Glomerular Dz

Question 1

Nephrotic Syndrome Epidemiology

Answer 1

• 15x more common in kids than adults
• In children, 2-7 cases per 100,000
• MCC = Minimal Change Disease (lipoid nephrosis)

Question 2

Nephrotic Syndrome risk factors

Answer 2

• Because nephrotic syndrome is not itself a disease, risk factors for it are diseases that cause it except when it is idiopathic

Question 3

Nephrotic Syndrome Etiologies

Answer 3

• MCD (lipoid nephrosis)
• Diabetes mellitus
• Membranous nephropathy: hepatitis B, gold, penicillamine, syphilis, carcinomas
• SLE
• Focal glomerulosclerosis: heroin, AIDS
• Amyloidosis

Question 4

Nephrotic Syndrome signs and symptoms

Answer 4

• Generalized edema
• Heavy proteinuria (>3.5 gm/24 hrs)
  
  • Foamy urine
• Hypoalbuminemia
• Hyperlipidemia
• Lipiduria
• NO HTN (unless pre-existing)
• Hypercoaguability (loss of anticoag proteins in the urine e.g. prot C, prot S)
  
  • PE,DVT
• Infections (loss of immunoglobulins in urine)
  
  • More susceptible to bacterial infections

Question 5

Maltese cross

Answer 5

• oval fat bodies
• seen from lipiduria

Question 6

Nephrotic Syndrome complications

Answer 6

• Cardiovascular ds bc of hyperlipidemia
  
  • atherlosclerosis
• DVT, PE bc of hypercoaguability
• Infections bc of hypoimmunoglobulinemia
  
  • Especially bacterial

Question 7

Nephrotic Syndrome Dx

Answer 7

• Easy to diagnose nephrotic syndrome, important thing is to find cause
  
  • H&P
  • UA, 24 hr urine collection
    
    • make sure min of 3.5g/min
  • Renal biopsy

Question 8

Nephrotic Syndrome management

Answer 8

• Steroids most useful for MCD or SLE
• Treat underlying cause
• General measures
  
  • control HTN if present
  • early treatment of infection
    
    • So it doesn’t turn into pyelonephritis
  • avoid nephrotoxic agents
    
    • NSAIDs
    • Aminoglycosides
    • contrast dye
      
      • If must use it, consult radiologist for alternative option

Question 9

Nephrotic Syndrome prevention

Answer 9

• ACE inhibitors or ARBs in DM with HTN
  
  • Microalbuminuria is 1st sign of DMà nephrotic syndrome
• Can be Idiopathic

Question 10

Diabetic Nephropathy Epidemiology

Answer 10

• MCC of end stage kidney disease in the US
• ¼ of diabetics have it
• Onset is usually 10-15 years after dx

Question 11

Diabetic Nephropathy Risk Factors

Answer 11

• inc. incidence of nephropathy in DM patients with
  
  • Poor glucose control
  • Uncontrolled HTN
  • Type 1 DM, with onset < 20yo
  • Past or current smoking
  • FH of diabetic nephropathy

Question 12

Diabetic Nephropathy Pathophys

Answer 12

• long-standing poorly controlled BG → changes in nephrons
• 1st efferent arteriole constriction and afferent arteriole dilation → glomerular capillary HTN and hyperfiltration
• gradually changes to hypofiltration
• concurrently, there are changes within glomerulus
  
  • BM thickening
  • widening of podocyte slit membranes
  • inc. number of mesangial cells and↑ mesangial matrix
  • matrix invades glomerular capillaries and produces deposits (Kimmelstiel-Wilson nodules)à true cause of complications
  • mesangial cells and matrix progressively expand and consume entire glomerulus, shutting off filtration

Question 13

Diabetic Nephropathy Signs and symptoms

Answer 13

• MC 1st symptom is nocturia
• 1st sign is microalbuminuria
• fatigue, malaise, anorexia
• HA
• N&V
• urinary frequency
• pruritis
• edema

Question 14

Diabetic Nephropathy Dx

Answer 14

• Screen pts with Type 1 after 5 years
• Screen pts with Type 2 upon dx
• Results + in 2 of 3 tests in a 3- to 6-month period confirm dx
  
  • transient elevations of microalbuminuria can be caused by exercise, UTI, hyperglycemia, febrile illness, severe HTN, or HF
• 3 ways to screen for albuminuria
  
  • albumin-to-creatinine ratio on a spot urine test
    
    • ratio >30 mg albumin/1 g creatinine is considered increased
  • timed collection (e.g., 10 hrs overnight)
  • 24-hour urine collection
    
    • Normal <30 mg/24 hr
    • Microalbuminuria 30–299 mg/24 hr
    • Macroalbuminuria >300 mg/24 hr

Question 15

Diabetic Nephropathy management

Answer 15

• Can progress to overtly nephrotic levels of proteinuria (>3.5 grams/24 hr)
• Main goal is to slow progression
  
  • Control blood sugar HgbA1c <7
  • Control HTN <130/80
  • ACEI or ARB
  • Low salt diet

**Diabetic nephropathy is not yet renal failure

**The goal is to slow the progression

Question 16

Glomerulonephritis (Nephritic syndrome) incidence and risk factors

Answer 16

• True incidence of biopsy-proven GN unknown
• Because it is a syndrome and not a single disease entity, risk factors are diseases known to cause it

Question 17

Glomerulonephritis Etiologies

Answer 17

• Post-infectious: MCC = strep throat
  
  • Autoimmune response to presence of Strep, which ends up attacking the kidney
• Membranoproliferative GN
• SLE
• IgA nephropathy
• Goodpasture’s syndrome
• Vasculitides: PAN, Wegener’s granulomatosis
• Henoch-Schonlein purpura, HUS (E. coli)
• Assoc with endocarditis and visceral abscesses

Question 18

Glomerulonephritis Acute vs. Chronic

Answer 18

• Almost any cause of acute may become chronic but post-infectious is almost always acute and self-limited
• Chronic GN is a major cause of CRF

Question 19

Glomerulonephritis Pathophys

Answer 19

• Inflammaiton of glomerulus often due to autoimmune damage
  
  • Damaged glomerulus allows leakage of red blood cells, protein, initiation of RAA which leads to fluid retention and HTN

Question 20

Glomerulonephritis signs and symptoms

Answer 20

• mild edema
• moderate proteinuria
• HTN
  
  • Will always cause
• hematuria (brown) and RBC casts
  
  • Blood can also be grey due to iron which is reduced; also called “smokey” urine
  • Having casts in urine is also called cylinduria

Question 21

RBC casts=..?

Answer 21

glomerulonephritis

Question 22

Glomerulonephritis Dx

Answer 22

• H&P
• UA, 24 hr urine collection
• Renal biopsy
• cANCA for Wegener’

Question 23

Glomerulonephritis management

Answer 23

• Steroids, cytotoxic drugs in SLE, Goodpasture’s, Wegener’s
• Treat underlying cause
• General measures:
  
  • control HTN
  • early treatment of infection
  • avoid nephrotoxic agents

Question 24

Hypertensive nephrosclerosis

Answer 24

• Intimal thickening and luminal narrowing of large and small renal arteries and glomerular arterioles
• Global and focal segmental sclerosis of glomeruli

Question 25

Hypertensive nephrosclerosis Demographics

Answer 25

• Associated with chronic HTN, especially if very high
• More common in Blacks, even at similar BP to whites
• More common in DM and others with underlying kidney dz

Question 26

Hypertensive nephrosclerosis Signs and Symptoms

Answer 26

• Typically present with long history of uncontrolled HTN
• Slowly progressive increase in BUN, creatinine
• Mild proteinuria with benign urine sediment
  
  • NOT RBC
  • NOT RBC CASTS
    
    • If they are seen then called “active urine sediment”
• Hyperuricemia
• May progress to ESRD

Question 27

Hypertensive nephrosclerosis Dx

Answer 27

• Cinical diagnosis, no specific tests
• Renal biopsy is diagnostic but rarely needed

Question 28

Hypertensive nephrosclerosis management

Answer 28

• CONTROL BP!!!!!
  
  • MAY slow progression
  • Damage may already be done
• BUT in AASK trial, pts with lower BPs did not have significantly better outcomes

AND

• ACEIs were only renoprotective in pts who initially presented with proteinuria