The kidney in systemic disease

Question 1

Saddle nose

Answer 1

GPA

Question 2

Renal biopsy shows segmental necrotising glomerulonephritis

Answer 2

Vasculitis

Question 3

Class I

Answer 3

Minimal mesangial

Question 4

Class II

Answer 4

Mesangial proliferative

Question 5

Class III

Answer 5

Focal proliiferative

Question 6

Class IV

Answer 6

Diffuse proliferative

Question 7

Class V

Answer 7

Membranous

Question 8

Class VI

Answer 8

Advanced sclerosing

Question 9

Anaemia in myeloma

Answer 9

Normocytic anaemia

Question 10

ESR/PV in myeloma

Answer 10

ESR/PV is raised

Question 11

Rouleaux formation

Answer 11

Myeloma

Question 12

The proportion of patients who develop proteinuria and elevated serum Cr is related to what?

Answer 12

The duration of diabetes

Question 13

What is overt diabetic nephropathy?

Answer 13

Overt diabetic nephropathy is characterized by persistent albuminuria .300mg/24h on at least 2 occasions separated by 3- 6 months

Question 14

Diagnosis of diabetic nephropathy?

Answer 14

History of Diabetes Mellitus
Proteinuria
Presence of other diabetic complications eg retinopathy
Renal Impairment in later stages

Note no haematuria – if present may require renal biopsy

Question 15

Haematuria in diabetic nephropathy

Answer 15

This is not essential for diagnosis of diabetic nephropathy

-if this is present then you will need to do biopsy to establish the cause of it

Question 16

Prevention and treatment of diabetic nephropathy?

Answer 16

Glycaemic control
Maintain tight glycaemic control 
	(HbA1c < 7)
Anti-hypertensive therapy
Tight BP control 
ACE inhibitors and ARBs
Lipid control

Question 17

Most common cause of renal failure in the UK?

Answer 17

Diabetes

Question 18

In diabetic nephropathy, what does microalbuminuria progress to?

Answer 18

Progresses to proteinuria and frank nephropathy

Question 19

Which type of vasculitis do nephrologists usually encounter?

Answer 19

Small vessel vasculitis

Question 20

How might small vessel ANCA associated vasculitis present?

Answer 20

Patients present with constitutional symptoms eg fever, migratory arthralgia, weight loss, anorexia and malaise
Prodromal symptoms may last for weeks to months before specific organ involvement

Question 21

Characterised by chronic rhinosinusitis, asthma, and prominent peripheral blood eosinophilia

Lung most commonly involved (asthma in > 95%)
2/3 have skin involvement (palpable purpura to subcutaneous nodules)

Answer 21

Churg-Strauss

Question 22

Nasal crusting, sinusitis, persistent rhinorrhea, otitis media, oral/nasal ulcers, bloody nasal discharge
WG-evidence of bony/cartilage destruction (saddle nose)

Answer 22

Granulomatosis with Polyangitis (Wegeners)

Question 23

Granulomatosis with polyangitis (Wegeners)

Answer 23

Nasal crusting, sinusitis, persistent rhinorrhea, otitis media, oral/nasal ulcers, bloody nasal discharge
WG-evidence of bony/cartilage destruction (saddle nose)

Question 24

Microscopic polyangitis lung symtpoms

Answer 24

Cough, hoarseness, haemoptysis, SOB, pleuritic pain

Question 25

Renal presentation in vasculitis

Answer 25

AKI- with proteinuria, red cell casts | Renal biopsy shows SEGMENTAL NECROTISING GLOMERULONEPHRITIS

Question 26

Segmental necrotising glomerulonephritis

Answer 26

Vasculitis (renal biopsy)

Question 27

Diagnosis of vasculitis and renal involvement

Answer 27

Examination Routine bloods, CRP, PV, complement, ANCA, virology Urinalysis Tissue –kidney, skin, nasal, lung

Question 28

Treatment for vasculitis and renal involvement

Answer 28

Immunosuppressive therapy Plasma Exchange May require renal support

Question 29

Most frequent presentation of lupus nephritis

Answer 29

Abnormality in proteinuria

Question 30

Complement in SLE/lupus nephritis

Answer 30

Low

Question 31

Antibodies in SLE

Answer 31

ANA dsDNA Sm Low complement

Question 32

Target BP in SLE?

Answer 32

130/80

Question 33

Immunosuppressive therapy for SLE

Answer 33

Cyclophosphamide MMF Prednisolone

Question 34

Poor prognosis factors for SLE survival

Answer 34

``` Renal disease Male sex Young age or older age at presentation Poor socioeconomic status ANTIPHOSPHOLIPID SYNDROME High overall disease activity ```

Question 35

Clinical presentation of renovascular disease?

Answer 35

AKI after treatment of hypertension, usually with ACEi. CKD in elderly with diffuse vascular disease ‘Flash’ pulmonary oedema Microscopic haematuria Hypertension Abdominal bruit Atherosclerotic disease elsewhere

Question 36

Diagnosis of ischaemic renal disease

Answer 36

Renal ultrasound Renal doppler studies MRA

Question 37

``` Bone Pain Weakness and Fatigue Weight Loss Symptoms related to other manifestations Hypercalcaemia Renal Failure Amyloidosis Increased risk of infection ```

Answer 37

Myeloma Kidney

Question 38

M protein

Answer 38

Multiple myeloma

Question 39

``` Normocytic Anaemia 75% Raised ESR/PV 30% Rouleaux formation 50% Renal Impairment Monoclonal Band 97% IgG 50% IgA 20% LC only 16% Kappa: Lambda 2:1 Increased β2-microglobulin Lytic lesions on skeletal survey ```

Answer 39

Multiple myeloma

Question 40

Kappa:lambda

Answer 40

Multiple myeloma

Question 41

Increased beta 2 microglobulin?

Answer 41

Multiple myeloma

Question 42

Incidence of MM in blacks?

Answer 42

Risk doubles in blacks

Question 43

Drug management of the patient with MM and acute renal failure

Answer 43

Stop nephrotoxins (NSAIDS, diuretics in view of risk increasing cast formation) Treat hypercalcemia: IV NaCL to volume resucitate IV Palmidronate if required AVOID contrast agents!! Chemotherapy to reduce tumour load High dose dexamethasone may help reduce tumour load. Thalidomide/ bortezomib Plasma exchange To remove light chains. Dialysis to support AKI and CKD

Question 44

What is IV palmidronate?

Answer 44

Good for treating hypercalcemia of malignancy