glomerulonephritis And DM Flashcards

1
Q

What is GN and what are the 4 structures that can be damaged

A
• ‘inflammation of glomeruli’
4 structures in glomerulus that can be damaged: 
• Capillary endothelium 
• Glomerular basement membrane 
• Mesangial cells 
• Podocytes
• Often involves the immune system
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2
Q

What are the types of damage that can occur to the nephron

A

Too many mesangium cell,s fusion of podocytes, subepithelial innume complexes, narrowed lumen,

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3
Q

How can GN be classified

A
  • Clinical presentation (e.g. nephrotic)
  • Histological appearance (e.g. minimal change disease)
  • Diagnosis (e.g. lupus)
  • Primary / Secondary
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4
Q

What is teh clinical presentation of GN

A
  1. Asymptomatic haematuria & / or proteinuria
  2. Chronic glomerulonephritis
  3. Acute glomerulonephritis - weeks-months
  4. Rapidly progressive glomerulonephritis. Matter of days
  5. Nephrotic syndrome
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5
Q

0

A

0

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6
Q

Compare nephrotic and nephritic syndrome

A

NEphrotic - podocytes damage leading t glomerular charge-barrier disruption - proteinuria - bigger molecules liek albumin can get out

Nephritic - inflammation disrupting glomerular basement membrane - haematuria

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7
Q

What is nephrotic syndrome

A

A triad of :
• Proteinuria > 350 mg/ mmol (or 3.5 g in 24 hours)
• Hypoalbuminaemia - Losing protein faster than liver cn make it
• Oedema
• Usually accompanied by high cholesterol

Other features:
• BP often normal (can be low or high)
• Creatinine may be normal
• Proteinuria > 350 mg/ mmol alone = nephrotic range proteinuria

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8
Q

What are the causes of nephrotic syndrome

A

Primary Renal Disease
• Minimal change disease • Membranous nephropathy
• Focal segmental glomerulosclerosis (FSGS)
Secondary Renal Disease
• Diabetes Most common cause
• SLE (lupus)
• Amyloid
(Amyloid and dm - Nephrotic syndrome but not GN)

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9
Q

What si the management for nephrotic syndrome

A

Oedema
– Diuretics, need large doses and may need to be i.v. if gut oedema
– Salt and fluid restriction

ACE-Inhibitor (if by ok)
– Anti-proteinuric but caution if intravascularly deplete or if renal function deteriorating acutely

Hypercholesterolaemia
– Atherogenic if long-term nephrotic
(dont give statin if cholesterol is high)

Treat underlying condition
– e.g. steroids for MCD, underlying cause of disease (e.g. amyloid)
Dont give steroid to diabetic

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10
Q

What is nephritic syndrome

A

A triad of:
• Haematuria - doesn’t need to be visible but has to be present on dippstick
• Reduction in GFR (renal impairment / oliguria)
• Hypertension

Other features
• Often some proteinuria but less than nephrotic syndrome
• Disruption of the endothelium results in inflammatory response & damage to the glomerulus
• Onset may be acute or rapidly progressive (RPGN)
• Rapidly Progressive / Crescentic GN - a fulminant form of nephritic syndrome

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11
Q

What are common causes of nephritic syndrome

A
  • Anti-GBM disease (Goodpasture’s)
  • ANCA-associated vasculitis
  • IgA / Henoch-Schönlein purpura*
  • Post-infectious*
  • Lupus*

• Associated with immune disease

*can also present as nephrotic

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12
Q

What is the management for nephritic syndrome

A

Blood pressure control / reduction of proteinuria
– ACE-I or AIIR first line if renal function allows
– Salt restrict

Treatment of oedema
– As for nephrotic syndrome if adequate renal function

Disease specific treatments
– Generally immunosuppressants
– e.g. RPGN
– prednisolone, cyclophosphamide +/- plasma exchange

Cardiovascular risk management
– Stop smoking, statin etc

Dialysis (often short-term)

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13
Q

Wat is ANCA associated vasculitis

A
  • Granulomatosis with polyangiitis (Wegener’s) & microscopic polyangiitis
  • Affect small arterioles
  • Often kidneys and lungs
  • ‘pulmonary-renal syndrome’
  • Often systemic symptoms (inflammatory condition)
  • Fatigue, arthralgia, myalgia, weight loss
  • No immune deposits in kidney – circulating antibodies to white cells
  • cause Endothelial damage
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14
Q

What is anti gbm disease

A

Anti-GBM Disease (Goodpasture’s disease)
• Caused by anti-bodies to α3 chain of type 4 collagen in glomerular basement membrane
• Can also affect α3 chain of type 4 collagen in alveolar basement
membrane but harder for anti-bodies to get here.
• Pulmonary haemorrhage more likely with pre-existing damage to alveolar endothelium e.g. smokers, infection
• Always causes RPGN
Present very acutely - goes from being nothing to being renal failure within days. Kidney failure - need dialysis sits.

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15
Q

What is systemic lupus erythematosus

A

• Auto-immune systemic disease. Can affect multiple systems
• Has many different patterns of renal disease
• Can cause nephritic or nephrotic syndrome
• Prognosis depends on type of lesion, activity and amount of kidney
involved
• Treatment also varies according to pattern of lupus nephritis

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16
Q

Wha is diabetic nephropathy

A
• Commonest cause of
ESRD
• Historically quoted that
30-40% all types of
diabetes eventually get
ESRD
• It is a glomerulopathy - NOT a gomerulonephritis
17
Q

What are the pathological changes in diabetic nephropathy

A
  1. Hyperfiltration / capillary hypertension
    • Happens before all other changes
  2. Glomerular basement membrane thickening
  3. Mesangial expansion
  4. Podocyte injury
  5. Glomerular sclerosis / arteriolosclerosis
18
Q

What happens in the early course of diabetic nephropathy

A

Hyperfiltration & hypertrophy
• Occurs early in course of
disease • Related to hyperglycaemia • Glomerular hypertension
• ↑ GFR

19
Q

What are the structural and functional relationships in gfr in diabetic hyerfiltratiob

A

Reabsorbing more glucose tiem each sodium - more water and salt held in the body. Delivering less to macula dense - sensory TGF feedback to dilate AA, - renin secreted - raas - constricts EA - increase pressure

20
Q

Describe teh glomerular filtration barrier in diabetic nephropathy

A

Damage to podocytes
Thickened GBM increases pore size
Mesangial expansion
High intraglomerular pressure

21
Q

Describe the histology in diabetic nephropathy

A

Ss

22
Q

What are teh clinical signs as diabetic nephropathy progresses

A
  1. Hyperfiltration & hypertrophy
    • Increased GFR
    Normal histology
  2. Latent stage
    • Normal albuminuria
    • GBM thickening & mesangial expansion
  3. Microalbuminuria (aka moderately increased albuminuria)
    • Variable mesangial expansion / sclerosis
    • Increased GBM thickening
    • Podocyte changes
    • GFR normal
  4. Overt proteinuria (aka severely increased albuminuria)
    • Diffuse glomerular histopathological changes
    • Systemic hypertension
    • Falling GFR
  5. ESRD - end stage renal disease
23
Q

Describe microalbuminuria

A

• First clinical sign (assuming isotope GFR not measured) • GBM thickening & mesangial expansion
• Albuminuria Potentially • 30 – 300 mg/day reversible at this stage
• ‘Albustix’
UHL spot sample • 0 – 3.5 mg / mmol Cr in women • 0 – 2.5 mg / mmol Cr in men

24
Q

What is overt proteinuria

A

• Previously associated with inexorable decline to ESRD in 3 – 7 years
• GFR normal initially (i.e. dropped from hyperfiltration) then generally drops in linear pattern
• mesangial expansion / sclerosis → reduced surface area for filtration
• Detectable on conventional dipstick Not
• Proteinuria > 30 mg/mmol Cr reversible – can be
• Frequently increases to nephrotic range proteinuria slowed
• Worsening systemic hypertension
• Microvascular changes (hyalinosis of arterioles)
– Causes tissue ischaemia

25
Q

Wat is the significance of overt proteinuri

A

• Normal GFR and proteinuria < 100 mg mmol = mild kidney disease - not likely to get to esrd
- EXCEPT in diabetes - oath to decline
• Average decline in GFR 12mls / min/ year (2 – 20 mls)
• Most patients reach end-stage kidney disease in 3-7 years

26
Q

Wha ar are the risk factors for diabetic nephropathy

A

• Genetic susceptibility DM type 1 with 1st degree relative with DN = 83% risk1
DM type 1 with 1st degree relative with DM type 1 but no nephropathy = 17% risk
• Race (aucasian less likely than Mexican, Caribbean, African saeAsian etc)
• Hypertension
• Hyperglycaemia
• High level of hyperfiltration
• Increasing age
• Duration of diabetes • Smoking

27
Q

What is teh primary prevention of diabetic neproathy

A

• Tight blood glucose control
– < 48 mmol/mol (<6.5%)
• Tight blood pressure control
– No particular agent shown to be better with normal albuminuria

  • ? SGLT-2 inhibitors
  • ? Not smoking
  • ? Statin therapy
28
Q

Describe tyight glycaemic control

A
  • Multiple injections or insulin pump → near normal blood glucose
  • Can reverse initial hyperfiltration and delay microalbuminuria
  • Can reduce microalbuminuria over 2 years treatment period
  • Doesn’t slow GFR loss once overt proteinuria develops
29
Q

What os the management of microalbuminuria and proteinuria

A
• Inhibition of RAAS 
• Tight blood pressure control
– <130/80 mmHg
• Statin therapy 
• CV risk management (exercise, diet, stop smoking)
• Moderate protein intake
• Tight blood glucose control (does not affect progression once overt
proteinuria develops)
30
Q

What does raas blockade do

A

• Reduces glomerular hyperfiltration
• Efferent > afferent arterioles
• Anti-proteinuric effect more than BP reduction alone
• Reduces proteinuria & slows progression at stages 2 - 4 of diabetic
nephropathy
• Hyperkalaemia limits use with advanced CKD

31
Q

What is thr principal of salt inhibition

A

If you cn block salut 2 reabsorption 0 glucoseuria - sodium delivered here- not triggering tgf feedback - pressure doesn’t increase