Glomerular and Tubular Diseases

Question 1

In 70kg person kidney filters about

Answer 1

180 L /d

Question 2

What fraction of cardiac output goes to renal blood flow

Answer 2

20% - 25%

Question 3

Classic collection of symptoms in glomerular

Answer 3

Hematuria
Proteinuria
Lowered GFR
HTN

Question 4

Two different special constellations of symptoms that can manifest in patients with glomerulonephritis

Answer 4

Nephritic and Nephrotic syndromes

Question 5

Nephrotic syndrome - collection of signs

Answer 5

Proteinuria (> 3.5g/day)

Hypoalbuminemia

Edema

Hyperlipidemia

Lipiduria

Question 6

Nephritic syndrome - collection of signs

Answer 6

Accumulation of RBC, WBC, immune complexes, and some protein - forming casts, brown urine

Decreased GFR > High BP, Oliguria

Question 7

Most common cause of secondary nephrotic syndrome

Answer 7

Diabetes

HTN #2

Question 8

Five categories of glomerular disease

Answer 8

Acute glomerulonephritis
Rapidly progressive glomerulonephritis
Chronic glomerulonephritis
Nephrotic syndrome

Question 9

The abrupt onset of hematuria and proteinuria with decreased GFR and salt/water retention. Typically followed by full renal recovery

Answer 9

Acute Glomerulonephritis

• hypercellular / thickened glomerulus
  - narrowed capillaries
  - decreased filtration

Question 10

Common cause of acute glomerulonephritis

Answer 10

Post-Strept, autoimmune

7-10 days after original infection

presents as Acute Nephritic Syndrome
(HTN, Hematuria, Increased BUN SrCr, Oliguria)

Question 11

Most common cause of primary glomerulonephritis

Answer 11

Berger’s Disease

IgA nephropathy

Question 12

Also called crescentric glomerulonephritis because of its tendency to cause proliferation of epithelial cells in the glomerulus.

Always autoimmune

Usually progresses to renal failure

Answer 12

Rapidly Progressive Glomerulonephritis

Question 13

GFR trends in Rapidly Progressive Glomerulonephritis

Answer 13

GFR drops by 50% within 3 months

Question 14

Rapidly Progressive Glomerulonephritis results when (specific to glomerulus)

Answer 14

When most of the glomeruli are damaged enough to allow FIBRIN to enter Bowman’s space, which prevents filtration and permanently scars

Question 15

Wegener’s granulomatos is an example of what type of Rapidly Progressive Glomerulonephritis (RPGN)

Answer 15

Type III, ANCA antibodies

Antibodies not visible histologically

Makes up 50% of RPGN

Question 16

SLE, IgA nephropathy, post-strep GN is an example of what type of RPGN

Answer 16

Type II, immune complex deposition

GRANULAR DEPOSITION OF COMPLEXES

25% of RPGN

Question 17

Goodpasture’s is an example of what type of RPGN

Answer 17

Type I, Anti-GBM (antibodies to type IV collagen)

LINEAR DEPOSITION OF COMPLEXES

25% of RPGN

Question 18

Patients with acute glomerulonephritis who develop chronic renal failure slowly over 5-20 years

Answer 18

Chronic Glomerulonephritis

Question 19

Typical features of chronic glomerulonephritis

Answer 19

Hypercellularity in the mesangium and obliteration of glomerular capillaries

Often found incidentally, occult proteinuria / HTN

*Significant scar tissue from ongoing autoimmune injury

Question 20

Hypercellularity in the mesangium and obliteration of glomerular capillaries are typical features of -

Answer 20

Chronic glomerulonephritis

Question 21

A classic example of chronic glomerulonephritis, and one of the most common causes of NEPHROTIC syndrome in adults

Answer 21

Membranous Glomerulonephritis

Autoimmune

25% recover completely

Question 22

Membranous GN vs RPGN Type II

Answer 22

Type II RPGN, immune complex deposition (IgA, SLE)

Unlike RPGN, in Membranus GN immune complexes trigger complement and MAC ATTACK

Question 23

Sudden appearance of proteinuria and edema (nephrotic), with unknown etiology. Relatively benign

Answer 23

Minimal Change GN

Question 24

Most common cause of renal failure

Answer 24

Secondary GM (diabetes, HTN, atherosclerosis, vasculitis)

Question 25

How to distinguish glomerular disease from interstitial or tubular

Answer 25

Patient Hx UA - Hematuria - RBC Casts - Lipiduria - Proteinuria

Question 26

UA with red cells, casts, mild proteinuria. More severe symptoms not present (edema, proteinuria >3.5g, HTN) Patients often present with asymptomatic haematuria and proteinuria discovered on routine examination, or in IgA nephropathy for eg with episodes of gross haematuria

Answer 26

Focal Nephritic UA patterns Damage to < 1/2 of patient's glomeruli

Question 27

Similar to focal disease, but may also have heavy proteinuria (even nephrotic range), obvious edema, hypertension and/or renal insufficiency ‘full house’ urinary sediment – red cells, white cells, red cell casts, white cell casts, hyaline casts

Answer 27

Diffuse Nephritic UA patterns Damage to all or nearly all glomeruli

Question 28

Heavy proteinuria (> 3.5g / d) Lipiduria (Maltese cross) Few cells, few casts

Answer 28

Nephrotic UA patterns

Question 29

Extrinsic causes of obstructive uropathy

Answer 29

Pregnancy Inflammation (PID, peritonitis, diverticulitis, salpingitis) Tumurs (PROSTATE, rectum, bladder, ovaries)

Question 30

Timeline of obstructive damage

Answer 30

1. Collecting system dilates - triggers growth of new tissue in ureters 2. Collecting system stretches and enlarges, damaging tubular cells 3. Fibrosis begins in the tubules and the interstitial space (repair process) 4. Fibrosis triggers cytokines, which causes more damage 1 week - 3 months

Question 31

Obstructive Uropathy Lab Findings

Answer 31

Dilute Urine (inability to concentrate) Metabolic Acidosis (inability to secrete H+) Hyperkalemia (inability to secrete K) Hyponatremia (inability to reabsorb Na) Uremia (can't secrete urea)

Question 32

Common cause of AKI, usually occurs due to ischemia or drug exposure, usually diagnosed with elevated BUN/Cr levels

Answer 32

Acute Tubular Necrosis Ischemic, Nephrotoxic

Question 33

Ischemic Acute Tubular Necrosis leads to

Answer 33

Tubule cell death > tubular occlusion by sloughed cell debris >Tubule occlusion raises pressure at Bowman's Space and LOWERS GFR

Question 34

Common Sites of Injury in Obstructive Uropathy

Answer 34

Uterosacral Ligament Pelvic Brim Crossing of Uterine Artery Tunnel of Wertheim Near Utero-vesicle junction

Question 35

How might ATN show in UA

Answer 35

Granular casts, muddy silty urine

Question 36

Sequence of ATN

Answer 36

1. Initiation phase - drop in GFR, bump in BUN/Cr 2. Maintenance phase - GFR low, BUNCr slowly rise, oliguria, uremia, fluid retention 3. Recovery phase - tubular cells regenerate and function slowly recovers

Question 37

ATN phase in which there is a drop in GFR, bump in BUN/Cr

Answer 37

Initiation phase

Question 38

ATN phase in which GFR is low, BUNCr slowly rise, oliguria, uremia, fluid retention

Answer 38

Maintenance phase

Question 39

ATN phase in which tubular cells regenerate and function slowly recovers

Answer 39

Recovery phase

Question 40

Diseases associated with Nephrotic Syndrome

Answer 40

Primary Renal Disease - Minimal Change GN - Focal segmental glomerulosclerosis - Membranous GN Secondary Renal Disease - SLE - Hep B C - HIV - DM - Malignancy

Question 41

Which kind of renal cystic disease can become neoplastic?

Answer 41

Acquired Renal Cystic Disease - usually a result of end stage renal disease - cysts found throughout, usually in cortex

Question 42

Autosomal Dominant PKD, which chromosome

Answer 42

Chromosome 16 Associated cysts throughout body

Question 43

Renal tumor found in infants/children

Answer 43

Wilm's tumor / Nephroblastoma

Question 44

Renal cancer found in adults

Answer 44

Renal Cell Carcinoma, Adenoma, Oncocytoma