Kidney: UTI, Pyelonephritis, Glomerulonephritides Flashcards
Classification of UTIs
Simple
- female
- 1st presentation
- not pregnant
- no pyelonephritis
Complicated
- male
- recurrent - 3+ in a year
- pregnant
- elderly
- catheters
Lower - bladder and distal
Upper - kidneys (pyelonephritis)
UTI risk factors
Past UTI
Sexually active
Pregnant
Low estrogen
DM, obesity, IC
Stones
Catheters
Surgery, renal transplant
Causative organisms for UTIs
MOST COMMON - Ecoli followed by staph saprophyticus
UTI
-presentation, history approach
-diagnosis
FUND
-assess triggers, sexual Hx
-DM, stones, neurology, IC
Red flags - sepsis, pyelonephritis (flank pain, fever, N+V)
Clinical diagnosis with urine dipstick (nitrites, leukocytes)
Culture if complicated, recurrent
UTI management
Non pregnant - 3 days nitro/trimeth
MCS needed if
-65+
-any form of hematuria
Pregnant - 7 days
1st trimester - nitro
3rd trimester - trimeth
2nd line - amox, cefalexin
TREAT EVEN IF ASYMPTOMATIC
Men - 7 days nitro/trimeth + MCS
-refer to urology if multiple UTIs
Catheterised - 7 days nitro/trimeth
-NO TREATMENT IF ASYMPTOMATIC
Supportive
- fluids, perineal hygiene, post coital voiding
- remove catheter if present
- if postmenopausal => HRTs to reduce future risk
Characteristics of nephrotic syndromes
- triad
- examples
Glomerular damage => proteinuria, hypoalbuminemia, peripheral edema
Foot effacement - Minimal change disease, FSGS
AB deposition - Membranous
Complex deposition - Membranoproliferative
Minimal change disease
- epidemiology and most common cause
- presentation, investigations
- management
Children - IDIOPATHIC
-NSAIDs, rifampicin
-Hodgkin, thymoma
-glandular fever
Nephrotic + hyperlipidemia - response to low albumin
Confirm nephrotic picture - urinalysis, U&E, lipids
Renal biopsy if not responding to steroids
- normal LM
- EM podocyte foot effacement
1st line - CS
2nd line - cyclophosphamide
2/3d will relapse, but will stop before adulthood
Focal segmental glomerular sclerosis
- epidemiology and most common cause
-presentation
- investigation
- management
Young adults (20-30s) - IDIOPATHIC
-HIV
-2ndary to other renal pathology
Nephrotic + HTN + hyperlipidemia
Renal biopsy
-glomerular scarring on LM
-effacement of feet on EM
1st line - CS
2nd line - cyclophosphamide
Untreated FSGS has U10% chance of spontaneous remission
Membranous glomerulonephritis
- epidemiology and most common cause
-presentation
- investigation
- management and prognosis
Adults - IDIOPATHIC - anti PLA2 IgG AB
-high association with malignancy - prostate, lung, lymphoma, leukemia
-AI - SLE, thyroiditis, RA
-drugs - gold, penicillamine, NSAIDs
Nephrotic + HTN + hyperlipidemia
EM - BM thickening ‘spike and dome’
Management
-BP and proteinuria control - ACEi/ARB
Definitive - self limiting but if severe => CS + cyclophosphamide combination
Can lead to ESRF
AC if high risk
Nephritic syndrome
- triad
- urinary findings
Examples of nephritic syndromes
Glomerular inflammation => inflammation
- Haematuria
- Oliguria and edema
- HTN
Anti GBM
SLE
IgA nephropathy/post streptococcal
ANCA
What is IgA nephropathy or post streptococcal GN?
- key differences
- investigations
- management
- prognosis
IgA/Bergers - most common GN
- young male, nephritic
- 1-2 days after URTI, visible hematuria
- renal biopsy - mesangial hypercellularity, high IgA, C3
Management
- Haematuria only - self limiting
- Persistent proteinuria - BP control
- Falling GFR - CS
Post strep glomerulonephritis => diffuse proliferative GN
- 1-2wks after URTI, proteinuria => edema
-confirm recent URTI with O-streptolysin test
- renal biopsy - low complement
Management - symptom relief
How would you manage nephrotic syndromes
Reduce edema => diuretics
Reduce HTN => ACEi
Reduce DVT risk => anticoagulation
Reduce cholesterol => statin
Renal biopsy to establish cause
How would you manage nephritic syndromes
Supportive
-Na, water restriction
Pharmacological
-proteinuria/HTN => ACEi, ARB, diuretics
Lupus nephritis => immunosuppressive therapy
AntiGBM AB => plasmapheresis
What are the rapidly progressing glomerulonephritides (crescenteric glomerulonephritides)
- what are 3 examples of this
- how might this present
- management
Rapid destruction of glomeruli => ESRD
Anti GBM disease
ANCA vasculitis (GPA, MPA)
Lupus with pulmonary haemorrhage
NEPHRITIC - hematuria, proteinuria, HTN
+features specific to underlying cause
Biopsy - crescent formation around glomerulus
Management - CS, cyclophosphamide, plasmapheresis
What is ANCA positive vasculitis
- main symptoms
- 2 main types and their associated AB
Renal - nephritic symptoms
Resp - SOB, haemoptysis
Systemic - fatigue, weight loss, fever
Vasculitic rash
ENT - sinusitis
GPA - cANCA (serine proteinase)
MPA - pANCA (myeloperoxidase)
If suspected => MDT approach
Definitive management - immunosuppression
What is Anti GBM/Goodpasture disease
- ABs are associated with Anti GBM
- investigations
- clinical presentation
- management
AB glomerular and alveolar BM => AKI, nephritis, pulmonary hemorrhage
OFTEN TRIGGERED BY ILLNESS
Renal biopsy - IgG deposits on BM
antiGBM AB
Management
-Plasmapheresis + CS + cyclophosphamide
What blood tests might you do in suspected glomerular disease
Blood cultures, virology
U&E, LFT, bone profile
CRP
RF (AB against Fc of IgG), ANCA, AntiGBM, ANA, dsDNA
C3, C4
Myeloma screen
ANCA associated vasculitis
- types
- common findings
- investigations
- diagnosis and management
Granulomatosis with polyangiitis
Eosinophilic granulomatosis with polyangitis
Microscopic polyangiitis
Renal impairment
-immune complex glomerulonephritis => high creatinine, haematuria, proteinuria
Resp involvement
-SOB, haemoptysis, sinusitis
Systemic upset
Vasculitic rash
Urinalysis - hematuria, proteinuria
U&E - renal impairment
FBC - normocytic anemia, thrombocytosis
High CRP
CXR - nodular, fibrotic, infiltrative lesions
Diagnosis aided by lung and kidney biopsies
-refer to specialist teams
Acute pyelonephritis
-causative organism
-pathophysiology
-investigations
Ecoli - most commonly from lower UT, but can come from bloodstream
Fever, rigors
Loin pain
N/V
LUTI signs
MSU before ABx
Hospital admission
Broad spec ABx - cephalosporin/quinolone 7-10days
Granulomatosis with polyangiitis
-key features
-investigations
-management
URT - nosebleeds, sinusitis, nasal crusting, saddle nose
LRT - SOB, hemoptysis
Renal - crescenteric changes
Vasculitis
cANCA
Renal biopsy - epithelial crescents in Bowmans
CS
Cyclophosphamide
Plasma exchange
Eosinophilic granulomatosis with polyangiitis
-key features
-investigations
-management
URT - sinusitis
LRT - Asthma, eosinophilic features
pANCA
Steroids
Cyclophosphamide
Plasmapheresis
