Glomerulonephritis (1) Flashcards

1
Q

Membranous glomerulonephritis

  • population profile
  • presentation (2)
A

Membranous glomerulonephritis

  • the commonest cause of glomerulonephritis in adults
  • presents with: proteinuria or nephrotic syndrome
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2
Q

Causes of membranous glomerulonephritis

A
  • idiopathic
  • infections: hepatitis B, malaria, syphilis
  • malignancy: lung cancer, lymphoma, leukaemia
  • drugs: gold, penicillamine, NSAIDs
  • autoimmune diseases: systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
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3
Q

Management of membranous glomerulonephritis

A

Management of membranous glomerulonephritis

  • immunosuppression: a combination of corticosteroid + another agent such as chlorambucil is often used
  • blood pressure control: ACE inhibitors have been shown to reduce proteinuria
  • consider anticoagulation
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4
Q

Nephritic syndrome

Basic presentation

A

Nephritic syndrome

  • inflammation of glomeruli
  • increased BP
  • cola-coloured urine (haematuria)
  • Berger’s disease (IgA nephropathy) -> the most common cause of primary glomerulonephritis
  • oliguria
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5
Q

Nephrotic syndrome

A

Nephrotic syndrome

  • hypoalbuminemia
  • hyperlipidaemia
  • peripheral oedema
  • massive proteinuria
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6
Q

What’s seen on renal biopsy of membranous glomerulonephritis?

A

Renal biopsy demonstrates:

  • electron microscopy: the basement membrane is thickened with subepithelial electron dense deposits. This creates a ‘spike and dome’ appearance
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7
Q
A
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8
Q

What is glomerulonephritis (in general)?

A

Glomerulonephritis

  • immune-mediated injury (that affects mainly glomerular tissue)
  • inflammation of the glomerulus and other components of the kidney -> inflammation of the nephron

*3rd commonest cause of renal failure in Europe, commonest worldwide

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9
Q

Which part of the kidney does the actual filtration?

A
  • endothelial cells (sitting on basement membrane) -> capillaries
  • epithelial cells - podocytes (help in filtration)
  • Mesangial cells -> produce collagen and hold capilaries in space
  • basement membrane

* all these components can be affected by inflammation

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10
Q

What are the components of the filtration barrier?

A
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11
Q

Primary vs Secondary glomerulonephritis

A
  • Primary - problem starts in the kidney itself e.g. autoimmune
  • Secondary - disease elsewhere in the body, but kidney is injured as a result of that (e.g. SLE -> Lupus nephritis)
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12
Q

Infective vs non-infective glomerulonephritis

(examples)

A
  • infective: HIV, Streptococcal, viruses, bacteria, parasites
  • non-infective: minimal change disease, focal segmental glomerulosclerosis, SLE etc. (idiopathic, systemic inflammatory diseases, drugs, malignancy, hereditary, infiltrative disease)
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13
Q

Nephrotic vs Nephritic

A
  • Nephrotic -> problem is about the loss of protein in the urine (hypoalbuminaemia + proteinuria)
  • Nephritic -> blood in the urine (haematuria)
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14
Q

Signs of Nephritic syndrome

A

Nephritic syndrome

  • haematuria

- proteinuria (not massive one)

- oliguria

-hypertension

*the above is TETRAD of Nephritic syndrome

HTN - as oliguria and fluid retention

  • dysmorphic red cells -> abnormally shaped red cells (as they are squeezed through the filtration barrier - normally not passed through it)
  • red cell casts -> RBCs get packed in the renal tubules and casts are formed
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15
Q

Signs of nephrotic syndrome

A

Nephrotic syndrome

  • heavy proteinuria >3.5g/day
  • hypoalbuminemia
  • oedema
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16
Q

Is it nephrotic syndrome if the proteinuria is less than 3.5 g / day?

A

No, it must be more than 3.5g/day

17
Q

3 components that are essential to classify the presentation as nephrotic syndrome

A

Nephrotic syndrome

  • proteinuria of >3.5 g a day
  • hypoalbuminemia
  • oedema

*all 3 components necessary for classification of nephrotic syndrome

18
Q

What are different classification of glomerulonephritis (based on structural histological appearance)?

A
  • focal -> if less than 50% of glomerulus is affected
  • global -> if the whole capillaries are affected
  • segmental -> if part of the capillary bed affected
19
Q

Focal segmental glomerulonephritis

  • what syndrome does it cause
  • population presentation
A

Focal segmental glomerulosclerosis

  • cause of nephrotic syndrome and chronic kidney disease
  • young adults
  • high recurrence in renal transplants
20
Q

Causes of focal segmental glomerulonephritis

A

Causes of focal segmental glomerulonephritis

  • idiopathic
  • secondary to other renal pathology e.g. IgA nephropathy, reflux nephropathy
  • HIV
  • heroin
  • Alport’s syndrome
  • sickle-cell
21
Q

Membranoproliferative glomerulonephritis

  • what is it known as
  • what syndrome does it present as
  • what happens
A

Membranoproliferative glomerulonephritis

  • also known as mesangiocapillary glomerulonephritis
  • may present as nephrotic syndrome, haematuria or proteinuria
  • poor prognosis

Immune deposits in the glomerulus

22
Q

General pathophysiology of glomerulonephritis

A

Immune response against the kidney cells - deposition of antigens/antibodies -> inflammation

  • Antigen - antibody complex -> start of complement response -> membrane-atack complex produced -> cellular destruction
  • chemotaxis factors produced -> neutrophils, cytokines etc -> damaging to the cells

*depends on what parts of the nephron is affected -> different presentation due to different cells being affected

23
Q

What is the main aim of treatment of glomerulonephritis?

A

We want to stop the scar to be formed in the glomerulus

*as result of every inflammatory process -> fibrosis and a scar formed (once the scar has formed = no way back)

* if the scar is already formed = sclerosis (scar tissue)

24
Q

What’s the ‘crescent’?

A

Crescent

Capillaries are squeezed towards the end -> nephron would not recover

25
What is the 'fluffy'/ 'foam' urine sign of?
Proteinuria - proteins make urine fluffy
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**Extrarenal** symptoms of ***glomerulonephritis*** ## Footnote \*consider different body systems
* **Constitutional**: fever, weight loss, fatigue * **Eye**: uveitis, retinitis * **ENT:** sore throat, sinusitis, oral ulcers * **skin:** rash * **MSK:** arthralgia, arthritis, myalgia * **GIT**: diarrhoea, colitis * **Chest:** haemoptysis, nodules * **Heart:** murmurs, pericarditis * **Nervous system**: peripheral neuropathy, seizures * thrombo-embolic complications
27
What are the features of uraemia?
**Uraemia:** - nausea and vomiting - alerted consciousness - chest pain (due to uremic pericarditis) - anorexia - metallic taste in the mouth - rash - altered sleep pattern
28
Why does uraemia happen? (in the picture of kidney problems)
***uraemia*** - happens in extreme situation e.g. oliguria -\> toxins stay back in the blood (instead of being excreted)
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Investigations for glomerulonephritis (1st line)
* **urine dipstick** -\> check for haematuria and proteinuria, SG - if urine is concentrated or dilute * **urine microscopy** -\> red morphology and casts * **ACR/PCR/24 hr Pr** -\> to assess a degree of proteinuria * **eGFR, U&E -\>** markers of kidney function * **FBC and bone profile -\>** to indicate it is acute or chronic * **CRP** and **ESR** -\> acute phase markers * **immunological** and s**erological screen -\>** look for antibodies * **USS kidney** * **kidney biopsy -\>** definitive way to find out what's happening inside the kidney
30
What is the max upper range of protein in a healthy: - men - lady
* Men: 2.5/L * Women: 3.5/L (in pregnancy more is allowed)
31
Other/extra investigations in ***glomerulonephritis***
* **serum C3 and C4 complement levels** -\> low complement level in the serum as used up for complement response (so inflammation is going on) * **different antibodies:** antineutrophil cytoplasmic autoantibodies, anti-glomerular basement membrane (GBM) autoantibodies, antinuclear antibodies, anti-dsDNA antibodies, anti-streptolysin O antibody, anti-DNAse \*different antibodies in different causes of glomerulonephritis * **serology** for hep C, hep B, HIV * **serum free light chains** and serum immunofixation - myeloma (?) * **blood cultures** - to role out infections
32
What are ***anti-glomerular basement membrane (GBM) autoantibodies*** suggestive of?
**anti-glomerular basement membrane (GBM) autoantibodies = *_Goodpasture's disease_*** (renal failure + pulmonary haemorrhage
33
What are anti-nuclear antibodies suggestive of?
**antinuclear antibodies** = Lupus
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**Anti- dsDNA antibodies** are found in what?
**Anti- double stranded** **DNA antibodies** = found in Lupus
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**Anti-streptolysin O antibody** and a**nti-DNAse antibodies** are found in what?
***Anti-streptolysin O antibody*** and ***anti -DNAse*** ***antibodies*** = **post-streptococcal glomerulonephritis**
36
**Antineutrophil cytoplasmic autoantibodies** are found in what?
**antineutrophil cytoplasmic antibodies** = in *vasculitis*
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Serum free light chains are found in what?
Myeloma
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