Nephritic vs Nephrotic

Question 1

Signs of nephritic syndrome

Answer 1

Haematuria (macro / micro) + red cell casts
Proteinuria → oedema (esp. periorbital) Hypertension
Oliguria and progressive renal impairment

Question 2

Causes of nephritic syndrome

Answer 2

1. Proliferative / post-streptococcal

2. Crescentic / RPGN

Question 3

Features of proliferative/ post-strept

Answer 3

Features
Young child develops malaise and nephritic syndrome c ̄ smoky urine 1-2wks after sore throat or skin infection.
↑ASOT ↓C3

Question 4

Biopsy results of proliferative/ post-strept

Answer 4

Biopsy: IgG and C3 deposition

Question 5

Treatment and prognosis of nephritic syndrome

Answer 5

Rx: Supportive
Prognosis:
95% of children recover fully
Minority develop Rapidly Progressive GN

Question 6

Crescentic / RPGN features

Answer 6

Most aggressive GN which can → ESRF in days

Question 7

Type 1 Crescentic / RPGN

Answer 7

Ab to NC domain of collagen 4
Haematuria and haemoptysis
CXR shows infiltrates
Rx: Plasmapheresis and immunosuppression

Question 8

Type 2 Crescentic / RPGN

Answer 8

Complication of any immune complex deposition Berger’s, post-strep, endocarditis, SLE

Question 9

Type 3 Crescentic / RPGN

Answer 9

cANCA: Wegener’s
pANCA: microscopic polyangiitis, Churg-Strauss Even if ANCA+ve, may still be idiopathic
i.e. no features of systemic vasculitis

Question 10

Percentage prevalence of Type 1,2,3

Answer 10

1 = 5%
2 = 45%
3 = 50%

Question 11

Nephrotic Syndrome features

Answer 11

Proteinuria: PCR >300mg/mM or >3g/24h
Hypoalbuminaemia: <35g/L
Oedema: periorbital, genital, ascites, peripheral
Often intravascularly depleted ̄c ↓ JVP (cf. CCF)

Question 12

Complications of Nephrotic Syndrome

Answer 12

Infection: ↓ Ig, ↓ complement activity
VTE: up to 40%
Hyperlipidaemia: ↑ cholesterol and triglycerides

Question 13

Investigations for nephrotic syndrome

Answer 13

Blood
  Basic: FBC, U+E, ESR
  Complement (C3 and C4)
  Abs: ANA, dsDNA, ANCA, GBM
  Serum protein electrophoresis and Ig
  Infection: ASOT, HBC and HCV serology
Urine
  Dipstick: proteinuria ± haematuria
  Spot PCR
  MCS
  Bence-Jones protein
Imaging
  CXR: infiltrates (Goodpasture’s, Wegener’s)
  Renal US ± biopsy
Check lipids
Biopsy
  All adults st
  Steroids 1  ̄c children: mostly minimal change

Question 14

Secondary causes of nephrotic syndrome

Answer 14

DM: glomerulosclerosis
SLE: membranous
Amyloidosis

Question 15

Minimal Change Glomerulonephritis - ass, biopsy, treatment, prognosis

Answer 15

Commonest cause of nephrotic syndrome in children
Assoc.: URTI
Biopsy: normal light micro, fusion of podocytes on EM
Rx: steroids
Prog: 1% → ESRF

Question 16

Membranous Nephropathy - ass, biopsy, treatment, prognosis

Answer 16

20-30% of adult nephrotic syndrome
  Associations
  Ca: lung, colon, breast
  AI: SLE, thyroid disease
  Infections: HBV
  Drugs: Penicillamine, gold
  Biopsy: subepithelial immune complex deposits
  Rx: immunosuppression if renal function declines
  Prog: 40% spontaneous remission

Question 17

FSGS - ass, biopsy, treatment, prognosis

Answer 17

Commoner in Afro-Caribs
Idiopathic or Secondary: VUR, Berger’s, SCD, HIV
Biopsy: focal scarring, IgM deposition
Rx: steroids or cyclophosphamide/ciclosporin
Prog: 30-50% → ESRF (may recur in transplants)

Question 18

Membranoproliferative/ mesangiocapillary GN - ass, prognosis

Answer 18

Rare
May → nephrotic (60%) or nephritic (30%) syndrome
Asooc. ̄c HBV, HCV, endocarditis
Prog: 50% → ESRF

Question 19

Membranoproliferative/ mesangiocapillary GN - management

Answer 19

Monitor U+E, BP , fluid balance, wt.
  Treat underlying cause
  Symptomatic / Complication Rx:
  Oedema: salt and fluid restrict + frusemide   Proteinuria: ACEi / ARA ↓ proteinuria
  ↑ Lipids: Statin
  VTE: Tinzaparin
  Rx HTN