Quiz 1 - Nephritic/Nephrotic Flashcards
3 major causes of Nephritic syndrome
Auto-immune (SLE, Wegener’s)
Post-infectious (strep PSGN)
IgA nephropathy (Berger’s)
DDX PHAROH
nephritic cirrhosis/liver failure severe HTN AIN RCHF DM Hemolytic-uremic syndrome
Glomerular bleeding characteristics
coca cola proteinuria HTN hx of URI fever, rash
Post-Infectious GN pathophys
HSN III
Ag-Ab complexes lodged in GBM podcytes leads to complement activation
Post-Infectious GN serology and light microscopy
Streptozymes (5)
Decreased complement
neutrophuils in glomerulus
Treatment of PSGN
1) Treat infection if present (penicillin, erythromycin) (tho won’t nec prevent PSGN)
2) Treat any edema or HTN (conventional: loop diuretics/ furosemide)
3) Limit (but adequate) protein and sodium
4) Bed rest
5) Botanicals– AI: Curcuma and boswelia; Antimicrobials: Echinacea
6) Anti–inflammatories: Quercitin, bromelain
7) Antioxidants; Vit C to bowel tolerance Vit E 800 IU
8) Constitutional hydrotherapy or wet sheet wrap
DDX/Variant of Post-Infectious GN
Rapidly Progressing Glomerulonephritis
can –> ARF
“crescentic GN” (Bowman’s capsule compressed)
Auto-Immune GN
Wegener’s
Churg-Strauss
Goodpasture’s
Berger’s dz/ IgA nephropathy etiology
?
assoc with Celiac, Hep B, alcoholic cirrhosis, sarcoidosis, HIV, SLE, RA, Sjogren’s
Berger’s dz/ IgA nephropathy sxs
PHAROH
Berger’s dz/ IgA nephropathy dz
kidnex bx= IgA
Berger’s dz/ IgA nephropathy Tx
monitor GF diet Artemesia (wormwood) fish oil S. boulardii Cordyceps Rheum palmatum
Nephritic Syndrome Tx
1) Avoid sodium, avoid high-potassium foods, low protein diet, low antigen diet (gluten, meat, dairy)
2) Immune amphoterics (Ganoderma, Grifola, Withania, Tinospora)
3) Diuretics may be needed for edema (use with caution)
4) Fish oil (4-12 g/d in divided doses) Donadio NEJM 1994 Nov 3;331(18) 1194-9
5) Treat HTN: goal BP is <125/75 mm Hg in presence of proteinuria >1g/d
Pharmacologic: ACEi
6) Probiotics: decrease uremic toxic production in gut
7) Remove other allergens (environmental, etc)
8) quit smoking, limit/no alcohol
9) maintain healthy weight
10) Conventional approach: corticosteroids, alkyating agents (cyclophosphamide),
calcineurin inhibitors, biologics: rituximab and ocrelizumab
Acute GN can progress to…
Chronic
Nephrotic Syndrome etiology
damage to podocytes–> lipid and protein wasting
Poorly controlled DM, IgA nephropathy and nephritic conditions,
SLE, amyloidosis, HIV, pre-eclampsia, drugs (penicillamine, NSAIDs, lithium, heroin, gold compounds), Snake bite, cancer (lymphomas and leukemias), FHx of congenital kidney dz (Alport dz, Fabry dz)
Nephrotic syndrome presentation
HTN, oliguria, edema, ascites, foamy urine, cough, DOE
> 3.5 g protein/d
Minimal change dz
90% kids
Focal segmental glomerulosclerosis
young adults, MC in AA
Secondary causes of nephrotic syndrome
SLE, diabetic nephropahty, amyloidosis, HIV, HBV, HCV, multiple myeloma
DDX Edema states
CHF liver failure Pyelo ATN multiple myeloma
Acute Interstitial Nephritis causes
Drug HSN (abx, NSAIDs), infections
Acute Interstitial Nephritis ssxs
Rash
fever, hematuria, oliguria, nausea, vomiting, malaise, flank pain, arthralgia
AIN labs
Eosinophiluria
FENa > 1%
WBCs, WBC casts
BX if persisting sx:
infiltration of inflammatory cells into interstitium, glomeruli usually spared (except SLE)
AIN Tx
discontinue case
Renafood
anti-inflammatories
‘roids
Acute Tubular Necrosis causes
aminoglycosides, amphotericin B, lithium, cisplatin, contrast dye, cisplatin
ATN imaging
Muddy brown casts
RTE and RTE casts with tubular fragments
ATN Tx
Silybum marianum, gingko biloba, Cordyceps, Urtica seed, CoQ10, selenium, Vit C
Obstructive Nephropathy causes
renal stone, prostate dz, carcinoma of cervix, colon, bladder
Obstructive Nephropathy labs
Azotemia and HTN
Hematuria or pyuria, but often benign UA
Obstructive Nephropathy labs
Azotemia and HTN
Hematuria or pyuria, but often benign UA
Analgesic nephropathy
Common overuse seen with chronic pain conditions (HA, myalgia, arthritis)
CT: small kidneys, papillary calcifications
Analgesic nephropathy Tx
1) Prevent renal scarring (irreversible!) if early stages: Treat the cause!
2) Tubular dysfunction may require K and Ph restriction, Na, Ca and bicarbonate supplementation
3) Chelation therapy for heavy metals
4) Natural analgesics, HP and physical medicines for chronic pain syndromes
5) Anti-inflammatories such as tumeric, boswellia, bromelain (eg, BCQ®)
6) Renal protectives: nettle seed, Salvia miltiorrhiza
7) Renal anti-oxidants: Ginseng, Coptis, Vaccinium, Quercetin, Vit C, Alpha Lipoic acid
8) Fish oil 8-12 g/d
Pre-Renal ARF causes
Hemorrhage, dehydration, trauma, peritonitis, sepsis, drugs, anaphylaxis, renal artery stenosis, CHF, PE
(decreased vol, changes in vasc R, low CO)
Pre-Renal ARF labs
BUN:creatinine >20:1
FENa <1%
Intrinsic ARF causes
Acute Tubular Necrosis
Acute Interstitial Nephritis
PSGN, RPGN
Acute pyelonephritis
Vascular diseases: vasculitis, polyarteritis nodosa, cortical necrosis/intravascular coagulation
Progressing nephrotic syndrome (multiple causes)
Intrinsic ARF labs
BUN:creatinine
<10:1
FENa >1%
Post-Renal ARF causes
urinary flow FROM both kidneys obstructed incr nephron intraluminal back pressure and dec GFR
stones, malignancy, medications
Post-Renal ARF tx
Rapidly treat the obstruction with catheterization or stent
Chronic Renal Failure Causes
Glomerulopathies (focal segmental, diabetic, sickle sell)
Tubulo-interstitial nephropathies (Drug HSN, toxicity, chronic PN)
Polycystic kidneys
Obstructive nephropathy (prostate dz, nephrolithiasis)
HTN nephrosclerosis, renal artery stenosis
CRF pathophys
Loss of functioning nephrons uremia, progressive inability to regulate fluids and electrolytes (HTN and edema), loss of vit D activation, loss of erythropoietin (chronic anemia)
CRF sxs
HTN, edema, osteodystrophy, anemia of chronic disease, uremia
CRF dx
GFR < 60 mL per min per 1.73 m2
CRF Tx
maintain Ca/P balance
limit Na and protein
tx HTN
Panax ginseng, Rheum off (Increases creatinine clearance),
Ginkgo
Urtica Seed tincture 1-2 ml TID (renal protective, dec prot loss)
