Nephrology and genitourinary Flashcards by Csaba Sali

Aetiology of acute nephritis

Caused by increased glomerular cellularity, restricting glomerular blood flow and therefore leads to decreased filtration

Post-infectious - eg. streptococcus

Vasculitis:
HSP
SLE
Wegener Granulomatosis
Microscopic Polyarteritis

IgA nephropathy
Goodpasture syndrome (rare..)

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Clinical features of acute nephritis

Oliguria
Hypertension - may lead to seizure
Oedema - characteristacally around eyes

Haematuria and proteinuria

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Management of acute nephritis

Monitor water and electrolyte balance.

Administer diuretics if necessary

If there is rapidly progressive glomerulonephritis (rare, but can occur with any acute nephritis, except post-streptococcal) which can cause irreversible renal failrure over weeks or months
-may need renal biopsy and treatment with immunosuppression and plasma exchange

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Prognosis of acute nephritis

0.5% mortality

5% long-term abnormalities

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Features of Henoch-Schönlein Purpura

HSP

Rash - purpura -
buttocks, extensor surfaces of legs, arms and ankles
Arthralgia (knees and ankles)
Periarticular oedema (joint swelling - knees and ankles)

Abdo pain - haematemesis and melaena
Glomerulonephritis - microscopic/macroscopic haematuria (80%)

Often there is fever

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in which age group does HSP occur

3-10yrs

2x as common in boys

Often preceded by an URTI

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Long term complications of HSP and follow up

With severe proteinuria, there may be nephrotic syndrome.

All children with renal involvement will be followed up for a year to detec those with persisting urinary abnormalities (5-10%).
HTN and declining renal function may develop after an interval of several years

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Risk factors for progressive renal disease in HSP

Renal biopsy will determine whether treatment is necessary, but:

Heavy proteinuria
Oedema
HTN
Deteriorating renal function

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Management plan for HSP. Prognosis

Same as acute nephritis.

Long-term follow up for severe renal involvement

<1% of HSP patients will progress to end-stage renal failure, but prognosis is worse in older children

Follow up in 6 months if normal urinalysis

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What are the commonest causes of acute glomerulonephritis in childhood?

Post-streptococcal/infection nephritis
Familial nephritis
Vasculitis
SLE

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What is post-streptococcal nephritis

usually follows a streptococcal sore throat or skin infection

Diagnosed by evidence of recent streptococcal infection (culture, raised ASO/anti-DNAse B titres)
Low C3 complement

Good longterm prognosis

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What is Familial nephritis

Commones is Alport syndrome - X-linked recessive

Progresses to end-stage renal failure by early adult life in males

Nerve deafness
Ocular defects

Mother may have haematuria

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Characteristic symptoms of vasculitis

(HSP, polyarteritis nodosa, microscopic polyarteritis, Wegener granulomatosis)

Fever
Malaise
Rash
Weight loss
Arthropathy

Renal involvement may be severe and rapidly progressing

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Treatment of vasculitis

steroids
plasma exchange
IV cyclophosphamide (for months)

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Epidemiology of SLE

Mainly presents in adolescent girls and young women

Commoner in Asians and Afro-caribbeans

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What is SLE

Presence of multiple autoantibodies
Antibodies to double-stranded DNA (C3 and C4 may be low)

Haematuria and Proteinuria are indicators for renal biopsy (determines intensity of immunosuppression)

Investigations in patients presenting with acute glomerulonephritis

Electrolytes and creatinine (renal function)

FBC - infection, anaemia

Urinalysis (infection, protein, blood)

Urine culture

Complement levels

ASO titre

Anti-DNAse B

Serum IgA measurement

Renal biopsy is the single most effective diagnosis

Renal ultrasonography usually performed to exclude other causes

What is enough to diagnose post-streptococcal glomerulonephritis without the need for renal biopsy

Fitting history
Low C3
Postive ASO
Anti-DNAse B

What histopathology does IgA nephropathy share with HSP?

Episodes of macroscopic haematuria

commonly associated with URTI

Same histological findings and management

Aetiology of nephrotic syndrome

Can be secondary to systemic disease:

HSP
vasculitides
SLE
Infections (malaria)
Allergens (eg. bee sting)

Clinical signs of nephrotic syndrome

Periorbital oedema
Particularly on waking
Scrotal or vulcal, leg, ankle oedema
Ascites

Breathlessness - due to pleural effusions and abdominal distension
Cloudy/frothy urine

Define nephrotic syndrome

Proteinuria > 200mg protein/mmol creatinine

Serum albumin (hypoalbuminaemia) <2.5g/dl
Oedema that begins in the face
Hyperlipidaemia

Name the commonest types of nephrotic syndrome in childhood

Steroid sensitive nephrotic syndrome

Steroid resistant nephrotic syndrome

Congenital nephrotic syndrome

Incidence of nephrotic syndrome

1 in 50000 per year

Median age of onset is 2.5 yrs

boys > girls

How much of nephrotic syndrome is responsive to steroid therapy?

85-90% It is the commonest type These children do NOT progress to renal failure

What may precipitate steroid-sensitive nephrotic syndrome

URTI associated with atopy

Features that suggest steroid-sensitive nephrotic syndrome

``` Age 1-10 years NO macroscopic haematuria Normal blood pressure Normal complement levels Normal renal function ```

Complications of nephrotic syndrome

Hypovolaemia Thrombosis (due to urinary loss of antithrombin and raised haematocrit) Infection (especially pneumococcus) Hypercholesterolaemia

Indicators for hypovolaemia in nephrotic shock

Abdo pain Feel faint Peripheral vasoconstriction Low urinary sodium (due to retention) High packed cell volume of RBCs Requires urgent treatment with IV albumin to prevent vascular thrombosis and shock

Management of steroid-sensitive nephrotic syndrome

Oral corticosteroids (60mg/m2 per day of prednisolone) If no atypical features, reduce the dose the dose after 4 weeks. This should happen over 4 weeks. Median time for urine free of protein is 11 days

Prognosis of steroid sensitive nephrotic syndrome

1/3 resolve directly 1/3 will relapse infrequently 1/3 will relapse to steroid-dependent Relapse identified by parent on urine testing

What are causes of steroid-resistant nephrotic syndrome

Focal segmental glomerulosclerosis (most common) Mesangiocapillary glomerulonephritis (haematuria and low complement level) Membranous nephropathy (associated with Hep B)

Management of oedema in nephrotic syndrome

Diuretic therapy Salt restriction ACE inhibitors NSAIDs may reduce proteinuria

What is congenital nephrotic syndrome

Presents in first 3 months of life High mortality due to hypoalbuminaemia - unilateral nephrectomy may be needed, followed by dialysis for renal failure (until fit enough for transplant)

Initial management of nephrotic syndrome

Fluid management: (difficult because there is fluid overload with possible hypovolaemic shock) Fluid restriction Diuretics Albumin infusions Treat underlying disease with Prednisolone and other immunosuppressants ``` Management of complications: Infections Thrombosis Side effects of treatment Renal failure ```

What are the atypical features of nephrotic syndrome

No response to 4-8 weeks of corticosteroid therapy ``` Age <12 months or >12 years HTN Haematuria Low C3 complement Renal failure ```

What should be done in atypical presentation of renal failure

Renal biopsy | -renal histology