Renal - Glomerular and Tubular Diseases

Question 1

Where are the 2 sites of possible renal protein loss?

Answer 1

The glomerulus and proximal renal tubule

Question 2

What are the three layers of the glomerulus?

Answer 2

Capillary endothelium, glomerular basement membrane, and visceral epithelium (podocytes)

Question 3

What size molecules and cells does the glomerulus exlude?

Answer 3

proteins > 67 kDa from the ultrafiltrate

Question 4

What can unchecked proteinuria lead to?

Answer 4

Hypoalbuminemia, thromboembolism, and decreased nephron lifespan

Question 5

At what age of onset do dogs get proteinuria?

Answer 5

Middle/old age. If the patient is younger, consider a familial glomerular disorder

Question 6

Is proteinuria more common in dogs or cats?

Answer 6

dogs - it is rare in cats

Question 7

What clinical signs are associated with mild gomerular disease?

Answer 7

azotemia

Question 8

What clinical signs are associated with late proteinuria?

Answer 8

edema/effusion, thromboembolism, and organ damage

Question 9

What will you find on CBC in a patient with proteinuria?

Answer 9

You may have anemia

Question 10

What may you find on a chemistry in patients with proteinuria?

Answer 10

Hypoalbuminemia, +/- signs of decreased renal function (+/- azotemia, +/- hyperphosphatemia), and +/- metabolic acidosis

Question 11

Will USG be affected by proteinuria?

Answer 11

Unlikely - the concentration ability is often intact

Question 12

What may you find on urine sediment in a patient with proteinuria?

Answer 12

casts

Question 13

What is the most common fist step to diagnosing proteinuria?

Answer 13

Urine dipstick

Question 14

What is the most quantitative test for proteinuria?

Answer 14

UPC ratio - it will correlate with daily protein loss

Question 15

What is the approach to proteinuric patients?

Answer 15

Confirm if the proteinuria is persistent or transient. Once persistency is confirmed then screen for underlying disease. Finally do a renal biopsy

Question 16

What are the causes of transient proteinuria?

Answer 16

Fever, physical exertion, and seizure

Question 17

What criteria does there need to be for proteinuria to be considered persistent?

Answer 17

It needs to be confirmed in 3-4 instances over 2-3 weeks

Question 18

What screening tests can be done for underlying disease/cause of proteinuria?

Answer 18

PE (fundic exam!), CBC/Chem/UA, blood pressure, urine culture, imaging, vector-borne disease testing, and endocrine testing

Question 19

What is the purpose of a renal biopsy in proteinuric patients?

Answer 19

To allow for definitive histopathological diagnosis

Question 20

What are the indications for renal biopsies?

Answer 20

Lack of response to standard therapy, UPC >3.5, and if you are considdering immunosuppresion

Question 21

What are the contra-indications for renal biopsies?

Answer 21

Underlying disease identified/treated, uncontrolled hypertension, coagulopathy, and end-stage CKD (stage 4)

Question 22

What are the differentials for glomerular disease?

Answer 22

Membranoproliferative glomerulonephritis (MGPN), membranous nephropathy, proliferative glomerulonephritis, immunoglobulin A nephropathy, amyloidosis, glomerulosclerosis, other non-IC glomerulopathies, non-IC glomerulopathies, and tubular diseases

Question 23

What accounts for 50% of cases of canine glomerular disease?

Answer 23

ICGN - immune-complex glomerulonephritis

Question 24

What is ICGN more likely to respond to?

Answer 24

immunosuppression

Question 25

How is glomerular disease managed?

Answer 25

Monitoring and treatment of underlying disorder, reduction and proteinuria, management of decreased renal function and other consequences, +/- immunosuppression

Question 26

How can proteinuria be reduced nutritionally?

Answer 26

Decrease dietary protein (25-50%) and omega-3 fatty acid supplementation

Question 27

How can proteinuria be reduced pharmaceutically?

Answer 27

Modulation of RAAS pathway with ace inhibitors or angiotensin receptor blockers

Question 28

How is hypercoagulability managed in proteinuric patients?

Answer 28

The use of platelet inhibitors - Clopidogrel and Aspirin

Question 29

What drug is used to manage hypertesion in proteinuric patients?

Answer 29

Amlodipine

Question 30

Aside from hypercoagulability and hypertension, what other consequences of decreased renal function need to be managed?

Answer 30

Phosphorus intake, anemia, metabolic acidosis, and gastrointestinal manifestations

Question 31

When is immunosuppression indicated in proteinuric patients?

Answer 31

If there is a lack of response to standard therapy

Question 32

When should proteinuria be monitored?

Answer 32

1-2 weeks after a new therapy has been initiated or after initiating a new therapy

Question 33

Since UPC varies day-to-day, how often should samples be collected during monitoring?

Answer 33

Samples over 2-4 days

Question 34

What side effects are associated with ACEi and ARBs?

Answer 34

Excessive drop in blood pressure and GFR

Question 35

What is nephrotic syndrome?

Answer 35

A syndrome associated with 4 concurrent findings

Question 36

What are the 4 concurrent findings associated with nephrotic syndrome?

Answer 36

Proteinuria, hypoalbuminemia, hypercholesterolemia, and edema/effusion

Question 37

What is the prognosis of proteinuric patients?

Answer 37

It varies - some cases can have long survival with appropriate control of disease

Question 38

What conditions of proteinuria have a poorer prognosis?

Answer 38

Amyloidosis, Nephrotic syndrome, and concurrent azotemia

Question 39

Fanconi's syndrome is associated with an abnormal presence of certain metabolies in urine. What are the?

Answer 39

Glucose, amino acids, proteins, phosphate, and bicarbonate

Question 40

What breed is the inherited form of Fanconi's syndrome most common in?

Answer 40

Basenjis

Question 41

What type of gene is the inherited form of Fanconi's syndrome?

Answer 41

autosomal recessive

Question 42

What can cause the acquired form of Fanconi's syndrome?

Answer 42

Medications, labradors with copper hepatopathies, and chicken jerky treats

Question 43

How is fanconi's syndrome diagnosed?

Answer 43

Concurrent normoglycemia with glucosuria, proteinuria, amino aciduria, hypokalemia/phosphatemia, and metabolic acidosis

Question 44

How is Fanconi's syndrome treated?

Answer 44

Discontinuation of trigger (acquired) and supportive care

Question 45

What supportive care can help in Fanconi's syndrome patients?

Answer 45

Correction of electrolyte and acid/base abnormalities, IV/SQ fluid support

Question 46

What is the prognosis of Fanconi's syndrome?

Answer 46

Variable - inherited have a survival time of 5-6 mean survival after diagnosis and aquired can have spontaneous return to normal tubular function is possible