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Kidneys Flashcards

1
Q

What is the pathophysiology of Alport’s Syndrome?

A

It is an X-linked genetic disease and therefore seen in males

There is a defect in the ALPHA CHAIN of TYPE 4 COLLAGEN

This collagen is present in 2 main regions- The Glomerular Basement Membrane and the Eyes and Ears (Cochlea, Retina and Cornea)

So there would be haematuria, proteinuria AND hearing/ visual loss or defects

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2
Q

What are the 5 signs of Nephritic Syndrome seen in Alport’s Syndrome?

What are the visual, auditory and behavioural symptoms also seen in Alport’s Syndrome

A

Proteinuria

Microscopic or gross haematuria

Hypertension

A PERIPHERAL oedema

Fatigue and Dyspnoea

Opthalmological- Cataracts, Corneal Dystrophy, Lenticonus (the lens protrude into the anterior chamber)

Auditory- Sensorineural Hearing Loss

Behavioural- Learning disability

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3
Q

What 5 investigations should be conducted if Alport’s Syndrome is suspected?

A

Assess for Sensorineural Hearing Loss

Urinalysis- check for Proteinuria and Haematuria

U&Es- Check for signs of Renal Failure- High Creatinine and Low eGFR

Renal Ultrasound to exclude structural abnormalities

Renal Biopsy- when viewed under Electron Microscopy, you’d see the Longitudinal Splitting of the Lamina Densa with short stubs of Fibrils- forming a BASKET WEAVE APPEARANCE

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4
Q

What is the 2 step management plan for Alport’s Syndrome?

Why may transplantation fail?

A

ACE inhibitor- used as a Renoprotective drug if Haematuria or Proteinuria is present

Renal Replacement Therapy- Dialysis and Transplantation may be needed in an advanced disease

But- after transplantation, transplant failure may occur due to the presence of Anti-GBM Antibodies- which results in a clinical picture similar to Goodpasture’s Syndrome

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5
Q

What determines whether a patient has Chronic Kidney Disease?

A

If there are abnormalities in either the kidney structure or function occuring for more than 3 months

Or any marker of kidney injury, or a GFR<60 measured on 3 different occasions- separated by at least 90 days

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6
Q

What are the 2 most common causes of Chronic Kidney Disease?

A

Diabetes and Hypertension

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7
Q

Chronic Kidney Disease can result in Glomerular Scarring- what are the 3 things this can typically result in?

A

Metabolic derangement- due to HYPERKALAEMIA and URAEMIA

Anaemia- due to the reduced ERYTHROPOEITIN

CKD Mineral Bone Disease

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8
Q

Why is Chronic Kidney Disease a risk factor for Cardiovascular Health?

A

It results in Hypertension, Hypercholesterolaemia and Heart Failure

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9
Q

What are the 7 risk factors for Chronic Kidney Disease?

A

Age>50

Afro-Caribbean

Diabetes

Hypertension

Glomerular Nephritis

Nephrotoxic Drugs (such as NSAIDs)

Enlarged PROSTATE

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10
Q

What are the 8 signs of Chronic Kidney Disease?

A

Lethargy

Pruritus

Frothy Urine

Swollen Ankles (Peripheral Oedema)

Fluid Overload

Hypertension

Anorexia

Uraemic Sallow (yellow or pale brown skin colour)

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11
Q

What 7 investigations are to be considered in Chronic Kidney Disease?

A

Urine Dip for Proteinuria and Haematuria

Work out the Urine Albumin:Creatine Ratio (a ratio that is 3 or above suggests Proteinuria)

FBC- Normocytic Normochromic Anaemia- due to the reduced Erythropoeitin

Bone Profile and PTH- The patient is at risk of (3)- Hypocalcaemia, Hyperphosphataemia and Secondary or Tertiary Hyperparathyroidism

Renal Ultrasound- Bilateral Kidney Atrophy can be seen

CT scan if an obstructive cause is suspected

Renal biopsy if an intrarenal cause is suspected- such as Nephritic or Nephrotic Syndrome

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12
Q

What is the 6 step management plan for Chronic Kidney Disease

A

Stop SMOKING

Avoid Nephrotoxic Drugs (such as NSAIDs)

Have a low salt/ potassium diet with FLUID RESTRICTION

Manage the Cardiovascular Risk Factors (2)

  • Hypertension- Give an ACE Inhibitor (first line) if the AC Ratio is raised (a sign of proteinuria). But stop if Creatinine rises higher than 30% or if the eGFR falls more than 25%. If AC ratio is not raised- then normal Hypertension management
  • Hypercholesterolaemia- Give a Statin- Like Atorvastatin

Anaemia- target 10-12 Hb

  • Iron Replacement
  • Then Erythropoeisis Stimulating Agents (such as Erythropoeitin or Darbepoetin)

Renal Replacement Therapy (if eGFR<10 or if there are signs of Uraemia)
- Dialysis then Renal Transplant

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13
Q

What are the 7 Complcations of Chronic Kidney Disease?

A

Heart Failure- due to the Fluid Overload and the Anaemia

Chronic Kidney Disease- Mineral Bone Disease

Secondary and Tertiary Hyperparathyroidism

Anaemia- Normocytic Normochromic

Hyperkalaemia

Uraemia

Metabolic ACIDOSIS

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14
Q

What is CKD mineral bone disease?

A

A bone disease which occurs in patients with Chronic Kidney Disease

It is characterised by the widespread bone pain

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15
Q

What 3 metabolic changes does CKD Mineral Bone Disease result in?

A

Reduced 1-Alpha Hydroxylase activity leads to REDUCED VITAMIN D ACTIVATION

Reduced renal excretion of Phosphate results in HYPERPHOSPHATAEMIA. This stimulates bone resorption and leads to OSTEOMALACIA

HYPOCALCAEMIA

The Low Calcium, High Phosphate and Low Vitamin D leads to Secondary Hyperparathyroidism

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16
Q

What 5 bone conditions can CKD Mineral Bone Disease manifest as?

A

Osteoporosis

Osteosclerosis

Osteomalacia (due to the low VITAMIN D)

Osteitis Fibrosa Cystica- The Hyperparathyroid Bone Disease

Adynamic Bone Disease- due to the reduction in Osteoblast and Osteoclast activity

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17
Q

What are the 4 metabolic changes seen in the bloods of Secondary Hyperparathyroidism

A

LOW or NORMAL CALCIUM
HIGH or NORMAL PHOSPHATE
LOW VITAMIN D

HIGH PTH

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18
Q

What are the 4 signs of CKD Mineral Bone Disease?

A

Asymptomatic in early stages

Bone and Joint Pain

Bone Fractures and Deformation

Reduced Mobility

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19
Q

What are the 5 investigations to be ordered if Chronic Kidney Disease Mineral Bone Disease is suspected (if eGFR is less than 30 in a patient with bone pain)?

A

Hypocalcaemia

Hyperphosphataemia

Low Vitamin D

Secondary or Tertiary Hyperparathyroidism

Measure their eGFR

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20
Q

What is the aim and 5 step management plan for CKD Mineral Bone Disease?

A

The Aim is to reduce the levels of SERUM PHOSPHATE and PTH

First line- Reduce DIETARY PHOSPHATE- reduce MEAT and FISH and NUTS/ BEANS and DAIRY PRODUCTS

Vitamin D Replacement- as the 1-Alpha Hydroxylase Enzyme is still functioning. Give CHOLECALCIFEROL. In Later Stages, give ALFACALCIDOL or CALCITROL

Give Phosphate-Binders to tackle the high phosphate levels.

  • Calcium-based phosphate binders can be used (CALCIUM ACETATE is first line) but can result in VASCULAR CALCIFICATION and HYPERCALCAEMIA.
  • Non-calcium-based phosphate binders can be used if the calcium-based binders are ineffective- such as SEVELAMER, LANTHANUM and ALUMINIUM (Sevelamer also tackles HYPERCHOLESTEROLAEMIA)

Bisphosphonates given to Prevent and Treat Osteoporosis if eGFR<30

Parathyroidectomy in Tertiary Hyperparathyroidism

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21
Q

What us the pathophysiology of IgA Nephropathy

A

It is the deposition of IgA immune complexes in the MESANGIUM of the GLOMERULUS- which results in nephritic syndrome and end-stage kidney failure

Deposition in the MESANGIUM results in MESANGIUM PROLIFERATIVE GLOMERULONEPHRITIS due to TYPE 3 HYPERSENSITIVITY

This activates the ALTERNATIVE COMPLEMENT PATHWAY- C3 is converted to C3a and C3b which triggers glomerular injury

(This has a significant overlap with Henoch-Schonlein Purpura)

This typically happens after an infection of the mucosal lining- such as a URTI or Gastroenteritis

22
Q

What are the 2 main risk factors for IgA Nephropathy?

A

Having a URTI or Gastroenteritis

23
Q

What are the 7 signs of IgA Nephropathy

A

Very similar to Post-streptococcal Glomerulonephritis

  • Haematuria- macroscopic in younger patients and microscopic in older patients
  • Foamy urine- proteinuria
  • Pink, red, coke urine- haematuria
  • Sore Throat- Sign of URTI
  • Loose stools and abdominal pain- Gastroenteritis
  • OEDEMA due to PROTEINURIA
  • Cervical Lymphadenopathy suggests URTI
24
Q

What 4 investigations should be ordered if IgA Nephropathy is suspected?

A

Proteinuria and Haematuria

U&Es- baseline renal function to be measured as well as the deterioration

C3 and C4- C4 levels will be normal (C4 is associated with the Classic Complement Pathway)- C3 may be normal or low

Renal biopsy- Mesangial Hypercellularity with positive immunofluorescence for IgA and C3

25
What are the 4 steps for IgA Nephropathy Management?
Statins ACE Inhibitor/ ARB- offer it immediately if Protein:Creatine ratio>100 Corticosteroids- if Proteinuria continues despite the ARB/ACE Inhibitor Omega 3 Fatty Acids- Offer with the Corticosteroids
26
What organism causes Post-streptococcal Glomerulonephritis?
Strep Pyogenes
27
What are the differences between IgA Nephropathy and Post-streptococcal Glomerulonephritis?
IgA Nephropathy occurs 1-2 days after URTI/ Gastroenteritis Post-streptococcal Glomerulonephritis occurs 1-2 weeks after URTI/ Pharyngitis/ Skin Infections IgA Nephropathy- C3 levels are normal or reduced Post-streptococcal Glomerulonephritis- C3 and CH50 levels are always reduced IgA Nephropathy- Mesangial IgA deposits on Renal Biopsy Post-streptococcal Glomerulonephritis- Positive Streptozyme test IgA Nephropathy- ACE Inhibitor/ ARB for treatment Post-streptococcal Glomerulonephritis- Furosemide for treatment
28
What is the pathophysiology of Lupus Nephritis? What is the most common form of Lupus Nephritis?
It occurs in patients with SLE and involves the deposition of antigen-antibody complexes in the kidney The most common form of Lupus Nephritis is Diffuse Proliferative Glomerulonephritis which presents with Nephritic Syndrome
29
What are the 6 main classes of Lupus Nephritis? And 2 facts about each
Class 1- Minimal Mesangial - Normal renal function. Mild or Incidental Class 2- Mesangial Proliferative - Microscopic HAEMATURIA (with or without PROTEINURIA) - Hypertension and Nephrotic Syndrome are rare here - Typically responds to Steroids Class 3- Focal Segmental - Usually Nephrotic Syndrome - Typically responds to high-dose Steroids Class 4- Diffuse Proliferative (Most Common) - Nephritic Syndrome - Treated with Steroids and IMMUNOSUPPRESSANTS Class 5- Diffuse Membranous - Nephrotic Syndrome- Extreme Oedema - May have hypertension Class 6- Sclerosing - Slowly progressing Renal Failure and Proteinuria
30
What are the 4 investigations to be ordered if Lupus Nephritis is suspected?
RENAL BIOPSY- GOLD STANDARD Check for signs of SLE Haematuria and Proteinuria in Urinalysis Reduced eGFR
31
What are the findings on Biopsy for Light Microscopy (5), Electron Microscopy (1) and Immunofluorescence (1) for Diffuse Proliferative Glomerulonephritis (most common form of Lupus Nephritis)?
Light Microscopy- - Hypercellular glomerulus - Thickened basement membrane - Endothelial and Mesangial Proliferation - Wire-loop appearance - Capillary wall thickening in SEVERE DISEASE Electron Microscopy- Subendothelial IMMUNE COMPLEX DEPOSITION Immunofluorescence- Granular Appearance
32
What is the 5 step management for Lupus Nephritis?
Corticosteroids Immunosuppressive Agents - Cyclophosphamide - Azathioprine Hydroxychloroquine Renal Replacement Therapy if eGFR continues to deteriorate (Dialysis or Transplant) ACE Inhibitor preferred in patients with Hypertension and Renal Disease
33
What is the pathophysiology of Membranoproliferative Glomerulonephritis?
It involves Mesangial Cell proliferation and Thickening of Glomerular Capillaries
34
What are the 3 types of Membranoproliferative Glomerulonephritis? What 5 conditions is Type 1 associated with?
Type 1 (Most Common)- Associated with (5)- - SLE - Hepatitis B and C - Chronic Lymphocytic Leukaemia - Lymphoma - Cryoglobulinaemia Type 2 (Dense Deposit Disease) - Activation of the Alternative Complement Pasthwya and therefore LOW levels of C3 - Associated with (2)- Factor H Deficiency and Partial Lipodystrophy Type 3- - Subendothelial and subepithelial deposits - Associated with (2)- Hepatitis B and C - ALL of them have LOW C3 levels (HYPOCOMPLEMENTAEMIA) and Mesangial Cell Proliferation
35
What are the 3 main risk factors for Membranoproliferative Glomerulonephritis?
Infections- HIV/ Hepatitis B and C/ Endocarditis Chronic Lymphocytic Leukaemia/ Cryoglobulinaemia Acquired Partial Lipodystrophy- loss of Fat- Associated with Type 2 Membranoproliferative Glomerulonephritis
36
What are the 4 signs of Membranoproliferative Glomerulonephritis?
Foamy Urine (Proteinuria) Pink, Red or Coke tinged urine (Haematuria) Oedema (due to Hypogammaglobuminaemia) Oliguria (<0.5)
37
What 4 things are observed in Renal Biopsy for Membranoproliferative Glomerulonephritis?
PAS Staining on Light Microscopy shows Mesangial Cell Proliferation and Capillary Thickening Type 1- Subendothelial and mesangial immune deposits result in Tram Track Appearance Type 2- Intramembranous immune complex deposits with Dense Deposits Immunofluorescence reveals C3 deposition
38
What 4 investigations are conducted in Membranoproliferative Glomerulonephritis?
Most children with Nephrotic Syndrome have Minimal Change Disease which would not show up on Renal Biopsy- so treat them with the treatment for MCD which is CORTICOSTEROIDS before the renal biopsy - Haematuria and Proteinuria - Type 1- Low C3 and C4 is Low or Normal - Type 2- Low C3 and C4 is Normal - Renal Biopsy is the definitive diagnosis
39
What is the 2 step approach to treating Primary Membranoproliferative Glomerulonephritis and 3 steps for treating Membranoproliferative Glomerulonephritis in general?
Primary Membranoproliferative Glomerulonephritis- - Oral Cyclophosphamide - Oral Mycophenolate Mofentil and Oral Corticosteroids General- - ACE Inhibitor/ ARB offered to all patients with Proteinuria generally - Statins are offered to all patients with Nephrotic Syndrome after they are evaluated for having Dyslipidaemia - Oral Warfarin- check their Serum Albumin. Patients with low Serum Albumin are at a higher risk of thrombosis
40
What are the three main symptoms of Nephritic Syndrome and Nephrotic Syndrome?
Nephritic- - Haematuria (mainly) - Hypertension - Oedema Nephrotic- - Proteinuria (mainly)>3.5 - Hypoalbuminaemia<30 - Oedema (may not always have hypertension)
41
What are the 4 main causes of Nephritic Syndrome?
Post-streptococcal Glomerulonephritis Alport's Syndrome IgA Nephropathy Rapidly-Progressive Glomerulonephritis
42
What are the 5 main causes of Nephrotic Syndrome?
Minimal Change Disease Membranous Glomerulonephritis Focal Segmental Glomerulosclerosis Amyloidosis Diabetic Nephropathy
43
What 2 conditions cause both Nephrotic or Nephritic Syndrome?
Diffuse Proliferative Glomerulonephritis Membranoproliferative Glomerulonephritis
44
What are the 5 main investigations that show signs of Nephrotic Syndrome?
Proteinuria >3.5 Hypoalbuminaemia<30- which causes an OEDEMA Hyperlipidaemia- liver increases synthesis of lipids in response to Low Albumin Hypogammaglobuminaemia- due to loss of Immunoglobulins in the urine Hypercoagulability- due to loss of Antithrombin 3, Protein C and S
45
What are the Light Microscopy Findings for Minimal Change Disease, Focal Segmental Glomerulosclerosis, Membranous Nephropathy, Diabetes and Amyloidosis?
Minimal Change Disease- Normal glomeruli Focal Segmental Glomerulosclerosis- Focal and Segmental Glomerulosclerosis Membranous Nephropathy- Thick Glomerular Basement Membrane Diabetes- Mesangial Sclerosis and Kimmelstiel-Wilson Nodules Amyloidosis- Apple-green Birefringence under Polarised Microscopy with Congo Red Stain
46
What are the Electron Microscopy Findings for Minimal Change Disease, Focal Segmental Glomerulosclerosis, Membranous Nephropathy and Membranoproliferative Glomerulonephritis?
Minimal Change Disease- Effacement of Foot Processes Focal Segmental Glomerulosclerosis- Effacement of Foot Processes Membranous Nephropathy- Subepithelial Immune Complex Deposition Membranoproliferative Glomerulonephritis- - Type 1- Subendothelial Immune Complex Deposition - Type 2- Intramembranous Immune Complex Deposition
47
What is the most common cause of Nephrotic Syndrome in children, adults and the elderly respectively? And what diseases are they associated with (1, 4, 4) ?
Minimal Change Disease in children - Hodgkin's Lymphoma Focal Segmental Glomerulosclerosis in adults - HIV - Heroin - SLE - Sickle Cell Anaemia Membranous Nephropathy in elderly - Malignancy - Hepatitis B - NSAIDs - SLE
48
What are the three types of Rapid Progressive Glomerulonephritis caused by?
Type 1- Autoantibodies (Anti-GBM antibodies) Type 2- Immune Complexes - Such as from (3)- SLE, IgA Nephropathy, Henoch Schonlein Purpura Type 3- ANCA-associated Vasculitides
49
What is the presentation for Rapid Progressive Glomerulonephritis?
Nephritic Syndrome (Haematuria with Red Cell Casts, Proteinuria, Hypertension and Oliguria)
50
What features of the underlying cause of Rapid Progressive Glomerulonephritis should be looked out for? (2)
Anti-GBM disease- Goodpasture's - Associated with Haemoptysis Granulomatosis with Polyangiitis (Wegener's) presents with a Vasculitis Rash or Sinusitis
51
How do you treat Rapid Progressive Glomerulonephritis?
Steroids and Cyclophosphamides

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