Systemic Disease and the Kidneys

Question 1

Describe the presentation of diabetic nephropathy. (3)

Answer 1

Proteinuria
Hypertension
Renal failure

Question 2

Describe the histology of diabetic nephropathy. (2)

What are these 2 features called collectively?

Answer 2

Kimmelstiel-Wilson kidney

Thickening of glomerular basement membrane
Nodular glomerulosclerosis

Question 3

What are the 5 ways in which systemic disease might present in the kidneys?

Answer 3

Proteinuria
Acute kidney injury
Chronic kidney disease
Nephrotic syndrome
Nephritic syndrome

Question 4

If a patient has deranged U&Es, what further tests would you do? (5)

Answer 4

Urinalysis - proteinuria? haematuria?

Quantitative protein tests (uPCR)

Antibodies

Complement proteins

Imaging

Question 5

What systemic conditions can

cause acute kidney injury? (3)

Answer 5

Obstruction
Renovascular disease (e.g. renal artery stenosis)
Interstitial nephritis

Question 6

How do you diagnose renal artery stenosis? (2)

Answer 6

Clinical features

NO angiogram/CT etc - contrast can make kidney failure worse

Question 7

How would you manage renal artery stenosis? (7)

Answer 7

Treat underlying conditions

Medical treatment:

• Stop ACE inhibitors
• Avoid ACEIs/ARBs in future
• Other BP control
• Statins

Lifestyle changes

Angioplasty

Question 8

Angioplasty is only rarely used in AKI.

List 3 indications.

Answer 8

Rapidly deteriorating renal failure
Hypertension despite multiple anti-hypertensives
Flash pulmonary oedema

Question 9

Which systemic conditions can cause nephrotic syndrome? (6)

Where relevant, give some examples.

Answer 9

Glomerulonephritis, e.g.

• Membranous glomerulonephritis
• Minimal change disease
• IgA nephropathy

Diabetic nephropathy
Lupus nephritis
Viral infections (e.g. HIV, hep B/C)
Amyloidosis
Myeloma

Question 10

How would you diagnose amyloidosis? (3)

Answer 10

Biopsy - fibrin strands

Light microscopy - apple green birefringence on Congo red stain

Electron microscopy - fibrin strands, mesangial expansion

Question 11

Describe the 2 types of amyloidosis.

Answer 11

AA - systemic amyloidosis (e.g. due to infection, inflammation)

AL - immunoglobulin fragments from haematological conditions (e.g. due to myeloma)

Question 12

How would you treat amyloidosis? (1)

Answer 12

Treat underlying condition

Question 13

Which systemic diseases can cause nephritic syndrome? (5)

Answer 13

Glomerular disease

Vasculitis, e.g.

• ANCA positive vasculitis
• Anti-GBM positive (Goodpasture’s syndrome)
• Lupus nephritis

IgA nephropathy

Question 14

Describe the pathophysiology of kidney damage in SLE. (3)

How is this diagnosed? (1)

Answer 14

1. Autoimmune
2. Immune complexes are deposited in mesangial cells
3. This causes complement activation, which then causes damage to the glomerulus

Biopsy

Question 15

How would you treat kidney damage in SLE? (4)

Answer 15

Immunosuppression, e.g.

• Steroids
• MMF
• Cyclophosphamide
• Rituximab (CD20)

Question 16

How would you treat ANCA positive vasculitis? (4)

Answer 16

ITU and ventilation

Removal of antibodies, e.g.

• Methyl prednisolone
• Plasma exchange
• Cyclophosphamide