Renal Pathology CASE 1 Final

8/3/2019 Renal Pathology CASE 1 Final

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Renal Pathology

Case 1Med 2 Section C

Srikirin, Ruangruj Movaliya, GhanshyamKaewnil, Kaewwalee Kathiriya, YogeshVirattayanon, Nantiwat Patel, Pinakin

Sindhupreechapong, Russarin Dave, Nischay


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Patient History and

Chief Complaint

65-year-old woman

Complaint of hematuria (gross) for the past6 months with right flank pain

No fever, dysuria, and oliguria


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Laboratory Results

Urinalysis results

Numerous red blood cells (no red cellcasts)

Few white blood cells

Normal range: CBC, Creatinine, and BUN


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DifferentialDiagnosis/PxsContd.

Renal

Trauma

Renal Cell

Carcinoma

Lower Urinary

Track

Infection

Nephro

lithiasis

Pyelo

nephritis

(Acute)

Hematuria

Flank Pain (maybewith mass)

(with mass)

No Fever (fever +NAV)

No Dysuria

No Oliguria (urineretention)

Urinalysis

Numerous

RBCs (no

red cell casts)

Few white

cells(complication

= infection)

Normal CBC,

Creatinine, BUN(w/ imparied

renal function)

(w/ impaired

renal function)

(increasedcreatinine)


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Final Diagnosis

Nephrolithiasis

Kidney stones result when urine becomes tooconcentrated and substances in the urine crystallizeto form stones

Symptoms arise when the stones begin to move downthe ureter causing intense pain.

Often as small as grains of sand and pass out of the

body in urine without causing discomfort. If deposited, the size can be pea sized, marble sized,

or even larger.


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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 urinaryconcentration of the stones' constituents, such

that it exceeds their solubility (supersaturation).


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Clinical Manifestations

and their Mechanisms

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

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

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

Red blood cells in the urine can come from the kidney oranywhere in the urinary tract. When kidney stones travelthrough the urinary tract, it can damage the inner lining of

the tract and may cause hematuria.
http://www.virtualmedicalcentre.com/symptoms.asp?sid=4http://www.virtualmedicalcentre.com/symptoms.asp?sid=4


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Additional Studies and the

Possible Results

A stone chemical composition analysis should be performed wheneverpossible, and information should be provided to motivated patientsabout possible 24-hour urine testing for long-term nephrolithiasisprophylaxis.

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 spontaneouspassage.

A stone less than 4 mm in diameter has an 80% chance of spontaneouspassage; this falls to 20% for stones larger than 8 mm in diameter.

However, stone passage also depends on the exact shape and locationof the stone and the specific anatomy of the upper urinary tract in theparticular individual.


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Morphologic Findings

(Gross)

Nephrolithiasis. A large stone impacted in the renal pelvis


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Morphologic Findings

(Microscopic)

(A) Extensive pelvicnephrolithiasis(between arrows) dueto uric acid stoneformation.

(B) Light microscopyof renal tissueshowing partlyamorphous, partlyrectangular andbirefringent crystals

(marked with *).

(C) Interstitialinfiltrates of myeloidcells in the kidney atautopsy.


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Complications

Complications include:

Kidney failure

Obstructed kidney:

May cause kidney damage or an infection

(pyelonephritis)

Pyelonephritis

Sepsis


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Prognosis

Kidney stones are painful but usually are excreted withoutcausing permanent damage.

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

nephrolithiasis in first-time stone formers is 50% at 5 years and80% at 10 years.

The patients at highest risk for recurrence are those who are notcompliant with medical therapy and dietary/lifestylemodifications, or where underlying metabolic abnormalities

exist.

Residual stone fragments from surgery will usuallyspontaneously pass as long as their size is


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Management/ Treatment

90% of stones 4 mm or less in size usually will passspontaneously, however 99% of stones larger than6 mm will require some form of intervention, basedon clinical history.

Hydration (at least 2.53 L/day ) and diuretics toencourage urine flow and prevent further stone

formation Caution in food with high concentrations of oxalate

(e.g. starfruit)


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Management/ Treatment

Extracorporeal Shock Wave Lithotripsy (ESWL) (nonsurgical)

The shockwaves are focused on the calculus, and the energyreleased as the shockwave impacts the stone producesfragmentation.

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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Thank you

Documents

Renal Pathology CASE 1 Final