CKD Lecture 2 Flashcards
What makes up the glomerulus and what can cause damage to this?
Epithelium, podocytes, basement membrane, endothelium
Many different ways to damage - overworking, inflammation, deposition
What typically is acute kidney disease (nephritic or nephrotic)
Nephritic (I = inflammation, immune system)
Urine sediment with hematuria, +/- RBC casts
Proteinuria (< 3 g/d)
What is nephrotic kidney disease?
Typically no urine sediment
PrOteinuria = nephrOtic
> 3 g of protein peed our per day
What blood abnormality is common in nephrotic kidney disease?
Hypoalbumunia (because you pee out albumin)
What causes chronic glomerulonephritis?
Same causes as acute, but it just progresses to scarring
- Immune complex deposition
- Pauci-immune (vasculitis)
- Anti-glomerular basement membrane
- C3 glomerulopathy
- Monoclonal Ig (too much IgG)
What is the MC chronic glomerulonephritis?
Immune complex deposition, with Berger disease often
What are the general findings of glomerulonephritis?
Fall in GFR (fast if acute, slower if chronic)
Edema and HTN
Smoky, cola-colored urine d/t heavy glomerular bleeding
What is BUN:Cr mainly used for chronic GN?
mainly hydration status
What urine sediment is typically seen in GN?
RBCs and RBC casts
RBCs often dysmorphic from crossing damaged glomerulus (squeezed through)
RBC casts - sign of heavy glomerular bleeding, tubular stasis (they clump together)
What is a CI to renal biopsy for GN?
Bleeding disorder
Uncontrolled HTN (damaging kidneys makes them increase RAAS system)
How do you manage chronic HTN for GN?
ACE/ARB in order to reduce proteinuria
Also corticosteroids, cytotoxic agent
Do you use ACE/ARB in AKI?
NO
What often causes post-infectious GN
GABHS
typically history of pharyngitis and impetigo
What is the treatment of post-infectious GN?
treatment of infection
Supportive - antihypertensives, salt restriction, diuretics
Steroids do not generally improve outcome
children recover, adults maybe progress to CKD
Who are the MC with IgA nephritis (berger’s disease)?
Males, children/young adults
What are the MC presenting symptom of Berger’s disease?
episode of gross hematuria
normal serum
33% spontaneous remission
How do you treat Berger’s disease?
Low risk - no HTN, normal GFR, minimal proteinuria - monitor yearly
High risk - proteinuria >1.0 g/d, decreased GFR, HTN - ACE or ARB
What is Henoch-Schönlein Purpura?
Systemic small-vessel vasculitis - MC systemic vasculitis of childhood
s/s Palpable purpura in lower extremities and butocks; arthralgias, abdominal symptoms
What is the treatment of Henoch-Schönlein Purpura?
no direct treatment proven successful
Supportive care - hydration, rest, pain relief
may make full recovery over several weeks; may progress to CKD
What is the MCC of nephrotic syndrome and what is it?
DM
“Nephrotic range” proteinuria - >3 g/day
What are the s/s of nephrotic syndrome?
Subnephrotic proteinuria - little to no s/s
Nephrotic Syndrome - peripheral edema (MC), can also have edema in other areas as well
What is the Urinalysis of nephrotic syndrome?
Proteinuria - 300 mg/d or more
must order specifically for protein
What is the urinary sediment of nephrotic syndrome?
few cells/casts
If marked HLD - oval fat bodies
“Grape clusters” (light microscopy) or “Maltese crosses” (polarized light)
What are the serum labs of nephrotic syndrome?
hypoalbuminemia
hypoproteinemia
hyperlipidemia (in order to try to increase osmotic pressure lost from peeing out protein)
Possible deficiencies d/t not having protein carriers
When do you order a renal biopsy for nephrotic syndrome?
If there is new-onset idiopathic nephrotic syndrome
Not ordered in people with long standing DM, because we know what it is coming from
How do you manage nephrotic syndrome?
Eat more protein
Restrict salt
What doses do you need for thiazide/loop diuretics?
MORE because they are protein-bound and more likely to get peed out
How do you manage hypercoagulabitilty?
Usually seen if serum albumin <2 g/dL
Urinary loss of antithrombin, protein C, protein S
Increased platelet activation
Anticoagulation x 3-6 months min. if evidence of thrombosis
Ongoing - if renal vein thrombosis, PE, recurrent thromboemboli
What is the MCC of nephrotic syndrome in kids and how does it present?
Minimal Change Disease
often full-blown nephrotic syndrome
Thromboembolic events, hyperlipidemia, protein malnutrition
What is the treatment of nephrotic syndrome?
Prednisone
Rarely progresses to ESRD
What is the MCC of primary nephrotic syndrome in adults?
Membranous Nephropathy
Often frothy urine (like a protein shake) and edema
How do you treat Membranous Nephropathy?
ACE/ARBs, immunosuppression, transplant
varying results
What is a secondary nephrotic syndrome and how does it present?
Amyloidosis, d/t EC deposition of amyloid
Large kidneys d/t holding too much amyloid
What is the MC of ESRD?
DM neuropathy
Early - hyperfiltration with increased GFR
Later - microalbuminuria (30-300 mg/d)
Progression - albuminuria 300+ mg/d
Treatment - as soon as microalbuminuria is found
Strict glycemic control
What is chronic tubulointerstitial disease?
Like AIN
Present with tubular dysfunction
What is the MCC of Chronic Tubulointerstitial Disease
obstructive uropathy
Vesicoureteral Reflux - mainly in childhood
-Analgesic Nephropathy
What is the pathophys of obstructive uropathy?
Prolonged obstruction of urinary tract
Backflow of urine → extravasation into interstitium → inflammation, fibrosis
Prolonged reflux of urine causes damage, scarring
Causes - enlarged prostate, renal calculi, cancer, retroperitoneal fibrosis or mass
What are the s/s of obstructive uropathy?
Hydronephrosis that is asymptomatic, somtimes have symptoms
What are the labs of obstructive uropathy?
Vary like crazy, so use imaging instead
What imaging do you use 1st line for obstructive uropathy?
US
non-contrast CT if non-diagnostic or suspected stone
How do you treat obstructive uropathy?
Get rid of obstruction RIGHT AWAY (once nephrons are gone, they are gone)
wanna protect the nephrons that we already have
What is vesicoureteral reflux?
Urine flows back up into kidney because one side of the ureter sphincter is not able to contract.
Leads to inflammatory response and scarring
What does vesicoureteral reflex typically seen in?
Frequent UTIs (kids and men)
Urine: mild-moderate proteinuria
How do you diagnose Vesicoureteral Reflux?
put in radiopaque dye instilled in bladder; pt then voids while x-ray is taken (should not back up, but should void)
What do you see in US of Vesicoureteral Reflux?
Hydronephrosis (often times) and renal scarring
see dilated urters
How do you treat Vesicoureteral Reflux?
Maintaining sterile urine with prophylactic AB to reduce scarring
surgical reimplantation or urters (ineffective in adolescence/adults, because there is already too much scar tissue, need a transplant)
Control HTN w/ ACE/ARBs
What is analgesic nephropathy caused by?
Normally caused by phenacetin
Chronic use of aspirin, NSAIDs, acetaminophen
at least 1 g/d for 3+ years
Where do we see the worst effects of Analgesic Nephropathy?
10x higher in renal papillae (concentrates here) than in renal cortex
What findings do you see in Analgesic Nephropathy?
Sloughed papillae in urine
CT - small, scarred kidney with papillary calcifications (seen w/out contrast as well)
IVP - contrast will fill area of sloughed papillae, causing a “ring shadow” or “golfball on a tee” sign
IVP rarely used due to risk of contrast nephropathy
How do you treat Analgesic Nephropathy?
Stop Analgesics if possible
renal function may stabilize
What is chronic AIN typically caused by?
multiple autoimmune disorders
often see small scarred kidneys d/t long-term damage
What is nephrocalcinosis?
Deposition of calcium in renal parenchyma and tubules
Can cause AKI, CKD
May also have normal renal function
Most pts do not progress to ESRD
What typically causes nephrocalcinosis?
Increased calcium excretion
hypercalcemia, hyperphosphatemia, or increased excretion of calcium, phosphate or oxalate in urine
Hyperparathyroidism
s/s of nephrocalcinosis
asymptomatic in most cases (incidental finding)
May see s/s of underlying cause
What is the MCC renal masses?
Solitary renal cysts 65-70%
high Bosniak score = fine
normally benign
What are the two different types of medullary cystic kidney diseases (MCKD)?
When dx in childhood - Juvenile Nephronophthisis
Childhood (Juvenile NPH) - autosomal recessive
Adult (MCKD) - autosomal dominant
What does MCKD cause
multiple small renal cysts at corticomedullary junction and in medulla
Cortex becomes fibrotic → interstitial inflammation, glomerular sclerosis
only cysts in the inner portion
What kidney disease typically cause flank pain?
Autosomal dominant PKD
hx of UTI and nephrolithiasis common
+ hx of HTN in >50 %
+ family hx of PKD in 75%
What happens to the size of kidneys in AD PKD?
Large, palpable kidney - leading to flake pain
Where are cysts also seen a lot of times in AD PKD?
In spleen and liver d/t higher predisposition of cysts
How do you treat AD PKD?
Pain management
If hematuria, hydration
HTN with ACE/ARBs
Cerebral aneurysm
If there is recurrent hematuria in ADPKD, what should you be sus of?
Cell carcinoma
What does an infected cyst in ADPKD present?
flank pain, fever, +WBC
How do you treat ADPKD with fever and inc WBCs?
Bactrim, quinolones
pentrate into cysts
How do you stop progression of ADPKD?
Tolvaptan (vasopressin V2 receptor antagonist)
slows renal decline
use if GFR at least 25
possibly avoid caffeine
What does tolvaptan do?
Reduce urine osmality, leading to less cyst formation
SE: hypernatremia
CI: liver disease
What is the presentation of autosomal recessive (AR) PKD?
Enlarged kidneys w/ small cysts on COLLECTING TUBULES only
Impaired urine concentration
Metabolic acidosis
HTN common
How to differentiate ARPKD from early-onset ADPKD
both parents will not have cysts
Renal artery stenosis MC
80-90% due to atherosclerotic occlusive disease
10-15% - fibromuscular dysplasia
Suspect if unexplained HTN in woman < 40
5% of all pts with HTN have RAS
MC - >45 yrs with atherosclerotic disease hx
Other risks - CKD, DM, tobacco use, HTN
What is the common cause of renal artery stenosis (RAS)?
HTN, may have audible abdominal bruit (because of back-up of blood flow)
What is imaging of RAS look like?
US can reveal asymmetric kidneys (if unilateral RAS) or small hyperechoic kidneys (if bilateral RAS)
Doppler US - >90% sensitive and specific with good sonographer
Very operator and pt dependent
Poor choice - obese pt, interfering bowel gas, or if pt cannot lie supine
Imaging - US can reveal asymmetric kidneys (if unilateral RAS) or small hyperechoic kidneys (if bilateral RAS)
MRA - excellent but expensive
Turbulent blood flow = false + results
Contrast can cause problems in pts with low GFR
Renal angiography - gold standard
How do you treat RAS?
often angioplasty to reduce meds (stenting)
can do surgical bypass
What leads to nephrosclerosis?
poorly controlled HTN for years
aka Hypertensive nephropathy
What do you see in Nephrosclerosis
Sclerosis of arteries and arterioles
Interstitial fibrosis and decreased glomerular tuft
Up to 27% of ESRD pts have HTN as cause of CKD
What patients are most likely to have Nephrosclerosis?
5x more common in AA
don’t know why, likely genetic predisposition
How do you treat Nephrosclerosis?
Manage HTN
Typically need multiple anti-HTN drugs
Cholesterol Atheroembolic Disease pathophys + seen in
Emboli to kidneys → usually due to cholesterol crystals breaking free of vascular plaque and lodging in downstream microvessels
Often follow angiographic procedures
May see with vascular surgery, trauma, heparin, thrombolytics
How do you treat Cholesterol Atheroembolic Disease
statins
sometimes biopsy
