00:01
So let's talk about some
of the most common causes
of chronic kidney disease
that you're going to encounter.
00:07
And when I do this,
I really like to subdivide them
into the different
parts of the Nephron
that are different parts of
the kidney that are affected.
00:14
So that includes the
tubules and interstitium
the vascular component
of the kidney
the glomerular
component of the kidney
and then post renal
parts of the kidney,
which means that there's
a process going on
anywhere from the renal
pelvis to the bladder.
00:30
So we'll start out with the
tubules and interstitium.
00:35
So some of the most common
diseases that you'll see
is polycystic kidney disease.
00:40
Polycystic kidney disease is
probably the number
one genetic disease
that we see in our
adult population.
00:47
It's autosomal dominant
and it presents
again in adulthood.
00:50
It's associated with a
PKD 1 + PKD 2 mutations.
00:55
That's poly system
one and poly system 2
and what that means is these
genes actually encode for cilia
on the epithelial cells.
01:05
Again, it's the most common
cause of genetic kidney disease
that we see certainly
in the adult population
and it's a disease
that really has progression
these patients when they're diagnosed
with polycystic kidney disease
will progress likely to the need
of renal replacement therapy.
01:21
Certainly if there
are PKD 1 mutation
meaning that they're going to
need dialysis or transplant
and although we do have
some therapies available
that can slow progression.
01:31
We don't have anything
that can cure this
disease as of yet.
01:35
Now there's also an
autosomal recessive variant
and that typically is going
to present in childhood
So my pediatric
Nephrology colleague
see these people more
common than I do.
01:44
It's also referred to as infantile
polycystic kidney disease
and that's associated
with cystic dilatation
of the collecting duct and
congenital hepatic fibrosis.
01:52
Most of the time
by the time these patients come
to me and see me in my clinic.
01:56
They've already
been transplanted
both with the kidney
and liver transplant.
02:00
Another category of
tubuleinterstitial diseases
that we have to think about are the
some of the autoimmune diseases.
02:06
This includes things
like Sjogren's syndrome,
if you remember Sjogren's syndrome
is associated with seckel syndrome,
that means dryness.
02:12
So patients will manifest
with destructions to the
lacrimal and salivary glands
and its associated with a
polyclonal B Cell Activation.
02:20
Sarcoidosis is another
autoimmune disease that we need
to worry about that can cause
tubule interstitial disease.
02:26
And remember this is
really kind of defined
by these non
non-caseating granulomas
as shown in our top
figure over here.
02:34
And that bottom figure
has a beautiful giant cell
that we can see
also in sarcoidosis.
02:40
Both of these are really marked
by an inflammatory infiltrate
in that tubuloininterstitium.
02:46
In the case of
Sjogren's syndrome,
I tend to get a lympho
plasmacyric infiltrate
and in the case of
sarcoidosis as seen here,
I get a lymphocytic infiltrate
with these kind of beautiful
non-caseating granulomas
and those giant cells as well.
03:00
And because of
this and because of
where these inflammatory
infiltrates are
our patients often will manifest
with tubular dysfunction.
03:10
So another tubulin are
still disease to think about
is something like
reflex nephropathy.
03:15
We can see this in our
pediatric population
who have vesicle ureter reflux.
03:19
And that means that they have
passage of urine from the bladder
to the upper urinary tract and
although some people
will think about this
as obstructive uropathy
or a post renal disease
because that urine is refluxing
into that renal pelvis
and into the cortex,
then we end up having damage
and inflammatory infiltrates
in that cortical
part of the kidney
and that's really how
that manifests more
as tubuloininterstitial disease.
03:41
So again when we see
reflux nephropathy
this is typically due
to inadequate closure
of the ureterovesical junction
almost seen exclusively in
our pediatric population.
03:54
Okay.
03:54
So those are probably
some of the most
important disease processes
that you're going to see
in the tubular
interstitial category
that will present as
chronic kidney disease.
04:03
Let's move on to the vascular
compartment of our kidney.
04:07
So one of the biggest
diseases to really think about
is something called
hypertensive vasculopathy.
04:14
So this is associated
with chronic hypertension
or hypertensive nephrosclerosis.
04:18
So very common the
number two cause
of people being on dialysis
in the United States.
04:24
And what we see pathologically
is these patients
have an intimal thickening
and luminal narrowing
of their large and
small renal arteries
and glomerular arterioles.
04:33
We can also see renal
vascular disease
and we're going to talk about this
in our secondary hypertension lecture
and this is can be
due to either having
bilateral or unilateral
renal artery stenosis
and you can see this image here
is actually a renal angiogram of a
patient who has fibromuscular dysplasia.
04:49
So they have renal artery
stenosis from their fmd
and they actually are
doing an angiogram
where they're doing percutaneous
transluminal angioplasty
to actually balloon up
that area of stenosis,
which is one of the treatments
for our patients who have fmd.
05:03
And again, we'll talk a
little bit more about that
when we get to our secondary
hypertension lecture.
05:09
Another category of vascular disease
is renal atheroembolic disease.
05:13
So we also talked about this in
our acute kidney injury lecture.
05:16
But again,
what happens here is we have
these cholesterol emboli
that embolize distally
and it's caused by
either having coronary,
aortic or renal
artery manipulation.
05:29
So again, it's also a cause
of acute kidney injury,
but the unfortunate part
is that many of our patients
don't recover function
and renal atheroembolic disease
ends up manisfesting and progressing
to chronic kidney disease.
05:43
So let's move on to our
next part of the kidney,
which is the glomerular part
and glomerular diseases.
05:49
So the number 1 common disease
in the glimmer of
the compartment
and actually the most
common cause of CKD
and end-stage renal
disease in the U.S.
05:57
is diabetic nephropathy.
06:00
So we're going to focus
a little bit more closely
on this later in the lecture.
06:03
But what I want you to notice
here in are pathological image.
06:06
This is a patient who
has diabetic nephropathy
and you can really see what
that arrow is pointing to
which is a diabetic nodule
that means at that
mesangial area
is actually really filled
with mesangial matrix
very acellular
and patients tend to get a very
nodular glomerular sclerosis.
06:25
Other diseases at the glomerulus
also manifest with
glomerular disease.
06:29
So these are some of
our primary diseases
and we're going to be
talking about these
as well as diabetes in our nephritic
and nephrotic disease lecture.
06:38
Okay moving on to
the last portion
is really the post renal portion
and we talked a little bit about
this before in our AKI lecture,
but this really occurs
when there's prolonged
obstruction of urine
anywhere from that renal pelvis
to the urethra.
06:54
And when we have prolonged
obstruction without intervention,
we can actually end up with
parenchymal loss in the kidney.
07:01
So you end up
losing nephron mass
because of that compression
for reflux of urine
back into that renal pelvis.
07:07
And these are going to
include conditions like
benign prostatic hyperplasia.
07:13
It's going to include things
like urethral strictures
chronic obstructive calculi
nephrolithiasis or stones
in particular these
big staghorn calculi
that take up the
entire renal pelvis
or pelvic masses
that can cause either intra or extra
renal compression of the ureters.