W3 Renal Disease, Glomeruloneph, Nephrotic/phritic, Diabetic, Hydronephrosis, Polycystic Etc Flashcards
26-year-old man who presents with hematuria, periorbital edema, and jaundice.
He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose.
He is on Suboxone but is non-adherent.
His blood pressure is 162/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura.
Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies.
Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts
Glomerulonephritis
Acute glomerulonephritis is an inflammation of glomeruli causing _____ and _____ leakage into the urine, typically caused by an ______
Two types and their characteristics
Acute glomerulonephritis is an inflammation of glomeruli causing protein and RBC leakage into the urine, typically caused by an immune response
Two types based on 24-hour urine protein
Nephritic syndrome:
—hematuria
—HTN
—moderate proteinuria 1-3.5 g/day
Nephrotic syndrome:
—edema
—severe proteinuria > 3.5 g/day
Classic presentation: edema + HTN + hematuria + RBC Casts/dysmorphic RBCs + proteinuria 1-3.5 g/day + azotemia
Nephritic syndrome:
Etiologies of nephritic syndrome — 5
Which is the most common?
- Postinfectious - Group A strep (skin or throat) - 10-14 days
- IgA Nephropathy (Berger disease) - most common cause of acute glomerulonephritis worldwide
- Alport’s Syndrome
- Membranoproliferative glomerulonephritis (MPGN) - due to SLE, viral hepatitis
- Rapidly progressive glomerulonephritis - crescent formation on biopsy due to fibrin and plasma protein deposition
a 10 y/o is brought to the clinic with her mother for dark urine. The mother mentions that the child was complaining of sore throat and cough/cold symptoms two weeks ago. The urine shows gross hematuria without nitrites or leukocytes.
What is the diagnosis?
Which labs?
Nephritic syndrome
Postinfectious - Group A strep (skin or throat) - 10-14 days after infection - diagnosed with ASO titers and low serum complement -
+ASO titers
Serum C3 C4 can be low (complement)
treatment is supportive + antibiotics
a 33-year-old man who comes to the ED because of blood in his urine for 2 days.
He has also been feeling unwell, with a sore throat, running nose, cough, and fever.
Medical history includes three episodes of hematuria in the past that have spontaneously resolved. His temperature is 98.9°F; pulse is 82/min; respirations are 18/min, and blood pressure is 145/90 mm Hg. PE is normal.
Urinalysis shows moderate numbers of erythrocytes, a few leukocytes, red cell casts, and a large amount of protein. No bacteria are cultured. A renal biopsy demonstrates large dark mesangial deposits.
Nephritic syndrome
2. IgA Nephropathy (Berger disease)
—most common cause of acute glomerulonephritis worldwide
—Gross hematuria and flank pain in a person with acute URI
—Often affects young males within days (24-48 hours) after URI or GI infection
—Caused by IgA immune complexes which are the first line of defense in respiratory and GI secretions so infections cause an overproduction which then damages the kidneys
—Diagnosed by (+) IgA deposits in mesangium and with immunostaining
a 15-year-old boy who comes to the office because of malaise, anorexia, nausea, and decreased urination. His mother says that he is having problems hearing. Physical examination shows decreased hearing bilaterally with the
Rinne test and bilateral edema in the lower extremities. Urinalysis shows microscopic hematuria and proteinuria.
A peripheral blood smear reveals microcytic anemia.
Nephritic Syndrome: Alpert’s syndrome
—Presents as isolated persistent hematuria
—A genetic condition that occurs in children resulting in renal failure and hearing loss
—Ophthalmologic exam reveals anterior lenticonus - anterior part of the lens has a conical shape
—DX - C3 and C4 Levels
a 26-year-old man who presents with hematuria, periorbital edema, and jaundice. He has a medical history of opioid use disorder with prior hospitalizations for a heroin overdose. He is on Suboxone but is non-adherent. His blood pressure is 162/102 mmHg. Physical examination is significant for scleral icterus, hepatomegaly, and palpable purpura. Serology shows decreased C3 and C4 levels and elevated anti-hepatitis C antibodies. Urinalysis demonstrates dysmorphic red blood cells and red blood cell casts.
Nephritic syndrome
4. Membranoproliferative glomerulonephritis (MPGN) - due to SLE, viral hepatitis
MPGN describes an injury to the glomerulus secondary to immune-complex deposition and/or a complement-mediated mechanism
Deposition of immune-complexes or complement proteins results in an inflammatory response that leads to glomerular injury
In response to this injury, the cell undergoes a number of changes such as mesangial proliferation, remodeling of the capillary wall, and development of a new basement membrane
MPGN can be idiopathic or result from a secondary condition, such as hepatitis C virus (HCV) infection
↓ serum C3 and C4 levels
a 27-year-old male presents to the clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrate interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab)
Nephritic Syndrome
- Rapidly progressive glomerulonephritis - crescent formation on biopsy due to fibrin and plasma protein deposition
Goodpasture’s syndrome: (+) anti-GBM antibodies, dx linear IgG deposits, treat with high dose steroids, plasmapheresis + cyclophosphamide
Vasculitis - lack of immune deposits (+) ANCA antibodies
—Microscopic polyangiitis (+) P-ANCA
—Granulomatosis with polyangiitis (Wegener’s) (+) C-ANCA
❗️[must know]
Glomerulonephritis
UA will reveal what 3 things
GFR will be high or low?
What else do you see in 60-80% of cases which could indicate a recent infection of what?
C3 is increased or decreased?
What is the gold standard to determine exact diagnosis?
Urinalysis reveals
—hematuria (>3 RBCs / high power field)
—misshaped RBCs (RBC casts) due to their passage through the glomerulus, and
—proteinuria (1-3.5 g/24 hours)
—GFR low
—An anti-strepto-lysin-o titer is increased in 60-80% of cases and should be considered if there is a possibility of recent streptococcal infection
—run hepatitis serology
—Serum complement (C3) is often decreased
—Renal biopsy is the GOLD STANDARD may be done to determine the exact diagnosis and severity of the disease
Glomerulonephritis treatment
Steroids and immunosuppressive drugs may be used to control the inflammatory response
—Dietary management: salt and fluid restriction
—Dialysis should be performed if symptomatic azotemia
—ACEI/ARBs (enalapril or losartan) are renoprotective - blood pressure goal < 130/80
⭐️In poststreptococcal GN Nifedipine is used instead of ACEI (ACE may cause hyperkalemia) ⭐️
—IgA nephropathy - Glucocorticoids
—Rapidly progressive glomerulonephritis - immunosuppressive therapy
—Use medications to control hyperkalemia, pulmonary edema, peripheral edema, acidosis and hypertension
Diabetic nephropathy
Most common cause of ______
Hyperfiltration — increased ______ / ______ — progressive decline in ______
Tx: (5)
______ is pathognomonic**
Most common cause of ESRD
Hyperfiltration — increased proteinuria / albuminuria — progressive decline in GFR
Tx:
—Blood glucose
—BP control
—RAAS inhibitors (ACEI/ARB)
—monitor for hyperkalemia
—SGLT inhibitors (~gliflozin)
glomerulosclerosis (Kimmelstiel-Wilson nodules) is pathognomonic
48-year-old woman who presents to the emergency department due to severe back pain and difficulty urinating. Her symptoms began approximately 3 hours ago and is associated with pain in her left mid-back which she describes as 9/10 and sharp. The pain radiates to her left groin. On physical exam, there is left-sided costovertebral angle tenderness. A non-contrast computerized tomography (CT) scan of the abdomen demonstrates left-sided urolithiasis and hydronephrosis. She is started on a nonsteroidal anti-inflammatory drug (NSAID) and intravenous normal saline.
Hydronephrosis
Hydronephrosis — refers to ______ of the renal ______ and ______, usually caused by ______ of the free flow of urine from the kidney.
Causes include 4
Symptoms include ______ and ______
Hydronephrosis — refers to distension and dilation of the renal pelvis and calyces, usually caused by obstruction of the free flow of urine from the kidney.
Causes include
—a kidney stone
—an infection
—vesicoureteral reflux
—an enlarged prostate
—a blood clot, or a tumor
Symptoms include difficulty urinating and
pain in the side, abdomen, or radiating to groin (testicles/labia)
In cases of hydroureteronephrosis, there is distention of both the ureter and the renal pelvis and calyces
Hydronephrosis diagnosis
—impaired kidney function = elevated urea and creatinine
—palpable abdominal mass/flank pain
—UA: elevated pH
—PVR = >100ml
—U/S, then CT urogram, CT, MRI
