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GI and Renal Exam 1 > 13 - Glomerular Disease Case Study > Flashcards

13 - Glomerular Disease Case Study Flashcards

1
Q

Describe the general concepts of glomerular disease

A
  • Glomerular disease can occur as part of a systemic syndrome.
  • The type of disease can vary significantly according to age and race.
  • Many glomerular disease processes are poorly understood.

Don’t need to know for exam

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2
Q

What are the difference between nephrotic disease and nephritic disease?

A 
Nephrotic = proteinuria
Nephritic = blood in the urine
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3
Q

What will you see in nephritic syndrome?

A
  • Glomerulonephritis = inflammation of the glomerulus
  • Edema (extracellular volume expansion)
  • Gross hematuria
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4
Q

What will you see in glomerulonephritis?

A

Glomerulonephritis

Red blood cells which hae been through in the glomeruli and exist in casts

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5
Q

What are the signs of glomerulonephritis?

A

Signs

  • Lipiduria
  • Proteinuria
  • Renal failure can occur and can be rapidly progressive
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6
Q

Describe the proteinuria in glomerulonephritis

A
  • Normal is less than 150 mg/day
  • Can be nephrotic (greater than 3.5 g/24 hours)
  • Correlates with glomerular damage
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7
Q

Describe the incidence of asymptomatic hematuria

A
  • Common - 5-10% of the general population
  • Glomerular disease in patient with no proteinuria – less than 10%
  • Microscopic examination of urine is helpful
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8
Q

What will you see in asymptomatic hematuria?

A

This is from a published biopsy series…

  • Hematuria
  • Proteinuria less than 1 g/day
  • Serum creatinine less than 1.5 mg/dl
  • There are three major findings on biopsy
  • Renal biopsy not usually performed

This would be good to know

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9
Q

What are the three major findings you may see on biopsy in patients with asymptomatic hematuria?

A
  • Normal
  • Thin basement membrane nephropathy
  • IgA nephropathy
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10
Q

What is IgA nephropathy?

A
  • Asymptomatic hematuria with proteinuria
  • Macroscopic hematuria associated with upper respiratory infection
  • This can be associated with Henoch-Schönlein Purpura

Board preferred question

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11
Q

Describe a case of asymptomatic hematuria

A

A 27 year old Asian-American medical student presents with asymptomatic hematuria. He notes gross hematuria, typically 1-2 days after an upper respiratory infection. It resolves quickly. His renal function is normal, and 24 hour urine reveals 1.5 g of proteinuria. His blood pressure is normal.

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12
Q

Would you do a kidney biopsy?

A

Yes

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13
Q

What would you probably see on a biopsy?

A

IgA nephropathy

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14
Q

What correlates best with this patient’s prognosis long term?

A

Fairly good prognosis

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15
Q

What is one condition that you will need to be able to recognize?

A

Rapidly Progressive Glomerulonephritis

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16
Q

What will you see in Rapidly Progressive Glomerulonephritis?

A
  • Renal failure
  • Oliguria
  • Edema
  • Hypertension
  • Proteinuria
  • Hematuria – active sediment
  • MEDICAL EMERGENCY***
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17
Q

Describe the pathology of rapidly progressive glomerulonephritis

A
  • Pathologically, this class of glomerular disease is characterized by the presence of cellular crescents ON RENAL BIOPSY **** KNOW THIS ***
  • Proliferation of parietal epithelial cells
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18
Q

What are three causes of rapidly progressive glomerulonephritis?

A
  • Direct immunoglobulin attack
  • Immune complex deposition
  • Pauci-immune
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19
Q

Describe direct immunoglobulin attack

A

Anti-GBM disease (Goodpasture Syndrome)

- Linear deposits of IgG in the glomerular basement membrane

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20
Q

Describe immune complex deposition

A
  • Lupus Nephritis Class III and Class IV
  • Post Infectious GN
  • Bacterial Endocarditis
  • Cryoglobulinemia
  • Shunt Nephritis
  • IgA Nephropathy (Henoch-Schönlein Purpura)
  • Fibrillary GN
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21
Q

What is the pathology of immune complex deposition?

A

Granular pattern of immune complex deposition

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22
Q

Describe Pauci-Immune Glomerulonephritis (ANCA associated)

A
  • Granulomatosis with Polyangiitis (GPA) (Wegener Granulomatosis)
  • Eosinophilic Granulomatosis with Polyangiitis (EGPA) (Churg-Strauss Syndrome)
  • Microscopic Polyangiitis (MPA)
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23
Q

Describe a case of rapidly progressive glomerulonephritis

A

36 year old African-American male with no significant past medical history presents to his primary care physician with a 2-3 month history of lower extremity edema.

  • Echocardiogram was normal.
  • Laboratory evaluation included a urinalysis which reveals >300 mg/dl of proteinuria and 4+ hematuria.
  • Microscopic examination revealed red blood cell casts.

KNOW URINALYSIS FINDINGS

CASTS = NEPHRITIC ****

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24
Q

Describe the further evaluation of this patient?

A
  • Laboratory evaluation revealed a serum creatinine of 2.0 mg/dl.
  • Ultrasound revealed normal kidneys without any evidence of hydronephrosis.
  • The patient was referred to a nephrologist for urgent evaluation.
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25
Q

What should you do next?

A

Renal biopsy

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26
Q

What would you find and diagnose?

A

Pathology findings of rapidly progressive glomerulonephritis

27
Q

Describe post-infectious glomerulonephritis

A
  • Post infectious glomerulonephritis is the most common cause of acute glomerulonephritis worldwide.
  • Most cases occur in developing countries
28
Q

What is the pathophysiology of post infectious glomerulonephritis?

A

In situ immune complex formation due to glomerular deposition of streptococcal nephritogenic antigens

29
Q

What are the bacterial causes of post-infectious glomerulonephritis?

A

*Streptococcus A
*Staphylococcus aureus
*Streptococcus viridans
E. Coli
Pseudomonas
Proteus mirabilis
Staphylococcus albus
Diplococcus pneumoniae
Mycoplasma
Salmonella typhi

*Strep is most common

30
Q

What are the clinical characteristics of post-infectious glomerulonephritis?

A
  • Usually an antecedent history of group A strep infection.
  • Latent period is weeks
  • Edema
  • Gross hematuria
  • Hypertension
31
Q

What are the laboratory findings in post-infectious glomerulonephritis?

A
  • Hematuria with and without red blood casts
  • Proteinuria
  • Depressed C3 and CH50 complement activity
  • Return to normal within 4-8 weeks
  • Elevated antibody titers to extracellular streptococcal antigens
32
Q

What are the viral causes of post-infectious glomerulonephritis?

A 
Epstein Barr virus
Parvovirus B19
Varicella
Cytomegalovirus
Coxsackie
Rubella
Mumps
Hepatitis B
33
Q

What are the parasitic infections that can cause post-infectious glomerulonephritis?

A

Schistosoma mansoni
Plasmodium falciparum
Toxoplasma gondii
Filaria

RARE in US

34
Q

Describe a case of post-infectious glomerulonephritis

A

An 8 year old male with no significant past medical history presents with gross hematuria, proteinuria (3 g/24 hours) and acute kidney injury. He had an upper respiratory infection 2 weeks ago. Testing for group A strep was positive.

35
Q

Should you biopsy?

A

Yes

36
Q

What would you find?

A

One of the causes of rapidly progressive glomerulonephritis

So you could see proliferation of parietal epithelial cells

37
Q

How do you treat this?

A

There is not really a treatment of this, so we typically just do steroids

38
Q

What is the prognosis?

A

The patient will improve over time (self-limiting)

39
Q

Describe nephrotic syndrome

A
  • Massive proteinuria (>3.5 g/24 hours)
  • Hypoproteinemia/ hypoalbuminemia (albumin less than 3 g/dl)
  • Edema
  • Hyperlipidemia
  • Thrombotic disease
  • Lipiduria
40
Q

What are the complications of nephrotic syndrome?

A
  • Thrombosis secondary to loss of hemostasis control proteins
  • Infections secondary to loss of immunoglobulins
  • Accelerated atherosclerosis from hyperlipidemia
  • Protein malnutrition
  • Iron-resistant microcytic hypochromic anemia due to transferrin loss
  • Hypocalcemia and secondary hyperparathyroidism
  • Vitamin D deficiency due to urinary excretion of cholecalciferol-binding proteins
  • Depressed thyroxine levels due to loss of thyroxine-binding globulins
41
Q

What are the causes of nephrotic syndrome?

A

Primary and secondary causes

42
Q

What are the causes of primary nephrotic syndrome?

A
  • Minimal change disease
  • Focal Segmental
    Glomerulosclerosis
  • Membranous glomerulopathy
43
Q

What are the causes of secondary nephrotic syndrome?

A
  • Diabetic glomerulopathy

- Amyloidosis

44
Q

What are minimal change diseases?

A

?

45
Q

What is focal segmental glomerulosclerosis?

A
  • Typically caused by obesity

- Can be misclassified as minimal change disease depending on the sample size and sampling error

46
Q

What are the variants of focal segmental glomerulosclerosis?

A

Can be primary or secondary and has variants

  • Etiology of primary FSGS may be related to minimal change disease
  • HIV – collapsing variant
  • Can be the endpoint of other causes of chronic kidney disease
47
Q

What is membranous glomerulonephropathy?

A

?

48
Q

What is diabetic glomerulopathy?

A
  • Increased pressure so filtering more
  • Nitroalbumineria will be the first sign of kidney damage in diabetics
  • Generally do NOT have hematuria
  • They DO have proteinuria and nephrotic syndrome

MOST COMMON CAUSE OF END STAGE RENAL DISEASE IN US ***

49
Q

What is amyloidosis?

A

Another systemic disease

50
Q

Give a case of diabetic glomerulopathy

A

A 76 year old male with 20 year history of type II diabetes mellitus complicated by diabetic retinopathy presents for evaluation of slowly progressive chronic kidney disease. His blood pressure is elevated at 160/80. 24 hour urine collection reveals 6 g per day of proteinuria.

51
Q

Would you biopsy this patient?

A

NO

Not typically done in diabetics

If you biopsy them, it usually does not change their treatment at all, so it is not useful

52
Q

What other testing might you do to evaluate this patient further?

A

Blood work and other non-invasive testing

53
Q

What is the most likely cause of his chronic kidney disease and proteinuria?

A

Diabetic glomerulopathy

54
Q

How would you treat this patient?

A

Treat the high BP

55
Q

What are the mechanisms of glomerular injury?

A

Immunologic vs. non-immunologic

56
Q

Describe antibody-mediated injury (immunologic injury)

A
  • Reactivity of circulating autoantibodies with intrinsic autoantigens with the glomerulus
  • In situ formation of immune complexes through interaction of circulating antibodies and extrinsic antigens planted within the glomerulus
  • Intraglomerular trapping of immune complexes that have formed in the circulation
57
Q

Describe the antineutrophil cytoplasmic antibodies (ANCA) (immunologic injury)

A
  • Pauci-Immune Glomerulonephritis
  • Immunoglobulins are not detected in the glomerulus
  • ANCA stimulate cytokine-primed neutrophils to generate reactive oxygen species that injure endothelium in vivo
58
Q

What are other immunologic injuries?

A
  • Antiendothelial Cell Antibodies
  • C3 Nephritic Factor
  • Cell-mediated injury
59
Q

What are non-immunologic injuries?

A
  • Metabolic (diabetic neuropathy)

- Hemodynamic glomerular injury (systemic and glomerular hypertension)

60
Q

Describe the metabolic cause of non-immunologic injury (diabetic nephropathy)

A
  • Glomerular hypertension
  • Hyperglycemia
  • Advanced glycosylation end-products
  • Growth factors (growth hormone, IGF 1, angiotensin II)
  • Cytokines (TGFβ)
61
Q

What are hemodynamic glomerular injury types?

A
  • Systemic hypertension

- Glomerular hypertension

62
Q

Describe glomerular hypertension

A
  • Intraglomerular pressure is a stimulus for mesangial matrix production and glomerulosclerosis
  • Blockade of the renin-angiotensin-aldosterone system (angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, renin inhibitors, and/or aldosterone antagonists) is important in alleviating this type of injury

The evidence for the effectiveness of these medications is the ability to LOWER PROTEIN IN THE URINE ****

THe lower we can suppress the protein, the less likely they are to progress and see a poorer prognosis **

63
Q

What are the indications for percutaneous renal biopsy?

A
  • The cause cannot be predicted with reasonable accuracy by less invasive procedure.
  • The signs and symptoms suggest a disease that can be diagnosed by pathologic evaluation.
  • The differential diagnosis included diseases that have different treatments or prognoses.

Treatment is really the key ***

64
Q

Focus on…

A
  • Remember what the signs and symptoms are for rapidly progressive glomerulonephritis
  • Know what you will see on a renal biopsy for rapidly progressive glomerulonephritis (crescent cells)
  • Characteristics of diabetic glomerularnephropathy
  • Characteristics of post-infectious glomerulonephrophathy

GI and Renal Exam 1 (16 decks)

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