Glomerular Injury Flashcards
What is the difference between a primary and secondary glomerular injury?
Primary: just affecting the glomerulus
Secondary: a systemic disease that has, in turn, damaged the glomerulus
What are the 4 sites of glomerular injury?
- subepithelial: anything that affects podocytes side of glomerular BM
- Within glomerular basement
- Subendothelial: inside the BM
- Mesangial/paramesangial: supporting capillary loop
What is the pathology of proteinuria?
Protein in the urine is caused by podocyte damage and widening of the fenestration slits, causing protein to leak out
What defines nephrotic syndrome? What is the likely site of injury?
> 3.5g of protein filtered in 24 hours. Oncotic pressure reduces, giving rise to edema. Podocyte and subepithelial damage is likely
Name 3 primary causes of proteinuria/nephrotic syndrome
- Minimal change glomerulonephritis (GN)
- Focal segmental glomerulosclerosis (FSGS)
- Membranous glomerulonephritis
Define glomerulonephritis and 6 stimuli
Damage/inflammation of the glomerular BM resulting in altered function
- virus
- post-infective
- bacteria
- parasites
- drugs
- hereditary
How might a patient present with nephrotic/nephritic syndrome?
Nephrotic: low albumin, oedema, frothy urine
Nephritic: Increased BP, coca-cola urine, decreased urine output
Name 6 things you could do to investigate a patient who may have a glomerular disease
- Urine dip
- Urine microscopy
- BP
- Blood
- Biopsy
- Microscopy: light and electron
When does minimal change glomerulonephritis usually present? What is a good investigation to do?
Childhood - adolescence
Do a renal biopsy and electron microscopy to see podocyte damage
When does focal segmental glomerulosclerosis typically present?
What is the significance of the ‘sclerosis’
What might you see under electron microscopy?
Adulthood:
Podocytes undergo damage and scar (sclerosis)
May see a thickened BM
When/how does membranous glomerulonephritis typically occur?
What histological features might be noticed?
It is the most common cause of nephrotic syndrome in adults, and is caused by immune complex deposits in the sub-epithelial space (probably an autoimmune basis against podocytes)
Histology: ‘speckly BM’ and thickened capillary
What is IgA nephropathy?
How does it classically present?
The commonest glomerular nephropathy, occuring at any age and characterised by deposition of IgA antibody in the glomerulus. Classically presents with visible/invisible hematuria and normal C3 complement levels
Name the 2 hereditary nephropathies
Anti GBM BM and Alport syndrome
What are the 2 common secondary causes of proteinuria/nephrotic syndrome?
- Diabetes mellitus
2. Amyloidosis
What is goodpasture syndrome? What investigations could you do and what might you see?
Very rapidly progressing glomerular nephritis, caused by an autoantibody to collagen IV in BM (but only affects kidney)
Could do chest x-ray: see pulmonary infiltrates and microscopy to see depositions of IgG along the glomerular BM
What is vasculitis?
Inflammation of blood vessels when glomerulus is attacked by ANCA
What is HSP Henoch Schonlein Purpur? How and when can it commonly present?
IgA and IgG interact to produce complexes that activate an immune response.
3-10 years old, more common in boys. Skin rash, fever, edema, abdominal pain, hematuria
What is post strep syndrome? What is a typical history and presentation?
Group A hemolytic streptococcus, history of throat infection and skin infection
Presents: coke cola urine, swollen ankles or puffy eyes
What kind of general management would you offer to a patient with glomerular disease?
- BP control
- Fluid/hydration
- Immunosuppressive drugs
- Diuretics: fluid overload
- Control of hyperkalemia, uremia
- Dialysis
- ACE inhibitor
- Thrombosis/infection
What does PHAROH stand for?
Acronym for nephritic syndrome:
P: Proteinuria
H: Hematuria
A; Azotemia: increased creatinine and urea
R: RBC casts (RBC gets a tubular skinny shape from squeezing through the kidney tubles)
O: Oliguria: abnormally small amounts of urine
H: Hypertension
Where can a urinary tract malignancy occur?
- Bladder
- Prostate
- Urethra and penis
Name 5 risk factors and 5 red flags for UT malignancies?
5 risk factors:
- Occupational; dyes
- genetic
- age
- sex: male
- Smoking + alcohol
5 red flags:
- Bone pain
- abdominal pain
- appetite or weight loss
- Hematuria
- ED
How common is renal adenocarcinoma? What are some causes and risks?
What is the ‘Triad’ Signs/symptoms?
95% of all upper urinary tract tumours.
Smoking, obesity, more common in males, poor prognosis
Triad: Have Fun Memorising…
- Hematuria
- Flank pain
- palpable flank mass
How would you diagnose renal adenocarcinoma and what are some treatments?
MRI
Partial nephrectomy: removing the part of the kidney with a disease or tumour in it
Radical nephrectomy: removing the whole kidney, the fatty part around it and a portion of the ureter
What is the cause of Wilm’s tumour? When/How do patient’s typically present?
A mutation on chromosome 11.
Typically 2-5 years old, with large abdominal mass + pain, anemia, hypertension, hematuria, weight loss
What is the prevalence, risk factors, diagnosis and treatment for ureteric (urothelial cancer)?
Uncommon
Smoking, dyes and chemicals in leather goods, Hereditary non-polyposis colorectal cancer
Diagnosis: Ultrasound, ureteroscopy, biopsy, etc
Treatment: nephro-ureterectomy; removing a patient’s renal pelvis, ureter, kidney and bladder cuff
What are the 3 main risk factors for bladder cancer? What is the prognosis and recurrence rate?
- Smoking
- Chemicals in dye making ‘aromatic amines’
- Caucasians: 2X more likely
Prognosis:
Recurrence rate of bladder cancer is 50-75% so people who have had bladder cancer have a higher chance of getting another UT tumour. Prognosis is low as most females get diagnosed at advanced stages
How could you diagnose and treat bladder cancer?
Investigations: urine culture and cytology with biopsy
Treat: transurethral resection of bladder tumour, radical cystectomy, radiotherapy
What is the incidence and what are the risk factors for prostate cancer?
Incidence: most common type of cancer in men, going up
Risk factors:
>50, black, genetics, obesity, FH,
What is PSA Testing and how can it be used? Is it reliable?
PSA is a protein produced by normal and cancerous prostate cells into prostatic fluid.
Not always reliable:
- Cancer can be present without raised PSA levels
- There are non-cancer causes of a raised PSA like a urine infection, vigorous exercise, ejaculation, anal sex, prostate biopsy and DRE
What is a major issue with diagnosing prostate cancer ?
No national screening, only do DRE (digital rectal exam) if someone is presenting with symptoms
Prostate biopsies also find <50% of clinically significant prostate cancers that MRI scans miss
What is one complication that can result from a biopsy?
Sepsis
What might you find on investigations of nephritic/nephrotic syndrome?
Urine: blood, frothy, protein
Blood: clotting will increase, reduced albumin, infections, lipids
How does prostate cancer typically present?
Mostly asymptomatic, may have difficulty urinating, bone pain and hematuria means advanced
