Nephritic and nephrotic syndrome

Question 1

Glomerulonephritis

Answer 1

Group of disorders resulting from glomerular damage

Can cause proteinuria ± haematuria

Can cause AKI or ESRF

Question 2

Presentation of glomerulnephritis

Answer 2

Asymptomatic haematuria
Nephrotic syndrome
Nephritic syndrome

Question 3

Ix

Answer 3

Blood:

• FBC, U+E, CRP
• Abs: ANA, dsDNA, ANCA, GBM

Urine:
Dipstick: proteinuria ± haematuria
Spot PCR
MCS

Imaging:

• CXR: infiltrates
• Renal US ± biopsy

Question 4

Nephritic syndrome

Answer 4

Triad:

• Haematuria
• HTN
• Oliguria

Other:
- Proteinuria → oedema

Question 5

Causes of nephritic syndrome

Answer 5

Anti-GBM (Goodpasture’s)
Alport’s syndrome
ANCA vasculitis
IgA nephropathy

Question 6

Anti-GBM disease

Answer 6

Anti GBM antibody - against type IV collagen
Associated with pulmonary haemorrhage
More common in males

Ix - renal biopsy - IgG deposits
- pulmonary infiltrates on CXR

Mx: Plasmapheresis and immunosuppression with cyclophosphamide and steroids

Question 7

Alport’s syndrome

Answer 7

X linked autosomal recessive
Ab against collagen V
Associated with sensorineural deafness and abnormalities of the eye (lens)
Often leads to end stage renal failure

Ix - biopsy - splitting of GBM and alternating thickening and thinning
FHx

Mx - supportive and immunosuppression

Question 8

ANCA vasculitis

Answer 8

Activated neutrophils attack small vessels including glomerulus - crescent segmental necrosis of glomerulus

Question 9

IgA nephropathy (Berger’s disease)

Answer 9

Most common cause of glomerulonephritis - immune complexes formed with galactose deficient IgA deposits in mesangial cells

• Commonly occurs after URTI of GI infection
• more common in 20 - 30 yr old men

Ix - biopsy - Mesangial immune complex deposits

Mx - supportive

Question 10

Nephrotic syndrome

Answer 10

Triad:
Proteinuria - > 3g/24 hrs
Hypoalbuminaemia
Oedema

Question 11

Causes of nephrotic disease

Answer 11

Focal segmental glomerulosclerosis

Membranous glomerulonephritis

Minimal change glomerulonephritis - commonly in children

Diabetic nephropathy

SLE

Question 12

Focal segmental glomerulosclerosis

Answer 12

Adults - unknown circulating factor damages podocytes causing scarring and decreased GFR

• Commoner in Afro - Carribeans
• Biopsy: focal scarring, IgM deposition, hyalinosis, foot processes effacement

Mx: steroids or cyclophosphamide/ciclosporin

Question 13

Membranous glomerulonephritis

Answer 13

IgG against podocytes forming immune complexes and deposited in GBM - immune deposits and spikes

Mx: immunosuppression

Question 14

Minimal change glomerulonephritis

Answer 14

Children - unknown circulating factor that causes acute podocyte damage

• associated with URTI
• biopsy - fusion of podocytes on electromicroscopy but normal on light microscopy

Mx: steroids

Question 15

Mx of nephrotic syndrome

Answer 15

MDT

• Monitor U+E, BP, fluid balance, wt.
• Treat underlying cause

Complication Mx:
• Oedema: salt and fluid restrict + furosemide
• Proteinuria: ACEi / ARB
• ↑ Lipids: Statin
• VTE: Tinzaparin - LMWH
• HTN control 
• DM control

Question 16

Diabetic nephropathy

Answer 16

1. Hyperinfiltration and capillary HTN
   - glycation of preoteins in glomerulus causes arteriosclerosis
2. GBM thickening
3. Mesangial expansion
4. Podocyte injury
5. Glomeruler sclerosis

Question 17

Diabetic nephropathy biopsy

Answer 17

Kimmel Wilson nodules

Question 18

Complications of nephrotic syndrome

Answer 18

Higher risk of Infection
Venous thromboembolism
Progression of CKD
Hypertension
Hyperlipidaemia

Question 19

Post-infectious GN

Answer 19

Post-streptococcal GN - Weeks after Group A beta haemolytic streptococci infection e.g. tonsillitis/cellulitis or impetigo

Affects children 3 - 12 y0

Mx: Usually self-limiting

• can give ACEi for proteinuria and HTN
• low sodium diet

Question 20

Complications of nephrotic syndrome

Answer 20

Higher risk of infection - excretion of immunoglobulins 
VTE - excretion of antithrombin III
Progression to CKD 
HTN 
hyperlipidaemia

Question 21

Post streptococcal glomerulonephritis investigation findings

Answer 21

Positive anti streptococcal antibody titres
Low serum C3

Biopsy - immune complexes

Question 22

ANCA vasculitis

Answer 22

Pulmonary and nasopharyngeal involvement - haemoptysis

Ix - cANCA or p-ANCA

Mx - immunosuppression

Question 23

Thin basement membrane disease

Answer 23

Hereditary - dominant
Persistent microscopic haematuria may be visible

Ix - biopsy - thinning of GBM

Mx - monitor renal function and supportive treatment

Question 24

Mx of glomerulonephritis

Answer 24

Discuss with renal team
MDT
ACEi/ARB - proteinuria
Control BP
Salt and water restriction if they are volume overloaded
Diuretics of fluid overloaded
If hypoalbuminaemia - consider LMWH prophylaxis

Question 25

Immunosuppression therapy

Answer 25

Oral corticosteroids 
Cyclophosphamide 
Tacrolimus 
Ciclosporin 
Rituximab