Glomerulonephritis Flashcards by Ciaran Gallagher

Classification of glomerulonephritis

Proliferative

Non-proliferative

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Appearance of glomerulus, tubules and interstitium in Non-proliferative glomerulonephritis

Glomeruli look normal or have areas of scarring. They have normal numbers of cells
Tubules and interstitium may be damaged

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Appearance of glomerulus in proliferative glomerulonephritis

Excessive number of cells in glomeruli.

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What extra cells are also present in proliferative glomerulonephritis

Leucocytes

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4 types of Proliferative glomerulonephritis

Diffuse proliferative - post-infective nephritis
Focal proliferative - mesangial IgA disease
Focal necrotizing (crescentic) nephritis
Membrano-proliferative nephritis

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Common presentation of diffuse proliferative glomerulonephritis

10-21 days after throat or skin infection

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4 presentations of acute nephritis

Fluid retention with oedema
Normal serum albumin
Little proteinuria
Hypertension
Renal impairment
(typical of post infection glomerulonephritis)

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Seven year old boy brought to GP generally unwell, dark urine
Puffy face, no rashes no oedema, BP 125/80mm
Had had a sore throat 2 weeks previously
Possible diagnosis and what investigations?

Post infective glomerulonephritis

FBC, U&E (and creatinine), MSSU Microscopy and Urinalysis (dipstick)

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Treatment of post-infective glomerulonephritis

Antibiotics for infection
Loop diuretics eg frusemide for oedema
Vasodilator drugs for hypertension
Consider immunosupression for severe disease

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Most common cause glomerulonephritis

IgA Nephropathy

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Presentation of IgA nephropathy

Typically occurs in the young
Presents with MACROSCOPIC haematuria
Provoked by intercurrent infection
Usually not hypertensive
No characteristic serology

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How is IgA nephropathy diagnosed

Renal biopsy

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14 year old boy presents to GP with bright red urine
No other urinary symptoms but concurrent URT infection
Physical examination including blood pressure normal
Urine dipstix showed blood++++, protein trace
Diagnosis and investigations?

IgA Nephropathy

FBC, U&E (and creatinine), MSSU Microscopy, renal Ultrasound, Urinalysis (dipstick) and RENAL BIOPSY (for diagnosis)

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Prognosis of IgA nephropathy

Children - good

Adults- 1/4 develop renal failure (treated with ACE-I)

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Clinical features of crescentic glomerulonephritis

Presents with rapidly progressive glomerulonephritis
May occur in isolation or complicate other diseases, e.g. chronic nephritis, vasculitis
IT IS A MEDICAL EMERGENCY

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3 causes of Focal Necrotizing (Crescentic) Glomerulonephritis

Anti-glomerular basement membrane antibodies
Associated with systemic vasculitis eg Wegener’s Granulomatosis
As a complication of another type of glomerulonephritis eg mesangial IgA disease

What causes goodpastures disease

Anti-glomerular basement membrane antibodies

Presentation, diagnosis and treatment of Goodpastures disease

Presents as nephritis with or without lung haemorrhage
Diagnosed by demonstrating anti-GBM antibodies in serum and kidney
Treated by plasma exchange and immunosupression

Management and prognosis of Crescentic glomerulonephritis

Immunosuppression (prednisolone)
Plasma exchange
Prognosis is good if treatment is started early enough

57 year old woman presents to GP with three month history of increasing tiredness, anorexia and weight loss
Over past 2 weeks she developed cough with haemoptysis
Physical examination revealed a rash on both ankles and lower legs, and bilateral basal crepitations: BP 150/85
Urine dipstix: protein+++ and blood++
Diagnosis, investigations and treatment

Focal necrotizing glomerulonephritis secondary to systemic vasculitis
Anti-neutrophil cytoplasmic antibodies positive, Urinalysis (dipstick)
RENAL BIOPSY
Immunosuppression (prednisolone)

Summary of Proliferative glomerulonephritis

Presents with nephritic syndrome
Blood on dipstix – none or minimal proteinuria
Can be medical emergency with crescentic glomerulonephritis

What causes nephrotic syndrome

Non-proliferative Glomerulonephritis

Clinical triad of nephrotic syndrome

Pitting Oedma
Proteinuria (>5 G)
Hypoalbuminaemia (<30 G/litre: normal >45)

Definition of nephrotic syndrome

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

Management of nephrotic syndrome

Specific management Treatment oedema Prophylaxis against complications

What is meant by 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.

Presentation of minimal change nephrotic syndrome

Sudden onset of oedema - days Proteinuria 2/3 of patients relapsed

Treatment of minimal change nephrotic syndrome

Prednisolone | Complete loss of proteinuria with steroids

Prognosis of minimal change nephrotic syndrome

Good

``` 22 year old woman presentes with severe oedema which developed suddenly over a week Breathless with left sided chest pain she also had colicky abdominal pain urine contained ++++ protein Diagnosis, investigations and treatment ```

``` Minimal change nephrotic syndrome U&E's (and creatinine ), FBC, Serum albumin, Haemoglobin, Fibrinogen, Cholesterol, Urinalysis (dipstick) and RENAL BIOPSY Immediate management: Diuretics Fluid/salt restriction Pencillin Heparin prophylaxis Daily Weights ```

Clinical feature of focal glomerulosclerosis

Severe nephrotic syndrome (especially in men in their fourth decade) Symptoms very disabling. At best an incomplete response to steroids Progresses to renal failure over 2-3 years. Can recur in renal transplants

Focal glomerulosclerosis AKA

Steroid resistant nephrotic syndrome

Treatment of focal glomerulosclerosis

Initial trial of steroids Continue steroids if clinically useful response Cyclosporin if steroids fail

Prognosis of focal glomerulosclerosis

If responds completely to steroids the prognosis is the same as minimal change If not poor prognosis

Clinical features of Membranous nephropathy

Commonest cause of nephrotic syndrome in adults | Half of cases are Idiopathic other half are related to other diseases eg Systemic Lupus Erthymetasous (SLE)

Management of membranous nephropathy

Control nephrotic symptoms | Immunosupression if deteriorating renal function (Prednisolone)

Prognosis for 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

66 year old man presents with steadily increasing oedema Recent change in bowel habit Proteinuria ++++ Diagnosis and investigations

Membranous Nephropathy | U&E's (and creatinine), FBC, Urinalysis (dipstick), RENAL BIOPSY

Summary of glomerulonephritis

1. Glomerulonephritis is an important cause of end stage renal disease 2. Different types of glomerulonephritis present in different ways and differ in prognosis 3. Precise diagnosis depends on renal biopsy and the results influence management