Renal Syndromes

Question 1

acute kidney injury

Answer 1

occurs in hours to weeks

possible recovery of some or all of the lost renal function

implies impaired ability of the kidneys to perform their normal physiologic functions

Question 2

classifications of intrinsic acute renal failure

Answer 2

glomerular (5%)

tubular (85%)

interstitial (10%)

Question 3

baseline parameters defining acute kidney injury

Answer 3

a rise in creatinine of 0.3 mg/dL

a decrease in GFR of 30-50%

Question 4

What is the specific gravity of normal urine?

Answer 4

1.002 - 1.030

Question 5

Major categories of acute tubular necrosis

Answer 5

ischemic in origin (60%)

toxic in origin (40%)

Question 6

What does pigmented cast suggest?

Answer 6

ATN

rhabdomyolysis

Question 7

What does a white cell cast suggest?

Answer 7

allergic interstitial nephritis

pyelonephritis

Question 8

What are the parameters that signify proteinuria?

Answer 8

normal < 150 mg/day

30-300 albumin/day is microalbuminuria (diabetic)

> 300 mg/day is overt nephropathy

> 3000 mg/day is nephrotic syndrome

Question 9

non-nephrotic range proteinuria

Answer 9

~2mg or less with no evidence of any systemic disease and an otherwise normal urine sediment

Question 10

allergic (acute) interstitial nephritis

Answer 10

a rash in the kidneys

acute kidney injury from medication exposure

can also be caused by multiple myeloma, SLE, and sarcoid

stopping the offending agent often is curative, with steroids given if needed

Question 11

clinical presentation of AIN

Answer 11

classic triad of rash, fever, and eosinophilia

can occur 2-3 days of exposure to agent, or after months

urinanalysis shows invariable hematuria, steril pyuria, mild proteinuria and +/- eosinphils

Question 12

treatment for acute interstitial nephritis

Answer 12

remove offending agent

maintain adequate intravascular volume

steroids are believed to be beneficial, but no prospective, randomized trials support them

Question 13

What are the types of glomerular renal syndromes?

Answer 13

nephrotic and nephritic

Question 14

What are examples of nephrotic glomerular renal syndromes?

Answer 14

minimal change disease

FSGS

membranous

Question 15

What are examples of nephritic glomerular renal syndromes?

Answer 15

immune complex mediated

anti-GBM disease

Pauci-immune

Question 16

indications for renal biopsy

Answer 16

acute kidney injury of unknown etiology

nephrotic syndrome of uncertain etiology

nephritis of uncertain etiology

kidney dysfunction in a renal transplant patient

Question 17

nephrotic syndrome

Answer 17

1) > 3.5 gm of proteinuria
2) hypoalbuminemia
3) lipiduria
4) hyperlipidemia
5) edema

Question 18

How is proteinuria used to rule out nephrotic syndrome?

Answer 18

mild proteinuria is under 2 grams, or 1-2+ by dipstick

for neprhotic range proteinuria, there will be greater than 3 grams of protein in the urine a day

Question 19

clinical presentation of glomerulonephritis

Answer 19

fever, malaise

edema

dark, tea colored urin - oliguria

hypertension

increased creatinine, azotemia

blood, protein in the urine (1-2+)

Question 20

immune complex glomerulonephritis

Answer 20

IgA nephropathy

post-infections

systemic lupus erythematosus

membranoproliferative GN

Question 21

IgA nephropathy

Answer 21

most common acute GN, men>women, more prevalent in asians

relapsing and remitting, associated with mucosal irritation - synpharyngitic hematuria

hematuria, proteinuria, and red blood cell casts

increased creatinine

normal complement levels

Question 22

treating IgA nephropathy

Answer 22

avoid mucosal infection

treat nephrotic syndrome if present

fish oil is used if risk factors for disease progression

can also use ace-inhibitor or angiotensin receptor blockers

if severe, add on steroids

Question 23

post-infectious GN

Answer 23

any age, usually children, mostly males

clasically, 1-3 weeks after group A beta-hemolytic strep infection

presents with edema and hypertension RBC casts, acanthocytes, hypocomplementemia

Question 24

diagnosis of Post-infectious glomerulonephritis (PIGN)

Answer 24

nephritic syndrome 10-14 days after documented infection

fever, malaise, edema

low serum C3

nephritic urine

rising ASO iters

prognosis is excellent in children

Question 25

treatment of PIGN

Answer 25

treat/clear infection

Question 26

lupus glomerulonephritis (SLE)

Answer 26

any age, usually 20-40 female to male ratio is 9:1 usually associated with other features of SLE, nephritic sediment diagnose with biopsy red blood cell casts, +ANA, +ds DNA, low complement levels treat with steroids, IV cyclophosphamide

Question 27

membranoproliferative GN

Answer 27

any age, usually 5-30 associated with HBV, HCV, HIV, EBV, chronic infections, CLL, B-cell lymphomas **nephritic or nephrotic**, low C3 (40%), low C4 (20%) edema, dyslipidemia, if nephrotic increased creatinine, hematuria, proteinuria if nephritic can present with features of both treat underlying cause - steroids in children and interferon for adults (for Hep C)

Question 28

anti-GBM disease

Answer 28

rare - found mostly in **young adult men** and older women pulmonary-renal syndrome caused by **autoantibodies that bind to type IV collagen** found in the glomerular basement membrane and lung presents with **hemoptysis and renal failure**, with a 3 month gap inbetween onset of pulmonary disease and renal disease associated with **hydrocarbon fumes, cocaine, cigarette smoke** treat with **plasmapheresis, steroids, or cyclophosphamide** ex. Goodpasture's Disease

Question 29

What are the classifications of glomerulonephritis?

Answer 29

immune complex anti-GBM pauci-immune

Question 30

pauci-immune GN

Answer 30

normal complement levels, no specific immunofluorescence pattern caused by granulomatosis with polyangiitis, microscopic polyangiitis, or Churg-Straus

Question 31

rapidly progressive glomerulonephritis

Answer 31

double serum creatinine or halving of creatinine clearance in 3 months or less pathology often reveals crescentic GN - infiltration of Bowman's space with mononuclear cells in a characteristic crescentic pattern often accompanied with endocapillary proliferation, focal necrosis, and tubulointerstitial cellular inflammation

Question 32

signs of nephrotic syndrome

Answer 32

\> 3.0 gm protein/day severe edema hypoalbuminemia hyperlipidemia lipiduria

Question 33

minimal change disease

Answer 33

90% of nephrotic syndrome in children - explosive edema selective proteinuria and non-selective proteinuria, selective thought to be less damaging effacement of foot processes symptoms include swelling of feet, history of cancer, medication exposure, dyslipidemia, proteinuria, oval fat bodies (maltese crosses) in sediment kidney biospy to diagnose treat with steroids and manage nephrotic syndrome

Question 34

complications of nephrotic syndrome

Answer 34

edema thromboembolic complications infection hyperlipidemia

Question 35

treatment of nephrotic syndrome

Answer 35

treat underlying cause, if identified control blood pressure in diabetes, control B.S. use ACE-inhibtors control lipids stop smoking sodium restriction

Question 36

tubulointerstitial diseases

Answer 36

often associated with subnephrotic (\< 1-2 grams) range proteinuria and perhaps some renal insufficiency creatinine is stable or increasing slowly no active systemic disease symptoms of concern often the result of an old renal inury does not require biopsy or specific treatment

Question 37

What are some common conditions that cause transient small amounts of proteinuria?

Answer 37

exercise, fever, and infection

Question 38

What are the ranges of albumin in the urine, and what do they suggest?

Answer 38

30 mg to 300 mg - microalbuminuria in a diabetic \>300 mg - overt nephropathy \> 3000 mg - nephrotic range proteinuria

Question 39

acute nephritic syndrome

Answer 39

represents the clinical sequelae of acute glomerular inflammation hematuria, red blood cell casts in the urine, dysmorphic red blood cells, proteinuria, along with varying degrees of renal insufficiency, hypertension, and some edema are the clinical features

Question 40

kidney disease with low complement levels

Answer 40

PIGN SLE

Question 41

granulomatosis with polyangitis (GPA - formerly known as Wegener's Granulomatosis)

Answer 41

often presents as a pulmonary renal syndrome, pulmonary involvement ranges from a chronic sinusitis to hemoptysis usually affects older individuals symptoms include fever, weight loss, nose ulcerations, lung findings, hematuria, proteinuria, and red blood cell casts **+ANCA (usually C-ANCA, PR3 pattern)** kidney biopsy for diagnosis

Question 42

treatment of GPA

Answer 42

small vessel vasculitis degree of immunosuppression depends on the degree of organ involvement and damage treatment ranges from **low dose steroids** or **cellcept** (an oral immunosuppressant) to **high dose steroids** and **cyclophosphamide**

Question 43

treatment of microscopic polyangiitis

Answer 43

degree of immunosuppression depends on the degree of organ involvement and damage treatment ranges from low dose steroids or mycophenolate mofetil (cellcept - an oral immunosuppressant) to high dose steroids and cyclophosphamide

Question 44

microscopic polyangitis

Answer 44

pulmonary renal syndrome, with pulmonary involvement in the lower lung can present acutely or chornically usuall affects older individuals symptoms include fever, wieght loss, lung findings, hematuria, proteinuria, and red blood cell casts **+ ANCA (usually P-ANCA, MPO patter, but C-ANCA also frequent)** kidney biopsy for diagnosis

Question 45

Churg-Strauss

Answer 45

common in patients with asthma and eosinophilia with blood and protein in their urine wheezing on lung exam if asthma is not controlled eosinophils hematuria, proteinuria, and red blood cell casts + ANCA up to 60% of the time (usually p-ANCA) kidney biopsy to diagnose

Question 46

treatment of Churg-Strauss

Answer 46

usually steroids control most maniestations, but if serious organ damage occurs, treatment can include high dose steroids and cyclophosphamide (like WG)

Question 47

focal segmental glomerulosclerosis

Answer 47

idiopathic but can also be secondary to other conditions men \> women African-American \> White assicated with HIV, heroin, obesity, sleep apnea, reflux swelling usually appears over a prolonged time dyslipidemia, proteinuria oval fat bodies "maltese crosses" in urine kidney biopsy to diagnose

Question 48

treatment of FSGS

Answer 48

treat underlying disease nephrotic syndrome treatment if idiopathic, try steroids, immunosuppresants, or chemotherapy

Question 49

membranous nephropathy

Answer 49

any age, uncommon in children **associated with cancer, medications (NSAIDs, gold, penicillamine), viral infections (Hep B, C, and HIV), and lupus** edema, dyslipidemia, proteinuria, oval fat bodiies "maltese crosses" in sediment kidney biopsy to diagnose thickened GBM, subepithelial deposits on EM prognosis worse in men

Question 50

treatment of membranous nephropathy

Answer 50

treatment depends on the amount of proteinuria can vary from watchful waiting to steroids to chemotherapy (chlorambucil, cyclophosphamide) to modulate the immune system