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Urinary Systems > Glomerulonephritis > Flashcards

Glomerulonephritis Flashcards

1
Q

What is glomerulonephritis?

A

Inflammatory disorder of the kidney

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2
Q

What percentage of end stage kidney disease is glomerulonephritis responsible for?

A

Up to 30%

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3
Q

Give some of the many ways glomerulonephritis can present

A

Proteinuria
Renal Failure
Hypertension

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4
Q

How is glomerulonephritis classified?

A

Morphology:

  • Proliferative
  • Non-proliferative
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5
Q

What do we mean by proliferative glomerulonephritis?

A

Characterised by excessive numbers of cells in glomeruli

These include infiltrating leucocytes

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6
Q

What do we mean by non-proliferative glomerulonephritis?

A

Glomeruli look normal or have areas of scarring.

They have normal numbers of cells

Tubules and interstitium may be damaged

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7
Q

What are the different types of proliferative glomerular nephritis?

A

Diffuse proliferative
-Post infective nephritis

Focal proliferative
-Mesangial IgA disease

Focal necrotising (crescentic) nephritis

Membrano-proliferative nephritis

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8
Q

How do you differentiate diffuse and focal proliferative glomerulonephritis?

A

Decided on percentage of glomeruli effected

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9
Q

How do you diagnose diffuse proliferative (post infective) glomerulonephritis?

A

Microscopy
Electron microscopy
Immunoflourescence

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10
Q

When does diffuse proliferative glomerulonephritis present?

A

Follows 10-21 days after infection typically of throat or skin

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11
Q

What organism is diffuse proliferative glomerulonephritis most commonly associated with?

A

Lancefield group A Streptococci

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12
Q

How does acute nephritis present?

typical of post infective glomerulonephritis

A

Fluid retention with oedema

Normal serum albumin

Little proteinuria

Hypertension

Renal impairment

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13
Q

What is the treatment for Post infective glomerulonephritis?

A

Antibiotics for infection

Loop diuretics such as frusemide for oedema

Vasodilator drugs (e.g. amlodipine) for hypertension

Consider immunosupression for severe disease

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14
Q

If someone presents with what looks like post infective glomerulonephritis when would you do a biopsy?

A

Test urine and bloods

If it looks like post infective treat as such

If they get better then great

If not biopsy
-Invasive

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15
Q

What is the commonest cause of glomerulonephritis?

A

IgA nephropathy

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16
Q

How does IgA nephropathy present?

A

Typically occurs in the young

Presents with macroscopic haematuria
-Very occassionally microscopic

Provoked by inter current infection

Usually not hypertensive

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17
Q

What are the investigative tests like in IgA nephropathy?

A

Laboratory tests reflect renal function

No characteristic serology

Diagnosed by renal biopsy

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18
Q

How does the renal biopsy in IgA nephropathy appear?

A

Microscopy
-Mesangia expansion
(mesangio-proliferative)

Immunoflourescence
-IgA deposits seen

Electron-Microscopy

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19
Q

how does IgA nephropathy present in adults?

A

Often have an insidious onset

Prognosis of IgA nephropathy is worse in adults - 25% develop renal failure

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20
Q

How do you treat IgA nephropathy?

A

Non-specific with ACE inhibitors and other hypotensives

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21
Q

What is segmental necrosis?

A

Such an intense proliferation that the capillaries rupture

morphological appearance -> not diagnosis

22
Q

How does crescentic glomerulonephritis present?

A

Rapidly progressive glomerulonephritis

May occur in isolation or complicate other diseases e.g. chronic nephritis, vasculitis

MEDICAL EMERGENCY

23
Q

What 3 main settings does focal necrotising (crescentic) glomerulonephritis occur?

A

In the presence of anti-glomerular basement membrae antibodies (Goodpastures syndrome)

Associated with systemic vasculitis (e.g. Wegener’s granulomatosis, Microscopic polyangiitis)

As a complication of other types of glomerulonephritis including post-streptococcal glomerulonephrotos and mesangial IgA disease

24
Q

What is goodpasture’s syndrome?

A

Rare disease caused by autoimmunity to the Glomerular basement membrane

Typically presents as nephritis with or without lung haemorrhage

Diagnosed by demonstrating anti-GBM antibodies in serum and kidney

Treated by plasma exchange and immunosupression

25
Q

How do you treat crescentic glomerulonephritis?

A

immunosuppression:

  • Prednisolone
  • Cytotoxic drugs (e.g. cyclophosphamide)
  • Plasma exchange
26
Q

Summerise Proliferative glomerulonephritis

A

Presents with nephritic syndrome

Blood on dipstix
-None or minimal proteinuria

Can be medical emergency with rapidly progressive glomerulonephritis

27
Q

What are the different types of non-proliferative glomerulonephritis?

A

Minimal change disease

Focal glomerulonephritis

Membranous nephropathy

CAUSE NEPHROTIC SYNDROME

28
Q

What is the clinical triad of nephrotic syndrome?

A

Pitting Oedema

Proteinuria (>5G)

Hypoalbuminaemia (

29
Q

What is the definition of nephrotic syndrome?

A

A clinical syndrome in which severe oedema is caused by hypoalbuminia due to loss of protein in the urine.

Specifically there is:

  • Serum albumin (5G/25hrs
  • (normal
30
Q

What additional features may be seen in nephrotic syndrome?

A

Hyperlipidaemia

Hypercoagulable state

Increased risk of infection, especially with pneumococcus

31
Q

What is the differential diagnosis of nephrotic syndrome?

A

Congestive Heart Failure

  • JVP raised,
  • Normal albumin
  • Minimal proteinuria

Hepatic disease

  • Abnormal LFTs
  • No proteinuria
32
Q

What are the principles of management of nephrotic syndrome?

A

Specific management

Treatment of oedema

Prophylaxis against complications

33
Q

What is the specific management of nephrotic syndrome?

A
  1. Make specific diagnosis, e.g. by renal biopsy
  2. Specific treatment when indicated
  3. Consider Rx with prednisolone if severe
34
Q

How do you treat oedema in nephrotic syndrome?

A
  1. Fluid and sodium restriction
  2. Normal to high protein diet
  3. Rx “ loop diuretics” such as frusemide
  4. Infusion of albumin with frusemide IV for resistant oedema
35
Q

What prophylaxis against complications do you use in nephrotic syndrome?

A
  1. Penicillin V (250mg qds) as prophylaxis against infection
  2. Consider heparin as prophylaxis against thrombosis
  3. Treat hyperlipidaemia in those with persistent nephrotic syndrome
36
Q

What is minimal change nephrotic syndrome?

A

Commonest form in children

Sudden onset of oedema - days

Complete loss of proteinuria with steroids

Two thirds of patients relapse

37
Q

Explain the morphology of minimal change nephrotic syndrome

A

Normal microscopy

Normal immunofluorescence

Only see small change on EM
-Slight change to podocytes

38
Q

What is the treatment of minimal change nephrotic syndrome?

A

Prednisolone
-60mg/M2 per day with rapid tapering dose after a max of 8 weeks

Initial relapse treated in the same way

Subsequent relapses treated with 8 week course on cyclophosphamide or with continuous cyclosporin

39
Q

What are the complications of steroid responsive (minimal change) nephrotic syndrome?

A

Bacterial infection, especially with pneumococcus

Thrombosis, especially in adults

40
Q

What is the prognosis of steroid responsive (minimal change) nephrotic syndrome?

A

Resolves eventually and the long term prognosis is good: patients so not develop renal failure

NB in the pre-antibiotic and pre-steroid era, 60% of patients died

41
Q

What are the clinical features of focal glomerulosclerosis (steroid resistant nephrotic syndrome)?

A

Severe nephrotic syndrome, especially in men in their 4th decade

Symptoms very disabling

At best an incomplete response to steroids

Progresses to renal failure over 2-3 years

Can recur in renal transplants

42
Q

What is the morphology of focal segmental sclerosis?

A

Immunohistology negative

Adhesion seen at edge of bowman’s

43
Q

What is the treatment of focal glomerulosclerosis (steroid resistant nephrotic syndrome)?

A

Initial trial of steroids
-If responds completely the prognosis as for minimal change; if not poor prognosis

Continue steroids if clinically useful response

Try cyclophosphamide or cyclosporin if steroids fail

Use non-specific drugs to reduce proteinuria
-ACE inhibitors and NNSAIDs (indomethacin)

Give non specific treatment for nephrotic oedema, and prophylaxis against nephrotic complications

44
Q

What is the commonest cause of nephrotic sundrome in adults?

A

Membranous nephropathy

About half the cases occur in isolation (idiopathic) and about half are associated with another disease

45
Q

What diseases are associated with membranous nephropathy?

A

Cancers
SLE
Rheumatoid arthritis

46
Q

What drugs are associated with membranous nephropathy?

A

Hypersensitivity to drugs

-e.g. gold and penicillamine

47
Q

What is the morphology of membranous nephropathy?

A

All glomeruli

IgG deposits with spikes around them
-These spikes are the hallmark and can be seen on EM

48
Q

What is the management of membranous nephropathy?

A

Control nephrotic symptoms

Immunosuppression for those with deteriorating renal function

Prednisolone and Chrorambucil alternating monthly for 6 months

Cyclosporin probably ineffective

49
Q

What is the prognosis of membranous nephropathy?

A

Resolves spontaneously in 25% over 5-10 years

Prognosis good in treated patients whose proteinuria resolves

About 25% are on dialysis at 10 years

Can recur in renal transplants

50
Q

Once you have diagnosed membranous nephropathy what must you rule out?

How do you do this?

A

Cancer

Tumour markers
-CEA

Search for likely places (according to history)
-e.g. Chest X-ray, barium enema etc

Urinary Systems (26 decks)

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