Systemic Diseases (Brozna)

Question 1

Nephrosclerosis

Answer 1

process, not diagnosis
Sclerosis of renal arterioles from age, hypertension, or diabetes–> focal ischemia–> tubuloinsterstitial injury–> reduced renal function

Question 2

Nephrosclerosis (benign)

Answer 2

Associated with mild to moderate hypertension
Associated with aging

uncommonly leads to renal insufficiency

Question 3

Longstanding Hypertensive Nephrosclerosis

Answer 3

Arteriolar sclerosis
Tubular atrophy
Interstitial fibrosis
Glomerulosclerosis
Interstitial 	inflammation

Question 4

Accelerated Nephrosclerosis

Answer 4

Associated with severe hypertension (>200/120 mm)
Petechial hemorrhages are frequently present
Relatively uncommon
Associated with marked elevation of plasma renin

can be associated with encephalopathy, retinal papilledema, acute and subacute kidney injury– elevated creatinine and proteinuria **

Important to exclude acute, ongoing target-organ damage (hypertensive EMERGENCY)

Question 5

Hypertensive intracerebral hemorrhage

Answer 5

associated w/ basal ganglia hemorrhagic infarct, small arteriole fibrinoid necrosis

Question 6

Malignant HypertensionPathogenesis

Answer 6

fibrinoid necrosis –> hyperplastic arteriolitis (onion skin change)

Question 7

typical presentation: blurry vision, elevated BP 245/125, wavy vision, decreased color vision,

Answer 7

papilledema etc. from malignant hypertension

Question 8

renal pathalogical findings w/ injury from severe hypertension

Answer 8

fibrinoid necrosis of small arterioles and hyperplastic arteriolitis (onion skinning) of small renal arteries.

Question 9

hypertension and diabetes mellitus

Answer 9

vascular changes are more severe –> systemic small vessel arteriolar sclerosis involving multiple organs.

–> nephropathy

Question 10

Diabetic Nephropathy

Answer 10

Diabetic nephropathy is a clinical syndrome characterized by:
Persistent albuminuria (> 300 mg/day for at least 3 months)
Progressive decline in the glomerular filtration rate
Elevated arterial blood pressure

*** Urine dipstick becomes positive when protein excretion exceeds ~300-500 mg/day

Question 11

Clinical stages of diabetic nephropathy

Answer 11

1. hyperfiltration
2. microalbuminuria 5-15 years

Overt proteinuria 10-20 years
Progressive nephropathy 15-25 years
End-stage renal disease 20-30 years

Question 12

Glomerulonephritis can be superimposed on diabetic nephropathy

Answer 12

A glomerulus showing a cellular crescent with rupture of Bowman capsule superimposed on nodular DN.

The patient, known to have DN, presented with rapidly deteriorating renal function and red cell casts in the urine

Question 13

biopsy of diabetic nephropathy

Answer 13

Nodular glomerulosclerosis with mesangial proliferation and diffuse thickening of capillary basement membranes.
Immunofluorescence shows mild linear staining for IgG
Electron microscopy shows diffuse thickening of the tubular and capillary basement membranes.
There are decreased numbers of podocytes and diffuse foot process effacement

Question 14

Hyaline arteriolosclerosis

Answer 14

Thickening and hyalinization lead to decrease in smooth muscle and collagen and in and more rigid vascular wall

Arteriolar hyalinosis (nonspecific)
Much worse systemically when associated with hypertension and responsible for many of the signs/symptoms of diabetes

Question 15

what might be an early initiating factor for microalbuminuria in early diabetes nephropathy?

Answer 15

disruption of the glycocalyx by glycosylated proteins

Thickening of the glomerular basement membrane, podocyte detachment and damage to the endothelial glycocalyx leads to disruption of the glomerular filtration barrier in diabetes.

Question 16

Pathogenesis of Microalbuminuria

Answer 16

Glomerular Filtration Barrier is anionic (strong negative charge)

Podocyte membrane coated with sialoglycoproteins
Glomerular basement membrane heparin sulfate

Glycocalyx membrane-bound negatively charged proteoglycans and glycoproteins with integrated soluble plasma proteins

Question 17

Systemic Lupus Erythematosus: common symptoms

Answer 17

Fatigue
Fever
Myalgia/arthralgias
Weight loss
Skin and mucous membrane involvement
Vasculitis
Raynaud’s phenomenon
Renal disease
photosensitivity
oral ulcers
non erosive arthritis
pleural pericarditis
positive ANA

Constellation of presenting clinical features can make the diagnosis of SLE relatively straightforward or presenting with 1 or 2 isolated complaints can make the diagnosis difficult

Question 18

Laboratory tests that can support the diagnosis of SLE

Answer 18

Antinuclear antibody
Antiphospholipid antibodies (lupus anticoagulant)
C3, C4 and CH50 complement levels
Erythrocyte sedimentation rate
C-reactive protein
Urine protein to your and creatinine ratio

Question 19

Systemic Lupus Erythematosus Nephritis

Answer 19

Approximately 60% of patients with SLE have renal disease within five years of diagnosis
Elevated serum creatinine
Urine red blood cells, white blood cells, red blood cell casts
Proteinuria
10-30% the progress to end-stage renal disease
*** Control of blood pressure is critical to delay progression of chronic kidney disease

Question 20

Clinical manifestations of lupus nephritis can include

Answer 20

Recurrent microscopic or gross hematuria
Nephritic syndrome
Rapidly progressive glomerulonephritis
Nephrotic syndrome
Acute and chronic renal failure
Hypertension

Question 21

Urine dipstick becomes positive when protein excretion exceeds

Answer 21

300-500 mg/day