RENAL: nephrotic and nephritic syndrome Flashcards
What triad of signs are characteristic of nephrotic syndrome?
Oedema
Albumin <30
Unine PCR (protien:creatinine ratio) >350 aka more than 3.5g/24hrs
What are the complications of nephrotic syndrome?
- increased risk of VTE related to loss of antithrombin III and plasminogen in the urine
( can also get renal vein thrombosis, resulting in a sudden deterioration in renal function) - hyperlipidaemia
- increasing risk of acute coronary syndrome, stroke etc
- ckd
- increased risk of infection due to urinary immunoglobulin loss
- hypocalcaemia (vitamin D and binding protein lost in urine)
Causes of nephrotic syndrome?
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Membranoproliferative glomerulonephritis
Amyloidosis, Myeloma, DM
Who does minimal change disease affect?
Children under 6yrs.
Describe the pathophysiology of membranous glomerulonephritis
(AR of Urinary module)
Subepithelial deposition of immune complexes - i.e. these deposit between the basement membrane and podocytes.
This causes thickening of the BM
What conditions can predispose to secondary focal segmental glomerulosclerosis?
Sickle cell disease
HIV
Heroin abuse
Kidney hyper perfusion
Alport’s syndrome
What are features of nephritic syndrome?
Haematuria
Oliguria
Proteinuria <3.5g/24hr
Fluid retention
Its may also have hypertension
What is the most common cause of primary glomerulonephritis?
IgA nephropathy aka Berger’s disease
What is the most common cause of nephrotic syndrome in:
a) children?
b) adults?
a) Minimal change disease
b) Focal segmental glomerulosclerosis or in older people = diabetes
A patient with post-streptococcal glomerulonephritis may have ____what?____ in their recent PMH?
Hint: there are 2.
1-2 weeks after tonsillitis/pharyngitis
3-4 weeks after impetigo/cellulitis
What are main treatments for most types of glomerulonephritis?
Immunosupression using steroids
Blood pressure control - ACEi/ARBs
A patient has IgA nephropathy. What may be present in their PMH?
URTI: 1-2 days ago
GI infection
Strenuous exercise
Associated with: alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura
In what age groups do Goodpastures syndrome incidence peak?
30s - usually male
60+ - usually female
What is the pathophyisology of Goodpastures Syndrome?
Antibodies against type 4 collagen (in glomerular basement membrane) develop .
What are complications of Goodpastures?
Pulmonary haemorrhage
Rapidly progressive glomerulonephritis
A patient has haematuria. What are your differentials?
Bladder cancer, prostate cancer, CKD, kidney stones, UTI, pylenonephritis, period, acute protastitis, BPH, trauma (depends on context of hx)
How does Anti-glomerular basement membrane disease (Goodpastures) present?
Typically with haemoptysis + AKI/proteinuria/haematuria
What part of the kidney does Nephrotic syndrome affect?
Glomerulus or Bowman’s capsule
What does proteinuria and/or haematuria indicate?
Damage to the glomerulus
A patient is losing > to 3g in 24hrs of protein in their urine. what conditions could it be?
Diseases that cause Nephrotic syndrome:
Diabetes
Minimal changes disease
Membranous
Focal segmental glomerular sclerosis
Amyloid
What is nephrotic syndrome symptoms?
Oedema- often periorbital swelling
Proteinaemia (> 3g in 24hrs)
Hypoalbuminaemia
Hyperlipidaemia
Hypercoagulable state
What is nephrotic syndrome proteinuria range?
> 3g in 24hrs
What are nephritic syndrome symptoms?
Haematuria
Proteinuria (less than 3g over 24hrs)
Hypertension
What diseases present with nephritic syndrome?
IgA nephropathy
Lupus
Mesangial proliferative glomerulonephritis
Vasculitis
What is the difference between nephrotic and nephritic syndrome?
Both manifestations of glomerulonephritis, different diseases present as either one but they are both due to damage to the glomerulus/bowmans capsule
How is kidney function affected by glomerulonephritis?
V often kidney function is not affected, the damage is to the glomerulus
What investigations would you do for a patient with suspected glomerulonephritis?
Urine dip- protein:creatinine, 24 hr- nephrotic syndrome: diagnostic criteria is 300. If less than this may be nephritic syndrome
Bloods- U&Es, FBC,Bone, serum glucose
Imaging
What is the pathophysiology of minimal change syndrome?
Podocytes become flattened- lose ability to control amount of protein that goes into the urine
After diabetes and hypertension, what is the most common glomerulonephritis?
IgA nephropathy
What type of kidney injury can vasculitis cause?
Acute
What type of kidney injury does glomerulonephritis cause?
Mostly chronic, however some may cause acute e.g. vasculitis
Name three investigations you would do for suspected glomerulonephritis
Urine dip - protein creatinine ratio
Bloods - U&Es, FBC, Bone, Serum glucose
Imaging - USS of renal system
What is common clinical presentation of minimal change disease in children/young adults?
Swelling - facial - peri-orbital swelling
What are ddx for swelling/odema in pt with pmh of proteinuria and angina?
Nephrotic syndrome, HF, Liver disease
What do patients with nephrotic syndrome need to help find cause?
Renal biopsy
A lady attends a&e with DVT and oedema. What renal condition must you rule out?
Nephrotic syndrome - dvt can be first sign; pts with nephrotic syndrome are at risk of dvt and stroke
How can you check pt with MCD is responding to steroids given?
Look at serum albumin - should be increasing if steroids are working.
What are risks of steriods?
Risk of osteoporosis
Risk of DM
Weight gain
Skin thinning
Risk of infection
What risk is associated to kidney biopsy?
- Heamatoma - biopsy can damage kidney and pt presents with heamaturia
- haematuria that may need a blood transfusion
- Infection
- Death
- Formation of atriovenous aneurysm
What is the rule of thirds in membranous glomerulonephritis?
1/3 get better
1/3 have a relaxing and remitting condition
1/3 progress to ESRD
Which protein is lost in nephrotic syndrome?
Antithrombin III
Why would a patient with Nephrotic syndrome develop a DVT /PE ?
Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III and plasminogen via the kidneys
Antithrombin III inhibits coagulation by inhibiting the action of thrombin while plasminogen is involved in fibrinolysis.
Which is higher in nephrotic syndrome LDL or HDL?
LDL
Who is at risk of diabetic nephropathy?
T1 DM or long duration of T2 DM patients
A patient has diabetic nephropathy. What 2 additional microvascular complications may be present?
Retinopathy
Peripheral neuropathy
What is glomerulosclerosis?
In Diabetic nephropathy - chronic high levels of glucose pass through glomerulus and cause scarring = glomerulosclerosis
What is key feature of diabetic nephropathy?
Proteinuria
Why do we get proteinuria in diabetic nephropathy?
Glomerulus is damaged - so allows protein to be filtered from the blood into the urine.
What is involved in screening for diabetic nephropathy ?
Urine Albumin:creatinine ratio
U&Es
What does albumin:creatinine ration show for patient with diabetic nephropathy?
Raised urine albumin:creatinine ratio
How is diabetic nephropathy managed?
Key: want to optimise blood sugar levels and blood pressure.
ACEi/ARB - reduces proteinuria and controls blood pressure
CVS risk modification (may involve lifestyle changes)
Continue screening for microvascular complication of diabetes e.g. retinal screening, foot checks.
Signs present in patient with diabetic nephropathy?
Presence of RF: Hyperglycaemia, HTN, FHx of DM, obesity, smoker
Retinopathy, odema, foot ulcers.
Drugs that cause acute interstitial nephritis?
Penicillin
Rifampicin
NSAIDS
Allopurinol
furosemide
What is alport syndrome?
X-linked (usually affects males) Mutation in gene coding for Type V collagen
Associated with hearing loss and abnormalities of the eyes
Often leads to ESRF
Presentation of alport syndrome?
- Persistent microscopic haematuria with intermittent visible haematura
- Sensorineural hearing loss
- Biopsy: splitting of GBM and alternating thickening & thinning of GBM
- Genetic studies – family history
