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Kidney Diseases

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KIDNEY DISEASES.' (For the anatomy of the kidneys, see Urinary System.) The results of morbid processes in the kidney may be grouped under three heads: the actual lesions produced, the effects of these on the composition of the urine, ' The word "kidney" first appears in the early part of the 14th century in the form kidenei, with plural kideneiren, kideneris, kidneers, &c. It has been assumed that the second part of the word is "neer" or "near" (cf. Ger. Niere ), the common dialect word for "kidney" in northern, north midland and eastern counties of England (see. Wright, English Dialect Dictionary, 1903, s.v. Near), and that the first part represents the O.E. cwi, belly, womb; this the New English Dictionary considers improbable; there is only one doubtful instance of singular kidnere and the ordinary form ended in -ei or ey. Possibly this represents M.E. ey, plur. eyren, egg, the name being given from the resemblance in shape. The first part is uncertain.

and the effects of the kidney-lesion on the body at large. Affections of the kidney are congenital or acquired. When acquired they may be the result of a pathological process limited to the kidney, in which case they are spoken of as primary, or an accompaniment of disease in other parts of the body, when they may be spoken of as secondary.

Congenital Affections

The principal congenital affections are anomalies in the number or position of the kidneys or of their ducts; atrophy; cystic disease and growths. The most common abnormality is the existence of a single kidney; rarely a supernumerary kidney may be present. The presence of a single kidney may be due to failure of development, or to atrophy in foetal life; it may also be dependent on the fusion of originally separate kidneys in such a way as to lead to the formation of a horse-shoe kidney, the two organs being connected at their lower ends. In some cases of horseshoe kidney the organs are united merely by fibrous tissue. Occasionally the two kidneys are fused end to end, with two ureters. A third variety is that where the fusion is more complete, producing a disk-like mass with two ureters. The kidneys may be situated in abnormal positions; thus they may be in front of the sacro-iliac articulation, in the pelvis, or in the iliac fossa. The importance of such displacements lies in the fact that the organs may be mistaken for tumours. In some cases atrophy is associated with mal-development, so that only the medullary portion of the kidney is developed; in others it is associated with arterial obstruction, and sometimes it may be dependent upon obstruction of the ureter. In congenital cystic disease the organ is transformed into a mass of cysts, and the enlargement of the kidneys may be so great as to produce difficulties in birth. The cystic degeneration is caused by obstruction of the uriniferous tubules or by anomalies in development, with persistence of portions of the Wolffian body. In some cases cystic degeneration is accompanied by anomalies in the ureters and in the arterial supply. Growths of the kidney are sometimes found in infants; they are usually malignant, and may consist of a peculiar form of sarcoma, which has been spoken of as rhabdo-sarcoma, owing to the presence in the mass of involuntary muscular fibres. The existence of these tumours is dependent on anomalies of development; the tissue which forms the primitive kidney belongs to the same layer as that which gives rise to the muscular system (mesoblast). Anomalies of the excretory ducts: in some cases the ureter is double, in others it is greatly dilated; in others the pelvis of the kidney may be greatly dilated, with or without dilatation of the ureter.

Acquired Affections. Movable Kidney

One or both of the kidneys in the adult may be preternaturally mobile. This condition is more common in women, and is usually the result of a severe shaking or other form of injury, or of the abdominal walls becoming lax as a sequel to abdominal distension, to emaciation or pregnancy, or to the effects of tight-lacing. The more extreme forms of movable kidney are dependent, generally, on anomalies in the arrangement of the peritoneum, so that the organ has a partial mesentery; and to this condition, where the kidney can be moved freely from one part of the abdomen to another, the term floating kidney is applied. But more usually the organ is loose under the peritoneum, and not efficiently supported in its fatty bed. Movable kidney produces a variety of symptoms, such as pain in the loin and back, faintness, nausea and vomiting - and the function of the organ may be seriously interfered with, owing to the ureter becoming kinked. In this way hydronephrosis, or distension of the kidney with urine, may be produced. The return of blood through the renal vein may also be hindered, and temporary vascular engorgement of the kidney, with haematuria, may be produced.

In some cases the movable kidney may be satisfactorily kept in its place by a pad and belt, but in other cases an operation has to be undertaken. This consists in exposing the kidney (generally the right) through an incision below the last rib, and fixing it in its proper position by several permanent sutures of silk or silkworm gut. The operation is neither difficult nor dangerous, and its results are excellent.

Embolism

The arrangement of the blood-vessels of the kidney is peculiarly favourable to the production of wedge-shaped areas of necrosis, the result of a blocking by clots. Sometimes the clot is detached from the interior of the heart, the effect being an arrest of the circulation in the part of the kidney supplied by the blocked artery. In other cases, the plug is infective owing to the presence of septic micro-organisms, and this is likely to lead to the formation of small pyaemic abscesses. It is exceptional for the large branches of the renal artery to be blocked, so that the symptoms produced in the ordinary cases are only the temporary appearance of blood or albumen in the urine. Blocking of the main renal vessels as a result of disease of the walls of the vessels may lead to disorganization of the kidneys. Blocking of the veins, leading to extreme congestion of the kidney, also occurs. It is seen in cases of extreme weakness and wasting, sometimes in septic conditions, as in puerperal pyaemia, where a clot, formed first in one of the pelvic veins, may spread up the vena cava and secondarily block the renal veins. Thrombosis of the renal vein also occurs in malignant disease of the kidney and in certain forms of chronic Bright's disease.

Passive congestion of the kidneys occurs in heart-diseases and lung-diseases, where the return of venous blood is interfered with. It may also be produced by tumours pressing on the vena cava. The engorged kidneys become brownish red, enlarged and fibroid, and they secrete a scanty, high-coloured urine.

Active congestion is produced by the excretion in the urine of such materials as turpentine and cantharides and the toxins of various diseases. These irritants produce engorgement and inflammation of the kidney, much as they would that of any other structures with which they come in contact. Renal disturbance is often the result of the excretion of microbic poisons. Extreme congestion of the kidneys may be produced by exposure to cold, owing to some intimate relationship existing between the cutaneous and the renal vessels, the constriction of the one being accompanied by the dilatation of the other. Infective diseases, such as typhoid fever, pneumonia, scarlet fever, in fact, most acute specific diseases, produce during their height a temporary nephritis, not usually followed by permanent alteration in the kidney; but some acute diseases cause a nephritis which may lay the foundation of permanent renal disease. This is most common as a result of scarlet fever.

Bright's disease is the term applied to certain varieties of acute and chronic inflammation of the kidney. Three forms are usually recognized - acute, chronic and the granular or cirrhotic kidney. In the more common form of granular kidney the renal lesion is only part of a widespread affection involving the whole arterial system, and is not actually related to Bright's disease. Chronic Bright's disease is sometimes the sequel to acute Bright's disease, but in a great number of cases the malady is chronic from the beginning. The lesions of the kidney are probably produced by irritation of the kidney-structures owing to the excretion of toxic substances either ingested or formed in the body; it is thought by some that the malady may arise as a result of exposure to cold. The principal causes of Bright's disease are alcoholism, gout, pregnancy and the action of such poisons as lead; it may also occur as a sequel to acute diseases, such as scarlet fever. Persons following certain occupations are peculiarly liable to Bright's disease, e.g. engineers who work in hot shops and pass out into the cold air scantily clothed; and painters, in whom the malady is dependent on the action of lead on the kidney. In the case of alcohol and lead the poison is ingested; in the case of scarlet fever, pneumonia, and perhaps pregnancy, the toxic agent causing the renal affection is formed in the body. In Bright's disease all the elements of the kidney, the glomeruli, the tubular epithelium, and the interstitial tissue, are affected. When the disease follows scarlet fever, the glomerular structures are mostly affected, the capsules being thickened by fibrous tissue, and the glomerular tuft compressed and atrophied. The epithelium of the convoluted tubules undergoes degeneration; considerable quantities of it are shed, and form the well-known casts in the urine. The tubules become blocked by the epithelium, and distended with the pent-up urine; this is one cause of the increase in size that the kidneys undergo in certain forms of Bright's disease. The lesions in the tubules and in the glomeruli are not generally uniform. The interstitial tissue is always affected, and exudation, proliferation and formation of fibrous tissue occur. In the granular and contracted kidney the lesion in the interstitial tissue reaches a high degree of development, little renal secreting tissue being left. Such tubules as remain are dilated, and the epithelium lining them is altered, the cells becoming hyaline and losing their structure. The vessels are narrowed owing to thickening of the subendothelial layer, and the muscular coat undergoes hypertrophic and fibroid changes, so that the vessels are abnormally rigid. When the overgrowth of fibrous tissue is considerable, the surface of the organ becomes uneven, and it is for this reason that the term granular kidney has been applied to the condition. In acute Bright's disease the kidney is increased in size and engorged with blood, the changes described above being in active progress. In the chronic form the kidney may be large or small, and is usually white or mottled. If large, the cortex is thickened, pale and waxy, and the pyramids are congested; if small, the fibrous change has advanced and the cortex is diminished. Bright's disease, both acute and chronic, is essentially a disease of the cortical secreting portion of the kidney. The true granular kidney, classified by some as a third variety, is usually part of a general arterial degeneration, the overgrowth of fibrous tissue in the kidney and the lesions in the arteries being well marked.

The principal degenerations affecting the kidney are the fatty and the albuminoid. Fatty degeneration often reaches a high degree in alcoholics, where fatty degeneration of the heart and liver are also present. Albuminoid disease is frequently associated with some varieties of Bright's disease, and is also seen as a result of chronic bone disease, or of long-continued suppuration involving other parts of the body, or of syphilis. It is due to irritation of the kidneys by toxic products.

Growths of the Kidney

The principal growths are tubercle, adenoma, sarcoma and carcinoma. In addition, fatty and fibrous growths, the nodules of glanders and the gummata of syphilis, may be mentioned. Tuberculous disease is sometimes primary; more frequently it is secondary to tubercle in other portions of the genitourinary apparatus. The genito-urinary tract may be infected by tubercle in two ways; ascending, in which the primary lesion is in the testicle, epididymis, or urinary bladder, the lesion travelling up by the ureter or the lymphatics to the kidney; descending, where the tubercle bacillus reaches the kidney through the blood-vessels. In the latter case, miliary tubercles, as scattered granules, are seen, especially in the cortex of the kidney; the lesion is likely to be bilateral. In primary tuberculosis, and in ascending tuberculosis, the lesion is at first unilateral. Malignant disease of the kidney takes the form of sarcoma or carcinoma. Sometimes it is dependent on the malignant growths starting in what are spoken of as "adrenal rests" in the cortex of the kidney. Sarcoma is most often seen in the young; carcinoma in the middle-aged and elderly. Carcinoma may be primary or secondary, but the kidney is not so prone to malignant disease as other organs, such as the stomach, bowel or liver.

Cystic Kidneys

Cysts may be single - sometimes of large size. Scattered small cysts are met with in chronic Bright's disease and in granular contracted kidney, where the dilatation of tubules reaches a high degree. Certain growths, such as adenomata, are liable to cystic degeneration, and cysts are also found in malignant disease. Finally, there is a rare condition of general cystic disease somewhat similar to the congenital affection. In this form the kidneys, greatly enlarged, consist of a congeries of cysts separated by the remains of renal tissue.

Parasitic Affections

The more common parasites affecting the kidney, or some other portion of the urinary tract, and causing disease, are filaria, bilharzia and the cysticercus form of the taenia echinococcus (hydatids). The presence of filaria in the thoracic duct and other lymph-channels may determine the presence of chyle in the urine, together with the ova and young forms of the filaria, owing to the distension and rupture of a lymphatic vessel into some portion of the urinary tract. This is the common cause of chyluria in hot climates, but chyluria is occasionally seen in the United Kingdom without filaria. Bilharzia, especially in Egypt and South Africa, causes haematuria. The cysticercus form of the taenia echinococcus leads to the production of hydatid cysts in the kidney; this organ, however, is not so often affected as the liver.

Stone in the Kidney

Calculi are frequently found in the kidney, consisting usually of uric acid, sometimes of oxalates, more rarely of phosphates. Calculous disease of the bladder (q.v.) is generally the sequel to the formation of a stone in the kidney, which, passing down, becomes coated by the salts in the urine. Calculi are usually formed in the pelvis of the kidney, and their formation is dependent either on the excessive amounts of uric acid, oxalic acid, &c., in the urine, or on an alteration in the composition of the urine, such as increased acidity, or on uric acid or oxalate of lime being present in an abnormal amount. The formation of abnormal crystals is oftendueto the presence of some colloid, such as blood, mucus or albumen, in the secretion, modifying the crystalline form. Once a minute calculus has been formed, its subsequent growth is highly probable, owing to the deposition on it of the urinary constituent forming it. Calculi formed in the pelvis of the kidney may be single and may reach a very large size, forming, indeed, an actual cast of the interior of the expanded kidney. At other times they are multiple and of varying size. They may give rise to no symptoms, or on the other hand may cause distressing renal colic, especially when they are small and loose and are passed or are trying to be passed. Serious complications may result from the presence of a stone in the kidney, such as hydronephrosis, from the urinary secretion being pent up behind the obstruction, or complete suppression, which is apparently produced reflexly through the nervous system. In such cases the surgical removal of the stone is often followed by the restoration of the renal secretion.

The symptoms of renal calculus may be very slight, or they may be entirely absent if the stone is moulding itself into the interior of the kidney; but if the stone is movable, heavy and rough, it may cause great distress, especially during exercise. There will probably be blood in the urine; and there will be pain in the loin and thigh and down into the testicle. The testicle also may be drawn up by its suspensory muscle, and there may be irritability of the bladder. With stone in one kidney the pains may be actually referred to the kidney of the other side. Generally, but not always, there is tenderness in the loin. If the stone is composed of lime it may throw a shadow on the Röntgen plate, but other stones may give no shadow.

Renal colic is the acute pain felt when a small stone is travelling down the ureter to the bladder. The pain is at times so acute that fomentations, morphia and hot baths fail to ease it, and nothing short of chloroform gives relief.

For the operative treatment of renal calculus an incision is made a little below the last rib, and, the muscles having been traversed, the kidney is reached on the surface which is not covered by peritoneum. Most likely the stone is then felt, so it is cut down upon and removed. If it is not discoverable on gently pinching the kidney between the finger and thumb, the kidney had better be opened in its convex border and explored by the finger. Often it has happened that when a man has presented most of the symptoms of renal calculus and has been operated on with a negative result as regards finding a stone, all the symptoms have nevertheless disappeared as the direct result of the blank operation.

Pyelitis

Inflammation of the pelvis of the kidney is generally produced by the extension of gonorrhoeal or other septic inflammation upwards from the bladder and lower urinary tract, or by the presence of stone or of tubercle in the pelvis of the kidney. Pyonephrosis, or distension of the kidney with pus, may result as a sequel to pyelitis or as a complication of hydronephrosis; in many cases the inflammation spreads to the capsule of the kidney, and leads to the formation of an abscess outside the kidney - a perinephritic abscess. In some cases a perinephritic abscess results from a septic plug in a blood-vessel of the kidney, or it may occur as the result of an injury to the loose cellular tissue surrounding the kidney, without lesion of the kidney.

Hydronephrosis, or distension of the kidney with pent-up urine, results from obstruction of the ureter, although all obstructions of the ureter are not followed by it, calculous obstruction, as already noted, often causing complete suppression of urine. Obstruction of the ureter, causing hydronephrosis, is likely to be due to the impaction of a stone, or to pressure on the ureter from a tumour in the pelvis - as, for instance, a cancer of the uterus - or to some abnormality of the ureter. Sometimes a kink of the ureter of a movable kidney causes hydronephrosis. The hydronephrosis produced by obstruction of the ureter may be intermittent; and when a certain degree of distension is produced, either as a result of the shifting of the calculus or of some other cause, the obstruction is temporarily relieved in a great outflow of urine, and the urinary discharge is reestablished. When the hydronephrosis has long existed the kidney is converted into a sac, the remains of the renal tissues being spread out as a thin layer.

Effects on the Urine. - Diseases of the kidney produce alterations in the composition of the urine; either the proportion of the normal constituents being altered, or substances not normally present being excreted. In most diseases the quantity of urinary water is diminished, especially in those in which the activity of the circulation is impaired. There are diseases, however, more especially the granular kidney and certain forms of chronic Bright's disease, in which the quantity of urinary water is considerably increased, notwithstanding the profound anatomical changes that have occurred in the kidney. There are two forms of suppression of the urine: one is obstructive suppression, seen where the ureter is blocked by stone or other morbid process; the other is non-obstructive suppression, which is apt to occur in advanced diseases of the kidney. In other cases complete suppression may occur as the result of injuries to distant parts of the body, as after severe surgical operations. In some diseases in which the quantity of urinary water excreted is normal, or even greater than normal, the efficiency of the renal activity is really diminished, inasmuch as the urine contains few solids. In estimating the efficiency of the kidneys, it is necessary to take into consideration the so-called "solid urine," that is to say, the quantity of solid matter daily excreted, as shown by the specific gravity of the urine. The nitrogenous constituents - urea, uric acid, creatinin, &c. - vary greatly in amount in different diseases. In most renal diseases the quantities of these substances are diminished because of the physiological impairment of the kidney. The chief abnormal constituents of the urine are serum-albumen, serum-globulin, albumoses (albuminuria), blood (haematuria), blood pigment (haemoglobinuria), pus (pyuria), chyle (chyluria) and pigments such as melanuria and urobilinuria.

Effects on the Body at large

These may be divided into the persistent and the intermittent or transitory. The most important persistent effects produced by disease of the kidney are, first, nutritional changes leading to general ill health, wasting and cachexia; and, secondly, certain cardio-vascular phenomena, such as enlargement (hypertrophy) of the heart, and thickening of the inner, and degeneration of the middle, coat of the smaller arteries. Amongst the intermittent or transitory effects are dropsy, secondary inflammations of certain organs and serous cavities, and uraemia. Some of these effects are seen in every form of severe kidney disease, and uraemia may occur in any advanced kidney disease. Renal dropsy is chiefly seen in certain forms of Bright's disease, and the cardiac and arterial changes are commonest in cases of granular or contracted kidney, but may be absent in other diseases which destroy the kidney tissue, such as hydronephrosis. Uraemia is a toxic condition, and three varieties of it are recognized - the acute, the chronic and the latent. Many of these effects are dependent upon the action of poisons retained in the body owing to the deficient action of the kidneys. It is also probable that abnormal substances having a toxic action are produced as a result of a perverted metabolism. Uraemia is of toxic origin, and it is probable that the dropsy of renal disease is due to effects produced in the capillaries by the presence of abnormal substances in the blood. High arterial tension, cardiac hypertrophy and arterial degeneration may also be of toxic origin, or they may be produced by an attempt of the body to maintain an active circulation through the greatly diminished amount of kidney tissue available.

Rupture of the kidney may result from a kick or other direct injury. Vomiting and collapse are likely to ensue, and most likely blood will appear in the urine, or a tumour composed of blood and urine may form in the renal region. An incision made into the swelling from the loin may enable the surgeon to see the torn kidney. An attempt should be made to save the kidney by suturing and draining; unless the damage is obviously past repair, the kidney should not be removed without giving nature a chance. (J. R. B.; E. 0.*)