown etiology disease with double nonsuppurative glomerulitis.
The nephritic patient usually presents with hematuria, red cell casts in the urine, azotemia, oliguria, and mild to moderate hypertension.
The patient also commonly has proteinuria and edema, but these are not as several those encountered in the nephrotic syndrome. The acute nephritic syndrome may occur in such multisystem diseases as SLE and polyarteritis nodosa. Typically, however, it is characteristic of acute proliferative GN and is an important component of crescentic GN.
Principles of glomeluronephritis classification
Gomerulonephritis may be primary or secondary.
According to the etiology it may be bacterial, viral, unclear.
According to the pathogenesis there are 2 types of glomeluronephritis: -immuno- associated and non-immunoassociated.
According to the course GN may be classified into acute, sub-acute, chronic.
According to the histological pattern of damage seen on renal biopsy; hence knowledge of this aspect of histopathology is needed to understand disease. In morphological classification, topography, character, propagation of pathological process are accounted:
1. According to topography: iner- and extracapillary GN.
2. According to character of inflammation: nonsuppurative exudative and proliferative.
3. According to propagation: diffuse and local.
Acute poststreptococcal glomerulonephritis
It usually appears 1 to 4 weeks after streptococcal infection of the pharynx or the skin.
In occurs most frequently in children of six to ten years of age, but adults of any age can be affected.
Duration of disease may 1,5 to 12 monthes.
Gross appearance: Kidney enlarged; cortex broad, pale, without markings; medullary rays congested; glomeruli just visible as grey avascular dots.
The classic diagnostic picture is one of enlarged, hypercellular, relatively bloodness glomeruli.
The most often the histological type is intracapilary proliferative GN:
Proliferation of endothelial and mesangial cells and, in many cases, epithelial cells.
Infiltration by leukocytes, both neutrophils and monocytes. The proliferation and leukocytes infiltration are diffuse, that is, involving all lobules of all glomeruli.
There is also swelling of endothelial cells, and the combination of proliferation, swelling, and leukocytic infiltration obliterates the capillary lumen.
Special stains can demonstrate small deposites of fibrin within capillary lumina and mesangium.
There may be interstitial edema and inflammation, and the tubes often contain red cell coasts and may show evidence of degeneration.
By immunofluorescence microscopy there are glandular deposits of IgG, IgM, and C3 in the mesangium and along the basement membrane. Although present, they are often focal and sparse. The characteristic electron microscopic findings are the discrete, amorphous, electron-dense deposits on the epithelial side of the membrane, often having the appearance of “humps”, presumably representing the antigen-antibody complexes at the epithelial cell surface. Subendothelial and intramembranous deposits sometimes seen, and there is often swelling of endothelial and mesangial cells.
Rapidly progressive (crescentic) glomerulonephritis
It is a syndrome characterized by the accumulation of cells in Bowman’s space in the form of “crescents”accompanied by a rapid, progressive decline in renal function, frequently with severe oliguria or anuria, usually resulting in irreversible renal failure in weeks or months.
Morphoplogy
According to histological picture there is extracapillary proliferative GN.
The kidneys are enlarged and pale, often with petechial hemorrhages on the cortical surfaces.
Depending on the underlying cause, the glomeruli may show focal necrosis, diffuse or focal endothelial proliferation.
The syndrome is characterized histologically by the accumulation of cells in Bowman’s space in the form of “crescents”.
The histologic picture, however, is dominated by the formation of distinctive crescents, which are formed by proliferation of parietal cells and by migration of monocytes and macrophages into Bowman’s space. Neutrophils and lymphocytes can be present. The crescents eventually obliterate Bowman’s space and compress the glomerular tuft. Fibrin strands are prominent between the cellular layers in the crescents.
Electron microscopy may disclose subepithelial deposits in some cases, but in all cases shows distinct ruptures in the GBM.
In time, most crescents undergo sclerosis.
This syndrome may occur in the course of three broad disease groups:
1. Postinfectious rapidly progressive (crescentic) glomerulonephritis, complicating acute GN.
2. Systemic diseases (SLE, Goodpasture’s syndrom, polyarteritis nodosa,etc.).
3. Idiopathic.
Nephrotic syndrome
Membranous glomerulonephritis (MGN)
It is a major cause of nephrotic syndrome in adults.
It is characterized by the presence of electron-dense, immonoglobulin-containing deposits along the epithelial side of the basement membrane.
In situ formation and deposition of circulating immune complexes, involving intrinsic glomerular antigens or endogenous and exogenous or planted antigens, are postulated to account for the subepithelial electron-dense deposits.
Early in the disease, the glomeruli may appear normal by light microscopy, but well-developed cases show diffuse thickening of the capillary wall.
MGN may occur in association with known disorders or etiologic agents. These include the following:
1. Malignant epithelial tumors, particularly carcinoma of the lung and colon and melanoma.
2. Systemic lupus erythematosus (SLE).
3. Exposure to inorganic salts (gold, mercury).
4. Drugs (penicillamine, captopril).
5. Infections (chronic hepatitis B, syphilis, schistomiasis, malaria).
6. Metabolic disorders (diabetes mellitus, thyroiditis).
In about 85% of patients, the condition is truly “idiopathic”.
Morphology
By light microscopy, the glomeruli appear normal in the early stages of the disease or exhibit uniform, diffuse thickening of the glomerular capillary wall, hence the term “membranous”.
By electron microscopy the apparent thickening is caused by irregular dense deposits between the basement membrane and the overlying epithelial cells, the latter having lost their foot processes.
Basement membrane material is laid down between these deposits, appearing as irregular spikes protruding from the GMB.
In time, these spikes thicken to produce dome-like protrusions and eventually close over the immune deposits, burying them within a markedly thickened, irregular membrane.
Immunofluorescence microscopy demonstrates that the granular deposits contain both immunoglobulins and complement.
Others changes: protein and fatty droplets in the tubular epithelium and stroma. Foamy macrophages and giant cells form granulomas is association with cholesterol deposits.
With progress of the disease, narrowing of the glomerular capillaries causes ischemic atrophy of the tubules and interstitial fibrosis.
Membranoproliferative glomerulonephritis (MPGN)
As the term implies, this group of disorders is characterized histologically by alteration in the basement membrane and proliferation of glomerular cells. Because the proliferation is predominant in the mesangium, a frequently used synonym is mesangiocapillary GN.
Like many other GN, histologic MPGN either can be associated with other systemic disorders and known etiologic agents (secondary MPGN) or may be primary, without known cause (idiopathic) in the kidney.
Patients have hematuria or proteinuria demonstrate a combined nephritic-nephrotic picture.
Morphology
Primary MPGN is devided into two major types on the basis of distinct ultrastructural, immunofluorescent, and probably pathogenic findings.
By light microscopy both types are similar.
The glomeruli are large and hypercellular.
The hypercellularity is produced by proliferation of cells in the mesangium, although infiltrating leukocytes and parietal epithelial crescents are present in many cases.
The glomeruli have a “lobular” appearance accentuated by the proliferating mesangial cells and increased mesangial matrix.
The GBM is clearly thickened, often focally, most evident in the peripheral capillary loops.
The glomerular capillary wall often shows a “double-contour” or “tram-track” appearance, especially evident in silver or PAS stains.
This is caused by “splitting” of the basement membrane because of the inclusion within it of processes of mesangial cells extending into the peripheral capillary loops, so-called “mesangial interposition”.
Injury of tubular structures and stroma take place.
Minimal change disease (MCD) (Lipoid nephrosis)
Nephrotic syndrom in children can be often; characterized by normal glomeruli on light microscopy but uniform and diffuse effacement of the foot processes of visceral epithelial cells on electronic microscopy.
Etiology is unknown.
Immunofluorescence shows no immune deposits.
The most characteristic feature of this condition is the good response to corticosteroid therapy.
Proteinuria is usually selective and is associated with loss glomerular filtration (negative changes) and a hyperpermeable capillary wall.
Morphology
GBM isn’t changes.
Tubules are dilated; their epithelium is swelling, conteining hyaline and fatty droplets.
Fatty degeneration, necrobiosis, atrophy, desquamation in tubular epithelium take place.
Gross appearances (“big white kidneys”): kidneys enlarged, flabby, yellow color.
Chronic glomerulonephritis (CGN)
CGN is the final stage of GN when sclerosis has eliminated many glomeruli and their associated tubules.
This is often the late result of membranous or membranoproliferative GN, less commonly postinfectious acute nephritis.
At the final stage, it is difficult to determine the etiology of the pathological lesion.
Morphology
The kidneys are symmetrically contracted and have diffusely granular, cortical surfaces. Pieces of renal tissue adhere to stripped capsule; capsule is adherent and strips with difficult. Weight is 50 gm each. On section, the cortex is thinned and irregular, pelvis dilated and they’re in an increasing peripelvic fat. Such kidneys are called “secondary shrinkage of kidneys.
The glomerular histology depends on the stage of the disease. In early cases, the glomeruli may still show evidence of the primary disease.
Kidneys from the patients with end-stage disease on long-term dialysis exhibit a variety of so-called “dialysis changes” that are unrelated to the primary disease. Histological feature is nephrosclerosis.
These include arterial intimal thickening caused by accumulation of smooth muscle-like cells and a loose, proteoglycan-rich stroma; calcification, most obvious in glomerular tufts and tubular basement membranes; extensive deposition of calcium oxalate crystals in tubules and interstitium; acquired cystic disease; and increased numbers or renal adenomas and borderline adenocarcinomas.
Patients dying with chronic GN also exhibit pathologic changes outside the kidney that are related to the uremic state and are also present in other forms of chronic renal failure. Often clinically important, these includes uremic pericarditis, uremic gastroenteritis, secondary hyperparathyroidism with nephrocalcinosis and renal osteodystrophy, left ventricular hypertrophy due to hypertension, and pulmonary changes of diffuse alveolar damage often ascribed to uremia (uremic pneumonitis).
Uremia, hypertensive cardiac failure or cerebral hemorrhage may cause death.
Tubulopathy
Acute renal failure
Acute renal failure (ARF) is a syndrome associated with acute suppression of renal function, often accompanied by oliguria, and rarely anuria or polyuria. ARF is caused by:
1. Organic vascular obstruction.
2. Severe glomerular disease.
3. Acute tubulointerstitial nephritis.
4. Massive infection.
5. Disseminated intravascular renal coagulation.
6. Urinary obstructions.
7. Acute tubular necrosis.
Acute tubular necrosis (ATN)
ATN is characterized by destrucrion of renal tubular epithelial cells either from ischemia or nephrotoxins.
Ischemic ATN is called tubulorrhectic ATN or shock kidney, occurs due to hypoperfusion of the kidneys resulting in focal damage to the tubules.
Etiopathogenesis
Ischemia may result from following causes:
Shock (post-traumatic, surgical, burns, dehydration, obstetrical and septic).
Crush injuries.
Non-traumatic rhabdomyolysis induced by alcohol, coma, muscle disease or extreme muscular exertion (myoglobinuria nephrosis).
Mismatched blood transfusions, black-water fever (hemoglobinuric nephrosis).
The pathogenetic mechanismof ischemic ATN is explained on the basis of:
Arteriolar vasoconstriction induced by renin-angiotensin system.
Tubular obstruction by casts in the lumina or by interstitial edema.
Back-leak of tubular fluid into the interstitium.
Morphology
The kidneys are enlarged and swollen. On cut section, the cortex is often widened and pale, while medulla is dark.
Predominant changes are seen in the tubules, while glomeruli are normal. Interstitium shows edema and mild chronic inflammatory cell infiltrate. Tubular changes are as follows:
Dilatation of the proximal and distal convoluted tubules.
Focal tubular necrosis at different points along the nephron.
Flattened epithelium lining the tubules.
Eosinophilic hyaline casts or pigmented hemoglobin and myoglobin casts in the tubular lumina.
Disruption of tubular basement membrane (tubulorrhexis).
Nephrotoxic ATN occurs as a result of direct damage to tubular cells by ingestion, injection or inhalation of a number of toxic agents.
Etiopathogenesis
The toxic agents causing toxic ATN are:
General poisons such as mercuric chloride, carbon tetrachloride, ethylene glycol, mushrooms and insecticides.
Heavy metals (mercury, lead, arsenic, phosphorus and gold).
Drugs, such as sulfonamides, certain antibiotics (gentamycin, cephalosporin), anaesthetic agents (methoxyflurane, halothane), barbiturates, salicylates.
Radiographic contrast material.
The pathogenetic mechanismproducing ARF in toxic ATN is in principle similar to that for ischemic ATN.
Morphology
The kidneys are enlarged and swollen. On cut section, the cortex is pale, while the medulla is slightly darker than normal.
In general it involves the segment of tubule diffusely. In mercuric chloride poisoning, the features are as follows:
Epithelial cells of mainly proximal convoluted tubules are necrotic and desquamated into the tubular lumina.
The desquamated cells may undergo dystrophic calcification.
Tubular basement membrane is generally intact.
The regenerating epithelium, which is flat and thin with few mitoses, may be seen lining the tubular basement membrane.
The clinical course of ATN may be devided into stages:
1. The initiating stage (shock), lasting for about 36 hours, is dominated by the inciting medical, surgical, or obstetric event in the ischemic form of ATN. Macroscopically, kidneys are diffusely swollen and edematous. It is characterized by ischemic cortex and congestion of pyramids. Acute renal failure and oliguria, hyperkalemia and fluid overload in patients develop.
2. The maintenance stage (Oliguric phase, 2-9 days) is characterized by sustained decreases in urine output to between 40 to 400 ml per day, with salt and water overload, rising blood urea nitrogens, hyperkaliemia, metabolic acidosis, and other manifestations of uremia dominating this phase. There is blockage of renal tubules by necrotic cells, and a secondary reduction in glomerular blood flow (caused by arteriolar constriction) reduces glomerular filtration. It stage may be fatal.
3. The recovery stage (Polyuric phase, 10-21 days) is ushered by a steady increase in urine volume that may reach up to 3 liters per day. Regeneration of renal tubular epithelium takes place, with removal of dead material by phagocytic cells, as well as in the form of casts in urine. As tubules open up and glomerular blood flow increases, patients develop polyuria. This is because the regenerated tubular cells are undifferentiated and have not developed the specializations necessary for resorption of electrolytes and water. Replacement of fluid and electrolytes is needed to compensate for excessive loss from urine. Hypokalemia, rather than hyperkalemia, becomes a clinical problem.
The prognosis of ATN depends on the clinical setting surrounding its development.
Tubulointerstitial Disease
The term tubulointerstitial nephritis is used for inflammatory process that predominantly involves the renal interstitial tissue and is usually accompanied by some degree of tubular damage. The term interstitial nephritisis reserved for those cases where there is no primary involvement of glomeruli, tubules or blood vessels. A number of bacterial and non-bacterial, acute and chronic conditions may produce tubulointerstitial nephritis.
Pyelonephritis (PN)
PN is a renal disorder affecting tubules, intrestitium, and renal pelvis and is one of the most common diseases of the kidney. The term urinary tract infection (UTI) implies involvement of either the bladder (cystitis) or the kidney and their collecting system (pyelonephritis), or both. UTIs are extremely common disorders.
It occurs in two forms:
1. Acute PN is acute pyogenic infection.
2. Chronic PN is a more complex disorder: bacterial infection plays a dominant role, but other factors (vesicoureteral reflux, obstruction) are involved in its pathogenesis.
Etiopathogenesis
The dominant etiologic agents are the gram-negative bacilli that are normal inhabitants of the intestinal tract: E.coli (Proteus, Klebsiella and Enterobacter), Str. fecalis etc.
In most patients with UTI, the infecting organisms are derived from the patient’s own fecal flora. This is thus a form of endogenous infection.
There are two routs by which bacteria can reach the kidneys:
a) Through the bloodstream (hematogenous).
b) From the lower urinary tract (ascending infection).
Although obstruction is an important predisposing factor in the pathogenesis of ascending infection, it is incompetence of the vesicoureteral orifice that allows bacteria to ascend the ureter into the pelvis.
Acute Pyelonephritis
Morphology
The hallmarks of acute PN are patchy interstitial suppurative inflammation and tubular necrosis.
Macroscopically, the kidneys show variable numbers of small, yellowish white cortical abscesses, which are usually spherical, under 2 mm in diameter, and are sometimes surrounded by a zone of hyperemia; the cortical abscesses are often most prominent on the sub-capsular surface, after the capsule has been stripped away. In the medulla the abscesses tend to be in the form of yellowish white linear streaks that converge on the papilla. The pelvicalyceal mucosa is hyperemic or covered with a fibrinopurulent exudate.
Histologically: the neutrophilic infiltration is limited to the interstitial tissue. Some tubules destroyed: abscesses formed; other tubules filled by puss cells. Glomeruli usually unaffected.
Clinical features. Classically, acute pyelonephritis has an acute onset with chills, fever, loin pain, lumbar tenderness, dysuria and frequency of micturition. Urine will show bacteria, pus cells and pus cell casts in the urinary sediment.
Three complications of acute PN are encountered in special circumstances.
Papillary necrosis is seen mainly in diabetics and in those with urinary tract obstruction. Papillary necrosis is usually bilateral, but may be unilateral.
Pyonephrosis is seen when there is total or almost complete obstruction, particularly when it is high in the urinary tract (pelvis filled with puss).
Perinephric abscess implies extension of suppurative inflammation through the renal capsule into the perinephric tissue.
At the acute phase of PN, healing occurs. The neutrophilic infiltration is replaced by macrophages, plasma cells, and (later) lymphocytes. The inflammatory foci are eventually replaced by scars. The pyelonephritic scar is almost always associated with inflammation, fibrosis, and deformation of the underlying calyx and pelvis.
Uncomplicated acute PN usually follows a benign course, and the symptoms disappear within a few days after the institution of appropriate antibiotic therapy. In the presence of unrelieved urinary obstruction, diabetes mellitus acute PN may be more serious, leading to repeated septicemic episodes.
Chronic Pyelonephritis (CPN)
Chronic PN is a chronic tubulointerstitial renal disorder in which chronic tubulointerstitial inflammation and renal scarring are associated with pathologic involvement of the calyces and pelvis.
Etiopathogenesis
Two types of chronic pyelonephritis are described:
Reflux nephropathy. Reflux of urine from the bladder into one or both the ureters during micturition is the major cause of chronic pyelonephritis. Vesicoureteric reflux is particularly common in children, especially in girls, due to congenital absence or shortening of the intravesical portion of the ureter so that ureter is not compressed during the act of micturition. Reflux results in increase in pressure in the renal pelvis so that the urine is forced into renal tubules, which are eventually followed by damage to the kidney and scar formation.
Obstructive pyelonephritis. Obstruction to the outflow of urine at different levels predisposes the kidney to infection. Recurrent episodes of such obstruction and infection result in renal damage and scarring.
Morphology
Gross examination. The kidneys are usually small and contracted (weighing less than 100 gm) showing unequal reduction; if bilateral, the involvement is asymmetric. The surface of the kidney is irregularly scarred; the capsule can be stripped off with difficulty due to adherence to scars. There is generally dilatation of pelvis and blunted calyces. This contrasts with chronic glomerulonephritis, in which the kidneys are diffusely and symmetrically scarred.
The microscopic changes involve predominantly tubules and interstitium.
The tubules show atrophy in some areas and hypertrophy in others, or dilatation. Dilated tubules may be filled with colloid crystals, producing thyroidisation of tubules (thyroid-like).
Interstitium. There is chronic interstitial inflammatory reaction, chiefly composed of lymphocytes, plasma cells and macrophages with pronounced interstitial fibrosis. Xanthogranulomatous pyelonephritis is an uncommon variant characterised by collection of foamy macrophages admixed with other inflammatory cells and giant cells.
Pelvicalyceal system. The renal pelvis and calyces are dilated. And show marked chronic inflammation and fibrosis.
Blood vessels. Blood vessels entrapped in the scarred areas show obliterative endarteritis.
Glomeruli. There is often periglomerular fibrosis. In advanced cases, there may be hyalinisation of glomeruli.
Clinical features
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