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Renal > Glomerulonephritis > Flashcards

Glomerulonephritis Flashcards

1
Q

What is glomerulonephritis?

A

Immune mediated disease of the kidney affecting the glomerulus with secondary tubulo-interstitial damage = 2nd commonest cause of end stage renal failure

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2
Q

What is the pathogenesis of glomerulonephritis?

A 
Humoral (antibody mediated) = intrinsic or planted antigen, deposition of immune complexes
Cell mediated (T cells)
Inflammatory cells, mediators and complements
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3
Q

What does disruption to the glomerular capillary wall cause?

A

Size and charge selective barrier = disruption leads to haematuria and/or proteinuria

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4
Q

What does damage to the endothelial and mesangial cells lead to?

A

Proliferative lesion and red cells in urine

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5
Q

What does damage to the podocytes lead to?

A

Non-proliferative lesion and protein in urine

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6
Q

What are some features associated with damage to the mesangium?

A

Proliferative, release angiotensin 2, chemokine release, attract inflammatory cells

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7
Q

What are some features associated with damage to the podocytes and endothelial cells?

A

Podocytes = atrophy, loss of size/charge specific barrier

Endothelial cells = vasculitis

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8
Q

How is glomerulonephritis diagnosed?

A

Clinical presentation and blood tests
Examination of urine
Kidney biopsy

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9
Q

How can urine be examined?

A

Urinalysis = haematuria, proteinuria
Urine microscopy = RBC (dysmorphic), RBC and granular casts, lipiduria
Urine protein:creatine ratio/24hr urine collection = quantify proteinuria

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10
Q

What is the renal presentation of glomerulonephritis?

A

Haematuria, proteinuria, impaired renal function, hypertension, nephrotic/nephritic/nephrotic-nephritic syndrome

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11
Q

How may haematuria present?

A

Asymptomatic microscopic haematuria

Episodes of macroscopic haematuria

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12
Q

What are the different forms of proteinuria?

A

Microalbuminuria = 30-300mg albuminuria/day
Asymptomatic proteinuria = 1g/day
Heavy proteinuria = 1-3g/day
Nephrotic syndrome = >3g/day

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13
Q

How may impaired renal function present?

A

AKI = rapidly progressive GN-RPGN

CKD/ESRD

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14
Q

What are the features of nephritic syndrome?

A

Acute renal failure, oliguria, oedema/fluid retention, hypertension, active urinary sediment

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15
Q

What may urinary sediment consist of?

A

RBC, RBC and granular casts

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16
Q

What is nephritic syndrome indicative of?

A

A proliferative process affecting the endothelial cells

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17
Q

What are some features of nephrotic syndrome?

A

Proteinuria >3g/day (mostly albumin, also globulin)

Hypoalbuminaemia (<30), oedema, hypercholesterolaemia, usually normal renal function

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18
Q

What is nephrotic syndrome indicative of?

A

A non-proliferative process affecting podocytes

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19
Q

What are some complications of nephrotic syndrome?

A

Infection = loss of opsonising antibodies
Renal vein thrombosis and pulmonary emboli
Volume depletion = due to over-aggressive diuretics use, may lead to ARF (pre-renal)
Vitamin D deficiency
Subclinical hypothyroidism

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20
Q

What are the two classes of glomerulonephritis?

A

10 (idiopathic) = majority of cases

20 = caused by infection/drugs, associated with malignancy or as part of systemic disease

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21
Q

How is glomerulonephritis looked at histologically?

A

Renal biopsy, light microscopy, immunofluorescence, EM

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22
Q

What does proliferative and non-proliferative classification refer to?

A

The presence or absence of proliferation of mesangial cells

23
Q

What are the histological classifications of glomerulonephritis?

A

Proliferative and non-proliferative
Focal and diffuse = < or > 50% glomeruli affected
Global and segmental = all or part of glomeruli affected
Crescenteric = presence of crescents

24
Q

What causes a crescenteric appearance?

A

Epithelial cell extracapillary proliferation

25
Q

What are the principles of glomerulonephritis treatment?

A

Reduce degree of proteinuria
Induce remission of nephrotic syndrome
Preserve long term renal function

26
Q

What are some non-immunosuppressive treatment options?

A

Anti-hypertensives, ACE inhibitors/ARBs, statins, diuretics, omega 3 fatty acids/fish oil, anticoagulants, aspirin, anti-platelets

27
Q

What is the target BP for patients with glomerulonephritis?

A

<130/80 mmHg or <120/75 mmHg if proteinuria present

28
Q

What are some immunosuppressive drugs used in the treatment of glomerulonephritis?

A

Corticosteroids = prednisolone/methylprednisolone IV
Azathioprine and mycophenolate mofetil (MMF)
Alkylating agents = cyclophosphamide, chlorambucil
Calcineurin inhibitors = cyclosporin, tacrolimus

29
Q

What are the immunosuppressive treatment options for glomerulonephritis?

A

Immunosuppressive drugs
Plasmapharesis = therapeutic plasma exchange
IV immunoglobulin, monoclonal T/B cell antibodies

30
Q

What is the treatment for nephrotic patients?

A

General = fluids, salt restriction, diuretics, ACEi/ARBs, anticoagulation, IV albumin (only if volume deplete)
Immunosuppression

31
Q

What is the aim of treatment for nephrotic patients?

A

Induce sustained remission:
Complete remission = proteinuria < 300mg/day
Partial remission = proteinuria < 3g/day

32
Q

What are the main idiopathic (10) types of glomerulonephritis?

A

Minimal change, focal segmental glomerulosclerosis, membranous nephropathy, membranoproliferative, IgA nephropathy

33
Q

What are some features of minimal change nephropathy?

A

Commonest cause of nephrotic syndrome in children

Doesn’t cause progressive renal failure

34
Q

What is a possible cause of minimal change nephropathy?

A

IL-3

35
Q

How does minimal change nephropathy appear on biopsy?

A

Normal renal biopsy on LM and IF with foot process fusion on EM

36
Q

How is minimal change nephropathy treated?

A

94% complete remission with oral steroids
Some are steroid resistant/dependent or have relapses
Second line agents = cyclophosphamide, CSA

37
Q

What are some features of focal segmental glomerulosclerosis (FSGS)?

A

Commonest cause of nephrotic syndrome in adults
10 or 20 = HIV, heroin, obesity, reflux nephropathy
Minimal Ig/complement deposition on IF

38
Q

What is the prognosis of focal segmental glomerulosclerosis?

A

Remission with prolonged steroids in 60%

50% progress to end stage failure after 10 years

39
Q

What are some features of membranous nephropathy?

A

2nd commonest cause of nephrotic syndrome in adults

10 or 20 = hep B, parasites, lupus, carcinoma, lymphoma, gold, penicillamine

40
Q

How does membranous nephropathy appear on biopsy?

A

Subepithelial immune complex deposition in basement membrane

41
Q

What is antibody is implicated in membranous nephropathy?

A

Anti-PLA2r antibody present in >70% of primary cases

42
Q

How is membranous nephropathy treated?

A

Steroids, alkylating agent, B cell monoclonal antibody

43
Q

What is the prognosis of membranous nephropathy?

A

30% progress to end stage renal failure in 10 years

44
Q

What are some features of IgA nephropathy?

A

Most common form of GN in the world

25% progress to end stage renal failure in 10-30 years

45
Q

How does IgA nephropathy present?

A

Asymptomatic microhaematuria and non-nephrotic range proteinuria, AKI/CKD, macroscopic haematuria after resp/GI infection

46
Q

What is IgA nephropathy associated with?

A

Henoch-Schonlein purpura = arthritis, colitis, purpuric skin rash

47
Q

How does IgA nephropathy appear on biopsy?

A

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

48
Q

How is IgA nephropathy treated?

A

BP control, ACEi/ARBs, fish oil

49
Q

What is rapidly progressive glomerulonephritis (RPGN)?

A

Rapid deterioration in renal function over days-weeks = may be part of systemic disease

50
Q

What are some features of rapidly progressive glomerulonephritis?

A

Active urinary sediment

Associated with glomerular crescents on biopsy

51
Q

What are some causes of rapidly progressive glomerulonephritis?

A

ANCA positive = GPA, microscopic polyangiitis

ANCA negative = Goodpasture’s (anti-GBM), Henoch-Schonlein purpura (IgA), SLE

52
Q

What are the aims of treatment for rapidly progressive glomerulonephritis?

A

Treatment should be prompt and consist of strong immunosuppression with supportive care

53
Q

What is the treatment of rapidly progressive glomerulonephritis?

A

Immunosuppression and plasmapharesis

54
Q

What immunosuppressive agents can be used to treat rapidly progressive glomerulonephritis?

A 
Steroids = IV methylprednisolone, oral prednisolone
Cytotoxics = cyclophosphamide, MMF, azathioprine

Renal (36 decks)

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