Glomerulonephritis

Question 1

Definition of glomerulonephritis

Answer 1

Inflammatory lesions of the glomerulus

Does not include:

• Non-inflammatory lesions affecting the Glomerulus
• Hypertension, diabetes, haematological malignancy
• Rhabdomyolysis
• AKI associated glomerulonephritis

Question 2

Nephrotic syndrome definition

Answer 2

Preserved renal function

• Characterised by proteinuria. (>3g/day)
• Decreased serum albumin and total protein

Features

• Oedema
• UPCR> 300mg/mmol
• ACR> 180mg/mmol

Question 3

Nephritic syndrome definition

Answer 3

Impaired renal function characterised by:

• Proteinuria
• Haematouria
• Leucosuria

Question 4

Glomerulus anatomy

Answer 4

Blood enters the apparatus via the afferent arteriole and undergoes filtration through the glomerulus

Inner lining= endothelial cells
Middle layer= basement membrane
Outer layer=Epithelial foot processes (podocytes). Wraps around capillaries, leaving slits.

Question 5

Histological categories for glomerular disease

Answer 5

Focal or diffuse

Segmental or global

Crescents

Minimal changes

Structures affected: Mesangium, basement membrane, epithelial comma and a video.

Question 6

Symptoms of glomerulonephritis

Answer 6

• Systemic, flulike symptoms
• rash
• arthralgia
• swelling

Question 7

Investigations into glomeurulonephritis

Answer 7

Urine analysis

Blood tests

• Serum albumin and protein
• Renal function tests
• Autoimmune screen

Renal biopsy analysis

• Light Microscopy
• immunohistology
• electron microscopy

Question 8

Urine analysis results

• Nephrotic syndrome
• Nephritic syndrome

Answer 8

Nephrotic

• Significant proteinuria
• Blood and leucocytes may be present.
• No nitrites

Nephritic

• Haematuria
• Proteinuria
• Leucouria
• No nitrites.

Question 9

Causes of GN

Answer 9

Idiopathic

Infection: HBV, HCV, Strep, HIV

Autoimmune: SLE, Goodpasteurs, Vasculitis

Drugs: penicillamine, gold

Amyloidosis

Question 10

Minimal change GN

• Associations
• Histology

Answer 10

Most common cause of nephrotic syndrome in children.

Associations

• NSAIDs
• Allergy
• Lithium, gold
• Hodgkin’s

Histology

• Electron microscopy: fusion of podocytes, loss of foot processes
• Appears normal in light microscopy.

Question 11

Minimal change GN

• Presentation
• Treatment

Answer 11

Presentation

• Nephrotic syndrome: oedema, hypoalbuminaemia, proteinuria
• Frothy urine
• Preserved renal function

Treatment

• Steroids
• Calcinuerin inhibitors, i.e tacrolimus.

Question 12

Membranous GN

• Associations
• Histology

Answer 12

Cause of nephrotic syndrome in 20-30% adults.

Associations

• Drugs: penicillamine, gold, captopril, mercury
• Paraneoplastic: colon, breast, lung
• Autoimmune: Sjorgen’s, SLE, RA, ank spondy
• Idiopathic
• Infection: Hep B, C

Histology
- Silver stain–> Sub-epithelial deposits of immune complex

Question 13

Membranous GN

• Presentation
• Treatment

Answer 13

Presentation

• Nephrotic syndrome
• AKI
• CKD

Treatment

• Treat underlying cause
• Steroids
• Calcineurin inhibitors
• Blood pressure control.

Question 14

Mesangial proliferative GN

• Pathology
• Causes
• Presentation

Answer 14

Mesangial proliferation and matrix desposits

• Due to increased IgA
• mesangial cells proliferate when IgA increases

Causes

• Thyphoid
• malaria
• IgA nephropathy

Presentation

• AKI
• haematuria
• CKD
• Hypertensive crisis

Question 15

Diffuse proliferative nephritis (DPN)

• Pathology
• Causes
• Treatment

Answer 15

Commonly affects people with SLE

• Endothelial and mesangial proliferation
• Can show crescents filling Bowman’s space
• IgM, IgG, C3 deposits.

Causes

• Endocarditis
• Post-strep GN

Treatment
- Treat underlying infection

Question 16

Focal segmental glomerulosclerosis (FSGS)

• Causes
• Pathology

Answer 16

Primary= Idiopathic

Secondary causes:

• Familial: after transplantation.
• Viral infection: HIV
• Drugs: Heroin, pamidronate.
• Obesity
• HTN
• Atheroemboli
• SCD

Pathology
- Segmental scarring of glomerulus.

Question 17

Rapidly progressing glomerulonephritis (Crescentic GN)

- Pathology

Answer 17

Anti-neutrophil cytoplasmic antibodies (ANCA) interact with antigens in neutrophil’s cytoplasm.
-Neutrophils release lytic enzymes, causing glomerular crescents containing parietal epithelial cells (Bowman’s capsule) and sometimes podocytes.

Question 18

Rapidly progressing glomerulonephritis (Crescentic GN)

- Associations

Answer 18

ANCA related small vessel vasculitis

• Granulomatosis with polyangitis (GPA)
• Microscopic polyangitis

Goodpastuer’s

Agressive IgA nephropathy
- As seen with SLE

Idiopathic

Question 19

Treatment for RPGn

Answer 19

Strict blood pressure control

ACEi if proteinuria >1g/day

Immunsuppresions

Question 20

Immunosuppressive drugs used for crescentic GN

Answer 20

Steroids

Cyclophosphamide

Azathiprine

Mycophenolate mofetil

Rituximab

Question 21

Membranoproliferative/ Mesangiocapillary GN

• Causes
• Pathology

Answer 21

Primary= idiopathic
Secondary causes
- Hep C
- Endocarditis
- Viral infections
- Malaria
- SCD

Pathology
- Deposits in intraglomerular mesangium.

Question 22

Membranoproliferative/ Mesangiocapillary GN

- Presentation

Answer 22

• AKI, CKD

- Nephrotic syndrome

Question 23

Membranoproliferative/ Mesangiocapillary GN

- Treatment

Answer 23

Strict BP control

ACE inhibitors for proteinuria >1g/day

Immunosuppression. (similar to crescentic)

• Steroids
• CNIs
• Mycophenolate mofetil
• Rituximab