Zawada, Edward T.

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Introductory Chapter: Renal Diseases

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Selection of our books indexed in the Book Citation Index in Web of Science™ Core Collection (BKCI)Interested in publishing with us? Contact book.department@intechopen.comNumbers displayed above are based on latest data collected. For more information visit www.intechopen.comOpen access books availableCountries delivered to Contributors from top 500 universitiesInternational  authors and editorsOur authors are among themost cited scientistsDownloadsWe are IntechOpen,the world’s leading publisher ofOpen Access booksBuilt by scientists, for scientists12.2%122,000 135MTOP 1%1544,800ChapterIntroductory Chapter: RenalDiseasesEdward T. Zawada1. IntroductionRenal diseases are notoriously silent. Renal diseases are notoriously expensiveonce they have led to end-stage renal failure requiring dialysis or transplantation.Most acute and chronic renal diseases present with rising serum creatinine andblood urea nitrogen, electrolyte abnormalities, frequent proteinuria, occasional redblood cells in the urine, occasional white blood cells in the urine, or renal cells in theurine often mistaken for white blood cells. It is not easy to make a specific diagnosisfrom these similar presentations.I will now present the rationale for renal biopsy to establish renal diagnoses [1].The classification which follows is the opinion of the author and editor based onover 45 years of experience and exposure to the pioneers in use of renal biopsy fordiagnosis [2–4]. My goal is to simplify this argument for performing this invasiveprocedure to clarify the confusing array of renal diseases with indistinct or asymp-tomatic presentations.2. Renal disease diagnosisAcute renal diseases are described as prerenal, renal, and postrenal, but mostpatients totally recover normal or near-normal renal function. It is the chronic,often symptomless chronic diseases which lead surreptitiously to end-stage renaldisease. Chronic diseases include vascular, glomerular, tubular, and interstitial dis-eases. The main structures of the kidney are arteries and veins, glomeruli, tubules,and interstitium. Renal biopsy is often required to determine the site of injury. Asdescribed below, even when the site of injury is known, such as in glomerulardiseases, the renal biopsy is needed to distinguish between the many similar dis-eases in order to develop possible remission-inducing therapy strategies.I have been teaching about renal diseases since for 40 years since 1979. I havebeen struck by three main perspectives. First, diseases can occur in very small areasof the structures of the kidney while the rest of the kidney tissues work well and tryto compensate. Second, glomerular diseases are confusing to understand becauseone needs a framework to separate the multiple very similar diseases into separateclinically relevant entities allowing individual management. Finally, the tubulardiseases are the most silent of renal diseases, needing more effort to teach, under-stand, identify, and manage. Renal biopsy results will be briefly described as thetool to make a definitive diagnosis necessary for proper patient management.13. Renal biopsyNormal renal histology must be known to the clinician before biopsy can beinterpreted. The glomeruli will be numerous and have wide-open, thin-walledcapillary loops; no inflammatory cells seen; and no increase in numbers ofmesangial cells. There can be less than 30% of any glomerulus or all glomeruli whichcontain amorphous loss of architecture called sclerosis. The blood vessels need to beopen without cellular or muscular thickening. Finally, the cross section of renaltubules normally abuts directly against each other without evidence of inflamma-tory cells or scarring by fibrosis between them.4. Renal diseases identified by biopsyGlomerular diseases require the visualization of light microscopy to best under-stand the numerous entities, many of which have similar immune-mediated patho-physiology. There are nine main light microscopic patterns. Each has a primary andsecondary form. This classification allows one to understand the differences of 18different confusing entities. These patterns are nil lesion, diffuse membranous,diffuse proliferative, diffuse membranoproliferative, focal proliferative, focal scle-rosis, nodular glomerulosclerosis, fibrillary, and amyloidosis. For almost everyone,there is a primary and secondary form. The primary forms are idiopathic. Thesecondary forms are due to a bacteria or virus, a drug, or a systemic disease such aslupus. Based on the light microscopy, the clinician determines if there is a definitecause or whether it is primary. From either category a specific management hasreached consensus by nephrologists through international symposia and guidelines.Tubular diseases do not often show azotemia early. Rather subtle electrolytefindings such as hyperkalemia, hyperuricemia, or non-anion gap metabolic acidosissuggest this category of disease. However, since those disturbances can occur withnonrenal diseases such as gastrointestinal problems, they are not often recognizedas early signs of renal damage. Renal biopsy helps distinguish the following mostcommon causes: obstructive or reflux nephropathy, hypertensive injury called acuteor chronic nephrosclerosis, drug-induced diseases such as due to analgesics, heavymetal injury such as due to lead, crystal diseases such as urate or oxalate, andunknown causes such as Balkan or other environmental nephritides.Vascular diseases may occur with or without glomerulonephritis. Fibrinoidnecrosis, chronic hypertensive changes of the arteries (nephrosclerosis), and vas-culitis are the most common patterns. Fibrinoid necrosis is seen with malignanthypertension, thrombotic thrombocytopenic purpura, scleroderma, eclampsia, anddisseminated intravascular coagulation.Interstitial diseases are identified by acute and chronic inflammatory cells orfibroblasts and collagenous scarring between the tubules causing secondary tubularinjury and renal failure. Chronic allograft nephropathy and chronic pyelonephritisare two examples.5. ConclusionThe above framework to be used for the management of patients with chronicunexplained or understood renal insufficiency is frequently changing. New entitiesare appearing to add more patterns, more secondary causes of glomerular diseases,and new algorithms for management [5, 6]. Renal disease due to human2Renal Diseasesimmunodeficiency virus, new drugs including new biologicals, and new immuno-logic diseases accounts for some of these newer entities.In conclusion, a word should be said about repeat renal biopsies. Repeat biopsiesare encouraged to assess response to treatment such as in allograft rejection. Repeatbiopsies are used to reassess those diseases such as lupus nephritis which can changecourse leading to new pathophysiology and demanding a change in therapeuticstrategy.Finally, the group at New York Presbyterian/Columbia University MedicalCenter should be commended as they have continued to provide the most compre-hensive annual tutorial and update of the interpretation of renal biopsies based onthe very large number of biopsies referred to them [7]. Many of the chapters in thisbook concentrate on the importance of renal biopsy for diagnosis. Other chaptersdeal with methods of performing renal biopsy. Finally, there are chapters dealingwith complications of renal biopsy.Author detailsEdward T. ZawadaDepartment of Internal Medicine, Sanford School of Medicine, University of SouthDakota, Sioux Falls, United States*Address all correspondence to: ezawada@sio.midco.net© 2020TheAuthor(s). Licensee IntechOpen. This chapter is distributed under the termsof theCreativeCommonsAttribution License (http://creativecommons.org/licenses/by/3.0),which permits unrestricted use, distribution, and reproduction in anymedium,provided the original work is properly cited.3Introductory Chapter: Renal DiseasesDOI: http://dx.doi.org/10.5772/intechopen.90067References[1] Luiano RL, Moekel GW. Update onthe native kidney biosy: Corecurriculum 2019. American Journal ofKidney Diseases. 2019;79:404-415[2] Pollak VE, Pirani C, Schwarz FD. Thenatural history of the renalmanifestations of systemic lupuserythematosus. The Journal ofLaboratory and Clinical Medicine. 1964;63:537-560[3] Kark RM. The development ofpercutaneous renal biopsy in man.American Journal of Kidney Diseases.1990;XVI:585-589[4] Visconti L, Camaro V, Ricciardi CA,Laava V, Pelliano V, Laoquaniti A, et al.Renal biopsy - still a landmark for thenephrologist. World Journal ofNephrology. 2016;5(4):321-327[5]Moutzouris DA, Herlitz L, Appel GB,Markowitz GB, Freudenthal B,Radhkrshman R, et al. Renal biopsy inthe very elderly. Clinical Journal of theAmerican Society of Nephrology. 2009;4(6):1073-1082[6] Ramirez G, Saba SR. Primaryglomerulonephritis in the elderly. In:Zawada ET Jr, Sica D, editors. GeriatricNephrology and Urology. LittletonMassahussetts: PSG PublishingCompany, Inc.; 1985. pp. 49-66[7]Hae-Yoon G, Bomback AS,Stokes MB, Santoriello D, Campenot ES,Batal I, et al. The spectrum of kidneybiopsy findings in patients with morbidobesity. Kidney International. 2019;95:647-6544Renal Diseases

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