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Problem Based Learning

Madeleine Edmonds

BLOCK 13: HUMAN DISEASES II

Problem 6 – The Liver and Liver Disease

THE LIVER
Overview
1. The liver is the largest internal organ in the body (1.2-1.5 kg) – plays a central role in digestion
and is responsible for the metabolism of drugs and environmental toxins
2. Liver diseases are a major cause of morbidity and mortality; worldwide 1 in 40 deaths are due to
liver disease or primary liver cell cancer
1. In developed countries, the most common cause of liver disease is alcohol abuse, although with
rising obesity rates, fatty liver disease incidence is rapidly increasing
2. In the developing world infections caused by hepatitis viruses and parasites are responsible for
most chronic liver disease

Functional Anatomy and Physiology

1. The liver is situated in the upper right quadrant of the abdomen, inferior to the diaphragm, and
extends across the midline
1. Occupies most of the right hypochondrium & part of epigastric region of abdominopelvic cavity
2. Roughly triangular in shape, covered by a capsule made of dense connective tissue
3. Capsule is further covered and reinforced by visceral peritoneum of the abdominal cavity, which
protects the liver and holds it in place within the abdomen

Macroscopic Structure
1. Comprises two lobes: right and left lobes by the falciform ligament
1. The right lobe is larger and contains the caudate and quadrate lobes
2. Functional division = right and left hemilivers, based on hepatic blood supply
2. Right and left hemilivers are further divided into 8 segments according to subdivisions of the
hepatic and portal veins
3. Each segment has its own branch of the hepatic artery and the biliary tree
3. Each segment is made up of multiple smaller units known as lobules

Microscopic Structure
1. Hepatic Lobule - functional unit of the liver that are hexagonal in shape, consisting of masses of
liver cells arranged around a central vein
2. At the periphery of each lobule are three vessels = portal triad:
1. A branch of the hepatic artery
2. A branch of the hepatic portal vein
3. A bile duct
1. Note: that each hepatic lobule has 6 portal triads
1. Blood from branches of both the hepatic artery and portal vein of the periphery of the lobule flows
into large, expanded capillary space (sinusoids)
1. Sinusoids are highly permeable blood capillaries between rows of hepatocytes that receive
oxygenated blood from branches of the hepatic artery and nutrient rich deoxygenated blood from
branches of the hepatic portal vein
2. Kupffer cells (tissue resident macrophages) line the sinusoids – engulf and destroy red blood cells
and bacteria that run through the blood
2. The central veins of ALL the lobules converge to form the hepatic vein which carries blood away
from the liver to join the inferior vena cava
1. The lobules are composed principally of many liver cellular plates that radiate from the central vein
3. Each hepatic plate is usually two cells thick and between adjacent cells lie small bile canaliculi that
empty into the bile ducts
2. Bile Canaliculi are thin bile-carrying channels that run between hepatocytes if the hepatic plate
carrying bile to bile ducts at the periphery
3. Bile ducts converge and are secreted through the common hepatic duct and has two fates:
1. Travels through the cystic duct to the gallbladder to be stored (between meals)
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2. Leaves the liver and/or gallbladder via the common bile duct, which enters the duodenum at the
hepatopancreatic sphincter (during digestion)
1. The sphincter prevents bile from entering the duodenum except during digestion of meals
Liver Cells
1. Hepatocytes – 80%
4. Major functional cells of the liver
5. Separated from endothelial lining of sinusoids by the space of Disse, which contains non-
parenchymal cells called stellate cells
2. Stellate cells store vitamin A and play a role in regulating liver blood flow
3. Also have a role in causing hepatic fibrosis, since they differentiate in response to cytokines
produced by Kupffer cells and hepatocytes following injury
2. Sinusoidal Endothelial Cells – 10%
1. Differ from other capillary beds because they have NO basement membrane
2. Contain fenestrations (openings) between each other about 0.1 µm in diameter
3. Allows free flow of fluid and particular matter to hepatocytes to carry out function (leaky)
3. Bile Duct Endothelial Cells – 1%
4. Immune Cells – 9%
1. Kupffer cells line the sinusoids and phagocytize aged RBCs and bacteria that pass through in the
blood (tissue resident macrophages)

Blood Supply
1. Hepatocytes have two blood sources: arterial blood (from the aorta) and venous blood (from GIT)
6. Hepatic Artery (20%) - oxygenated arterial blood; supplies O2 and metabolites for hepatic
processing
7. Hepatic Portal Vein (80%) - deoxygenated blood from GIT; newly absorbed nutrients, drugs and
microbes/toxins
1. Veins that drain the GIT do not directly communicate with the inferior vena cava, instead leave via
the hepatic portal vein to enter the liver
1. Here, processing, storage or detoxification takes place before gaining access to general circulation
2. Within the liver, the portal vein breaks up into capillary networks (liver sinusoids) to permit
exchange between blood and hepatocytes
2. Blood leaves the liver through the hepatic vein – upon convergence of all central veins – enters the
inferior vena cava to return to heart

SUMMARY
1. The liver receives blood from two sources:
1. Hepatic Artery – arterial blood, which provides the livers O2 supply and carries blood-borne metabolites for
hepatic processing
2. Hepatic Portal Vein – blood raining the digestive tract is carried by the hepatic portal vein to the liver for
processing and storage of newly absorbed nutrients
2. Blood leaves the liver via the hepatic vein

Biliary System and the Gallbladder

3. Hepatocytes create osmotic gradients of bile salts (bile acid-dependent bile flow) and sodium (bile
acid-independent bile flow) that provides the driving force of bile flow
4. Bile is secreted by hepatocytes and flows through bile canaliculi  intrahepatic bile ducts 
right and left hepatic ducts  common hepatic duct
1. Common hepatic duct becomes the common bile duct (to duodenum) after joining with the cystic
duct (from gallbladder)
1. Pressure in the common bile duct is maintained by rhythmic contraction and relaxation of the
sphincter of Oddi
2. Fasting State – pressure is greater than in gallbladder so bile is stored in gallbladder and diverted
from entering the duodenum
3. In the gallbladder, bile is concentrated by 10-fold due to the reabsorption of H2O and electrolytes
2. Gallbladder contraction is maintained by CCK and vagal afferent activity – force bile into duodenum

Functions of the Liver

1. Metabolism – carbohydrates, lipids, and amino acids
1. Amino acids from dietary proteins are used by hepatocytes to synthesize endogenous proteins
(plasma proteins and albumin)
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1. Albumin plays a crucial role in transport of bilirubin, hormones (steroid and thyroid hormones) and
other drugs through body
2. Also synthesizes angiotensinogen – important for RAAS
3. Excess amino acids are broken down into urea and excreted in urine
2. Glucose – absorbed from GIT and stored as glycogen; can be broken down to maintain blood
glucose levels (prevent hypoglycemia)
3. Lipids – hepatocytes store some triglycerides, break down fatty acids, use cholesterol to make
bile salts, VLDLs and further metabolizing LDLs, HDLs
2. Synthesizing Clotting Factors
1. Production of coagulation factors
2. Factors II, VII, IX, and X are post-translationally modified by vitamin K-dependent enzymes, thus
their synthesis is impaired when vitamin K is deficient
3. Bilirubin Metabolism and Bile Production
1. 250-300 mg of water insoluble bilirubin (bound to albumin) is produced from catabolism of heme
(derived from senescent RBCs)
2. Bilirubin is taken up at sinusoidal membrane and conjugated by UDP-glucuronyl transferase to
produce bilirubin mono- & diglucuronide
3. This conjugated bilirubin is exported into bile canaliculi by specific carriers on hepatocyte membrane
and excreted in lumen of small intestine  large intestine
4. In large intestine it is subject to bacteria and metabolized to form stercobilinogen (further oxidized
to stercobilin)
1. Both are excreted in feces – giving brown colour
1. Some of this stercobilinogen is absorbed in intestines and excreted in urine through kidneys as
urobilinogen or its oxidized form, urobiln
4. Storage of Vitamins and Minerals
1. Large amounts of vitamins A, B12, D, are stored by the liver
2. Small amounts of vitamin K and folate (B9) – correlates with dietary intake
3. Activation of vitamin D – participates in activation of vitamin D  25-OH vitamin D
4. Storage of minerals (iron, copper)
5. Immune Regulation
1. Kupffer cells (9% of liver cells) constitute the largest single mass
of tissue-resident macrophages in the body and account for 80% of
the phagocytic capacity
2. They remove aged and damaged red blood cells, bacteria, viruses,
Ag-Ab complexes, and endotoxins, etc.
3. Can also produce a variety of inflammatory mediators to be
released into systemic circulation
6. Detoxification - detoxify substances such as alcohol and excrete
drugs and foreign compounds
7. Secreting hormones
1. Hepcidin - inhibits iron uptake from the intestine
2. Insulin-like growth factor I that stimulates growth
3. Thrombopoietin - stimulates platelet production

INVESTIGATION OF LIVER DISEASE

3. The aims of investigation in patients with suspected liver disease are to:
1. Detect hepatic abnormality, measure severity of damage, detect pattern of abnormality (hepatic or
obstructive/cholestatic), identify the specific cause, investigate possible complication

Liver Function Tests (LFTs)

4. Liver function tests include the measurement of serum bilirubin and albumin, aminotransferases,
alkaline phosphatase, and gamma-glutamyl transferase
5. Most analytes measured by LFTs are not truly ‘function’ tests, but rather provide biochemical
markers of liver cell damage
6. Liver function is BEST assessed by serum albumin, prothrombin time and bilirubin
2. Levels of these tests are related to clinical outcome in patients with severe liver disease
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Test Notes
Serum Bilirubin 1. Normal range: 0.3-1.9 mg/dL
2. Degree of elevation of bilirubin reflects the degree of liver damage
3. >3 mg/dL is a sign of Jaundice
Albumin 1. Reduced in patients with liver disease
2. Due to: a) change in distribution of albumin, and b) reduction in synthesis
3. Plasma half-life is rather long (2 weeks), SO in acute liver failure levels
may be normal
4. Almost always reduced in chronic liver failure
Aminotransferases 1. Alanine (ALT) and Aspartate (AST) Aminotransferases – transfer
amino groups to a ketoacid = pyruvate OR oxaloacetate (respectively)
2. Both ALT and AST are located in the cytoplasm of hepatocytes; AST also
found in the mitochondria
3. High levels in bloodstream = hepatocellular damage
4. This pattern of abnormality is known as ‘hepatic’
Alkaline Phosphatase 1. Enzymes capable of hydrolyzing phosphate esters at alkaline pH
(ALP) 2. Produced in liver (and some other locations)
3. ALPs are located in cell membranes of sinusoids and bile canaliculi
3. Rise in levels = intrahepatic and extrahepatic biliary obstruction and
with sinusoidal obstruction
Gamma-glutamyl 1. Microsomal enzyme (drug metabolism) found in high concentration in liver
transferase (GGT) 4. Produced by hepatocytes and epithelium of bile ducts
2. Transfers glutamyl groups from gamma-glutamyl peptides to other
peptides and amino acids
3. Increase in activity = biliary obstruction (‘cholestatic’ or ‘obstructive’)

Hematological Tests – Complete Blood Count (CBC)

1. Red Blood Cells
5. GI hemorrhage – normochromic normocytic anemia (normal concentration of hemoglobin and
normal mean cell volume (MCV) but less total RBC)
6. Chronic blood loss – hypochromic microcytic anemia (decrease concentration of hemoglobin,
decreased MCV and less total RBC)
7. Macrocytic anemia (increase in MCV) – jaundice or alcohol misuse
2. White Blood Cells
1. Leucopenia (↓ WBC) – portal hypertension and hypersplenism (spleen destroys white blood cells
prematurely and at a rapid rate)
2. Leukocytosis (↑ WBC) – alcohol hepatitis and hepatic abscesses
3. Atypical lymphocytes – seen in infectious mononucleosis (complicated by acute hepatitis)
3. Platelet Count
1. Thrombocytopenia – decreased platelets; common in cirrhosis due to reduced platelet production
(less Thrombopoietin production in liver)
2. Thrombocytosis – excess platelets; rare in liver failure
4. Coagulation Tests
1. Usually abnormal in patients with liver disease
2. Prothrombin time – INCREASED; indicative of severe liver damage
2. This is because the half-lives of vitamin K dependent coagulation factors in the blood are short (5-
75 hours)
3. Administering vitamin K does not reverse this unless underlying cause is a vitamin K deficiency

Immunological Tests – Chronic Liver Disease Screen

5. Viral Markers - specific antibodies, proteins, and nucleic acids to indicate the presence of:
4. Hepatitis B: HBsAg – surface antigen, or HBV DNA
5. Hepatitis C: anti-HCV antibodies, HCV RNA
6. Cytomegalovirus markers
6. Liver Autoantibodies
1. Anti-mitochondrial antibody may suggest presence of primary biliary cholangitis (PBC)
2. Antinuclear and or anti-smooth muscle antibodies may indicate autoimmune hepatitis
7. Iron Studies
1. Elevations in serum iron, transferrin saturation and ferritin may indicate hemochromatosis
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8. A low level of α1-antitrypsin may indicate lung or liver disease
9. A deficiency of ceruloplasmin is usually seen in patients with a copper metabolism disorder called
Wilson disease

Radiological Imaging
1. Several imaging techniques can be used to determine the site and general nature of structural
lesions in the liver and biliary tree
2. Ultrasound – non-invasive; detects gallstones effectively but focal lesions (tumors <2cm may not
be detected unless characteristics differ from normal liver tissue)
3. Doppler Ultrasound – investigate blood flow of hepatic artery, portal
veins and hepatic veins
4. Endoscopic/laparoscope ultrasounds – high resolution images of
pancreas, biliary system & liver
5. CT – same purpose as ultrasound but detects smaller focal lesions in
liver
6. MRI – used to localize and confirm etiology of focal liver lesions
7. Cholangiography – imaging of bile duct (percutaneous and
endoscopic)

Liver Biopsy
1. Can confirm the severity of liver damage and provide etiological information
2. Performed percutaneously with a needle, through an intercostal space, under LA

Markers of Hepatic Fibrosis

1. Non-invasive marks of liver fibrosis have been developed and can obviate the need for liver biopsy
when being used to evaluate progression of liver fibrosis or where underlying cause is clear
2. Differentiate severe fibrosis from scarring, but are limited in their ability to detect subtle changes
2. Serological markers of hepatic fibrosis – pro-collagen type peptide, MMPs

LIVER DISEASE
3. Liver injury can either be acute or chronic
3. Acute liver injury – may present with non-specific symptoms of fatigue and abnormal LFTs, or with
jaundice and acute liver failure
4. Chronic liver injury – defined as hepatic injury, inflammation, and/or fibrosis for > 6 months
3. Early stages – may be asymptomatic with abnormal LFTs
4. Severe presentation - jaundice, portal hypertension and cirrhosis signs
4. NAFLD = non-alcoholic fatty liver disease
5. PBC = primary biliary cirrhosis, PSC = primary sclerosing cholangitis

Jaundice
1. A yellowish pigmentation of the skin, the conjunctiva membranes over eyes (whites of the eyes) and
other mucous membranes
2. Clinically detectible when plasma bilirubin levels are elevated (>3 mg/dL)
3. Three classifications:
1. Pre-Hepatic Jaundice
1. Characterized by increased bilirubin levels
2. Caused by hemolysis
1. Lysis of RBC or precursors that causes an increase in bilirubin production
2. Usually a mild form due to livers ability to excrete 6 times normal levels of bilirubin before
unconjugated bilirubin accumulates in plasma
3. Congenital hyperbilirubinemia – Gilberts syndrome (inherited bilirubin disorder)
2. Hepatocellular Jaundice
4. Results from inability of liver to transport bilirubin across the hepatocyte bile
5. Transport can be impaired at any point between uptake of unconjugated bilirubin into cells and
deposit of bilirubin into bile canaliculi
6. Swelling of cells and edema resulting from disease may result in obstruction of biliary canaliculi
7. Concentrations of both unconjugated and conjugated bilirubin increase in blood
8. Characteristic increase in transaminases (ALT and AST)
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9. Acute jaundice with high AST levels (> 1000 U/L) indicates: infection (Hepatitis A), drugs
(Paracetamol), or hepatic ischemia
10. Imaging is essential to identify: cirrhosis (irregular liver outline, splenomegaly) and define patency of
hepatic arteries, veins, and portal veins
11. Liver biopsy is important in determining the etiology of hepatocellular jaundice
3. Post-Hepatic Jaundice OR Obstructive (Cholestatic) Jaundice
1. May be caused by:
1. Failure of hepatocytes to initiate bile flow
2. Obstruction of bile flow in the bile ducts of portal tracts
3. Obstruction of bile flow in the extrahepatic bile ducts – gallstones
2. Intrahepatic origin – primary cirrhosis, drugs, alcohol, cystic fibrosis, bacterial infiltrations, hepatic
infiltrations (lymphoma, granuloma, amyloid, metastases)
3. Extrahepatic origin – carcinoma (pancreatic, bile duct, liver metastases), chronic pancreatitis,
parasitic infection, traumatic biliary strictures
4. These tend to become more severe without treatment
5. Conjugated bilirubin is unable to enter the bile canaliculi and hence is passed into blood
6. Also unconjugated bilirubin is not cleared as it arrives at the liver
7. NO peripheral signs of chronic liver disease
8. Greater elevations of ALP and GGT

Cirrhosis
1. Hepatic cirrhosis – disease characterized by diffuse hepatic fibrosis and nodule formation
2. Most common causes - viral hepatitis and prolonged excessive alcohol consumption
1. Any condition leading to persistent or recurrent hepatocyte death may lead to cirrhosis
1. Pathophysiology
2. Cardinal features
1. Increased fibrous tissue
2. Progressive and widespread death of cells
3. Inflammation
3. Leads to a loss of liver architecture
4. Following liver injury, stellate cells are activated into myofibroblasts-like cells, capable of producing
collagen = fibrosis
5. Destruction of liver architecture causes distortion and loss of normal hepatic vasculature with the
development of shunts and nodules
2. Diagnostic markers – diffuse hepatic fibrosis and nodule formation
3. Clinical Features
1. It is the most common cause of portal hypertension and its associated complications
2. Can be high variable – completely asymptomatic or others present with portal hypertension
3. Symptoms: weakness, fatigue, muscle cramps, weight loss, etc.
4. Often present with features of hepatic insufficiency

Viral Hepatitis
1. Viral hepatitis is a common cause of jaundice
2. Causes:
1. Common: Hepatitis A, B±D, C, E
2. Less common: Cytomegalovirus, Epstein-Barr virus
3. Rare: Herpes Simplex, Yellow fever
1. All of these viruses cause illnesses with similar clinical and pathological features BUT differ in their
tendency to cause acute or chronic infections
2. Clinical features of acute infection:
1. A non-specific illness characterized by headache, myalgia, nausea and anorexia
2. Development of jaundice by a few days to 2 weeks
3. Vomiting and diarrhea may follow, and abdominal discomfort is common

Other Common Liver Diseases

1. Alcoholic Liver Disease – one of the most common causes of chronic liver disease
1. Alcohol is metabolized almost exclusively in liver – two pathways (acetaldehyde and CYPE2E1) –
activate immune system and release free radicals respectively
2. This causes hepatic injury
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3. It is thought that pro-inflammatory cytokines may also be involved – endotoxin released in blood
because of gut permeability = release of cytokines (TNF, IL-1, IL2, etc.)
4. Clinical features: abnormal biochemistry, normal/large liver, jaundice, malnutrition, etc.
5. In about 80% of patients with severe alcoholic hepatitis, cirrhosis will coexist
2. Non-alcoholic Fatty Liver Disease – increasing with rise in obesity
1. Current two hit hypothesis for pathophysiology = fatty liver (1st) and inflammation (2nd)
2. Fatty liver occurs as a result of increased fat import into hepatocytes and reduce fat export
3. Insulin resistance causes hepatic steatosis, which also perpetuates insulin resistance
4. Subsequent activation of TNF, oxidant stress through free radicals and production of endotoxin
leads to inflammation and eventually fibrosis

Dental Implications
1. Impaired synthesis of blood clotting factors – can pose serious bleeding problems if surgery
required
1. Clotting screen and prothrombin time taken
2. If prothrombin time increases – vitamin K 10mg parenterally given for several days pre-op
2. Poor wound healing and anemia
3. May also have an increased susceptibility to infection
1. Spontaneous bacterial peritonitis; consider prophylaxis
4. Cross-infection control measures are essential to prevent disease transmission (HBV, HCV)
5. Impaired metabolism of drugs
1. CNS depressants tend to become more serious and cause a coma (LA, GA, sedatives)
2. LA dose should be lower and if GA needed, consult specialist
1. Drug interactions
1. Clindamycin, metronidazole and Paracetamol are safe at normal doses
2. Erythromycin and tetracycline’s are hepatotoxic and should be avoided
3. Aspirin and NSAIDs should be avoided due to risk of gastric hemorrhage

Problem 7 – Carcinogenesis and Neoplasia

Overview
2. Tumour (neoplasms) – a lesion or mass of tumour cells, resulting from the autonomous abnormal
cell growth, that persists in the absence of the initiating stimulus
1. Can result from neoplastic transformation of any nucleated cell
2. Arise due to accumulation of multiple genetic alterations (e.g. mutations, deletions, translocations,
rearrangements, amplifications) and epigenetic changes (e.g. promoter methylation silencing
transcription)
3. Result: cells that can escape permanently from normal growth regulatory mechanisms
3. Metastasize – spreading to other body tissues
4. Benign – non-invasive and remain localized; slow growth rate with close histological resemblance
to parent tissue
5. Malignant – invasive and capable of spreading directly or by metastasis; rapid growth grate and
variable histological resemblance to parent tissue
6. Polyp – abnormal growth of tissue projecting from mucous membranes; often benign, but can
become malignant (cancerous); common locations: colon, stomach, nose, ear, uterus, etc.
7. Cancer – refers to a malignant neoplasm
8. Epidemiology
1. Malignant neoplasms develop in approximately 25% of the human population
2. Risk increases with age, but certain tumours can occur even in infancy
3. Mortality rate is high (but varies based on specific tumour type), so that cancer accounts for about
one-fifth of all deaths in developed countries
4. Lung cancer is the most frequent malignant neoplasm un UK and USA, followed by colorectal
cancer, breast (woman) and prostate (men) also common

GENERAL CHARACTERISTICS
Structure of Tumours
1. Solid tumours consist of: a) neoplastic cells and b) stroma
1. Neoplastic Cells – tend to reproduce (to a variable extent) the growth pattern and synthetic activity
of the parent cell of origin
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1. E.g. a skin tumour will try to replicate a skin epithelial cell
2. Depending on functional resemblance to the parent tissue, they continue to synthesize or secrete
cell products
3. These often accumulate within the tumour, making them recognizable histologically
2. Stroma – supportive connective tissue framework in which neoplastic cells are embedded
1. Provides mechanical support, intercellular signaling and nutrition to the neoplastic cells
2. Stroma always contains blood vessels, which perfuse the tumour and help it to grow
3. Growth and nutrient supply is dependent on blood supply from stroma and limited perfusion will
cause tumour growth cessation
4. Can also contain lymphocytic infiltration – host reaction, often better prognosis

Figure: Tumor angiogenesis; a) Neoplastic transformation of a single cell results in growth of tumor nodule, limited by
ability of nutrients to diffuse into it (< 2mm); b) angiogenic factors (AF) stimulate the proliferation and ingrowth of blood
vessels, enabling tumour perfusion; c) tumour outgrown blood supply, necrosis results
Tumour Morphology (& correlation to behaviour)
2. Behaviour of a tumour often correlates with its gross appearance
3. Gross appearance of a tumour on a surface may be described as:
1. Sessile, polypoid, papillary – usually benign
2. Ulcerated or annular – usually malignant
4. Shape, however, can be misleading – some CT malignant tumours have well circumscribed borders
(characteristic of benign epithelial tumours)
5. Tumours are usually firmer than surrounding tissue due to stromal fibrosis – this can cause a
palpable lump (easily identified during examination, i.e. breasts)

Tumour Histology
1. Neoplasms may differ histologically from their corresponding normal tissue by various features:
1. Loss/reduction of differentiation
2. Loss/reduction of cellular cohesion
3. Nuclear enlargement, hyperchromasia (dark staining), and pleomorphisms (different size/shape of
cells or nuclei)
4. Increased mitotic activity

CLASSIFICATION OF TUMOURS
2. Tumors are classified by:
1. Behaviour – benign or malignant
2. Histogenetic – cell or tissue of origin

1. Behavioural Classification
3. Behavioural classification divides tumours into: a) benign and b) malignant
4. Various features deem a tumour as benign or malignant (see table), with invasion being the
characteristic property that distinguishes them
5. ‘Borderline’ tumours – defy behavioural classification because their histology is intermediate
1. Benign Tumours
1. Non-invasive and remain localized
2. Slow growth rate but well differentiated
3. Close histological resemblance to parent tissue
4. Enveloped by a thin layer of compressed CT (i.e. encapsulated)
5. Exophytic – grows away from surface because it cannot invade; often forming a polyp which can
be pedunculated (stalked) or sessile (sitting on surface)
6. Clinical effects
1. Pressure on adjacent tissues (e.g. benign meningeal tumour causing epilepsy)
2. Obstruction of fluid flow (blockage of a duct)
3. Production of hormone (excess) – hypersecretion
4. Transformation into a malignant neoplasm
5. Anxiety experienced by patient
2. Malignant Tumours
1. Invasive and thus capable of spreading directly or by metastasis
2. Relatively rapid growth rate but have an irregular margin
3. Variable histological resemblance to the parent tissue
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4. Pathophysiology: malignant tumours invade and destroy adjacent tissue, enabling cells to penetrate
blood vessels and lymphatic tissues = metastasis (spread)
1. Resulting secondary tumours are referred to as metastases
2. Note: not all tissues will metastasize even if malignant
1. Endophytic – inward growth of underlying tissue
2. Often show central necrosis due to inadequate perfusion (see above)
3. Show a greater degree of nuclear changes (enlargement of nuclear, darker staining, etc.)
4. Clinical effects:
1. Pressure on and destruction of adjacent tissue by invasion
2. Formation of secondary tumours (metastases)
3. Blood loos from ulcerated surfaces
4. Obstruction of flow (malignant tumour of colon causing intestinal obstruction)
5. Production of hormone in excess or inappropriate (ACTH and ADH secretion in lung due to small-
cell carcinoma)
6. Other effects - weight loss, malaise, anxiety and pain
Principal Characteristics of Tumours
Feature Benign Malignant
Growth Rate Slow Relatively rapid
Mitosis Infrequent Frequent and atypical
Histological Good Variable; often poor
resemblance to
normal tissue
Nuclear Near normal Usually enlarged, hyperchromatic,
morphology irregular outline, multiple nucleoli, and
pleomorphic (variable size & shape)
Invasion* No Yes
Metastases Never Frequent
Border Often circumscribed or Often poorly defined or irregular
encapsulated
Necrosis Rare Common
Ulceration Rare Common on skin or mucosal surfaces
Direction of growth Exophytic (outward) Endophytic (inward)
on skin or mucosal
surfaces

2. Histogenetic Classification
1. Histogenesis – the specific cell or tissue of origin of an
individual tumour, is determined by histopathological
examination and specifies the tumour type
1. This is then incorporated in the name given to the
tumour – squamous cell carcinoma
2. Major categories of origin:
2. Epithelium  carcinoma
3. Connective Tissue  sarcoma
4. Lymphoid and/or hemopoietic organs  lymphoma or leukemia
3. Histological Grade – Degree of differentiation
1. Definition: extent to which the tumour resembles the cell or tissue of origin (malignant only)
2. Graded either as well, moderately or poorly differentiated OR numerically as 1, 2, or 3
3. Well differentiated = more closely resembles parent tissues
4. Poorly differentiated tumours are more aggressive and some are so bad they lack all common
features (termed anaplastic)
4. Histological Stage – extent of spread
1. TNM System
1. T = size of tumour for anatomical site (scale 1-4)
2. N = lymph node involvement (scale 0-3)
3. M = distant metastases (No = 0, Yes = 1)
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Principal Characteristics of Carcinomas and Sarcomas
Features Carcinoma Sarcoma
Origin Epithelium Connective tissue
Behaviour Malignant Malignant
Frequency Common Relatively rare
Preferred route of metastasis Lymph Blood
In situ phase Yes No
Age group Usually >50 years Usually <50 years

NOMENCLATURE OF TUMOURS
5. Tumours have different names, although they represent the same disease process, as they have
unique cause, appearance and behaviour
6. ALL have the suffix ‘-oma’ and prefix is specific for cell of origin, etc.

Epithelial Tumours
1. Epithelial tumours are named based on behaviour (benign, malignant) and histogenetic (cell type)
1. Benign Epithelial Tumours
2. Papilloma – benign tumour of non-glandular or non-secretory epithelium (squamous or transitional
cell papilloma)
3. Adenoma – benign tumour of glandular or secretory epithelium (thyroid adenoma)
2. Malignant Epithelial Tumours – are ALWAYS called carcinomas
1. Non-glandular origin include cellular prefix (squamous cell carcinoma)
2. Glandular origin always designated adenocarcinomas of “tissue”
3. Carcinoma in situ defines an epithelial neoplasm with features associated with malignancy BUT
has not yet invaded basement membrane
1. No potential routes for metastasis – blood vessels or lymphatics
2. This phase can last several years (screening programmes aid in early detection)
3. May be preceded by dysplasia (abnormal proliferation of cells)

Connective Tissue Tumours

2. Tumours of connective and other mesenchymal tissues are like epithelial tumors, names according
to their cell of origin and their behavioural classification
1. Benign Connective Tissue Tumor – prefix denotes cell of origin, suffix ‘-oma’
1. Lipoma – benign tumour of lipocytes of adipose tissue
2. Rhabdomyoma – benign tumor of striated muscle
3. Leiomyoma – benign tumour of smooth muscle cells
4. Chondroma – benign tumour of cartilage
5. Osteoma – benign tumour of bone
6. Angioma – benign vascular tumour
2. Malignant Connective Tissue Tumor – are ALWAYS designated sarcomas with prefix that
describes cell or tissue of origin
1. Angiosarcoma – malignant vascular tumour (all same as above but with sarcoma)

Eponymously Named Tumours

3. Some tumours have inherited the name of the person who first recognized or described the lesion
4. Burkitt’s lymphoma - a B-cell lymphoma associated with the Epstein-Barr virus and malaria and
endemic in certain parts of Africa
5. Ewing’s Sarcoma - a malignant tumour of bone of uncertain Histogenesis
6. Hodgkin’s Lymphoma – a malignant lymphoma characterized by Reed-Sternberg cells (mature B
cells that have become malignant); first sign of disease is enlarged lymph nodes
2. Non-Hodgkin’s lymphoma – by contrast can be derived from B cells or T cells and can arise in the
lymph nodes as well as in other organs
7. Kaposi’s Sarcoma – malignant neoplasm derived from vascular endothelium, now commonly
associated with AIDS and human herpesvirus-8 infection

Miscellaneous Tumours
8. Teratomas – neoplasm of germ cell origin; form cells representing all three germ layers
3. In their benign form, these cellular types are often easily recognized but in malignant form they are
not easily identifiable
 11
4. Tumour may contain teeth and hair or various tissue types (epithelium, cartilage, etc.)
5. Occur most often in gonads, where germ cells are abundant
9. Blastomas – Embryonal Tumours
1. Occur almost exclusively in very young children (< 5 years)
2. Some resemblance to the embryonic form of the organ in which they arise
3. Retinoblastoma – the eye (inherited predisposition)
4. Nephroblastoma – kidney (Wilms’ Tumor)
5. Neuroblastoma – adrenal medulla or nerve ganglia
6. Hepatoblastoma – arise in the liver
10. Mixed Tumours – show a characteristic combination of cell types
1. Ex. Fibroadenoma of breast – a lobular tumour consisting of epithelium-lined glands or clefts in a
loose fibrous tissue matrix
11. Neuroendocrine/Endocrine Tumors – derived from peptide hormone-secreting cells scattered in
various epithelial tissues
2. Many are functionally active and clinical syndromes often result in excessive secretion
3. Previously thought to have neural origin (so called neuroendocrine) and also referred to as
APUDomas (acronym: amine content and/or precursor uptake and decarboxylation)
4. Examples:
1. Insulinoma – episodes of hypoglycemia (tumour of B cells of islets of Langerhans)
2. Gastrinoma – excessive peptic ulceration in gut (Zollinger-Ellison syndrome)
3. Phaeochromocytoma – tumour of adrenal medullar (adrenaline increase = hypertension)
4. Carcinoid – tumors of gut and respiratory tract that do not produce peptide hormone or a mixture of
peptide hormones
12. Cysts – fluid-filled space lined by epithelium
1. Some cysts are neoplasms, other are not
2. BUT, they may have local effects similar to tumours AND some tumors are cystic
3. Common types of cysts (neoplastic, congenital, parasitic, retention – epidermoid and pilar cysts of
skin, implantation – surgery/accident)

BIOLOGY OF TUMOR CELLS

13. No single biological or therapeutically exploitable feature unique to neoplastic cells
14. Neoplastic cells show relative or absolute growth autonomy, are unresponsive to extracellular
growth control, showing self-sufficiency to growth signaling and evading apoptosis
15. They frequently display genomic instability – leading to the formation of many clones with
divergent properties within the same tumour

Aberrant Proliferation and Cellular Immortalization

1. Appear immortal – show uncontrolled proliferation with a prolonged or indefinite lifespan
2. This is enabled by:
1. Autocrine growth stimulation – often due to increased expression of genes (oncogenes) that
encode growth factors, their receptors, intracellular signaling proteins, or transcription factors OR
inactivation of genes (tumour suppressor genes) that normally inhibit growth pathways
2. Reduced apoptosis – due to abnormal expression of apoptosis inhibiting genes (e.g. bcl-2)
3. Telomerase – an enzyme present in germ cells and stem cells that prevents shortening of genes
with each cell cycle (this essentially inhibits the number of cell division cycles); thus neoplastic cells
have unlimited replicative potential

Genomic Instability
1. Tumour cells have abnormal nuclear DNA – total amount
increased, dark staining (nuclear hyperchromasia) or
pleomorphic
2. Amount of DNA may increase in exact multiples of the
diploid state (polyploidy) or inexact multiples (aneuploidy)
1. These are associated with increased tumour aggressiveness
and influences appearance (nuclear size, shape and staining
patterns – pleomorphic)
1. Chromosomal (karyotypic) abnormalities may also arise
– additional parts or whole chromosomes, translocations or
rearrangements
 12
2. Example: the best known and one of the most consistent is the association of the Philadelphia
chromosome with chronic myeloid leukemia
3. Hybrid protein is formed = tyrosine kinase signaling protein that is “always on” = uncontrollable cell
division
2. Abnormalities affecting oncogenes and tumour suppressor genes – considerable interest due to
involvement in carcinogenesis

Mitotic and Apoptotic Activity

3. Malignant tumours exhibit more mitotic activity than normal cell populations
4. Estimations of cell proliferation via mitosis counting, DNA measurements, and frequency of
expression of cell cycle associated proteins
1. Higher proliferation frequency is often associated with a worse prognosis
1. Neoplastic cells also exhibit deregulation of cell death mechanisms (↓ apoptosis)
2. Ex. Some lymphomas show increased bcl-2 expression (apoptosis-inhibiting gene)

Metabolic and Other Abnormalities

2. Tumor cells show deregulated energy production – tend to undergo anaerobic glycolysis (high
consumption of glucose often indicator)
3. Have poor cell cohesion because intercellular junctions (desmosomes) are reduced – THIS allows
tumours to spread and metastasize
4. Usually retain the capacity to synthesize and secrete products (e.g. hormones) characteristic of
parent tissue but this is often uncontrolled
5. Gene derepression – in some tumour cells are expressed that are not normally (synthesis of
unexpected substances) and others are silenced

Tumour Products
1. These can be useful tumour markers for diagnosis or follow-up
2. Substances appropriate to their cell origin (e.g. steroids from adrenocortical adenoma)
3. Unexpected substances (ACTH and ADH from small cell carcinomas of lung)
4. Substances required for growth and invasion (e.g. autocrine growth factors, collagenases, etc.)

CARCINOGENESIS
1. Definition: the process that results in the transformation of normal cells to neoplastic cells by
causing permanent genetic alterations
2. Neoplasms arise from single cells that have undergone cumulative mutational events – they are
said to be clonal proliferations
3. Spontaneous mutations occur during DNA replication, but most are corrected by repair mechanisms
4. The probability of neoplastic transformation increases with the number of cell cycles a cell
undergoes – this may explain why incidence of cancer increases with age
3. It also increases with exposure to carcinogens
1. Carcinogen is an environmental agent participating in the causation of tumours
4. May be a) carcinogenic (cancer causing) or b) oncogenic (tumour causing)
5. Carcinogens act on cell DNA to induce mutations (mutagenic)
6. Multi-step hypothesis  > 1 carcinogen is necessary to cause neoplastic transformation
2. Note: once transformation has taken place, the stimulus (carcinogen) is NO longer required for
neoplastic behaviour to continue (‘hit-and-run’)
1. Some exceptions: genetic material of virus remaining in tumour, asbestos (insoluble substance) that
cannot be eliminated from tissues

Carcinogens
3. Formation of tumours involves environmental factors (85%) and inherited factors (15%)
2. Many require co-factors for evolvement
 13
4. Isolation of single causative factors is difficult – ethics prohibit testing, complex environment, latent
period in tumour development, etc.
5. Main classes of carcinogenic agents are:
1. Chemicals
2. Viruses
3. Ionizing and non-ionizing radiation
4. Exogenous hormones
5. Bacteria, fungi and parasites
6. Miscellaneous agents

Chemical Carcinogens
1. Many chemical carcinogens have been identified
2. Risk cannot be predicted based on structural formula
because closely related compounds have different effects
3. Some act directly, while others require metabolic
conversion
3. Procarcinogens  enzyme  ultimate carcinogens (active)
1. If the enzyme for conversion is ubiquitous in tissues, the
tumour will occur at the site of entry/contact
4. Polycyclic aromatic hydrocarbons induce skin tumours if
in contact with skin OR lung cancer if inhaled by smoke)
2. Others require metabolic conversion confined to certain
organs and so induce tumours at a remote site from entry
5. Aromatic amines require hydroxylation in liver before
expressing carcinogenic effects)
3. Ingestion of nitrates and nitrites (fertilizers) that have been
washed into the water table and contaminated drinking water
6. Metabolized be commensals within the gut and converted to
carcinogenic nitrosamines
Chemical Carcinogens and Associated Tumours
Chemical Tumours Comments
Polycyclic aromatic hydrocarbons Lung Cancer Strong link with smoking
Skin Cancer Repeated exposure
Aromatic amines Bladder cancer In rubber and dye workers
Nitrosamines Gut cancers Proven in animals
Azo dyes Bladder and liver cancer Proven in animals
Alkylating agents Leukemia Small risk in humans
Other organic chemicals (e.g. Liver Angiosarcoma Used in PVC manufacture
vinyl chloride)

Oncogenic Viruses
1. Tend to be more common in younger people and favoured by immunosuppression
2. Pathophysiology - oncogenic viral DNA or RNA (reverse transcribed) incorporated into host DNA

Viruses Implicated in Human Carcinogenesis

Virus Tumour Comments
Human Papillomavirus - Common wart (squamous cell - Benign, spontaneously regressing
papilloma) (HPV 6 or 11)
- Cervical carcinoma - Strong association with high-risk HPV
types 16 & 18
Epstein-Barr virus Burkitt’s lymphoma Requires a cofactor, probably malaria in
Nasopharyngeal cancer Far east and Africa
Hepatitis B and C Viruses Hepatocellular carcinoma Strong association
Human herpesvirus-8 Kaposi’s sarcoma Explains association b/w sexually
Primary effusion lymphoma acquired AIDS and Kaposi’s sarcoma
Human T-cell lymphotropic Adult T-cell leukemia/lymphoma Endemic in southern Japan and
virus-1 Caribbean
(RNA Retrovirus)
 14

Figure: Mechanisms of Integration of oncogenic viral sequences into the host cell genome leading to
expression of oncogenes
1. Oncogenic DNA Virus – HPV; DNA genome is integrated into host cell DNA, expression of viral oncogenes
(E6 & E7) occurs; in some cases this results in neoplastic transformation (cervical cancer)
2. ‘Acute’ transforming RNA retrovirus – retroviral RNA combines with host cell oncogene RNA transcript
(e.g. src) this is reversed transcribed to DNA and integrated into host  transcribed again and now it is a viral
oncogene (virus RNA and oncogene parts)  infects another cell and causes neoplastic transformation
3. ‘Slow’ transforming RNA retrovirus – RNA of virus converted to DNA and incorporated into host, there may
be insertion of viral promoter and enhancer sequences next to a cellular oncogenes = overexpression

Other Carcinogens
1. Radiation
7. Non-ionizing (UV light) – is a major cause of skin cancer
8. Ionizing – associated with increased risk of cancer at many sites; dose-dependent and some
tissues are more vulnerable than others (thyroid, breast, bone marrow)
2. Hormones – e.g. exogenous estrogens can shown experimentally to promote formation of
mammary and endometrial carcinomas (although association with oral contraceptives is weak)
3. Bacteria, fungi and parasites
1. Helicobacter pylori (bacterium) – major cause of gastric and peptic ulceration and is now strongly
implicated in gastric MALT lymphomas
2. Fungal myotoxins – Aspergillus flavus producing aflatoxin B1 are among most potent carcinogens
and linked to hepatocellular carcinomas in Africa
3. Parasites: Schistosoma hematobium (bladder cancer), and liver flukes (Opisthorchis viverrini and
Clonorchis sinensis) that dwell in bile ducts and cause adenocarcinomas
1. Parasites can be found actually within or in immediate vicinity of the tumour
1. Miscellaneous – asbestos (minerals) and metals
1. Inhalation of asbestos fibers results in lesions (mesothelioma and lung carcinoma)
2. Metals – compounds containing nickel can cause carcinoma nasal cavity linings and lungs

Host Factors in Carcinogenesis

2. In addition to the extrinsic or environmental factors, several host factors influence cancer risk:
 15
3. Race
1. The role of race in determining an individual’s risk of developing specific types of cancer is
complicated by the fact that racial differences often coincide difference in place of residence, diet
and habit
2. Some links are obvious – skin cancer is uncommon in blacks because the melanin in the skin
protects them from the carcinogenic effects of UV light
3. Oral cancer is relatively common in India and SE Asia – tobacco or betel nut chewing (not directly
linked to race)
4. Relative contributions of race and environment can be deduced by comparing incidence in racial
groups that have migrated to other countries
4. Diet
1. Dietary factors may be linked to cancer risk – Procarcinogens and carcinogens OR to the lack of
protective factors in diet
2. Positive correlation between high dietary fat or red or processed meat and colorectal cancers
3. Diet may also contain protective factors – fiber appears to be protective for colorectal cancer by
promoting more rapid intestinal transit
5. Constitutional factors – Inherited Predisposition
1. Some individuals inherit an increased risk of developing certain tumours as part of a syndrome
2. Often involve a mutant gene that does not carry out its function properly
3. Ex. Breast cancer – increased predisposition to breast cancer occurs in women inheriting mutant
BRCA1 (chromosome 17) or BRCA2 (chromosome 13)
6. Constitutional factors – Age
1. Incidence of cancer increases with age, potentially due to:
2. Cumulative risk of exposure to carcinogens
3. Long latent interval between exposure to initiating carcinogen and clinical appearance
4. Accumulating genetic lesions (mutations) may render the aging cell more sensitive to carcinogenic
effects – due to many replicative DNA cycles
5. Immune system is weaker as you grow old
7. Constitutional factors – Gender
2. Breast cancer is at least 200 times commoner in women than in men – larger mammary epithelium
volume and effect of estrogen in women
3. In other types of cancer, it is usually due to gender habits and social stereotypes

CELLULAR EVENTS IN CARCINOGENESIS

Multistep Theory
1. Latency
1. There is often a long latency period between exposure to carcinogen and the clinical presentation of
a tumour
2. Reason 1: tumours result from the clonal proliferation of single cells
1. It takes an appreciable time for this transformed cell to grow into a group of cells large enough to
cause detectable signs and symptoms
3. Reason 2: neoplastic transformation often requires multiple genetic events
4. Latency is represented by the time interval between exposure to the initiator and growth of a
detectable neoplasm
2. Initiation, Promotion, and Progression
5. Initiation – carcinogen induces genetic alteration(s) that give(s) the transformed cell its neoplastic
potential = initiated cell
6. Promotion – promoter stimulates clonal proliferation of initiated cell to form a benign tumour
7. Progression – process culminating in malignant behaviour characterized by invasion and its
consequences; involves further genetic and epigenetic changes
 16

MOLECULAR BASIS OF CANCER

Genetic Mechanism in Carcinogenesis

8. Genetic alterations are the root cause of
neoplastic cellular behaviour
9. Three key genetic alterations are needed to
transform a cell into a neoplastic cell:
1. Telomerase expression, to avoid replicative
senescence (a limit to the number of times a
cell can divide) resulting from telomeric
shortening with each cell division
2. Most cells do not expressive this and thus
have limited replicative ability
2. Loss or inactivation of both copies of tumor
suppressor gene, to remove the inhibitory
control of cellular replication
3. Activation or abnormal expression of
oncogenes, for autonomous growth
stimulation
3. Either the cell now produces a growth factor for
which it already has a receptor, OR expresses
a receptor for a growth factor it normally
produces OR activates an intracellular growth
stimulatory signaling pathway/transcription
factor (TF)

Figure: Oncogenes and tumour suppressor genes.

Abnormal expression of oncogenes drives cells towards the
neoplastic state by deregulation of cell cycle control or
suppression of apoptosis. Loss of tumour suppressor gene
function enables neoplastic transformation by permitting
mutations or reducing growth inhibition mechanisms

Genetic Abnormalities – Summary

1. Chromosomal Abnormalities – sometimes consistent, e.g. Philadelphia chromosome

2. Tumour Suppressor Genes – inherited or acquired inactivation of tumour suppressor genes (by
mutation or deletion or epigenetic silencing) contributes to tumour development
1. DNA Repair Genes and regulatory genes of apoptosis
3. Oncogenes – genes that regulate cell growth, are abnormally expressed or mutated (‘activated’) in
many tumours; this drives autonomous growth
4. Epigenetics – alteration of gene expression rather than code

1. Chromosomal Abnormalities
1. Simplest technique for examining the genome of
cells is chromosomal (karyotypic) analysis
2. Abnormalities such as additional chromosomes
and translocation of part of one chromosome to
another are common
3. A notable example is the Philadelphia
chromosome – this 9-22 translocation results in
 17
the bcr-abl chimeric gene, and is one of the most consistent chromosomal abnormalities yet
discovered
1. Commonly found in chronic myeloid leukemia
1. Chromosome abnormalities can be studied by in situ hybridization, allowing determination of the
number and location of specific DNA sequences
2. High throughput sequencing gives a comprehensive view of mutations and other genomic
changes, including translocations, inversions, deletions and complex rearrangements, etc.

2. Tumour Suppressor Genes

1. These genes act as a cell’s brakes; they encode proteins that restrain cell growth and prevent cells
from becoming malignant
2. Mutational loss of function of BOTH alleles is required for cell to undergo neoplastic transformation
– first allele may be an inherited defect while the second is an acquired mutation
3. Transformation of a normal cell to a cancer cell is accompanied by the loss of function of one or
more tumour-suppressor genes
4. At the present time more than two dozen genes have been implicated as tumour suppressor genes:
2. Include: genes that encode, transcription factors, cell cycle regulators, components that regulate G
proteins, proteins that regulate protein degradation
3. In one way or another, most proteins encoded by TSG act as negative regulators of cell
proliferation, which is why their elimination promotes uncontrolled cell growth
5. Two types of tumour suppressor genes based on mechanism of action:
1. Caretaker Genes – maintain integrity of genome by repairing DNA damage (DNA repair genes)
2. Gatekeeper Genes – inhibit proliferation or promote apoptosis with damaged DNA (regulatory
genes of apoptosis)
1. Tumor suppressor gene p53 (chromosome 17) is the most frequently mutated and extensively
studied in human cancer
4. It is a transcription factor that activates the expression of a large number of genes involved in cell
cycle regulation and apoptosis
5. Normal functions of p53:
4. Repair mutations before replication by arresting cells in G1 phase until DNA repaired
5. Programmed cell death - stimulate apoptotic pathways if extensive DNA damage
6. Cells that have sustained DNA damage have higher levels of p53 – which prevents mutations from
propagating
7. Loss of function can result from:
1. Mutations – non-sense (gene unreadable) missense (defective protein or protein with altered
function)
2. Complexes – of normal p53 and mutant p53 inactivating or subverting the function of the normal
protein
3. Binding of normal p53 to proteins encoded by oncogenic DNA viruses (e.g. HPV)
2. Note – cells with damaged DNA, or mutated oncogenes and tumour suppressor genes undergo
mitotic division rather than apoptotic death

3. Oncogenes
3. Oncogenes encode proteins that promote the loss of growth control and the conversion of a cell
to a malignant state (drive neoplastic behaviour)
1. Oncogenes are derived from proto-oncogenes, which are genes that encode proteins having a
function in the normal cell
2. Most known proto-oncogenes play a role in the control of cell growth and division
4. V-oncogenes – oncogenes of RNA retroviruses that have been incorporated into host DNA
5. Cellular oncogenes are essential for normal cell and tissue growth and differentiation, particularly
embryogenesis and healing
1. BUT, when activated or inappropriately expressed they contribute to the growth of a tumour
1. Oncogenes are classified into give groups according to the function of the gene product:
1. Growth factors
2. Receptors for growth factors
3. Tyrosine kinase activity
4. Nucleotide binding activity
5. Nuclear-binding transcription factor – involved in regulation of cellular proliferation (e.g. myc)
2. Oncogenes can be activated by:
 18
2. Mutations – resulting in oncoprotein molecule altered in such a way that it is excessively active
3. Excessive production of normal oncoprotein – because of gene amplification or enhanced
transcription or reduce degradation
3. Increased numbers of oncogene copies may result from infection by a retrovirus which increases
number of copies of gene by inserting cDNA OR by gene amplification
4. Increased transcription can occur if a normally silent oncogene is moved to another part of the gene
where active transcription is occurring
1. Often evident from the karyotype, part of one chromosome which is known to bear an oncogene
may be translocated to another chromosome
1. Alternatively the oncogene may undergo a point mutation which results in a gene product with
increased or inappropriate activity
2. Oncogene products play an important role in controlling cellular growth and behaviour
2. If expression is inappropriate, a cell can become autonomous, proliferating without the usual
requirement for external signals

4. Epigenetics
1. Definition: study of changes in organisms caused by
modification of gene expression rather than
alteration of the genetic code itself
2. Epigenetic contributions usually results from
aberrant expression of normally repressed non-
mutated genes or repression (silencing) of
normally active genes
3. Gene silencing by hyper methylation of promoter
DNA sequences
4. Gene up or down regulation due to histone
modification (methylation, acetylation, phosphorylation) – “histone code”
5. Interference with gene transcription by microRNA (short sequences of inhibitory DNA), with
increased miRNA leading to more degradation of mRNA and reduce expression
6. Enhancer and silencer DNA sequences alter control of gene expression

BEHAVIOUR OF TUMOURS
Invasion
1. Invasion is the single most important criterion of malignancy
2. Metastases are a consequence of invasion
3. Invasiveness of malignant neoplasms is determined by the properties of the neoplastic cells:
1. Decreased cellular adhesion
1. Altered expression of adhesion molecules (E-cadherin) = ↓ cell-cell adhesion in carcinomas
2. Integrin receptors become dispersed around the tumour cell to allow altered tumour cell-matrix
adhesion
2. Secretion of proteolytic enzymes
1. Matrix metalloproteinases are secreted by malignant neoplastic cells and allow them to digest the
surrounding connective tissue and invade
2. E.g. collagenases, gelatinases and stromelysins
3. Abnormal or increased cellular motility
1. Neoplastic cells are more mobile than their normal counterparts
2. Show a loss of mechanism that arrests cellular migration
1. In epithelial tissues – basement membrane provides recognition of invasion, if tumour passes this,
than invasion is occurring
2. In connective tissue, invasion is less recognizable unless there is clear evidence of vascular or
lymphatic permeation or mitotic activity

Metastasis
1. The process where malignant tumours spread from their site of origin (primary tumour) to form other
tumours (secondary tumour) at distant sites
2. Metastatic Sequence – must complete this before forming a metastatic tumour (see below)
1. Only a proportion of neoplastic cells in a malignant tumour have the full repertoire of properties
necessary for completion of this sequence
1. Steps involved in the sequence are:
 19
1. Detachment - of tumour cells from their neighbors (loss of cell adhesion)
2. Invasion - into surrounding connective tissue to reach conduits (blood and lymph vessels)
3. Intravasation - into lumen of vessels (blood or lymph)
4. Evasion – of host defense mechanisms, such as NK cells in blood
5. Adherence – to endothelium at remote location
6. Extravasation – of cells from vessel lumen into surrounding tissue
2. On reaching the site of metastasis – a recapitulation of evens required for primary growth occurs
2. Tumour cells MUST proliferate and angiogenesis must occur to supply nutrients
3. Alteration in cell-adhesion molecules are important
3. Decreased expression of cadherins (adhesion between epithelial cells)
4. Increased expression of integrins (important for invasive migration)
4. Routes of metastasis: a) blood, b) lymph, and c) pleura, pericardium and peritoneal cavities
1. Carcinomas (epithelium) prefers lymphatic spread) whereas sarcomas prefer to spread in the blood
stream

Problem 8 – Repair and Regeneration

*See “Human Diseases and Pathology” for more

detailed information on Healing and Repair*

5. The ultimate consequences of injury depend on many factors:

1. Replicative capacity of cells to replace those lost (cell type)
2. Ability to rebuild complex tissue architecture (tissue type)
3. Extent of injury
4. External factors
6. Three cell groups based on replicative capacity: a) labile, b) stable, or c) permanent
2. Only labile and stable cells can be replaced if lost
7. Complex tissue architecture may not be reconstructed
8. Healing is restitution with no, or minimal, residual defect e.g. superficial skin abrasion
9. Repair is necessary when there is significant tissue loss: healing by second intention

Overview of Tissue Repair

1. Restoration of tissue architecture and function
after injury occurs by two types of reactions:
1. Healing/Regeneration – replacement of
damaged cells and return to normal state
(complete healing, final result is
indistinguishable from before injury)
1. Occurs by proliferation of residual
(uninjured) cells that retain the capacity to
divide, and by replacement of injured cells
from tissue stem cells
2. This is the typical response to injury in the
rapidly dividing epithelia of the skin and
intestines, and some organs (liver)
2. Organization/Scar Formation – injured
tissues are incapable of regenerating, or
supporting structures of tissue are severely
damaged
1. Repair occurs by laying down of connective
(fibrous) tissues = scar formation
2. Left with a residual defect/scar – this scar
cannot perform the function of lost cells, but
provides enough structural stability that
injured tissue is usually able to function
3. Fibrosis – extensive deposition of collagen
that occurs as a consequence of chronic
inflammation, or necrosis
 20
Regeneration/Healing Repair/Scar Formation
1. Loss of part of labile/stable population 3. Loss of permanent cells (non-dividing cells) e.g.
1. Capable of replacing specialized cells by cardiac muscle
cell division 4. OR loss of large volume of stable/labile cells
2. Requires intact tissue architecture - 5. Damage to tissue architecture – e.g. liver, kidney
basement membrane/CT 6. Repair of specialized tissues by fibrous scar –
2. Results in complete restitution myocardial fibrosis post myocardial infarction
(replacement of specialized cells) with 7. 2 Stage Process:
NO residual defect 1. Early: defect replaced by granulation tissue
1. Superficial skin abrasion, hepatocyte 2. Late: collagen deposition, wound contraction,
toxicity, acute renal tubular necrosis scar organization and remodeling

Cell Classification
1. Cells are classified according to their potential for renewal:
1. Labile cells – e.g. skin epithelium; have a good capacity to regenerate as they are constantly lost
form the surface and replaced from deeper layers
2. Stable cells – e.g. hepatocytes/renal tubular cells; divide at a slow rate normally BUT still retain the
capacity to divide when necessary
3. Permanent cells – e.g. nerve cells and striated skeletal/cardiac muscle cells; no effective
regeneration
2. Stem Cells – cells that are lost through injury or normal senescence are replaced from the stem cell
pool present in many labile and stable populations
2. Stem cell differentiation: one daughter cell differentiates based on needs and functional state of
tissue (various cell types) and one daughter cell retains stem cell characteristics
3. Location of stem cell population varies on tissue: in epidermis they are in basal layer, in intestinal
mucosa they are in the bottom of the crypts, etc.
4. A separate pool of stem cells from the bone marrow is available – able to seed into other organs
and differentiate locally into appropriate tissue
5. Ability of a tissue to regenerate may be dependent on integrity of the stem cell population
1. Loss of stem cells (radiation injury) can impair regenerative ability of tissue
2. Mutations in propagated daughter cells may result in neoplastic transformation

Complete Restitution – Healing

3. Loss of part of a labile cell population can be completely restored (complete healing)
4. Steps in Complete Restitution/Healing – e.g. minor skin abrasion
1. Epidermis is lost over a limited area – cells left at margins that can cover the defect
2. Dermis remains intact (connective tissue and adnexa [skin appendages])
3. Proliferation of epithelium from intact edges and necks of adnexal structures (scab) – form a thin
sheet until the defect is covered
1. Note: once a confluent layer is formed, the stimulus to proliferate is switched off (contact inhibition)
to control growth and movement
2. This is important to control cell proliferation; often this mechanisms is lost in neoplastic
transformation of cells
4. Epithelium is rebuilt from the base upwards until it is
indistinguishable from normal
5. Complete restitution/healing

Organization – Scar Formation

1. Definition: the process whereby specialized tissues are
repaired by the formation of mature fibro vascular
connective tissue (formation of a fibrous scar)
2. Early Stages: granulation tissue is formed, often on a
scaffold of fibrin, and any dead tissue is removed by
phagocytosis (neutrophils and macrophages)
3. Later Stages: collagen deposition occurs and the scar
undergoes remodeling
1. Organized area is often firmer than normal, shrunken or
puckered
 21
1. Common example of organization process: myocardial fibrosis post myocardial infarction
1. Granulation Tissue
2. When specialized or complex tissue is severely destroyed, it cannot be reconstructed – thus it can
only be repaired
3. Angiogenesis – capillary endothelial cells proliferate and grow into the area to be repaired (initially
as buds but soon open up into vascular channels)
4. Fibroblast migration – flood to site of injury and are stimulated to divide and secrete collagen and
other matrix components
5. Fibroblasts also differentiate into myofibroblasts that display features of both fibroblasts and
smooth muscle cells (alpha-actin complex component) = wound contraction
6. Granulation tissue is made up of the combination of the capillary loops and myofibroblasts
2. Wound Contraction and Scarring
1. Wound contraction is important for reducing the volume of tissue for repair (tissue defect may be
reduced by 80%)
2. Contraction and reduction results from myofibroblasts in granulation tissue – they are attached to
each other and the adjacent matrix components (pull surrounding tissue inwards)
3. Collagen is continuously secreted to form a fibrous scar, replacing the lost cell population – this then
undergoes remodeling
4. Disadvantages of wound contraction: stenosis (narrowing) or stricture (obstruction) in tube
structures; or contracture (distortion in permanent shortening of muscle)
5. Burns may show considerable contraction → cosmetic damage and often impaired mobility

OUTCOME OF INJURIES IN DIFFERENT TISSUES

SKIN
2. The process of healing in skin wounds depends on the size of the defect
1. Epidermis only – healing by regeneration of cells and complete restitution (see above)
2. Epidermis and Dermis – depends on size; 1) Healing by first intention (incised wound with
approximated edges) OR 2) Healing by second intention (extensive tissue loss)

Healing by First Intension – Incised Wound

3. An incision, such as that made by a surgical scalpel, causes very little damage to tissues on either
side of the cut
4. If the two sides of the wound are brought together accurately, then healing can proceed with
minimum delay or difficulty
5. Some blood vessels will be cut, but occluded by thrombosis, and apposition of the wound will help
6. Fibrin deposited locally will bind the two sides together
7. Coagulated blood on the surface forms a scab and helps to keep the wound clean
8. Over next few days, capillaries proliferate sufficiently to bridge the tiny gap
9. Fibroblasts secrete collagen as they migrate into the fibrin network
10. While this is occurring in the dermis, epidermal cells are proliferating to spread over any gap

Figure: Skin incision healed by first intention – as little or no tissue has been lost, the apposed edges of the
incision are joined by a thin layer of fibrin, which is ultimately replaced by collagen covered by surface epidermis

Healing by Second Intension – Tissue Loss

1. Occurs: when there is extensive tissue loss or wound margins are not apposed
2. Characterized by:
1. Phagocytosis to remove debris
 22
2. Granulation tissue to fill defects and repair specialized tissue lost
3. Epithelial regeneration to cover the surface
3. Timescale depends on the size
– as this determines the amount
of granulation tissue to be
generated and the area to cover
with epithelium
4. Result – final cosmetic result
depends on how much tissue is
lost (this affects scar size)
5. Differences to first intention:
more dermal damage, more
wound contraction, slower than
first intention healing, more scar
formation and thinning of
epidermis

SUMMARY
Healing by First Intention Healing by Second Intention
1. Fibrin enters the wound from injured blood vessels 1. Fibrin enters into the wound
2. Macrophages migrate into area and phagocytize 2. Influx of macrophages to phagocytize
necrotic tissue necrotic tissue (larger amount)
3. Granulation tissue forms in base of wound 3. MORE granulation tissue forms at the
4. Wound contraction initiates and fibrosis of base of the wound
damaged tissue occurs 4. Fibrosis via collagen deposition and
5. Epithelium regenerates from intact edges and wound contraction
necks of adnexal structures to cover dermal scar 5. Epithelium regeneration

Mechanisms of Skin Healing and Repair

1. Healing and repair involves a complex interplay of cytokines
2. Initiating signals - hypoxia (O2 deprivation) and release of growth factors from platelet degradation
1. These trigger release of cytokines such as epidermal growth factors and keratinocyte growth
factor from platelets, macrophages, and dermal fibroblasts
2. Control of myofibroblasts and collagen formation is partly influence by transforming growth factor-
beta (TGF-B)

BONE
1. Immediately following bone fracture there will be hemorrhage within the bone from ruptured vessels
in the marrow cavity, and also around the bone in relation to the periosteum
1. A hematoma (swelling of clotted blood in tissue) at the fracture site facilitates repair by providing a
foundation for growth of cells
2. It is likely that there will be devitalized fragments of bone and soft tissue damage nearby
3. Initial stages of repair = a) removal of necrotic tissue and b) organization of hematoma
4. Later stages – fibroblasts and osteoblasts have migrated and have been activated
2. ECM of bone is deposited in an irregularly woven pattern = this new mass with islands of cartilage
is referred to as a callus
3. Woven bone undergoes remodeling and subsequently replaced with more orderly, lamellar bone
4. This in turn is gradually remodeled according to the direction of mechanical stress
1. Problems with Fracture Healing – factors that can delay or arrest repair
1. Inadequate immobilization – results in excessive callus formation and slows down
 23
1. Persistent movement prevents bone formation, and collagen is laid down instead to give a fibrous
union (false joint at fracture site = pseudoarthrosis)
2. This is often why fractures are splinted to prevent movement and help healing
2. Interposed soft tissues – increase risk or non-union and delay healing
3. Gross misalignment – slows rate of healing and will prevent a good functional result
3. Can lead to degenerative disease (osteoarthrosis) in
adjacent joints
4. Infection – not likely unless skin is broken over fracture =
compound fracture
4. Predisposes to chronic osteomyelitis (infection in the bone)
5. Pre-existing done disease – pathological fracture; bone
weakened from primary disease
5. Ex. Inadequate calcium, phosphate, vitamin c deficiency,
osteoporosis, etc.
6. CAN heal, but sometimes treatment of underlying cause is
required first

Figure: Healing of a bone fracture – the hematoma at the fracture site

gives a framework for healing. It is being replaced by a fracture callus,
which is subsequently replaced by lamellar bone, which is then remodeled
to restore the normal trabecular pattern of the bone

Timeframes of Healing
2. Healing by first intention
6. 24 hours – neutrophils appear and migrate towards fibrin clot; basal cells of cut edges show
increased mitotic activity
7. 24-48 hours – epithelial cells proliferate under scab and meet at the midline (thin layer)
8. Day 3 – macrophages dominate (phagocytize necrotic tissue); granulation tissue fills space
9. Day 5 – new blood vessels form and collagen deposition continues (normal thickness)
10. Second Week – continued collagen accumulation and fibroblast proliferation; inflammatory
processes are diminished; “blanching” – increased collagen and reduce vascular channels
11. Month – scar consists of cellular connective tissue; epidermis is relative normal but dermal
appendages in incision area are permanently lost
3. Healing by second intention – wound strength reaches approximately 70-80% of normal (usually
maximum) by 3 months
1. Severe burns in this category = would take the longest to heal
4. Bone fracture
1. The fracture hematoma initiates the healing response
2. 48 hours – chemotactic signaling mechanisms attract inflammatory cells to promote healing
3. 1-2 weeks – granulation tissue is formed, vascularization of hematoma; cytokines activate bone
progenitor cells and matrix synthesis beings
4. 4-16 weeks: fibroblast, chondroblasts, osteoblasts – ECM of tissue and cartilage formed, woven
bone is deposited by osteoblasts (can last 4-16 weeks)
1. Mesh of woven bone is replaced by lamellar bone and organized parallel to the axis of bone
5. Average healing times of common fractures differ based on location – lower arm (8-10 weeks),
humerus (6-8), tibia (10 weeks)

External Influences of Healing and Repair – Local and Systemic

Local Factors
5. Infection
6. Foreign bodies
7. Mechanical factors – motion, poor fixation of fracture, masses (tumours)
8. Vascular disturbance – ischemia (traumatic, atheroma, radiation)
9. Size, location and type of wound – more severe takes longer, sole of foot as stepping on it all day

Systemic Factors
1. Age – children > adults
6. Before birth cellular injury is likely to impair or prevent normal growth & development of an organ
7. Organogenesis at risk if there’s impaired function, migration or differentiation of precursor cells
 24
8. The physiology of aging is complex – characteristic is reduced ability to repair damaged tissues
2. Wound healing = rapid in healthy children, and fractures unite more quickly than in adults
3. Wound healing is often delayed in old age because of ischemia or other disease
9. However, if tissue damage occurs during childhood it can result in growth disturbance
2. Nutrition – wound healing profoundly influenced by the ability to synthesize protein and collagen
10. Vitamin C is dependent for collagen synthesis; scurvy or vitamin C deficiency leads to wound
healing of greatly reduced strength; capillaries are fragile and hemorrhage occurs
11. Protein malnutrition also impairs wound healing; severe malnutrition impairs response to infection
which can be fatal
3. Neoplasia
1. In advanced malignant disease with widely disseminated tumours, the patient is malnourished
2. May be evidence of impaired healing in vicinity of tumour
3. Skin stretch over superficial tumour will break down and ulcerate and its necessary to treat the
tumour to promote healing
4. A pathological fracture of bone through a metastatic tumour may not heal unless tumour is dealt
with first
4. Corticosteroids/Cushing’s Syndrome
1. Excessive corticosteroids: a) immunosuppressive (infection more severe) and b) steroids impair
healing by interfering with formation of granulation tissue and thus wound contraction
5. Immunosuppression & Diabetes Mellitus
2. Increases susceptibility to infection by low virulence organisms and increases risk of injury
3. Normal response to healing may be impaired by continuing infection
4. Diabetes may affect polymorph function and result in occlusion of BV and cause neuropathy
5. Direct effect on keratinocytes, reducing their motility and also that of fibroblasts, both of which delay
healing
6. Bleeding Disorder
1. Adequate blood supply is necessary for cellular function – impaired supply (ischemia/infarction)
2. Impaired healing results from reduced vascular supply – due to hypoxia and reduced local
nutrition resulting in poorer tissue regrowth or repair
7. Denervation
1. An intact nerve supply supports structural and functional integrity of many tissues
2. Nerves also have a role in mediating inflammatory response – host response to limit the effects of
injury
3. Tissues that are denervated may become severely damaged, probably due to unresponsiveness to
repeated minor trauma and lack of pain

Terminology of Blisters
8. Vesicles are slightly raised skin lesions filled with serous fluid
9. Grouped vesicles are typical of herpes simplex infections
10. Larger vesicles measuring > 0.5 cm are called bulla (often called blisters)

Problem 9 – Kidney and Renal Disease

*See PBL Block 3 – Renal Function for details on normal kidney anatomy and function*

GENERAL FUNCTION AND ANATOMY

Overview
1. The kidneys perform a variety of functions aimed at maintaining homeostasis
1. In conjunction with hormonal and neural inputs that control their function, the kidneys are the organs
responsible for maintaining the stability of ECF volume, electrolyte composition and osmolarity
(solute concentration)
2. They carry out their mechanism of action by adjusting the quantity of water and various plasma
constituents that are either conserved for the body of eliminated in the urine
3. The kidneys adjust for wide variations in ingestion of water (H2O), salt, and other electrolytes
4. Also adjust urinary output of these ECF constituents to compensate for abnormal losses through
heavy sweating, vomiting, diarrhea, or hemorrhage
5. When the ECF has a surplus of water or a particular electrolyte (NaCl), the kidneys can eliminate
the excess in the urine
 25
6. However, if a deficit exists, the kidneys cannot provide additional quantities of the depleted
constituent, but they can limit urinary losses to conserve what is in short supply
7. Kidneys compensate more efficiently for excesses than for deficits - sometimes the kidneys cannot
completely stop the loss of a valuable substance in urine even if it is in short supply
2. Ex. Water deficit - even if a person is not consuming any H2O, the kidneys MUST put out about half
a liter of H2O in the urine each day to fill another major role as the body’s cleaners
1. Another important function of the kidneys is to rid the body of waste materials that are either
ingested or produced by metabolism
3. These wastes cannot be eliminated as solids; they must be excreted in solution (obligating the
minimum volume of 500 ml of waste-filled urine per day)
2. Most H2O eliminated in the urine is derived from the blood plasma and so a person stranded
without water eventually experiences a fatal drop in plasma volume levels

Major Functions of Kidney

3. The kidney’s perform the following specific functions, most of which help preserve internal fluid
environment
4. With chronic kidney disease or acute failure of the kidney’s, these homeostatic functions are
disrupted and severe abnormalities of body fluid volumes and composition rapidly occur
5. With complete renal failure, enough potassium acids, fluid and other substances accumulate in the
body to cause death within a few days, unless clinical interventions (hemodialysis) are initiated to
restore at least partially, the body fluid and electrolyte balances
1. Excretion of metabolic waste products and foreign chemicals
4. The kidneys are the primary means for eliminating waste products of metabolism that are no longer
needed by the body
5. These products include urea (from metabolism of amino acids), creatine (from muscle creatine),
uric acid (from nucleic acids), end products of hemoglobin breakdown (such as bilirubin) and
metabolites of various hormones
6. These waste products must be eliminated as rapidly as they are produced
7. Kidneys also eliminate most toxins and other foreign substances that are either produced by the
body or ingested, such as pesticides, drugs and food additives
2. Regulation of water and electrolyte balances
1. For maintenance of homeostasis, excretion of water and electrolytes must match intake
2. Intake > excretion = increase in substance in body; Intake < excretion = decrease
3. Intake of water and many electrolytes is governed by a person’s eating and drinking habits,
requiring the kidney’s to adjust their excretion rates to match the intake of various substances
4. Ex. increase in sodium intake 10-fold (30 to 300 mEq/day) also increases renal excretion to about
300mEq/day so a balance is re-established. However during the 2-3 days of renal adaptation to the
high Na intake, there is an increase in ECF volume (due to increased water retention), which
triggers hormonal changes and other compensatory responses that signal the kidneys to increase
their sodium excretion.
5. Capacity of kidney’s to alter Na excretion due to changes in Na intake is enormous - can be
increased or decreased by 10 times with relatively small changes in ECF volume
3. Regulation of arterial pressure
1. Kidneys play a dominant role in long-term regulation of arterial pressure by excreting variable
amounts of sodium and water
2. Kidneys also contribute to short-term arterial pressure regulation by secreting vasoactive factors or
substances, such as renin, that lead to the formation of vasoactive products (angiotensin II)
4. Regulation of acid-base balance
1. Contribute to acid-base regulation, along with the lungs and body fluid buffers, by excreting acids
and by regulating the body fluid buffer stores
2. Kidneys are the only means of eliminating certain types of acids (sulfuric and phosphoric acid),
generated by the metabolism of proteins
5. Secretion, metabolism, and excretion of hormones
1. Regulation of erythrocyte production - kidneys secrete erythropoietin, which stimulates the
production of RBC
2. Kidneys normally account for almost all the erythropoietin secreted in circulation and people with
severe kidney disease develop anemia as a result of decreased erythropoietin production
3. Regulation of 1-25-dihydroxyvitamin D3 production - kidneys produce the active form of vitamin D, 1,
25-diydroxyvitamin D3 (calcitriol) by hydroxylating this vitamin at the number 1 position
 26
4. Calcitriol is essential for normal calcium deposition in bone and calcium reabsorption in the GIT
6. Gluconeogenesis
1. Synthesize glucose from aa and other precursors during prolonged fasting (gluconeogenesis)

Functional Anatomy
1. The kidneys are paired organs that lie retroperitoneally on either side of the vertebral column at the
level of T12 to L3
2. Renal parenchyma comprises an outer cortex and an inner medulla
3. Functional unit: nephron, and each contains approximately one million
1. Each nephron is made up of a glomerulus, proximal tubule, loop of Henle, distal tubule and
collecting duct
1. Arterial blood is supplied to the kidneys via the renal arteries, which branch off the abdominal
aorta, and venous blood is conveyed to the inferior vena cava via the renal veins
2. Renal artery undergoes a series of divisions within the kidney forming successively the interlobar
arteries and then into arcuate arteries that run circumferentially along the corticomedullary junction
3. Interlobular arteries then run through rental cortex towards the surface of kidney
4. Afferent glomerular arterioles arise from interlobular arteries to supply the glomerular capillary bed,
which drains into efferent glomerular arterioles
5. Efferent glomerular arterioles drain into peritubular capillary network within the renal cortex
6. Juxtamedullary nephrons are supplied by vasa recta
2. The glomerulus comprises four main cell types:
1. Endothelial cells with 500-1000 Å fenestrations
2. Visceral epithelial cells (podocytes) which support the delicate glomerular basement membrane with
trabecular network (foot processes)
3. Parietal epithelial cells which cover the Bowman’s capsule
4. Mesangial cells – believed to be related to macrophages; phagocytic
3. Renal tubules – are lined by epithelial cells, which are cuboidal except in the thin limb of the loop of
Henle where they are flat
1. Proximal tubular cells differ as they have a luminal brush border (most of tubular reabsorption
takes place here)
2. Collecting ducts contain principal cells (ADH regulation and water reabsorption) and intercalated
cells (acid-base balance)
3. Fibroblast-like cells in the renal cortical interstitium have been shown to produce erythropoietin in
response to hypoxia
4. The juxtaglomerular apparatus comprises the macula densa – a plaque containing large, tightly
packed cell nuclei within the thick ascending limb of the loop of Henle
1. This anatomical arrangement is such as to allow changes in the renal tubule osmolarity to influence
behaviour of the adjacent glomerulus (tubular-glomerular feedback)
 27
INVESTIGATIONS OF RENAL FUNCTION
Examination of the Urine
5. Appearance
2. Little value in differential diagnosis except in hematuria (bloody urine) – this should be checked
using dipsticks (Stix testing)
3. Concentrated urine may also appear dark or smoky
4. Other causes of discoloration: cholestatic jaundice, hemoglobinuria, drugs (rifampicin), etc.
6. Volume
1. In health, the volume of urine passed is primarily determined by diet and fluid intake; usually within
the range of 800-2500 mL per 24 hours
2. In diseases such as chronic kidney disease (CKD) impairment or concentrating ability requires
increased volumes of urine to be passed, given the same solute output
7. Specific gravity and osmolarity of urine – can be used in the differential diagnosis of renal failure
an investigation of polyuria or inappropriate ADH secretion
8. Urinary pH – usually unnecessary except in investigation of renal tubular acidosis

Chemical (Stix) Testing – Urine

1. Routine Stix testing of urine for a) blood, b) protein and c) sugar is obligatory in all patients
suspected of having renal disease
1. Blood
1. Hematuria may be obvious (bloody urine) or microscopic and found only on chemical
2. A positive Stix test must always be followed by microscopy of fresh urine to confirm presence of
red cells casts, which are diagnostic of glomerulonephritis
1. AND to exclude other rare conditions (hemoglobinuria, myoglobinuria)
3. Bleeding may come from any site in the urinary tract:
1. Overt bleeding from urethra is suggested when blood is seen at start and then urine is clear
2. Blood diffusely present throughout the urine comes from the bladder or above
3. Blood only at the end suggest bleeding from prostate or bladder base
1. In the absence of red-cell casts, further investigations are done (urine cytology, renal imaging)
2. Protein – proteinuria is one of the most common signs of renal disease
2. Healthy adults excrete up to 30 mg daily of albumin
3. Detection via Stix testing – most strips can detect protein if albuminuria exceeds 300 mg/d
4. If confirmed on repeated testing, protein excretion in 24 hour urine collections should be measured
3. Glucose – renal glycosuria is uncommon, so a positive test for glucose always requires exclusion of
diabetes mellitus
2. Other Stix Tests
1. Bacteriuria – based on detection of nitrite produced from the reduction of urinary nitrate by bacteria
and a neutrophilic enzyme (positive test may indicate urinary tract infection)

Microscopy – Urine
3. Urine microscopy should be carried out in all patient suspected of having renal disease, on a ‘clean’
sample of mid-stream urine
4. White blood cells – presence of > 10 WBC/mm3 is
abnormal and indicates an inflammatory reaction within the
urinary tract (UTI, stones, tuberculosis and interstitial
cystitis)
5. Red cells – presence of > 1 RBC/mm3 is abnormal
6. Casts – aggregation of red cells as a ‘cast’ of the tubule
(see photo)
2. Cylindrical bodies, molded in the shape of the distal tubular
lumen, and may be hyaline, granular or cellular
3. Red cell casts – even if only single, always indicate
renal disease
1. Bacteria – always culture urine PRIOR to starting antibiotic therapies for sensitivities

Blood and Quantitative Tests

2. The use of serum urea, creatinine, and GFR as measure of renal function
3. Creatinine – is a waste product that comes from muscle activity
1. GFR can be estimated using blood levels of creatinine
 28
2. If levels of creatinine are high, then GFR is lower and less creatinine is cleared from system
(indicative of renal failure)
1. Blood urea nitrogen (BUN) – urea nitrogen is a normal waste product in your blood that comes
from breakdown or proteins
1. It is normally removed from your blood by the kidneys, but when kidney function slows down, BUN
levels rise
2. Other quantitative tests – ANCA, immunofluorescence and complement

Imaging Techniques
3. X-ray – valuable to identify renal calcification or radiodense calculi in the kidney, renal pelvis, line of
ureters or bladder
4. Ultrasound – advantage over x-ray is that they avoid ionizing radiation; method of choice for:
2. Renal measurement and for renal biopsy or other interventional procedures
3. Characterizing renal masses
4. Detecting intrarenal fluid (pus, blood)
5. Demonstration renal arterial perfusion (thrombosis using Doppler ultrasound)
6. Measurement of bladder wall thickness
1. Computed tomography (CT)
1. Characterize renal masses which are indeterminate with ultrasound
2. To stage renal tumours
3. To evaluate tumours
4. Asses renal trauma
2. MRI – an alternative to CT for masses

RENAL DISEASE
3. Nephrology deals with many different kidney disorders including acid-base disorders, electrolyte
disorders, hypertension, acute kidney disease, and end-stage renal disease
4. Renal failure can come on suddenly (acute renal failure), as after surgery or severe injuries, or
when renal blood vessels become obstructed
5. But more usually develops slowly (chronic renal failure)
6. Progression: Initial diabetic nephropathy through to acute and chronic renal failure to end
stage failure
7. Result: fluid retention, acidosis, accumulation of metabolite and drugs, damage to platelets (leading
to a bleeding tendency), hypertension, anemia and endocrine effects

Classification
8. Historically, chronic
kidney disease has been
classified according to
the part of the renal
anatomy that is involved:
1. Vascular – includes
disease of large vessels
(e.g. bilateral renal artery
stenosis) or small vessels
(e.g. ischemic
nephropathy, hemolytic-
uremic syndrome and
vasculitis)
2. Glomerular – a diverse
group sub classified into
disease that is primary or
secondary
1. Primary – focal
segmental
glomerulosclerosis and
immunoglobulin A
nephritis
 29
2. Secondary – diabetic nephropathy and lupus nephritis
3. Tubulointerstitial – include polycystic kidney disease, drug and toxic induced chronic nephritis and
reflex nephropathy
4. Obstructive – as with renal or bladder stones and prostate diseases

Acute Renal Failure

9. Acute renal failure is a medical emergency, which may lead to confusion, seizures and coma
10. Management is often by dialysis
11. Acute renal failure (ARF) can be caused by:
1. Pre-renal factors (55%)
1. Such as hypotension (hemorrhage or severe burns), renal thrombosis, sepsis, heat stroke, or drugs
causing renal shutdown, for example NSAIDs and ACE inhibitors
2. Renal Factors (15%)
2. Interstitial nephritis, toxic acute tubular necrosis, complicated surgery or trauma (myoglobin blocks
tubular function)
3. Drugs – contrast dyes used in arteriography, antibiotics (streptomycin), aspirin and other NSAIDs,
acetaminophen overdose]
4. Toxins (betel, heavy metals, solvents)
5. Multiple organ failure in which heart, lungs, liver, brain and kidneys totally or partially shut down
(most likely due to trauma or sepsis)
6. Hemolytic-uremic syndrome – caused by E. coli O157:H7 (Shiga toxin expression) in children, and
HIV in adults
7. Post-partum renal failure, malignant hypertension, cancer chemotherapy
3. Post Renal factors – such as obstructed urine flow

Chronic Kidney Disease – CKD

1. Chronic kidney disease (CKD) is defined as “the presence of kidney damage, or a reduction in the
GFR, for 3 or more months”
1. Reduced GFR < 90ml/min per 1.73m2 for 3 months with proteinuria or hematuria
2. Increased risk of loss of kidney function and development of cardiovascular disease
3. CKD is NOT a specific disease, the most common causes (75% of all adult cases):
1. Diabetes
2. Hypertension
3. Glomerulonephritis
4. Other causes:
2. Renal disease (polycystic renal disease)
3. Systemic diseases (lupus erythematosus, myeloma, amyloid)
4. Poisoning and drugs (aspirin and NSAIDs)
5. Compensation by structural and functional hypertrophy (cellular adaptation = increase in cell size) of
surviving nephrons to a point at which around 50% of renal function remains
1. This inevitably progresses to end-stage renal disease (ESRD)
6. Leads to a progressive loss of renal function through FIVE STAGES defined by the National
Kidney Foundation (see chart)

Stages of Chronic Kidney Disease

Stages Renal Health GFR Features

ml/min/1.73m2
- Normal 130 -
1 Diminished renal reserve (early > 90 Abnormalities in blood or urine tests or
CRF) imaging studies but FEW symptoms
2 Mild CRF 60-89 Abnormalities in blood or urine tests or
imaging studies
3 Moderately Severe 30-59 Abnormalities in blood or urine tests or
imaging studies
4 Severe CRF 15-29 Uremic symptoms
5 End-stage renal failure (ESRF) or < 15 Life-threatening and requires some form
disease (ESRD) of renal replacement therapy
CRF = chronic renal failure
 30

Clinical Features of Chronic Kidney Disease

7. Asymptomatic at first until kidney function
has fallen to < 25% of normal
8. Affects virtually ALL body systems and
causes changes in urea, electrolytes and
other blood constituents

1. CKD can result in a range of clinical manifestations

2. Common clinical features:
2. Hypertension
3. Anemia – due to toxic suppression of the bone marrow, lack of renal production of erythropoietin
and/or iron deficiency
4. Purpura (rash of tiny spots caused by internal bleeding of small vessels) and bleeding tendency
1. Abnormal platelet production
2. Diminished platelet factor 3 (thromboxane)
3. Raised prostaglandin I – causing vasodilation and poor platelet aggregation
4. Defective von Willebrand factor
5. Increased susceptibility to infection due to defective phagocytic function

Clinical Features
Blood and Cardiovascular GIT Neuromuscular Metabolic and Skin
Immune Endocrine
Bleeding Hypertension Anorexia Weakness Polyuria Bruising
Anemia Congestive Nausea and Drowsiness Thirst Infection
Lymphopenia cardiac failure vomiting Headaches, Raised urea and Hyper-
Liability to Pericarditis Hiccoughs confusion creatinine Pigmentation
infection Cardiomyopath Peptic ulcer Disturbances of Electrolyte
y and GIT vision disturbance
Atheroma, bleeding Sensory Secondary
peripheral disturbances hyperparathyroidis
vascular Tremor m
disease

Diagnosis
1. Clinical history and presentation
6. Raised plasma urea and creatinine levels
7. Falling GFR, measured by an estimate (eGFT) – using the MDRD equation (accounting for age,
gender, ethnicity, and serum creatinine level)
2. Decline in eGFR can be plotted over time to extrapolate the prognosis of events (i.e. timing dialysis
requirement; creation of arteriovenous fistulae)

General Management
3. Most important therapy is Blood pressure control
1. Angiotensin-converting enzyme (ACE) inhibitors
2. Angiotensin-II receptor blockers
4. Treat underlying causes where possible – stress, infection or urinary tract obstruction
5. Goal of treatment is to slow down or halt progression of CKD to stage 5
1. Measure by a falling GFR and rising plasma urea and creatinine levels
2. Aimed to reduce cardiovascular risk – the main cause of mortality
1. Reduction of disease:
1. Normal diet and smoking cessation
2. Potassium restriction
3. Salt and water control
4. Pharmacological management – aspirin, statins, etc.
2. Iron stores are replenishing with iron supplements and epoietin (recombinant erythropoietin) which
has a longer half-life
3. Inhibit bone resorption – calcium carbonate, vitamin D3, low phosphate diet, IV bisphosphonates
4. Drugs to be used with caution
 31
1. Those that undergo renal clearance: Penicillin, cephalosporin, erythromycin
2. Nephrotoxic drugs – NSAIDs or tetracycline’s

Renal Replacement Therapy

1. Required when the patient reaches stage 5 chronic kidney disease

Dialysis
2. Dialysis is used to remove metabolites (e.g. urea, potassium) and excess water, by exposing the
patient’s blood across a semi-permeable membrane to a hypotonic solution
1. This allows diffusion and osmosis of solutes and fluid from the body
3. Dialysis solution
1. Has similar levels of minerals (K & Ca2+) similar to normal concentration in healthy blood
2. Levels of bicarbonate are slightly HIGHER to promote diffusion of bicarbonate into the body –
neutralizes metabolic acidosis
4. Dialysis can rehabilitate up to 20% of patients but cannot prevent all complications
5. Two primary types of dialysis:
1. Peritoneal Dialysis (PD) - uses peritoneal membrane, less effective, more frequently used
1. Principle – peritoneal membrane (lines abdominal cavity) acts as natural semi-permeable
membrane
2. Dialysis fluid is instilled via a catheter into the patients abdominal cavity placed near the umbilicus or
tunneled under the skin from near the sternum
3. Less efficient than hemodialysis, but done more frequently
4. Easier to perform at home and fluid balance is easier to achieve
5. Also easy to travel with bags of dialysis solutions
6. Continuous ambulatory peritoneal dialysis (CAPD) – 4-5 changes daily
7. Continuous cyclic peritoneal dialysis (CCPD) - machine does the exchanges at night
8. Intermittent peritoneal dialysis (IPD) – same machine as CCPD
9. Nocturnal intermittent – same as IPD but done overnight
2. Hemodialysis (HD) – uses man-made membrane
1. Often carried out at home or as an outpatient
2. Optimal effects are from 5-7 dialysis sessions at 6-8h each per week, but most patients have two or
three 3-6 hourly session per week
3. Uses a man-made membrane (dialyzer) to filter wastes and remove extra fluid
4. Arteriovenous fistula is created surgically above wrist to facilitate infusion lines
5. Patient is heparinized (blood thinner) to keep infusion lines and tubing patent
1. Adverse Effects of dialysis
1. Associated with some adverse effects = dialysis hangover or washout
2. Occurs due to rapid and excessive fluid removal
3. Includes: induction of low BP, fatigue, chest pains, leg cramps, nausea, headaches
4. Long term effects: worsened ischemic heart disease, cardiac valve calcification, dialysis related
amyloidosis and neuropathies
2. Note: cardiovascular disease and infections are of paramount importance (PD carries risk of
peritonitis)
1. Infections of PD catheters exit site or runnel
2. HD grafts and catheters may also be at risk of infection, bacterial endocarditis, osteomyelitis, and
blood-borne viral infections (HIV, Hepatitis, TB)
3. Periodontal disease may contribute to infective load
4. Therapy may decrease systemic levels of C-reactive protein
5. HD can mechanical damage platelets, creating an additional bleeding tendency

Hemofiltration
3. Blood is pumped through a hemo filter, as in dialysis, but rather then a dialysate being used, a
pressure gradient is applied
4. Water moves across the very permeable membrane rapidly, facilitating removal of metabolites
(importantly those with high MW)
5. Salts and water lost from blood during hemofiltration are replaced with a substitution fluid

Renal Transplantation
1. Strongly recommended for patients with end-stage renal disease
 32
2. Enhanced quality and duration of life and is more effective
3. Transplant compatibility – relative or cadaver donors
4. Life-long immunosuppression is needed to prevent a T-cell alloimmune rejection response (anti-
rejection medication)
1. Patients undergo induction therapy – IV anti-lymphocyte antibody
2. Immunosuppressant’s – corticosteroid, ciclosporine, etc.
1. Complications – rejection, atheroma and ischemic heart disease, ciclosporine induce neuropathy
OR gingival hyperplasia, infection susceptibility

Dental Implications
2. Main implications: bleeding tendencies and susceptibility to infections, enhanced activity of
drugs, or drug interactions (nephrotoxic, e.g. NSAIDs and aspirin)
1. Nephrotoxic drugs can cause GI irritation and bleeding
2. Delayed excretion
3. Bleeding tendency
1. Intrinsic defects of platelets as well as abnormal platelet endothelial interaction
2. Platelet dysfunction is due to uremic toxins present in circulating blood
4. Dental treatment is best carried out on the day after dialysis – when there is maximum benefit
dialysis and effects of heparin has worn off
5. If bleeding is prolonged, desmopressin (DDAVP) may provide hemostasis for up to 4 hours
6. Infections are poorly controlled and may spread locally or cause septicemia
1. Can be hard to recognize as inflammation is masked
7. TB is more frequent but often extra pulmonary
8. LA is safe
9. Conscious sedation is preferred analgesia
2. If IV required, do not place into AV fistula – risk of thrombophlebitis
3. Midazolam > diazepam
4. GA contraindicated if hemoglobin levels are low
10. In general, CKD, have more periodontal disease, and osseous lesions