Urinary: Pathology Flashcards

1
Q

Which areas can pathology in kidney affect?

A
  • Glomerulus
  • Tubular compartment
  • Interstitium
  • Vascular
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2
Q

What can the glomerular filter leaking cause?

A
  • Proteinuria
  • Haematuria

One or both

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3
Q

What is area of the glomerulus is affected in nephrotic syndrome?

A

Podocyte/Sub-epithelial damage

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4
Q

How is nephrotic syndrome managed?

A

Oedema - Salt and fluid restriction, diuretics
Proteinuria - ACE inhibitors
Hypercholesteraemia - Statins

Treat the underlying cause

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5
Q

What are the common primary causes of nephrotic syndrome?

A
  • Minimal change glomerulonephritis
  • Focal segmental glomerulosclerosis
  • Membranous glomerulonephritis
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6
Q

What are the features of minimal change glomerulonephritis?

A
  • Usually arises in childhood and adolescence.
  • Responds to steroid but may recur if the steroid are stopped
  • Doesn’t usually progress to renal failure
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7
Q

What is minimal change glomerulonpehritis?

A
  • Damage to podocyte layer so patient can’t selectively filter so proteins pour out of the glomerulus.
  • Thought to be immune associated
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8
Q

What is focal segmental glomerulosclerosis?

A
  • Damage to podocyte layer so patient can’t selectively filter so proteins pour out of the glomerulus.
  • Heals by scarring after being damaged by circulating factors in the blood (haven’t found out which it is)
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9
Q

What are the features of focal segmental glomerulosclerosis?

A
  • Scarring of the glomerulus occurs
  • Less effectively treated by steroids
  • Progression rapidly to renal failure
  • Patients can get FSGS even after they have a kidney transplant
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10
Q

What is membranous glomerulonephritis?

A
  • Autoimmune

- Immune complex deposits on sub-epithelial layer causing damage to the podocyte layer

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11
Q

What are the features of membranous glomerulonephritis?

A
  • Rule of thirds
  • Commonest in adults
  • May be secondary for example lymphoma
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12
Q

What are secondary causes of nephrotic syndrome?

A
  • Amyloidosis

- Diabetes Mellitus

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13
Q

What are the pathological changes that occur in diabetes mellitus?

A
  • Hyperfiltation/Capillary hypertension
  • Glomerular basement membrane thickening Mesangial expansion
  • Podocyte injury
  • Glomerular sclerosis
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14
Q

Why does hyperfiltation/capillary hypertension occur in diabetes mellitus?

A

Occurs in early course of disease.Related to hyperglycaemia

  • Increase in glucose levels
  • Upregulates SGLT2 transporter
  • Less glucose passed out in urine
  • Increase in reabsorption of sodium
  • Less sodium gets to the macula densa
  • Less effect on JGA
  • Afferent vasodilation
  • Efferent vasoconstriction
  • Glomerular hypertension occurs as a result
  • GFR increases
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15
Q

What are the risk factors for diabetes mellitus?

A
  • Genetic susceptibility
  • Race
  • Hypertension
  • Hyperglycaemia
  • High level of hyper-filtration
  • Increasing age
  • Duration of diabetes
  • Smoking
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16
Q

What are the stages of of diabetic nephropathy?

A
  1. Hyperfiltration and hypertrophy
  2. Latent stage
  3. Microalbuminuria
  4. Overt proteinuria
  5. ESRD
17
Q

What happens in the latent stage of diabetic nephropathy?

A
  • Normal albuminuria

- GBM thickening and mesangial expansion

18
Q

What happens in the microalbuminuria stage of diabetic nephropathy?

A
  • Variable mesangial expansion/sclerosis
  • Increase GBM thickening
  • Podocyte changes
  • GFR normal
19
Q

What happens in the overt proteinuria phase of diabetic nephropathy?

A
  • Diffuse histopathological changes
  • Systemic hypertension
  • Falling GFR
  • Mesangial expansion/sclerosis leads to reduced surface area for filtration
  • Microvascular changes (hyalinosis of arterioles) leads to tissue ischaemia
20
Q

What is the primary prevention of diabetic nephropathy?

A
  • Tight blood pressure control
  • SGLT2 inhibitors (Reduced hyper-filtration)
  • Statin therapy
  • Cardiovascular risk management (diet, exercise)
  • Moderate protein intake
21
Q

How is diabetic nephropathy managed?

A
  1. Hyper-filtration & hypertrophy – primary prevention
  2. Latent stage – primary prevention
  3. Microalbuminuria -RAAS Blockage to reduced glomerular hyper filtration. Hyperkalaemia limits use with advanced CKD
  4. Overt proteinuria
  5. ESRD
22
Q

What are the clinical features of hypertensive renal disease?

A
  • Microalbuminuria is the first sign
  • Slow and progressive
  • Disease of exclusion (no evidence of hypertensive disease elsewhere)
23
Q

What is the management of hypertension renal disease?

A
  • Slow progression
  • Good BP control
  • ACE inhibitors or angiotensin receptor blockers with albimunuria
24
Q

What are the histoligcal changes that occur in hypertensive nephrosclorosis?

A
  • Vascular changes
  • Fibro-elastic intimal thickening leading to lumen narrowing
  • Hyalinosis of the afferent arterial wall (diabetes affects efferent as well)
  • Secondary insult causing glomerular changes such as wrinkling of glomerulus and glomerulosclerosis
  • Leads to CKD
25
What is renal disease associated with acute severe hypertension?
- Damage to endothelium leading to haematuria - Activation of RAAS - Glomerulus is punched out so acute kidney injury. - Fibrinoid necrosis of arterioles so ischaemia which leads to activation of RAAS - Haemolytic anaemia due to shearing of blood vessels - Associated with Scleroderma and Haemolytic uraemic syndrome - Leads to AKI
26
What are the differentiating factors between hypertensive renal disease and renal vascular disease?
- Hypertension is often more acute in renal vascular disease and refractory to treatment - Decline in GFR often more rapid - Evidence of atherosclerosis elsewhere - Acute worsening with RAAS blockade leads to reduction in GFR even more as kidney thinks its hypovolaemia
27
What are the primary features of nephritic syndrome?
- Loss of protein - Blood in urine - Acute renal failure usually - Hypertensive - Low GFR
28
How is nephritic syndrome managed?
- Blood pressure control - Treatment of oedema - Cardiovascular risk management - Disease specific treatment such as immunosuppressant
29
What are the conditions that cause nephritic syndrome?
- Anti-GBM disease | - Vasculitis
30
What are the site affected by glomerular injury?
- Basement membrane - Podocyte - Sub-epithelial - Sub-endothelial
31
What are the causes of haematuria?
Blood vessels are commonly injured Non nephrological - IgA Nephropathy - Thin glomerular basement membrane nephropathy - Hereditary Nephropathy (Alport) Cancer - Renal cell carcinoma (RCC) - Upper tract transitional cell carcinoma (TCC) - Bladder cancer - Advanced prostate carcinoma Other causes - Stones - Infection - Inflammtion - Benign prostatic hyperplasia
32
How is IgA nephropathy managed?
- Can detect abnormal IgA | - No effective treatment. ACE inhibitors can slow it down but not that underlying cause
33
What is IgA nephropathy?
- Commonest glomerular membrane - IgA is naturally secreted into mucosal membrane. IgA deposited in the kidney. If you get infected you produce more IgA. - IgA is deposited in the mesangium as there is nothing to stop it getting into the mesangium - Causes the capillary loop to become fragile as a result which leads to haematuria (visible/invisible) - Can also get protein in urine
34
What are the features of thin glomerular basement membrane nephropathy?
- Doesn’t progress | - Benign
35
What is Hereditary Nephropathy (Alport syndrome) ?
- X-linked - Abnormal collagen 4 - Associated with deafness as collagen 4 is used in the ear - Abnormal appearing glomerular basement membrane - Progress to renal failure
36
What are the symptoms of chronic kidney disease?
- Fatigue / malaise - Loss of appetite / Loss of weight - Acute illness / recent infection - Ankle swelling - Haematuria / nocturia
37
What are the symptoms of acute kidney disease?
- Dysuria - Change in urine –amount / colour - Pain (supra-pubic / loin / joints) - S/E of drugs with renal metabolism - Nausea & vomiting - Ankle swelling / SoB - Fatigue / Malaise - Fever
38
What are risk factors of acute kidney disease?
- Ishaemic heart disease - Hypertension - Cerebrovascular disease - Known CKD (risk factor for AKI) - Diabetes mellitus - In younger patient – enuresis in childhood, problems in pregnancy
39
What examination are undertaken for acute kidney disease?
- Blood pressure - Urine dipstick - Urine microscopy if dipstick positive