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Y4: Nephrology > Gomerulonephritis > Flashcards

Gomerulonephritis Flashcards

1
Q

What does glomerulonephritis mean?

A
  • ​Disease of the glomerulus
  • Most are immunologically mediated
  • Present with proteinuria, haematuria, or both
  • Diagnosed by renal biopsy
  • Can progress to kidney failure (except minimal change disease)
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2
Q

Nephrotic or nephritic?

A
  • Spectrum from:
    • Nephrosis
      • Proteinuria due to podocyte pathology
        • to
    • Nephritis
      • Haematuria due to inflammatory damage
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3
Q

Describe the investigations into a suspected glomerulonephritis?

A
  • Bloods:
    • FBC, U&E, LFT, CTP, immunoglobulins, electrophoresis, complement
    • Autoantiboidies: ANA, ANCA, anti-dsDNA
    • Culture
  • Urine
    • MC&S, Bence jones protein, A:CR/P:CR
  • Imaging
    • CXR (pulmonary haemorrhage), Renal US (size/anatomy for biopsy
  • Renal biopsy
    • Required for diagnosis
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4
Q

Describe the process of renal biopsy?

A
  • Pre-procedure
    • BP <160/95, FBC, G&S, written consent required
    • Stop anticoagulation (aspirin 1 week, warfarin PT <1.2, LMWH 24h)
  • Post-procedure
    • Bed rest for 4 hours
    • Monitor BP, pulse, urine
    • Aspirin, warfarin can be restarted next day if no complications
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5
Q

General management of glomerulonephritis conditions?

A
  • Treat as CKD
  • BP control
  • Inhibition of RAS
  • Specific treatment depending on histology, severity and comorbidity
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6
Q

Types of Nephritic glomerulonephritis?

A
  • IgA nephropathy
  • Henoch-schonlein purpura (HSP)
  • Post-streptococcal GN
  • Rapidly progressive GN
  • Anti-glomerular basement membrane (anti-GBM) disease
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7
Q

Describe IgA nephropathy?

When is their a worse prognosis?

A
  • Common in rich countries
  • Mesangial IgA and C3
  • Haematuria, proteinuria <1g, HTN
  • Idiopathic, flares triggered by upper RT infections, coeliac, liver disease
  • Worse prognosis in men, hypertension, raised creatinine, proteinuria
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8
Q

Describe the diagnosis and treatment of IgA nephropathy?

A
  • Diagnosis
    • Renal biopsy: IgA deposition in mesangium
  • Treatment
    • Acei/ARB: reduce proteinuria and protect renal function
    • Corticosteroids + fish oil: if persistent proteinuria and GFR >50
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9
Q

Describe Henoch-schonlein purpura (HSP)?

A
  • Small vessel vasculitis
  • Variant of IgA nephropathy in children:
    • IgA deposition in kidney + skin/joints/gut
  • Presentation:
    • Purpuric rash on extensor surfaces, polyarthritis, abdominal pain, nephritis
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10
Q

Describe the diagnosis and treatment of HSP?

A
  • Diagnosis
    • Clinical
    • Immunofluorescence for IgA and C3 in skin
    • Renal biopsy identical to IgA nephropathy
  • Treatment
    • Acei/ARB: reduce proteinuria and protect renal function
    • Corticosteroids + fish oil: if persistent proteinuria and GFR >50
    • Corticosteroids for gut involvement
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11
Q

Describe post-streptococcal GN?

A
  • Following thoat or skin infection
  • Streptococcal antigen deposits in glomerulus
  • Presentation:
    • Varies from haematuria => acute nephritis
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12
Q

What are the symptoms of acute nephritis?

A
  • Oliguria
  • Oedema
  • Haematuria
  • Hypertension
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13
Q

Describe the diagnosis and treatment of post-streptococcal GN?

A
  • Diagnosis
    • Evidence of strep infection
    • Raised ASOT, anti-DNAse B, reduced C3
  • Treatment
    • Supportive
    • Antibiotics to clear bacteria
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14
Q

Describe anti-GBM disease?

Anti-glomerular basement membrane disease

A
  • (Goodpastures)
  • HLA-DR15
  • Usually crescenteric nephritis
  • Auto-antibodies to type IV collagen in GBM
  • Renal + lung disease
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15
Q

Diagnosis and treatment of anti-GBM disease?

A
  • Diagnosis
    • Anti-GBM in circulation/kidney
    • Crescenteric nephritis on biopsy
  • Treatment:
    • Plasma exchange, corticosteroids, cyclophosphamide
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16
Q

Describe Rapidly progressive GN?

A
  • Any aggressive GN, progressing to renal failure
  • Causes:
    • Small vessel/ANCA vasculitis
    • Lupus nephritis
    • Anti-GBM disease
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17
Q

Describe the diagnosis of rapidly progressive GN?

A
  • Breaks in the GBM allow influx of inflammatory cells
    • Crescents seen on renal biopsy
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18
Q

Describe the treatment of Rapidly progressive GN?

A
  • Corticosteroids and cyclophosphamide
  • Treat cause:
    • Anti-GBM/ANCA vasculitis: plasma exchange
    • Lupus nephritis: monoclonal antibodies
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19
Q

What is pictured here?

A
  • Immunofluorescence for IgA
    • Linear stain characteristics of anti-GBM disease
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20
Q

What is pictured here?

A
  • Crescentic GN
    • Proliferation of epithelial cells
    • Macrophages with rupture of Bownman’s capsule
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21
Q

What is the definition of nephrotic syndrome?

A
  • Triad:
    • Oedema
    • Proteinuria >3g/24hr
    • Hypoalbuminaemia (30g/L)
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22
Q

What are the types of cause of nephrotic syndrome?

A
  • Primary renal disease
  • Secondary to a systemic disorder
23
Q

Primary renal causes of Nephrotic syndrome?

A
  • Minimal change
  • Membranous nephropathy
  • Membranoproliferative GN
  • Focal segmental glomerulosclerosis (FSGS)
24
Q

Secondary causes Nephrotic syndrome?

A
  • DM
  • Lupus nephritis
  • Myeloma
  • Amyloid
  • Pre-eclampsia
25
Q

What makes up the filtrations barrier of the kidney?

A
  • Podocytes
  • Glomerular BM
  • Endothelial cells
26
Q

Describe the pathophysiology of nephrotic syndrome?

A

Podocyte pathology => proteinuria

27
Q

Presentation of nephrotic syndromes?

A

Generalized, pitting oedema

28
Q

Describe the general management of nephrotic syndromes?

A
  • Reduce oedema
    • 1L fluid/day + salt restriction
    • Loop diuretics eg furosemide (+thiazide diuretic if resistant)
    • Aim for 0.5-1kg weight loss per day
  • Treat underlying cause
    • Renal biopsy to diagnose
  • Reduce proteinuria
    • ACE-i/ARB
29
Q

Describe the complications that can occur with nephrotic syndromes?

A
  • Thromboembolism
    • Tx with LMWH + warfarin
  • Infection
    • Ensure pneumococcal vaccination
  • Hyperlipidaemia
30
Q

Describe Minimal change disease?

A
  • Normal histology, no immune deposits
  • Idiopathic, NSAIDs, lithium or haematological malignancies
  • Does not cause renal failure
31
Q

Describe the diagnosis of Minimal change disease?

A
  • Light microscopy is normal
  • Electron microscopy shows effacement of podocyte foot processes
32
Q

Describe the treatment of Minimal change disease?

A
  • Glucocorticoids
  • Frequenct relapses:
    • Increase dose or
    • Cyclophosphamide
33
Q

Describe Focal segmental glomerulosclerosis (FSGS)?

A
  • Most common glomerulonephritis seen on renal biopsy
  • Categories:
    • Primary (idiopathic)
    • Secondary (HIV, heroin, lithium, HTN, obesity)
  • Risk of progressive CKD and renal failure
  • Disease may recur after renal transplant
34
Q

Describe the diagnosis of FSGS?

A
  • No acute inflammation
  • Scarring of glomeruli in certain segments of biopsy
  • Podocyte foot fusion in primary disease
  • Higher proteinurias indicate worse prognoses
35
Q

Describe the treatment of FSGS?

A
  • ACEi/ARB and BP control in all
  • Primary disease:
    • Corticosteroids
  • Recurrence in transplants:
    • Plasma exchange and rituximab
36
Q

Describe Membranous nephropathy?

A
  • Granular subepithelial IgG
  • Primary (idiopathic, HLA-DQA1)
  • Secondary to:
    • Malignancy
    • HBV
    • Lupus
    • Heavy metals, penicillamine
37
Q

Describe the diagnosis of Membranous nephropathy?

A
  • Anti-phospholipid A2 receptor antibody
  • Diffuse thickened GBM
  • Spikes on silver staining
38
Q

Describe the treatment for Membranous nephropathy?

A
  • ACEi/ARB and BP control in all
  • High progression risk:
    • Corticosteroids + cyclophosphamide
  • 1/3 progress, 1/3 remit, 1/3 remain stable
39
Q

Describe Membranoproliferative glomerulonephritis?

Aka mesangiocapillary glomerulonephritis

A
  • Higher in low-middle income countries due to infection
  • Divided into:
    • Immune complex associated
    • C3 glomerulopathy
40
Q

Describe Immune-complex associated Membranoproliferative glomerulonephritis?

A
  • Deposits of immune complexes
  • Activate complement in the kidney
  • Underlying cause in most causes:
    • Infection, monoclonal gamopathy, autoimmunity
41
Q

Describe C3 glomerulopathy Membranoproliferative glomerulonephritis?

A

Defect in the alternative complement pathway (C3 nephritic factor)

42
Q

Describe the diagnosis of Membranoproliferative glomerulonephritis?

A
  • Proliferative glomerulonephritis with electron dense deposits
  • Immunoglobulin deposition in immune-complex associated version
43
Q

Describe the treatment for Membranoproliferative glomerulonephritis?

A
  • ACEi/ARB and BP control in all
  • Immune-complex disease
    • Treat the cause
  • C3 glomerulopathy
    • Treatments to block C3 activation
44
Q

When performing light microscopy, what does the term focal mean when describing glomerular disease?

A

Affecting some but not all glomeruli

45
Q

When performing light microscopy, what does the term diffuse mean when describing glomerular disease?

A

Affecting >50% of glomeruli

46
Q

When performing light microscopy, what does the term segmental mean when describing glomerular disease?

A

Affecting a portion of the glomerulus

47
Q

When performing light microscopy, what does the term global mean when describing glomerular disease?

A

Affecting all of the glomerulus

48
Q

When performing light microscopy, what does the term necrotising mean when describing glomerular disease?

A
  • Severe injury leading to an area of necrosis
  • Usually associated with vasculitis
49
Q

When performing light microscopy, what does the term crescenteric mean when describing glomerular disease?

A

A crescent-shaped area of inflammatory cells responding to severe glomerular injury

50
Q

When performing electron microscopy, what do subendothelial immune deposits indicate?

A
  • Deposits found between the endothelial cells and the GBM
  • Often with nephritic presentations
51
Q

When performing electron microscopy, what do intramembranous immune deposits indicate?

A
  • Deposits found within the GBM
  • Found in the dense deposit variant of Mesangiocapillary glomerulonephritis
52
Q

When performing electron microscopy, what do subepithelial immune deposits indicate?

A
  • Found between the epithelial cells and GBM
  • Often with nephrotic syndromes
    • eg Membranous presentation of lupus
53
Q

What are . the features often present in someone with Henoch-schonlein purpura?

A
  • Arthralgia
  • Haematuria +/- proteinuria
  • Petechial rash of buttocks and lower legs
  • Abdominal pain from vasculitis of the GIT
54
Q
A

Y4: Nephrology (8 decks)

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