Fig.20.30Nodularglomerulosclerosisinarenalspecimenfromapatientwithlong-standingdiabetes.(Courtesy of Dr. Lisa Yerian, Department of Pathology, University of Chicago, Chicago, Illinois.) mesangialsclerosisalsomaybeseeninassociationwitholdageandhypertension;bycontrast,thenodularformofglomerulosclerosisisvirtuallypathognomonicofdiabetes.Boththediffuseandthenodularformsofglomerulosclerosisinducesufficientischemiatocausescarringofthekidneys,manifestedbyafinelygranular–appearingcorticalsurface(
Fig.20.31
Renalatherosclerosisandarteriolosclerosisconstitutepartofthemacrovasculardiseaseseenindiabetics.
Thekidneyisoneofthemostfrequentlyandseverelyaffectedorgans;thechangesinthearteriesandarteriolesaresimilartothosefoundthroughoutthebody.Hyalinearteriolosclerosisaffectsnotonlytheafferentbutalsotheefferentarterioles.Suchefferentarteriolosclerosisisrarelyifeverencounteredinindividualswhodonothavediabetes.
Fig.20.31Nephrosclerosisinapatientwithlong-standingdiabetes.Thebisectedkidneydemonstratesdiffusegranulartransformationofthesurface(left) andmarkedthinningofthecortex(right). Additionalfeaturesincludesomeirregulardepressions,theresultofpyelonephritis,andanincidentalcorticalcyst(far right).
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Fig.20.32Characteristicmorphologicchangesofdiabeticretinopathy.Fea-turesincludeadvancedproliferativeretinopathywithretinalhemorrhages,exudates,neovascularization,andtractionalretinaldetachment(lower-right corner). (Courtesy of Dr. Rajendra Apte,Washington University School of Medicine, St. Louis, Missouri.)
Pyelonephritisisanacuteorchronicinflammationofthekidneysthatusuallybeginsintheinterstitialtissueandthenspreadstoinvolvethetubules.Boththeacuteandchronicformsofthisdiseaseoccurinnondiabeticsaswellasindiabeticsaremorecommoninindividualswithdiabetes,andonceaffected,diabeticsalsotendtohavemoresevereinvolvement.Onespecialpatternofacutepyelonephritis,necrotizingpapillitis(orpapillarynecrosis),ismuchmoreprevalentindiabeticsthaninnondiabetics.
Ocularcomplicationsofdiabetes.Visualimpairment,sometimeseventotalblindness,isoneofthemorefearedconsequencesoflong-standingdiabetes.Theocularinvolvementmaytaketheformofretinopathy,cataractformation,orglaucoma.Retinopathy,themostcommonpattern,consistsofaconstellationofchangesthattogetherareconsideredbymanyophthalmologiststobevirtuallydiagnosticofthedisease.Thelesionintheretinatakestwoforms:nonproliferativeretinopathyandproliferativeretinopathy.
Nonproliferativeretinopathyincludesintraretinalorpreretinalhemorrhages,retinalexudates,microaneurysms,venousdilations,edema,and,mostimportantly,thickeningoftheretinalcapillaries(microangiopathy).Theretinalexudatescanbe“soft”(microinfarcts)or“hard”(depositsofplasmaproteinsandlipids)(