Atlas of Renal Pathology

83 Pages·1980·10.418 MB·English

by  R. A. Risdon, D. R. Turner (auth.)

Atlas of Renal Pathology
Current Histopathology
Consultant Editor
Professor G. Austin Gresham, TD, SeD, MD, FRC Path.
Professor of Morbid Anatomy and Histology, University of Cambridge
VolumeTlNo
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RENAL
PATHOLOGY
BY R. A. RISDON
Reader in Morbid Anatomy and Honorary Consultant Pathologist
The London Hospital Medical College
AND D. R.TURNER
Reader in Pathology and Honorary Consultant Pathologist
Guy's Hospital Medical School, London
Published by
MTP Press Limited
Falcon House
Cable Street
Lancaster, England
Copyright © 1980 R. A Risdon and D. R. Turner
Softcover reprint of the hardcover 15 t edition 1980
All rights reserved. No part of this publication
may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording
or otherwise, without prior permission from the
publishers.
British Library Cataloguing in Publication Data
Risdon, R A
Atlas of renal pathology.- (Current
histopathology series; vol. 2).
1. Kidneys-Diseases
I. Title II. Turner, DRill. Series
616.6'1 '07 RC904
ISBN-13: 978-94-009-8691-6 e-ISBN-13 978-94-009-8715-9
001 10.1007/978-94-009-8715-9
Contents
Consultant editor's note 7
Introduction 9
1 Microscopical anatomy of the kidney 11
2 Congenital malformations of the kidney 15
3 Renal cystic disease 19
4 Renal infection 23
5 Arteriosclerosis, benign and malignant
nephrosclerosis and renal artery stenosis 27
6 Renal infarction, cortical necrosis and
tu bu lar necrosis 31
7 I nterstitial nephritis 35
8 Glomerulonephritis 41
9 Diffuse endocapillary and mesangial
proliferative glomerulonephritis 43
10 Diffuse mesangiocapillary and extra-
capillary proliferative glomerulonephritis 47
11 Diffuse membranous glomerulonephritis
and 'minimal change' disease 51
12 Focal g lomeru lonephritis 55
13 Microangiopathic haemolytic anaemia
and scleroderma 63
14 Renal disease in pregnancy 67
15 Amyloidosis and myelomatosis 71
16 Diabetic renal disease and urolithiasis 75
17 Renal transplantation 79
18 Alport's syndrome and congenital
nephrotic syndrome 83
Index 87
Current Histopathology Series
Already published in this series:
Volume 1 Atlas of Lymph Node Pathology
Other volumes currently scheduled in this
series include the following titles:
Atlas of Breast Pathology
Atlas of Cytology
Atlas of Gastro-intestinal Pathology
Atlas of Gynaecological Pathology
Atlas of Joint and Connective Tissue Pathology
Atlas of Liver Pathology
Atlas of Male Reproductive System Pathology
Atlas of Muscle Pathology
Atlas of Neuropathology
Atlas of Oral Pathology
Atlas of Pulmonary Pathology
Atlas of Skin Pathology
Atlas of Toxicology
Consultant Editor's Note
At the present time books on morbid anatomy and techniques which should be within the com
histology can be divided into two broad groups: pass of the worker in a unit with reasonable
extensive textbooks often written primarily for facilities.
students and monographs on research topics. 3. New types of material e.g. those derived from
This takes no account of the fact that the vast endoscopic biopsy should be covered fully.
majority of pathologists are involved in an essentially 4. There should be an adequate number of
practical field of general Diagnostic Pathology. pro illustrations on each subject to demonstrate the
viding an importantservicetotheirclinical colleagues. variation in appearance that is encountered.
Many of these pathologists are expected to cover a 5. Colour illustrations should be used wherever
broad range of disciplines and even those who they aid recognition.
remain solely within the field of histopathology
The present concept stemmed from this definition
usually have single and sole responsibility within
but it was immediately realized that these aims could
the hospital for all this work. They may often have no
only be achieved within the compass of a series. of
chance for direct discussion on problem cases with
which this volume is one. Since histopathology is.
colleagues in the same department. In the field of
by its very nature. systematized. the individual vol
histopathology. no less than in other medical fields.
umes deal with one system or where this appears
there have been extensive and recent advances. not
more appropriate with a single organ.
only in new histochemical techniques but also in
Several volumes of this series of current histo
the type of specimen provided by new surgical
pathology are now being prepared. This is the
procedures.
second volume of the series; the first volume
There is a great need for the provision of appro
appeared in January 1980 and has been accepted
priate information forthis group. This need has been
as a valuable bench manual for the histopathologist.
defined in the following terms.
The design and content of this second volume on
1. It should be aimed at the general clinical patho renal pathology has the same aims in view and will.
logist or histopathologist with existing practical without doubt. achieve them. The authors have
training. but should also have value for the selected topics which often provide problems for
trainee pathologist. the diagnostic histopathologist. The concise text
2. It should concentrate on the practical aspects coupled with comprehensive illustrations is a model
of histopathology taking account of the new for the series.
G. Austin Gresham
Cambridge
Introduction
This book is intended as a practical bench manual phological abnormalities in renal diseases, and
for the hospital pathologist who wishes to have where appropriate these have been illustrated.
access to a simple informative account of renal Although the main emphasis is on the pathology,
pathology, particularly for the interpretation of the relevant clinical aspects of the conditions cov
percutaneous needle biopsy specimens. I n addition ered are included in recognition of the fact that
we trust it will be valuable to physicians working renal disease is an area in which correlation of the
in the field of renal disease, for whom the interpre clinical and histopathological findings is particularly
tation of renal biopsy material is directly relevant to important in reaching an informed diagnosis.
patient management.
Whilst a comprehensive coverage more appro
priate to a larger text has not been attempted, the
Acknowledgements
text has been planned to give an adequate account
of the more important non-neoplastic disease pro We would like to thank the technical staff of the
cesses and their pathological appearances in the Histopathology Laboratories of The London Hos
kidney. Points of difficulty in interpretation and dif pital Medical College, The Hospital for Sick Chil
ferential diagnosis are covered both in the text and in dren, Great Ormond Street, and Guy's Hospital
the illustrations. Special staining techniques, immu Medical School for the preparation of the sections
nofluorescence, and immunoperoxidase methods, from which the majority of the illustrations have
electron microscopy and the use of plastic been made, the staffs of the Medical Illustration
embedded sections for light microscopy are often Departments of these institutions for their help and
useful and occasionally vital in identifying the mor- advice, and Rose Heron who typed the manuscript.
1
Microscopical Anatomy of the Kidney
The functional units of the kidney are the nephrons the vascular compartment whilst the slit pore mem
of which about a million are present in each organ. branes act as a fine filter for relatively small macro
Each nephron consists of a tubule (about 50 mm molecules. The cytoplasm of the tuft epithelial cell
long and between 20 and 50jLm in diameter) with contains an abundant granular endoplasmic reticu
a lobulated tuft of specialized capillaries at the ex lum, the cisternae of which sometimes contain
panded blind proximal end which forms the glo secretory bodies which may be concerned in the
merulus. Blood flow to the kidneys is large in relation formation of the GBM. The nucleus is characteristi
to their size and about one-fifth of the plasma volume cally indented and mitochondria are present in its
passing through the kidneys is filtered through the vicinity. Myofilaments and microtubules, arranged
.glomerular capillary walls to produce a nearly randomly or in bundles, are sometimes demon
protein-free glomerular filtrate. This is modified by strable in the foot processes and these may possibly
selective reabsorption and secretion during its pas have contractile potential.
sage through the tubules to form urine. The various Within the confines of the GBM, the endothelial
mechanisms controlling this process help to main cells line the vascular lumina of the capillaries, and
tain the normal volume and constitution of the the mesangial cells lie within the stalks of the lobules
extracellular fluid. and are separated from the adjacent capillary lumina
by an endothelial cell (Figures 1.5 and 1.6).
The endothelial cell nucleus and much of its cyto
Glomerulus
plasm is usually situated on the axial side of the
The glomerular tuft capillaries are supplied with capillary loop, but the rest of the capillary circum
blood by an afferent arteriole and drained by an ference is lined by a very thin layer of endothelial
efferent arteriole. Within the tuft the capillaries are cytoplasm. This layer is not completely continuous,
grouped in lobules; in histological sections, the being breached at intervals by numerous holes or
capillaries are often cut obliquely so that their cross fenestrations up to 100 nm in diameter. Around the
sectional profiles are oval, irregularly curved or endothelial cell nucleus are mitochondria, a Golgi
sometimes branched. The glomerular tuft lies in a apparatus and endoplasmic reticulum. Vacuoles of
spherical space (the urinary space) bounded by varying size and fibrillar elements are also found in
Bowman's capsule. This consists of a basement the cytoplasm.
membrane lined by flattened ep"ithelial cells (Figures The centrilobular mesangial cells possess numer
1.1 and 1 .2). ous cytoplasmic processes which interdigitate be
The capillaries of the glomerular tuft have a con tween adjacent cells. They are separated by an
tinuous basement membrane (GBM) common to amorphous fibrillary material (mesangial matrix) re
all the loops. This consists of three layers, a central sembling the GBM in consistency and electron
electron-dense layer (the lamina densa) between density, and continuous with the lamina rara interna
two less electron-dense layers (the lamina rara in at the edge of the mesangium. Some workers claim
terna and externa) (Figure 1.3). The prominence of that tiny intercellular channels can be demonstrated
the three layers varies somewhat depending on the in the mesangial matrix, and that particulate matter
method of fixation, and some authors consider the and plasma from the capillary lumina can gain access
layering to be purely a fixation artefact. to them via fenestrations in the endothelial lining of
Three types of cell are recognized in the glomeru the glomerular capillaries situated over the mesan
lar tuft. Epithelial cells envelop the outer surface of gium. The mesangial cell has an irregularly shaped
the GBM and endothelial and mesangial cells lie nucleus with relatively little cytoplasm and the
within the GBM. The epithelial cells (or podocytes) usual organelles. It is presumably responsible for
are attached to the GBM by innumerable thin cyto the formation of mesangial matrix, and may be con
plasmic processes (foot processes) (Figure 1.3). cerned with the regulation of glomerular blood flow.
Scanning electron microscopy reveals the three A typical ultrastructural feature is the presence of
dimensional aspect of their structure and shows localized densities on the inner aspect of the cytoc
that the foot processes form a complex 'herring plasmic membrane similar to those seen in smooth
bone' array, and that the foot processes of adjacent muscle cell cytoplasm.
·podocytes interdigitate with one another like the
clasps of a zip-fastener. High magnification trans
mission electron microscopy reveals thin diaphragms
Juxtaglomerular Apparatus (Figure 1.7)
(slit pore membranes) bridging the gaps between
adjacent foot processes (Figure 1.4). It has been The juxtaglomerular apparatus (JGA) is situated at
suggested that the GBM acts as a 'coarse' filter pre the (vascular) hilum of the glomerulus and has three
venting the escape of large macromolecules from components:
12 MICROSCOPICAL ANATOMY OF THE KIDNEY
Figure 1.1 A glomerulus stained by Jones' methenamine silver tech Figure 1.2 A normal glomerulus from a renal biopsy embedded in Epon.
nique to demonstrate normal thickness of mesanglal matrix and glomerular and stained with toluidine blue. Note the improved histological clarity
capillary basement membranes. x 480. achieved by this technique. x 600.
Figure 1.3 Electron microscopy of part of a normal glomerular capillary Figure 1.4 High power electron micrograph of GBM showing the thin
loop. The basement membrane is composed of a central lamina denss with slit pore membranes between individual epithelial foot processes. x 36 250.
an inner and outer lamina rara. There is a thin fenestrated lining of endo
thelial cytoplasm and on the outer aspect of the GBM are the inter·
digitating foot processes of the epithelial cells. x 7750.
Figure 1.5 Electron micrograph of part of a glomerular tuft lobule. The Figure 1.6 High power light photomicrograph of part of a glomerular
GBM of the three capillary profiles is continuous. Within its confines are tuft stained as in Figure 1.1. By comparison with the last figure epithelial.
two nuclei: one. that of an endothelial cell (En) lining the capillary lumen. endothelial and mesangial cells can be identified. The capillary lumina
the other. that of a mesangial cell (M). Outside the GBM two epithelial contain many red blood cells and a single neutrophil polymorph. The
nuclei (Ep) are present together with numerous foot processes. Part of silver impregnation details a normal amount oJ mesangial matrix. x 1680.
Bowman's capsule (B) is also present with a few collagen fibres. x 3600.
MICROSCOPICAL ANATOMY OF THE KIDNEY 13
Figure 1.7 The juxtaglomerular apparatus (JGA) is often an incon Figure 1.8 An electron micrograph of part of a proximal convoluted
spicuous structure unless sectioned fortuitously. This example is hyper tubule showing the microvilli of the brush border and numerous densely
plastic. Towards the top left part of the glomerular tuft an afferent arteriole staining mitochondria. x 3600. .
is visible and in the wall of the latter are many granular epithelioid cells and
agranular lacis cells. The distal convoluted tubule is cut across twice and
the macula densa is easily recognized by the crowding of the nucleI.
x 960.
Figure 1.9 Electron micrograph of the thin limb of the loop of Henle Figure 1.10 Electron micrograph of an afferent arteriole. The wall is
(rat kidney). Adjacent to this on the right-hand side is an interstitial cell composed of smooth muscle cells and the lumen is lined by endothelial
containing electron-dense lipid droplets. x 4200. (By courtesy of Dr E A. cells. Adjacent to the arteriole are thin walled capillaries. x 1625.
Molland)