7 - Glomerular Diseases Flashcards
Oliguria
Urine output <400 mL/day
Azotemia
Buildup of nitrogenous waste in blood, secondary to decreased renal function
Crescents
Proliferation of cells w/in bowmans capsule
- response to glomerular rupture
- marker of severe glomerular injury
Oval fat bodies
Sloughed tubular epithelial cells that have reabsorbed some of the excess lipoproteins in the urine
Abnormalities of glomerular function cause damage to?
The major components of the glomerulus
- epithelium (podocytes)
- basement membrane
- capillary endothelium
- messangial cells
How is glomerular disease diagnosed?
Visualization of specific histologic patterns on biopsy
Glomerular disease classifications?
Nephritic syndrome
Nephrotic syndrome
They usually exhibit primarily nephritic or nephrotic but there is some overlap
Nephritic findings
Ne phritic • Hematuria ± RBC casts • Mild proteinuria • ↓ GFR • Edema • HTN
Nephrotic findings
Nephrotic • Heavy proteinuria (>3.5 g/24h) • Hypoalbuminemia • Marked Edema • HLP (lipiduria)
Sweet pic on slide 9
Slide 10
Look at it
Nephrotic vs nephritic onset?
Nephrotic: insidious
Nephritic: acute
UA findings for nephrotic vs nephritic?
Nephrotic: proteinuria
Nephritic: hematuria; RBC casts
Edema w nephrotic and nephritic?
Nephrotic: ++++
Nephritic: ++
arterial BP and Central venous pressure for nephrotic vs nephritic?
- Nephrotic: normal
- nephritic: increased
Nephritic specturm disorders range from?
Glomerular hematuria —> rapidly progressive glomerulonephritis (RPGN)
Where on the spectrum does nephritic syndrome land?
Somewhere in the middle
Nephritic syndrome is aka?
Acute glomerulonephtitis
Nephritis syndrome
Nephritic syndrome causes ___ of the glomeruli
Inflammation
Inflammatory response of nephritic syndrome is caused by?
- due to immune response triggered by infection of other diseases
Essentials of diagnosis for nephritic syndrome
Essentials of diagnosis – Hematuria ± red cell casts –Edema –Hypertension (may be normotensive initially) –Subnephrotic Proteinuria (< 3 g/day) –↑ serum creatinine
S/s of nephritic syndrome?
Dark, “cola colored” urine
• ± ↓ urine volume (oliguria)
Edema in regions of low tissue pressure
• Periorbital
• Scrotum
HTN, if present, is due to volume overload
• Due to ↓ GFR
• Check for JVD & adventitious lung sounds
Lab testing for nephritic syndrome?
Testing:
– BUN, Creatinine, GFR
– UA:
• Dark, “cola” colored • Hematuria:
– Dysmorphic RBCs
– RBC casts
• Subnephrotic proteinuria
– Renal biopsy
• To definitively establish underlying cause
• Not always necessaryWith nephritic syndrome you should also order?
Miscellaneous serologic markers based on presentation:
– Complement levels – Antinuclear antibodies (ANA) – Cryoglobulins – Hepatitis serologies – ANCA (antineutrophil cytoplasmic antibodies) – Anti-glomerular basement membrane (GBM) antibodies – Anti-streptolysin O (ASO) titers – C3 nephritic factor
Nephritic UA and metabolic syndrome?
Slide 18
Goal of tx for nephritic syndrome?
Reduce the glomerular inflammation
Nephrtic syndrome treatment?
Admit - usually Nephrology referral Monitor - renal function - BP - edema - serum albumin - urine protein HTN and fluid overload reduction Corticosteroids
Nephritic syndrome prognosis?
Kids do better than adults
IgA nephropathy is aka?
Berger disease
IgA nephropathy is?
IgA deposition in the glomerular mesangium
MC form of nephritic syndrome
MC pax for berger?
Most Common: young males»_space; females
Common: Asians
MC presentation of IgA nephropathy?
Painless gross hematuria
May present at any point on the nephritic spectrum
- MC less sever end of spectrum
With IgA you need to look for?
URI
- freq associated w current URI “synpharyngitic hematuria”
IgA nephropathy labs?
Renal
- UA
- BUN
- Cr
- GFR
Serum IgA
- elevated
Confirm IgA nephropathy diagnosis?
Renal biopsy
- Focal glomerulonephritis w/ diffuse mesangial IgA deposits & mesangial cell proliferation
– Not always indicated
Tx of IgA nephroptathy?
ACE/ARB
- target BP <125/75
Corticosteroids
- if proteinuria persists > 3-6 mo
REFERRAL to nephrology
ACE and ARB are titrated to? (IgA nephropathy)
Proteinuria < 1g/day
Most unfavorable prognostic indicator (IgA nephropathy)
Proteinuria > 1g/day
Postinfectious glomerulonephritis is due to?
Infection w
- group A Beta-hemolytic streptocci
- 7-10 days after pharyngitis/impetigo
- get a good hx
S/s of postinfectious glomerulonephritis?
- coffee/cola urine
- oliguria
- edema
- HTN (varies)
Labs for postinfectious glomerulonephritis?
– UA: • Urinary RBCs, red cell casts • Mild proteinuria – Throat culture – ASO titers may be elevated • May be WNL due to antibiotic treatment
postinfectious glomerulonephritis tx?
- tx infection
- supportive
- bed rest
- anti-hypertension
- diuretics (PRN)
- nephrology consult
Prognosis for postinfectious glomerulonephritis?
Kids - full recover 2 months
Adults - progress to RPGN
IgA vs PSGN
Slide 29
Henoch-schonlein purpura is?
HSP
Small vessel leukocytoclastic vasculitis
- mediated by IgA (vasculitis)
HSP is not related to?
Unrelated to IgA nephropathy however pathophysiology and
histologic findings are the same.
HSP is MC in?
Young males
Post infection
HSP ask about?
Fever and hematuria
S/s of HSP?
– Palpable purpura (most often on legs) – Arthralgias – Abdominal symptoms (nausea, colic, melena) – ↓GFR – Hematuria
HSP tx?
– Usually self-limiting & most patients recover fully over several weeks • Bed rest • Hydration • Analgesics – +/- corticosteroids
HSP indications for inpatient
- cant maintain fluids
- severe abd pain
- sig gastrointestinal bleeding
- mental status changes
- severe joint involvement
- renal insufficiency
Goodpasture syndrome is?
Anti-Glomerular Basement Membrane (anti-GBM)
Glomerulonephritis
Goodpasture syndrome is defined by?
- glomerulonephritis
- pulmonary hemorrhage
Goodpasture syndrome symptoms?
- hemoptysis
- tachypnea
- malaise
- anorexia
- HA
- preceding URI (poss)
Nephritic syndrome
- HTN
- Edema
Goodpasture syndrome prognosis?
Rapidly progressive and fatal
Labs for Goodpasture syndrome ?
– Gross or microscopic hematuria
– Proteinuria
– ↑ BUN/Creatinine
– Anti-GBM antibodies
Goodpasture syndrome radiographs?
Pulmonary infiltrates due to pulmonary hemorrhage
Tx for Goodpasture syndrome ?
– ADMIT
– Plasmapheresis → remove circulating anti GBM antibodies
– Medications → inhibit formation of new antibodies:
• Cortiocsteroids (i.e., Prednisone)
• Cyclophosphamide
Nephrotic syndrome is characterized by?
– Heavy proteinuria – Hypoalbuminemia – Edema – Hyperlipidemia • Oval fat bodies in urine
Uncommon With nephrotic syndrome
HTN
Hematuria
Adults (usually its kids)
Essentials of diagnosis for nephrotic syndrome
– Urine protein > 3.5 g 24h
– Hypoalbuminemia (albumin < 3 g/dL)
– Rapid onset of peripheral edema
• Typical presenting symptom
S/s of nephrotic syndrome?
Massive peripheral edema
• When serum albumin is < 3 g/dL
–> Due to loss of plasma oncotic pressure
• Facial edema usually presenting symptom in children
Dyspnea due to pulmonary edema, pleural effusions, and/or diaphragmatic compromise w/ ascites
• Due to massive third spacing of fluid
Pic on 41
Lab findings for nephrotic syndrome?
Heavy proteinuria (3+/4+)
Hyperlipidemia (TG)
- oval fat bodies in urine
L serum albumin (<3g/dl)
Nephrotic syndrome cause profound?
Hypoalbuminemia
- risk of VTE
<2g/dL
What happens when the serum albumin is <2g/dL?
- H hepatic synthesis of clotting factors
- h platelet activation
- H serum viscosity (oncotic pressure)
- L circulating
—>antithrombin III,
—>protein C/S
nephrotic syndrome definitive diagnosis?
Renal biopsy
- adults: get one
- kids: not usually done
Tx for nephrotic syndrome?
Based on symptoms
Protein loss - ACE/ARB Edema - Na restriction - loop diuretic Hyperlipidemia - exercise/diet - statins Pt education on H infection risk
nephrotic syndrome infection risk?
Increased pneumonia and peritonitis etc
Tx for nephrotic syndrome specific to serum albumin <2g/dL?
IV albumin
Long term anticoagulation therapy
- warfarin
nephrotic syndrome admit if?
- renal failure
- refractory edema
- complications
nephrotic syndrome complications that lead to admission?
Sepsis Peritonitis Pneumonia Thromboembolic problem Failure to thrive
What causes adults to get nephrotic syndrome?
1/3 comes from systemic disease
- DM
- amyloidosis
- SLE
The rest have primary renal disease
MC primary nephrotic syndromes?
- Minimal change disease
- Membranous nephropathy
- Focal segmental glomerulosclerosis
MC cause of primary nephrotic syndrome in kids?
Minimal change disease
80%
Most minimal change disease is?
Idiopathic
Can also be
- S/P viral URI
- Tumors - hodgkins
- meds (lithium)
- hypersensitivity reactions (NSAIDS, bee)
Minimal change s/s?
Sudden swelling in child
Nephrotic syndrome manifestations
Biopsy for mcd?
Reserved for steroid tx failures
- electron microscopy shows effacement of podocyte foot process
MCD tx?
Prednisone (90% respond)
- 4-8 wks in kids
- 16 wks in adults
Continue several weeks after remission
Prognosis for MCD?
Many relapse and require subsequent steroid tx
Progression to ESRD is rare (adults > kids)
MC cause of primary nephrotic syndrome in adults?
Membranous nephropathy
- adults 40s or 50s
Membranous nephropathy is sometimes secondary to?
Carcinoma
Infections (HBV, HCV, syphilis)
Autoimmune disease
Menbranous nephropathy s/s?
Nephrotic syndrome manifestations
VTE (high incidence)
- renal vein thrombosis
- high PE risk
Membranous nephropathy tx?
R/o secondary causes
Tx renal progression
Biopsy (maybe)
Meds:
- ace/arb
- statin
- immunosuppression (steroids/cytotoxic)
Renal transplant
Focal segment glomerulosclerosis is associated with?
Renal inj
- podocyte damage
Nephrotic syndrome manifestations
- proteinuria
Focal segment glomerulosclerosis diagnosis?
Biopsy
- fusion of epithelia foot processes
Focal segment glomerulosclerosis tx?
Steroids
Ace/arb
Statins
Systemic diseases that adversly affect the glomeruli?
Secondary renal disease
- DM (DM nephropathy)
- Hep C
- SLE
- SCD
- HIV (HIV associated nephropathy)
- renal amyloidosis
- alport syndrome (hereditary nephritis)
MC cause of ESRD in US?
The big DM
- type 1 more likely to develop ESRD
Why does DM1 get more ESRD?
DM1 lives longer so they can develop ESRD,
- DM2 folks die faster
When does diabetic nephropathy present?
10 yrs after DM onset
- may be at diagnosis for DM2
MC lesion in diabetic nephropathy?
Diffuse glomerulosclerosis
Diabetic nephropathy pathogenesis?
Glomerular HTN -> glomerular hyperfiltration -> sclerosis
DM pts must be screened for?
Microalbuminuria
- earliest detector
Diabetic nephropathy tx?
Strict glycemic control
Aggressive HTN control
- ACE/ARB
PT education
Avoid contrast material - acute renal failure
Hep C nephritic and nephrotic features?
– Membranoproliferative glomerulonephritis
– Cryoglobulinemic glomerulonephritis
– Membranous nephropathy
Hep c glomerular disease typically has?
Hematuria
Proteinuria
HTN
Anemia
SLE pts need?
Routine UA
- hematuria
- proteinuria
SLE has what glomerular lesions?
Wide spectrum of lesions
- 6 lupus nephritis classification based on biopsy results
SLE renal is?
Aggressive
- 50% + greater loss of renal function w/in weeks/months
SCD renal problems?
RBC sickling
- renal medula
- renal dysfunction
Hematuria and flank pain
Congestion and stasis
- hemorrhage
- interstitial inflammation
- papillary infarcts
Glomerular involvement
- proteinuria and progressive GFR disease
SCD nephropathy leads to?
ESRD
HIV pts get?
Nephrotic syndrome w/ decreased GFR
Leads to secondary focal segmental glomerulosceroisis
- sever tubulointerstitial damage may present
Renal amyloidosis leads to?
Extracelular amyloid deposition
Glomeruli are filled w/ amorphous deposits
Primary emyloidosis leads to?
ESRD in 2-3 yrs
Alport syndrome is aka?
Hereditary nephritis
- X linked
Alport syndrome is?
Type IV coallegen defects of kidneys, ears and eyes
- microscopic hematuria (birth)
- progressive proteinuria
- nephritic syndrome
- hearing loss
Alport syndrome leads to?
Progressive glomerulosclerosis and interstitial scarring develop -> ESRD
What do testicles and prostates have in common?
Not much, there is a vas deference between them
