Block 4: CKD and glomerulonephritis Flashcards

1
Q

CKD: monitoring ACEi and ARB’s

A
  • Measure serum potassium concentration and calculate eGFR before starting after 1-2 weeks and with each dose increase. Do not modify the dose if either
  • the GFR decrease from pre-treatment baseline is less than 25% or
  • the serum creatinine increase from baseline is less than 30%.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

CKD complications: A WET

A
  • A: Metabolic acidosis, managed with oral bicarbonate or dialysis
  • W: water removal, avoid excessive water and sodium intake. Treatment with diuretics and dialysis
  • Erythropoiesis: anaemia of chronic kidney disease, can be treated with erythropoietin stimulating agents (erythropoietin) and iron supplements
  • Toxin removal: uraemic encephalopathy, treat with dialysis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

CKD complications: BED

A
  • Blood pressure control: cardiovascular disease due to a combination of water and salt overload, hypertension and atherosclerosis
  • Electrolyte balance: Hyperkalaemia, treatment includes restriction of dietary potassium, med review, use oral potassium binders, dialysis
  • Vitamin D activation: due to increased secretion of PTH, impaired renal hydroxylation of vitamin D and renal phosphate retention. Management includes giving hydroxylated vitamin D (calcitriol), restrict dietary phosphate and administer phosphate binders (sevelamer)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

CKD: refer to a nephrologist is

A
  • a urinary albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
  • a urinary ACR of 30 mg/mmol or more, together with persistent haematuria (two out of three dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection
  • consider referral to a nephrologist for people with an ACR between 3-29 mg/mmol who have persistent haematuria and other risk factors such as a declining eGFR, or cardiovascular disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Creatinine

A
  • Creatine is an energy store for twitch muscles this is then broken down into creatinine.
  • It is excreted at a constant rate from the kidneys.
  • Blood concentration of creatinine is specific for determining kidney injury, if it goes up suggests kidney damage.
  • Creatinine depends on muscle mass. If high creatinine and eGFR then normal but if eGFR is low then damage
  • Affects creatinine levels: pregnancy, muscle mass, limb amputation, pregnant, elderly
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Urea

A
  • Ammonia is converted to urea in the liver, its then transported to the kidneys where it is excreted.
  • Not specific for kidney injury
  • High levels: dehydration, Gi bleed, increased protein breakdown
  • Low levels: malnutrition, liver disease, pregnancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Sodium

A
  • Main component of extra-cellular fluid
  • Sodium content is monitored by aortic / carotid bodies and reflects fluid status by cardiac stretch
  • Juxtaglomerular apparatus monitors sodium and causes renin release
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Potassium

A
  • Main intracellular electrolyte component
  • Controlled by aldosteron in the DCT acting to increase K+ excretion
  • Levels vary with hydrogen ion concentration as they compete for the transporter in the kidney
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Indications for kidney biopsy

A
  • Unexplained renal impairement
  • Unexplained proteinuria
  • Unexplained glomerular haematuria
  • Renal masses (urology)
  • Renal transplant: rejection, dysfunction
  • Connective tissue diseases
  • Treatment monitoring/Research
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Kidney biopsy

A
  • Invasive procedure: uses anaesthetics
  • Patient lies on stomach: tends to go for left kidney
  • Must lie on back for 6 hours after with 15 minute observations
  • Sample is hand delivered to lab
  • Ultrasound guided- uses biopsy gun
  • Need 2 cores of tissue and 10 glomeruli
  • Can show: inflammation, scarring, infection and deposition
  • Risks: bleeding (visible haematuria), pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Autosomal dominant Polycystic Kidney disease (ADPKD) multisystem disease which can cause

A
  • Berry aneurysms: intracranial haemorrhage
  • Valvular heart disease
  • Dilatation of aorta
  • Diverticulosis
  • Pancreas, spleen, liver cysts
  • Epididymal cysts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

ADPKD: genetics

A
  • PKD1 (Chr16p) polycystin-1
  • PKD2 (Chr4q) polycystin-2
  • (subfamily of transient receptor potential (TRP) channels)
  • Genes are involved in calcium ion transport and have a role in the primary cilia
  • Genetically unresolved cases (7-10%) - GANAB
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

ADPKD: definition and presentation

A

Definition: most commonly inherited disorder of the kidneys. Characterised by the formation of renal cysts and extrarenal manifestations like hepatic cysts, intracranial aneurysms and aortic root dilation

Presentation: normally between 30 and 60 causes haematuria, loin pain and hypertension. 50% will develop end stage renal disease. Accounts for 10% of patients with renal failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

ADPKD types

A
  • Type 1 ADPKD:85% of cases. Caused by a mutation in PKD1 on chromosome 16. Symptoms tend to be more severe in this type
  • Type 2 ADPKD:15% of cases. Caused by a mutation in PKD2 on chromosome 4. Symptoms tend to be less severe in this type
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

ADPKD: signs on examination

A
  • Palpable kidneys/abdominal mass
  • Hepatomegaly due to hepatic cysts
  • Abdominal wall hernias: These are more common in ADPKD, affecting 45% of patients
  • Cardiac murmur: This is due to an increased incidence of mitral valve prolapse, mitral regurgitation, aortic regurgitation and dilated aortic root in patients with ADPKD.
  • Symptoms: haematuria, chronic loin pain, hypertension, recurrent UTI’s, kidney stone, headaches
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management and investigations of ADPKD

A

Management: control symptoms. Should refer to a nephrologist, control blood pressure and manage renal pain. In end stage renal disease may need transplant or dialysis.

Tolvaptan can slow cyst formation

Investigations: if positive family history ultrasound to look for cysts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Alport syndrome

A

X linked inheritance: females carry the disease and men get the symptoms. Men cant give it to men.

A gene which encodes collagen in the basement membranes of the kidney, inner ear and eye. Defect in type IV collagen

Glomerular disease with haematuria and proteinuria. With early onset sensorineural deafness and blindness

Causes mutations in COL4A3, COL4A4 and COL4A5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Glomerulonephritis definition

A

Refers to several renal diseases which affect both kidneys. Causes inflammation of either the glomeruli or the small blood vessels in the kidneys. Causes proteinuria and haematuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Glomerulus

A
  • A collection of capillaries surrounded by the Bowmans capsule
  • Capillaries are supported by cells and connective tissue known as the mesangium
  • Fluid and other substances pass from the capillaries to the urinary space which pass into the PCT
  • The endothelium, basement membrane and podocytes make up the filtration barrier.
  • Damage to the glomerulus causes blood and protein to leak
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Glomerulonephritis: classification

A
  • Primary: glomerular injury due to primary renal pathology. For example, IgA nephropathy, minimal change disease, focal segmental glomerulosclerosis
  • Secondary: glomerular injury occurring as part of a systemic process. For example, Vasculitis (ANCA associated vasculitis), amyloidosis, diabetes mellitus
  • Focal versus diffuse: a glomerulopathy can be focal (only some glomeruli are involved) or diffuse (all glomeruli are affected)- 50% cut off
  • Global versus segmental: global affects all parts of the glomeruli and segmental only part of the glomeruli is affected- 50% cut off
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Glomerulonephritis: MoA

A
  • Immune-mediated: deposition or in situ formation of immune complexes (collections of antibodies) that fix complement and activate a pro-inflammatory response. Alternatively, circulating antibodies may directly target key proteins on the basement membrane or endothelial cells precipitating an inflammatory reaction (e.g. ANCA- associated vasculitis).
  • Non-immune mediated: the structure and/or function of podocytes may be affected that disrupts the filtration barrier (e.g. minimal change disease). This leads to larger macromolecules leaking through glomeruli. Alternatively, accumulation of non-immune material (e.g. proteins) can disrupt the glomeruli structure causing dysfunction (e.g. diabetes mellitus, amyloid).
22
Q

Glomerulonephritis: Histopathology

A
  • Proliferative: increase in number of cells in the glomerulus. Associated with marked inflammatory response. Causes glomerular inflammation with haematuria and/or nephritic syndrome
  • Non proliferative (structural): may show structural changes and sclerosis, associated with protein loss and nephrotic syndrome
  • Crescents: extra capillary lesions in the Bowmans capsule due to accumulation of immune cells, fibroblasts, epithelial cells and fibrin. Due to severe injury in the capillary wall causing glomerular membrane rupture. Means rapidly progressive
23
Q

Features that suggest haematuria is from the glomerular

A
  • Dysmorphic red blood cells: appear normal
  • Red blood cell casts: blood cells within urinary casts
  • A cast is a cluster of particles coated in uromodulin
24
Q

Causes of Glomerulonephritis

A
  • Isolated haematuria: IgA nephropathy, Alport syndrome, Thin basement membrane disease. Persistent haematuria without proteinuria and with normal renal function
  • Isolated proteinuria: glomerular, tubular, overflow (myeloma), post renal. Degree of proteinuria is non-nephrotic (<3.5 g/day)
  • Nephrotic syndrome
  • Nephritic syndrome
  • Rapidly progressive glomerulonephritis
25
Q

Benign causes of proteinuria

A
  • Transient proteinuria: common in young individuals. Absent on repeat testing and exercise is a common precipitant.
  • Orthostatic proteinuria: presence of proteinuria only in the upright position
26
Q

Nephritic syndrome

A
  • Prescence of haematuria, variable proteinuria (can be nephrotic range), oliguria (i.e. AKI), renal impairment and hypertension
  • Due to an inflammatory process within the glomeruli
27
Q

Classification of nephritic syndrome

A
  • Mild: presentation with minimal haematuria and proteinuria only
  • Severe: typically presents with the classical ‘nephritic syndrome’
  • Self-limiting: development of an acute
    glomerulonephritis that gets better without treatment
  • RPGN: severe glomerulonephritis that has a fulminant course with rapid deterioration in renal function over days to weeks to a few months.
  • Chronic: slowly progressive renal disease presenting with features of CKD
28
Q

Proliferative glomerulonephritis

A

Characterised by increased number of cells in the glomerulus, typically presents with nephritic syndrome

29
Q

Causes of nephritic syndrome

A
  • Immune complex deposition: Poststreptococcal glomerulonephritis, autoimmune (e.g. lupus), IgA nephropathy, SLE. Due to deposition of components of the immune system i.e. immunoglobulins that initiate a local inflammatory response
  • Anti-GBM deposition: anti-glomerular basement membrane disease
  • Small-vessel vasculitis: eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, polyangiitis with granulomatosis. Patients normally have circulating autoantibodies known as ANCA which target self antigens leading to vasculitis (inflammation of arterioles, capillaries and venules) that might be limited to the kidneys or multisystem
30
Q

Anti-GBM autoantibodies

A

A rare small vessel vasculitis that result from GBM antibodies that target type IV collagen in the basement membrane. Causes deposition of IgG in the glomerular capillaries. Different to ANCA associated vasculitis

31
Q

Presentation of nephritic syndrome

A
  • Minimal haematuria and proteinuria
  • Acute self-limiting disease
  • Acute severe disease: severe renal impairment usually develops without treatment
  • Rapidly progressive glomerulonephritis: deterioration in renal function over days to weeks to a few months
  • Chronic kidney disease: slowly progressive deterioration in renal function due to inflammation
32
Q

Symptoms of nephritic syndrome

A
  • Lethargy
  • Recent infection: fever, sore throat, coryzal symptoms. Typical of post streptococcal glomerulonephritis and IgA nephropathy
  • Haematuria
  • Oliguria: reduce urine output
  • Oedema: peripheral or periorbital
  • Shortness of breath: due to fluid overload
  • Haemoptysis: due to pulmonary haemorrhage (e.g. Anti-GBM, ANCA-vasculitis)
  • Signs: Haematuria, hypertension, oedema (peripheral, periorbital), fluid overload (raised JVP, bibasal crackles on auscultation, peripheral oedema, ascites), reduced urine output
33
Q

Extra-renal manifestations of nephritic syndrome

A
  • Skin: vasculitic rash (palpable purpura)
  • ENT: rhinosinusitis, nasal discharge, polychondritis (inflammation of cartilage)
  • Eyes: red, painful eyes (e.g. conjunctivitis, scleritis, uveitis)
  • Lungs: haemoptysis, pleuritic pain, wheeze
  • Heart: chest pain due to pericardial or myocardial involvement
  • Nervous system: mononeuropathies
  • Seen in patients with systemic causes: vasculitis, SLE, anti-GBM disease
34
Q

Nephritic syndrome: diagnosis and investigations

A
  • Need to identify worsening renal function, haematuria and proteinuria whilst excluding UTI and renal stones. Identify haematuria of glomerular origin:
  • Dysmorphic red blood cellsin urine: red cell structure appears abnormal under the microscope
  • Red blood cell casts: red bloods cells within urinary casts seen under the microscope.
  • Full renal screen
  • Renal biopsy to confirm glomerulonephritis
35
Q

Management of nephritic syndrome

A
  • Depends on underlying cause
  • Rapidly progressive glomerulonephritis: aggressive immunosuppressants
  • Temporary RRT might be needed whilst treatment is initiated
36
Q

Poststreptococcal glomerulonephritis (PSGN)

A
  • Cause of nephritic syndrome: due to prior infection with group A beta haemolytic Streptococcus. Most common cause in children, reduced incidence in developed countries because of antibiotics. Uncommon in adults
  • Normally 1-3 weeks after a skin or throat by Group A beta haemolytic Streptococcus
  • Due to development of immune complexes containing Streptococcal antigens that are deposited in the renal glomeruli causing cross-reactivity
37
Q

PSGN diagnosis and management

A
  • Highly variable presentation: asymptomatic or acute severe
  • Diagnosis: measuring antibody titres against Streptococcus (ASOT). In adults renal biopsy.
  • Suspect if nephritis with recent streptococcal infection
  • Management: No specific treatment about managing complication i.e. hypertension, oedema. In severe cases renal replacement therapy is needed. In children resolution is rapid. Active infection should be treated with antibiotics
38
Q

Post-infectious glomerulonephritis (PIGN)- cause of nephritic syndrome

A
  • An immunologically mediated glomerular injury triggered by infection, most commonly associated with streptococcus (PSGN)
  • Nephritic syndrome presents two weeks after infection
  • Investigations: on renal biopsy shows diffuse proliferative and exudative glomerular histology, Dominant C3 staining and subepithelial humps
  • Diagnosis: precense of symptoms and signs of glomerulonephritis, history of recent infection (Streptococcal), raised streptococcal titres)
  • Management: supportive with monitoring of fluid balance
  • Prognosis: self limiting especially in children, long term follow up indicates persistent low grade renal abnormalities
39
Q

Lupus nephritis

A
  • Renal involvement in patients with SLE
  • Classified and diagnosed based on renal biopsy
  • Deposition of immune complexes within the glomeruli causing injury. Immune complexes form due to anti-double stranded DNA
  • Management: depends on classification in class IV need high dose immunosuppression
40
Q

Classification of lupus nephritis

A
  • Class I (minimal mesangial): rarely diagnosed as patients usually asymptomatic
  • Class II (mesangial proliferative): typically causes non-visible haematuria and proteinuria
  • Class III (focal): variable presentation. May have haematuria, proteinuria, renal
    impairment and/or nephrotic syndrome
  • Class IV (diffuse): most common and most severe form. May present with nephrotic or nephritic syndrome.
  • Class V (membranous): presents with nephrotic syndrome similar to membranous nephropathy
  • Class VI (advance sclerosis): global sclerosis and slowly worsening renal function
41
Q

IgA nephropathy

A
  • Most common primary chronic glomerular disease worldwide. Causes nephritis
  • Causes deposition of IgA immunoglobulins in the glomeruli
  • Presents with visible or non-visible haematuria and proteinuria, rarely can cause Nephritic or even Nephrotic syndrome
  • Treatment is supportive with good blood pressure control
  • Also known as Berger’s disease- most common form of glomerulonephritis in adults worldwide- presents 24-48 hours after an upper respiratory tract infection
42
Q

IgA nephropathy: investigations and management

A
  • Investigations: microscopically will see increased number of mesangial cells and an increased matrix. Immunohistochemistry will show IgA deposition in the matrix
  • Management: high dose prednisolone (reduces proteinuria and delays renal impairment), other immunosuppressive drugs (used in patients with deteriorating renal function)
  • Variable prognosis
43
Q

ANCA associated vasculitis

A
  • Umbrella term for three small vessel vasculitis’s: Microscopic polyangitis (MPA), Granulomatosis with polyangitis (GPA), Eosinophilic granulomatosis with polyangitis (EGPA)
  • Causes nephritis
  • Affect arterioles, capillaries and venules
  • Characterised by positive ANCA
  • These autoantibodies specifically target
    myeloperoxidase and proteinase 3 and can affect multiple organs systems.
  • Patients may develop rapidly progressive glomerulonephritis and treatment involved high dose immunosuppression
44
Q

Anti-GBM disease

A
  • Rare small vessel vasculitis: causes nephritis
  • Formation of anti-GBM antibodies that are directed against type IV collagen in the kidneys and lungs
  • Can cause life-threatening glomerulonephritis and/or pulmonary haemorrhage
  • Treatment: immunosuppression and plasmapheresis (removing patients plasma and replacing it human albumin to remove the autoantibodies)
45
Q

Nephritic syndrome versus glomerulonephritis

A

Nephritic syndrome and glomerulonephritis can be used interchangeably. Nephritic syndrome describes a more classic presentation of glomerular disease with haematuria, variable proteinuria (may be nephrotic), renal impairement, hypertension. Glomerulonephritis is a more encompassing term reflecting the variable clinical presentation of glomerular inflammation i.e. minimal haematuria

46
Q

Membranoproliferative glomerulonephritis

A
  • A group of immune mediated disorders caused by glomerular basement membrane (GBM) thickening and proliferative changes
  • Associated with hepatitis C and other autoimmune disorders like SLE
  • Typical findings on renal biopsy include: Thickened basement membrane, thickened Mesangium, ‘Tram-tracking’ appearance
  • Immunofluorescence shows subendothelial deposition of IgG
  • Management: children with nephrotic range proteinuria- corticosteroids, Adults- dipyridamole and asprin, kidney transplant in end stage renal disease
47
Q

Rapidly progressive glomerulonephritis- RPGN (crescentic glomerulonephritis)

A
  • An acute nephritic syndrome accompanied by microscopic glomerular crescent formation with progression to renal failure within weeks to months.
  • Tends to occur in 20-50
  • Can be caused anti-glomerular basement membrane antibody disease and vasculitic disorders
48
Q

Small vessel vasculitis: cause of nephritic syndrome

A
  • Little to none immune deposition
  • Due to ANCA which target self antigens causing vasculitis that can be limited to the kidney or multisystem
  • Vasculitic disorders which may cause proliferative glomerulonephritis include
    granulomatosis with polyangiitis (GPA) and microscopic polyangiitis.
49
Q

Granulomatosis with polyangitis- cause of nephritic syndrome

A
  • Extremely rare long term systemic disorder that involves granuloma formation and inflammation of blood vessels (vasculitis)
  • Affects small and medium sized vessels in many organs (upper respiratory tract, lungs, kidneys)
  • Symptoms depend on what vessel is affected, vasculitis is caused by anti-neutrophil cytoplasmic antibodies (c-ANCA)
  • A biopsy (e.g. of kidney or cutaneous tissue) will show leukocytoclastic vasculitis with necrotic changes and granulomatous inflammation (clumps of typically arranged white blood cells) on microscopy.
  • Management: involves immunosuppression. Remission is induced with rituximab or cyclophosphamide in combination with high dose corticosteroids. Maintenance therapy may include methotrexate and corticosteroids.
50
Q

Microscopic polyangiitis: cause of nephritic syndrome

A

A systemic small vessel vasculitis without clinical evidence of necrotising granulomatous inflammation. Symptoms: weight loss, fevers, fatigue and renal failure. Ongoing inflammation is driven by anti-neutrophil cytoplasmic antibodies (p-ANCA), which is positive in almost all cases. Management involves long-term prednisolone and cyclophosphamide therapy. Plasmapheresis can remove p-ANCA antibodies.