Glomerulonephritis

Question 1

What is GN?

Answer 1

Immune mediated disease of the kidneys affecting the glomeruli (with secondary tubulointerstitial damage)

Question 2

Damage to endothelial or mesangial cells leads to which type of lesion?

Answer 2

Proliferative lesion and red cells in urine

Question 3

Damage to podocytes leads to which kind of lesion?

Answer 3

Damage to podocytes leads to a non-proliferative lesion and protein in the urine

Question 4

Urinalysis findings of glomerulonephritis?

Answer 4

Haematuria, proteinuria

Question 5

Urine microscopy would show what in glomerulonephritis?

Answer 5

RBC (dysmorphic), RBC and granular casts, lipiduria

Question 6

Haematuria in GN presentation

Answer 6

Episodes of painless macroscopic haematuria

Question 7

Nephrotic syndrome

Answer 7

> 3g protein per day

Question 8

Heavy proteinuria

Answer 8

1-3g/day

Question 9

Asymptomatic proteinuria

Answer 9

<1g per day

Question 10

Microalbuminuria

Answer 10

30-300mg albuminuria/day

Question 11

Red cell casts are pathogonomic of what?

Answer 11

GN

Question 12

Red blood cells in GN?

Answer 12

Dysmorphic

Question 13

Acute Renal Failure
Oliguria
Oedema/ Fluid retention
Hypertension
Active urinary sediment
RBC’s, RBC & Granular Casts

Indicative of a proliferative process

Answer 13

Nephritic syndrome

Question 14

Proteinuria  3 g/day (mostly albumin, also globulins)
Hypoalbuminaemia (<30)
Oedema 
Hypercholesterolaemia
Usually normal renal function

Indicative of a non proliferative process

Answer 14

Nephrotic syndrome

Question 15

Hypercholesterolaemia in nephritic or nephrotic syndrome?

Answer 15

Nephrotic

Question 16

Nephrotic syndrome complications?

Answer 16

Infections - loss of opsonising antibodies
Renal vein thrombosis
Pulmonary emboli
Volume depletion (overaggressive use of diuretics) - may lead to ARF (pre-renal)

Vit D deficiency
Subclinical hypothyroidism

Question 17

Most common cause of glomerulonephritis?

Answer 17

Idiopathic

Question 18

Systemic diseases associated with glomerulonephritis?

Answer 18

ANCA associated systemic vasculitis
Lupus
Goodpastures
HSP

Question 19

Proliferative or non-proliferative

Answer 19

usually refers to presence or absence of proliferation of mesangial cells

Question 20

Focal/diffuse

Answer 20

< or > 50% of glomeruli affected

Question 21

Global/segmental

Answer 21

All or part of glomerulus affected

Question 22

Crescenteric

Answer 22

Presence of crescents - epithelial cell extracapillay proliferation e.g. RPGN in vasculitis

(RPGN = rapidly progressing glomerulonephritis)

Question 23

Easier explanation of crescenteric glomerulonephritis?

Answer 23

Crescenteric more often seen in conditions like Goodpastures and systemic vasculitis
(crescenteric GN = when there is an accumulation of cells outside the capillary loops, but within the Bowman’s capsule)
-Presents as RPGN

Question 24

Treatment of GN
(non-immunosuppression)
DASH

Answer 24

DASH
Diuretics
ACEi/ARB
Steroids
anti-Hypertensives

Question 25

Treatment of GN (immunosuppression)

Answer 25

Drugs Corticosteroids (Prednisolone po/MethylPred IV) Azathioprine Alkylating agents (Cyclophosphamide/ Chlorambucil) Calcineurin inhibitors (Cyclosporin/Tacrolimus) Mycophenolate Mofetil (MMF) Plasmaphoresis: TPE (therapeutic plasma exchange) Antibodies: IV immunoglobulin Monoclonal T or B cell antibodies

Question 26

General treatment of nephrotic patients

Answer 26

Fluid restriction Salt restriction Diuretics ACE inhibitors/ARBs ``` ?anticoagulation IV albumin (only if volume deplete) ```

Question 27

What is complete remission?

Answer 27

Proteinuria <300mg/day

Question 28

What is partial remission?

Answer 28

Proteinuria <3g/day

Question 29

What is partial remission?

Answer 29

Proteinuria <3g/day

Question 30

Commonest cause of nephrotic syndrome in children

Answer 30

Minimal change nephropathy

Question 31

Biopsy, ML & IF and EM findings of minimal change nephropathy

Answer 31

Normal biopsy Normal LM & IF Foot process fusion on EM

Question 32

How to treat minimal change nephropathy

Answer 32

94% remission with oral steroids Second-line drugs: cyclophosphamide/CSA (some are steroid resistant/dependent or have multiple relapses

Question 33

Does not cause progressive renal failure | Possibly caused by IL-13

Answer 33

Minimal change nephropathy

Question 34

Commonest cause of nephrotic syndrome in adults (35%) 10 or 20 (HIV/Heroin use/Obesity/ Reflux nephropathy) Renal biopsy: As its name describes on light microscopy with minimal Ig/ Complement deposition on IF Remission with prolonged steroids in 60 % 50 % progress to end stage renal failure after 10 years

Answer 34

Focal Segmental Glomerulosclerosis

Question 35

Risk factors for FSGS

Answer 35

HIV/heroin use/obesity/reflux nephropathy

Question 36

Renal biopsy findings of FSGS

Answer 36

Focal segmental glomerulosclerosis (as the name tells you lol) Minimal Ig/complement deposition on IF

Question 37

Treatment of FSGS

Answer 37

Remission with prolonged steroids in 60% 50% progress to end stage renal failure after ten years

Question 38

New data implicating soluble urokinase plasminogen activator receptor (suPAR). Upregulate integrins (cell signalling molecules). Podocyte effacement. 67% of patients have increased suPAR levels.

Answer 38

FSGS

Question 39

2nd commonest cause of nephrotic syndrome in adults (15-30%) 10 or 20 Important 20 causes include: infections (hepatitis B/ parasites) connective tissue diseases (lupus) malignancies (carcinomas/ lymphoma) drugs (gold/penicillamine) Renal biopsy: subepithelial immune complex deposition in the basement membrane Steroids/ Alkylating agents/B cell monoclonal Ab 30% progress to end stage renal failure in 10 years

Answer 39

Membranous nephropathy

Question 40

Causes of nephropathy

Answer 40

Infections (hep B/parasites) Connective tissue diseases (lupus) Malignancies (carcinomas/lymphoma) Drugs (gold/penicillamine)

Question 41

Renal biopsy findings in membranous nephropathy

Answer 41

Subepithelial immune complex deposition in the basement membrane

Question 42

Treatment for membranous nephropathy?

Answer 42

Steroids Alkylating agents B cell monoclonal antibodies -30% progress to end stage renal failure in 10 years

Question 43

Anti PLA2r antibody

Answer 43

Present in >70% cases of primary membranous nephropathy

Question 44

Thickened basement membrane on silver stain?

Answer 44

Membranous nephropathy

Question 45

What does the basement membrane look like in membranous nephropathy? and what stain would you use?

Answer 45

Thickened basement basement membrane using silver stain

Question 46

Commonest GN in the world?

Answer 46

IgA nephropathy

Question 47

Associated with HSP

Answer 47

IgA nephropathy | remember HSP is IgA complex mediated anyway

Question 48

Renal biopsy findings of IgA nephropathy?

Answer 48

Mesangial cell proliferation and expansion on light microscopy with IgA deposits in mesangium on IF

Question 49

Drugs used in IgA nephropathy?

Answer 49

BP control ACEi & ARB Fish oil

Question 50

Which stain would show mesangial cell proliferation and expansion?

Answer 50

H&E stain

Question 51

A treatable cause of acute renal failure Rapid deterioration in renal function over days/weeks Active urinary sediment (RBC’s, RBC & Granular Casts) May be part of systemic disease. Associated with glomerular crescents on biopsy.

Answer 51

Rapidly progressing glomerulonephritis | RPGN

Question 52

How do you detect ANCA? (anti-neutrophil cytoplasmic antibodies)

Answer 52

Immunofluorecence

Question 53

Treatment for RPGN

Answer 53

Treatment must be prompt! | Strong immunosuppression with supportive care including dialysis if needed

Question 54

Treatment for RPGN

Answer 54

Immunosuppression Steroids (IV Methylprednisolone / Oral Prednisolone) Cytotoxics (Cyclophosphamide/ Mycophenolate/ Azathioprine Plasmapheresis