Glomerular Disease

Question 1

What causes proteinuria?

Answer 1

Physiological: strenuous exercise, fever, stress

Pre-renal: abnormal concentrations of proteins being presented to the kidneys (multiple myeloma: Bence-Jones proteins)

Renal: defective renal fxn or inflammation of renal tissue (glomerular or tubular)

Post-renal: inflammation in the ureter, bladder, urethra or prostate

Question 2

How is proteinuria first detected?

Answer 2

On the urine dipstick!

Question 3

What protein are dipsticks most sensitive to?

Answer 3

Albumin

Question 4

If you suspect multiple myeloma but the dipstick comes back as normal, should you rule out MM?

Answer 4

No! Bence jones proteins which are monoclonal protein produced by plasma cells and usually occurs w MM and don’t get picked up on dipstick

Question 5

What is the gold standard method to quantifying proteinuria?

Answer 5

24 hour urine protein measurement but it’s difficult to do so not used clinically

Question 6

How do we quantify proteinuria?

Answer 6

Urine protein: creatinine ratio

Question 7

If sediment is negative, what UPC ratios in cats and dogs are considered non proteinuric, borderline proteinuric and proteinuric?

Answer 7

Dogs Cats

0.5 >0.4 Proteinuric

Question 8

What are the ways renal proteinuria can occur?

Answer 8

Defective renal fxn: 
   1. Glomerular pathology 
   2. Tubular pathology 
Inflammation of renal parenchyma: 
   1. Pyelonephritis 
   2. Acute tubular necrosis

Question 9

How does glomerular disease occur?

Answer 9

Due to INCREASED glomerular permeability

Leads to greater protein loss (UPC ratio >2.0)
If UPC ratio >8 consider amyloidosis

Question 10

How does tubular disease occur?

Answer 10

Due to DECREASED tubular protein reabsorption

UPC ratio usually

Question 11

Why does CKD result in proteinuria?

Answer 11

Due to adaptive changes within the nephron

Causes low level proteinuria

Question 12

T/F CKD can be caused by primary glomerular pathology (especially dogs) . . . causing a significant proteinuria.

Answer 12

True!

Question 13

What is the most significant proteinuria?

Answer 13

Protein Losing Nephropathy (PLN)

Term used for condition causing severe proteinuria due to primary glomerular dz

Question 14

What are glomerulonephritis?

Answer 14

Group of conditions where immune complexes are deposited in the glomeruli. More common in dogs than cats.

Question 15

What causes glomerulonephritis?

Answer 15

1. Chronic antigenic stimulation: inflammation (immune mediated dz, chronic inflammatory dz); infectious (endocarditis, leishmania, erlichia); neoplasia
2. Idiopathic 50%
3. Familial Nephropathy basement membrane: X linked hereditary PLN of Samoyeds or Alport syndrome of English Cocker Spaniels (type IV collagen dz)
4. Glomerulonephritis may be d/t immune complex deposition in glomerulus
5. Immune complex glomerulonephritis (ICGN)
6. Amyloid deposits in glomeruli: Familial in Shar pei, Beagle, Abyssinian and Siamese

Question 16

How do we screen for neoplasia?

Answer 16

Thoracic radiographs and abdominal ultrasound

Question 17

How many times should we test for BP?

Answer 17

five times!

Question 18

Regarding blood pressure, what organs would show of evidence of end organ damage?

Answer 18

Kidneys, brain, eyes, heart. Especially eyes!

Question 19

How do we measure hyper coagulability?

Answer 19

Thromboelastography

Question 20

What are the clinical signs of glomerulonephritis?

Answer 20

Early Signs: 
  - may have no clinical abnormalities 
  -loss of body condition 
  -lethargy, anorexia 
Later: nephrotic syndrome 
Very Late: uremic syndrome

Question 21

What characterizes nephrotic syndrome?

Answer 21

kidney dz characterized by edema and loss of protein from the plasma into the urine d/t increased glomerular permeability

• abdominal and pleural fluid
• subcu pitting edema
• acute onset blindness (hypertensive retinopathy)
• thromboembolic dz

Question 22

When are kidney biopsies contraindicated?

Answer 22

IRIS stage IV or coagulopathies

Question 23

What are common findings in nephrotic syndrome?

Answer 23

1. proteinuria
2. hypoALB
3. ascites/edema
4. hypercholesterolemia
5. often have systemic hypertension and hyper coagulability

Question 24

How do we tx glomerulonephritis?

Answer 24

Immunosuppressive therapy

• provided proteinuria has been confirmed to be glomerular in origin
• provided a biopsy confirms ICGN (immune complex glom nephritis)

Question 25

When are immunosuppressive therapy contraindicated?

Answer 25

1. pancreatitis
2. bone marrow suppression
3. DM

Question 26

What is the ideal deal for immunosuppressive therapy?

Answer 26

Mycophenolate: recommended as the first choice, rapid onset, low rate of adverse drugs runs

Question 27

If hypertension is present, how do we tx it?

Answer 27

ACE inhibitors or ARBs or Calcium channel blockers (amlodipine)

Question 28

We use ACE inhibitors and ARB to treat proteinuria. Why?

Answer 28

ACEi: inhibit RAAS

• reduce intraglomerular BP
• contraindicated in IRIS Stage IV
• monitor creatinine-discontinue if increased >30%
• titrate dose

ARB

• more complete blockade
• may be used in combination

Question 29

How do we tx hyper coagulability?

Answer 29

Aspirin or Clopidogrel

DO NOT: drain effusions unless you have difficulty breathing or treat w diuretics unless difficult breathing !!

Question 30

What is the prognosis ?!

Answer 30

Variable depending on underlying cause and severity of dysfxn