Glomerulonephritis Flashcards by Andrew Hay

What is glomerulonephritis?

Inflammatory disorder of the kidney

How well did you know this?

Not at all

Perfectly

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

Up to 30%

How well did you know this?

Not at all

Perfectly

Give some of the many ways glomerulonephritis can present

Proteinuria
Renal Failure
Hypertension

How well did you know this?

Not at all

Perfectly

How is glomerulonephritis classified?

Morphology:

Proliferative
Non-proliferative

How well did you know this?

Not at all

Perfectly

What do we mean by proliferative glomerulonephritis?

Characterised by excessive numbers of cells in glomeruli

These include infiltrating leucocytes

How well did you know this?

Not at all

Perfectly

What do we mean by non-proliferative glomerulonephritis?

Glomeruli look normal or have areas of scarring.

They have normal numbers of cells

Tubules and interstitium may be damaged

How well did you know this?

Not at all

Perfectly

What are the different types of proliferative glomerular nephritis?

Diffuse proliferative
-Post infective nephritis

Focal proliferative
-Mesangial IgA disease

Focal necrotising (crescentic) nephritis

Membrano-proliferative nephritis

How well did you know this?

Not at all

Perfectly

How do you differentiate diffuse and focal proliferative glomerulonephritis?

Decided on percentage of glomeruli effected

How well did you know this?

Not at all

Perfectly

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

Microscopy
Electron microscopy
Immunoflourescence

How well did you know this?

Not at all

Perfectly

When does diffuse proliferative glomerulonephritis present?

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

How well did you know this?

Not at all

Perfectly

What organism is diffuse proliferative glomerulonephritis most commonly associated with?

Lancefield group A Streptococci

How well did you know this?

Not at all

Perfectly

How does acute nephritis present?

typical of post infective glomerulonephritis

Fluid retention with oedema

Normal serum albumin

Little proteinuria

Hypertension

Renal impairment

How well did you know this?

Not at all

Perfectly

What is the treatment for Post infective glomerulonephritis?

Antibiotics for infection

Loop diuretics such as frusemide for oedema

Vasodilator drugs (e.g. amlodipine) for hypertension

Consider immunosupression for severe disease

How well did you know this?

Not at all

Perfectly

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

Test urine and bloods

If it looks like post infective treat as such

If they get better then great

If not biopsy
-Invasive

How well did you know this?

Not at all

Perfectly

What is the commonest cause of glomerulonephritis?

IgA nephropathy

How well did you know this?

Not at all

Perfectly

How does IgA nephropathy present?

Typically occurs in the young

Presents with macroscopic haematuria
-Very occassionally microscopic

Provoked by inter current infection

Usually not hypertensive

How well did you know this?

Not at all

Perfectly

What are the investigative tests like in IgA nephropathy?

Laboratory tests reflect renal function

No characteristic serology

Diagnosed by renal biopsy

How well did you know this?

Not at all

Perfectly

How does the renal biopsy in IgA nephropathy appear?

Microscopy
-Mesangia expansion
(mesangio-proliferative)

Immunoflourescence
-IgA deposits seen

Electron-Microscopy

How well did you know this?

Not at all

Perfectly

how does IgA nephropathy present in adults?

Often have an insidious onset

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

How well did you know this?

Not at all

Perfectly

How do you treat IgA nephropathy?

Non-specific with ACE inhibitors and other hypotensives

How well did you know this?

Not at all

Perfectly

What is segmental necrosis?

Such an intense proliferation that the capillaries rupture

morphological appearance -> not diagnosis

How does crescentic glomerulonephritis present?

Rapidly progressive glomerulonephritis

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

MEDICAL EMERGENCY

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

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

What is goodpasture’s syndrome?

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

How do you treat crescentic glomerulonephritis?

immunosuppression: - Prednisolone - Cytotoxic drugs (e.g. cyclophosphamide) - Plasma exchange

Summerise Proliferative glomerulonephritis

Presents with nephritic syndrome Blood on dipstix -None or minimal proteinuria Can be medical emergency with rapidly progressive glomerulonephritis

What are the different types of non-proliferative glomerulonephritis?

Minimal change disease Focal glomerulonephritis Membranous nephropathy CAUSE NEPHROTIC SYNDROME

What is the clinical triad of nephrotic syndrome?

Pitting Oedema Proteinuria (>5G) Hypoalbuminaemia (

What is the definition of nephrotic syndrome?

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

What additional features may be seen in nephrotic syndrome?

Hyperlipidaemia Hypercoagulable state Increased risk of infection, especially with pneumococcus

What is the differential diagnosis of nephrotic syndrome?

Congestive Heart Failure - JVP raised, - Normal albumin - Minimal proteinuria Hepatic disease - Abnormal LFTs - No proteinuria

What are the principles of management of nephrotic syndrome?

Specific management Treatment of oedema Prophylaxis against complications

What is the specific management of nephrotic syndrome?

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

How do you treat oedema in nephrotic syndrome?

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

What prophylaxis against complications do you use in nephrotic syndrome?

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

What is minimal change nephrotic syndrome?

Commonest form in children Sudden onset of oedema - days Complete loss of proteinuria with steroids Two thirds of patients relapse

Explain the morphology of minimal change nephrotic syndrome

Normal microscopy Normal immunofluorescence Only see small change on EM -Slight change to podocytes

What is the treatment of minimal change nephrotic syndrome?

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

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

Bacterial infection, especially with pneumococcus Thrombosis, especially in adults

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

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

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

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

What is the morphology of focal segmental sclerosis?

Immunohistology negative Adhesion seen at edge of bowman's

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

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

What is the commonest cause of nephrotic sundrome in adults?

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

What diseases are associated with membranous nephropathy?

Cancers SLE Rheumatoid arthritis

What drugs are associated with membranous nephropathy?

Hypersensitivity to drugs | -e.g. gold and penicillamine

What is the morphology of membranous nephropathy?

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

What is the management of membranous nephropathy?

Control nephrotic symptoms Immunosuppression for those with deteriorating renal function Prednisolone and Chrorambucil alternating monthly for 6 months Cyclosporin probably ineffective

What is the prognosis of membranous nephropathy?

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

Once you have diagnosed membranous nephropathy what must you rule out? How do you do this?

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