Kidneys & Systemic Disease

Question 1

Heres some systemic disorders than can affect the kidneys [5]

Answer 1

DM
Vascular disease: Hypertension, HF, atheroemboli & atherosclerosis
Infections - Post infective GN, infective endocarditis, sepsis

Inflammatory - SLE, Wegener’s

Myeloma

Amyloidosis

Drug Treatments e.g. Aminoglycosides and ACE inhibitors, penicillamine or gold, NSAIDS or contrast

Question 2

Review the NKF DOQI staging of chronic kidney disease? [5]

Answer 2

National Kidney Foundation Dialysis Outcome Quality Initiative.
1 - Kidney damage but GFR >90
2 - Kidney damage, GFR 60-89
3 - Moderate impairement, GFR 30-59
4 - Severe Impairment - GFR 15-29
5 - Advanced impairment (probably on dialysis) - GFR <15

Question 3

What blood tests might suggest a systemic disorder? [4]

Answer 3

An elevated CRP
Thrombocytosis (platelets)
Anaemia
Raised ALKP

Question 4

How does diabetic nephropathy progess? [3]

Answer 4

1) Silent subclinical phase in which GFR may increase due to hyperfiltration
2) Microalbuminuria phase in which 20-200ug/d reaches the urine
3) Clinical Nephropathy phase in which proteinuria exceeds 0.5g/d & GFR starts to fall
4) Renal Failure where GFR is very low and proteinuria is very high or eventually falls off to 0 as the kidneys fail completely

Question 5

How does type of DM affect

Answer 5

Types 1 & 2 are equally at risk

DM is the commonest cause of ESRF

Question 6

How does infective endocarditis lead to kidney disease? [3]

Features [3]

Answer 6

1. Immune complex formation in response to endocarditis.
2. Complexes become trapped in the glomeruli
3. Glomerulonephritis +/- small vessel vasculitis

You may see:

• Abnormal U&Es
• Haematuria & Red cell casts (nephritic syndrome)
• Reduced complement

Question 7

How do we handle glomerulonephritis from infective endocarditis?

Answer 7

IF the underlying infection is treated the kidneys should recover

Question 8

What is myeloma?

Answer 8

A monoclonal proliferation of plasma cells –> Excess immunoglobulins & Light chains

Quite common in the elderly

Question 9

What features would make you think myeloma? [6]

Answer 9

Renal Disease along with:

• Markedly elevated ESR
• Anaemia
• Weight loss
• Fractures
• Infections
• Back pain/cord compression

Question 10

What test would confirm endocarditis?

Answer 10

Echocardiography

Question 11

Granulomatosis with polyangitis
AKA
Define

Answer 11

Granulomatosis with polyangiitis is now the preferred term for Wegener’s granulomatosis.
Def: an autoimmune condition associated with a necrotizing granulomatous vasculitis, affecting both the upper and lower respiratory tract as well as the kidneys.

Question 12

Granulomatosis with polyangitis

Features [6]

Answer 12

• upper respiratory tract: epistaxis, sinusitis, nasal crusting
• lower respiratory tract: dyspnoea, haemoptysis
  rapidly progressive glomerulonephritis (‘pauci-immune’, 80% of patients)
• saddle-shape nose deformity
• vasculitic rash
• eye involvement (e.g. proptosis)
• cranial nerve lesions

Question 13

Granulomatosis with polyangitis

Investigations [4]

Answer 13

cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
Renal biopsy: epithelial crescents in Bowman’s capsule

Question 14

Granulomatosis with polyangitis Mx [4]

Answer 14

steroids
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years

Question 15

Eosinophilic granulomatosis with polyangitis
AKA
Define
Features [4]

Answer 15

Eosinophilic granulomatosis with polyangiitis (EGPA) is now the preferred term for Churg-Strauss syndrome. It is an ANCA associated small-medium vessel vasculitis.

Features
asthma
blood eosinophilia (e.g. > 10%)
paranasal sinusitis
mononeuritis multiplex