Week 4 - B - Hameaturia and ankle sweling core clinical problems (nephropathy)

Question 1

You are Anne Brown’s GP
She is a 28 year old secretary, who attends your surgery, giving a 2 week history of increasing ankle swelling

She also mentions that her face is swollen when she wakes in the morning

She feels tired, but otherwise well

She has no serious past medical history, and is on no medication

Her blood pressure is normal (108/72)

What would you do next?

Answer 1

Carry out a urinalysis

Question 2

What do you think the urinalysis in this patient would show?

Answer 2

Think the urinalysis would show proteinuria with no haematuria or any other abnormalities

Question 3

Urinalysis showed protein ++++, no haematuria and no other abnormalities

What would you do next?
(think about measuring stuff)

Answer 3

Quantify the protein produced
Either by carrying out a protein:creatinine ratio or by measuring protein produced in a 24 hour period

Also take a blood sample to measure kidney function (urea, elctrolytes, creatinine) and serum albumin

Question 4

Urine protein:creatinine – 460mg/mmol (equivalent to about 4.6G protein per day)
Serum creatinine 78micromol/L (normal), urea 5.2mmol/L (normal), sodium normal, potassium 3.2mmol/L

Serum albumin 22G/L - low

What is the name of this syndrome?

What characterises it?

Answer 4

Nephrotic syndrome

Proteinuria

Hypoalbuminaemia

Oedema

Question 5

What is the expected protein in nephrotic syndrome? and the expected protein:creatiine ratio?

And the expected serum albumin ratio?

Answer 5

Expected protein is greater than 3 g/day

Protein:creatinine ratio is greater than 300mg/mmol

Serum albumin is less than 30g/l

Question 6

Nephrotic syndrome
Features of nephrotic syndrome are proteinuria, hypo-albuminaemia, oedema and hyperlipidaemia

What are the causes of nephrotic syndrome?

What two types of nephropathy present as nephrotic syndrome however normal blood pressure

Answer 6

Primary glomerulonephritis - idopathic
Diabetes

Minimal change nephropathy and membranous nephropathy commonly present with nephrotic syndrome, with normal renal function and blood pressure

Question 7

You refer Miss Brown to the Renal Clinic
The doctor at the clinic arranges to admit her 2 days later for a diagnostic procedure

What is this procedure?

Answer 7

This is a renal biopsy

Question 8

Before the renal biopsy is carried out to diagnose, what is carried out?

Answer 8

Blood count and coagulation screen

and carry out a renal ultrasound to make sure that both kidneys are present

Question 9

What does minimal change disease look like on electromicroscopy?

Answer 9

Can see the podocyte foot process fusion of microscopy

Question 10

Small kidneys, uncontrolled hypertension and untreated urine infection all increase the risk of bleeding after a biopsy

The renal biopsy shows minimal change nephropathy

What treatment will be prescribed?

Answer 10

For minimal change nephropathy patient will be started on oral steroids - prednisolone and a PPI to protect against peptic ulcer ulceration

Question 11

Minimal change nephropathy has a good prognosis. Her renal function is not expected to deteriorate. Almost all patients with this condition respond to steroids, though some relapse later. Patients who relapse may need further treatment

What may be given to the patient if they have relapses?

Answer 11

Immunosuppresant such as cyclophosphamide

Question 12

In nephrotic syndrome, the body becomes edematous due to the loss of protein and therefore the salt and water in the body seeps into the surrounding tissue

How does this cause low serum potassium?

Answer 12

The patients body will be fighting to reserve salts and waters in the kidneys and therefore this will cause the loss of potassium - leading to hypokaleamia

Question 13

James MacDonald, a 19 year old engineering student, consults you (his GP); he reports that 2 weeks ago he had a sore throat, and at the same time noticed that his urine was ‘rusty coloured’.
He now feels completely well

His blood pressure is 162/96

What would you do?

Answer 13

Carry out a urinalysis

Question 14

What do you think it would show?

Answer 14

Haematuria

Question 15

Urinalysis showed haematuria +++; proteinuria++
You check his urea, creatinine and electrolytes, which are normal.

You refer him to the renal clinic.

What is the most likely diagnosis?

Answer 15

IgA nephropathy; this is a common form of glomerulonephritis. It classically presents with episodes of macroscopic haematuria, often associated with upper respiratory tract infections

How could the diagnosis be confirmed?

Question 16

When seen in the renal clinic, his blood pressure is 174/102
A urine specimen is sent for measurement of protein:creatinine ratio. The ratio is 520mg/mmol (approximately equivalent to 5.2G/day protein excretion)

The doctor in the renal clinic decides that renal biopsy is indicated. What must he/she do before the biopsy is carried out?

Answer 16

Doctor must control the patients blood pressure - probably use an ACEinhibitor

Check for a blood count and coagulation screen

Question 17

What type of drug should be prescribed to treat his hypertension?

Answer 17

An ACE inhibtor - will reduce the blood pressure and reduce protein excretion

Question 18

Lisinopril is prescribed, and his BP falls to 138/ 86
Renal biopsy is performed, and confirms IgA nephropathy. The biopsy contains 10 glomeruli, of which 4 are sclerosed (scarred).There is also extensive interstitial scarring. These features indicate a high risk of progression (ie declining renal function).

What would you say to the patient about the prognosis?

(as in what percentage of patinets with IgA nephropathy progress to end stage renal failure)

Answer 18

Uncertain prognosis as 25% progress to end stage renal failure in 10-30 years

Stress importance of adhering to blood pressure control

Question 19

Heavy proteinuria, and certain histological features, are poor prognostic signs, being associated with a higher risk of progression

What is a favorable prognostic factor in the urine that this patient had?

Answer 19

Macroscopic haematuria

Question 20

Mr MacDonald takes his medication reliably and attends clinic regularly. Despite this, his renal function declines steadily.
8 years after his biopsy, his creatinine is 370micromol/L, and estimated GFR 18ml/min

What issues should be discussed at this stage?
What are the treatment options?

Answer 20

Should discuss the issue that the patient may need to go through dialysis in 1 to
2 years

Haemodialysis, peritoneal dialysis and pre emptive transplantation are options

Question 21

Education about treatment options is usually given by specialist nurses, and medical staff, so that the patient can make an informed choice.

If haematuira and proteinuria are both present, where is likely to be the source of the haematuria?

Answer 21

The kidneys

Question 22

In young patients (age <45), isolated haematuria (without proteinuria) is most likely to be from the kidneys; in older patients, where is likely to be the source?

Answer 22

Source is likely to be from the bladder if isolated haematuria in older patients

Question 23

IgA nephropathy is a common condition, and a common cause of microscopic and macroscopic haematuria
Some patients with IgA nephropathy progress to established renal failure; heavy proteinuria and certain features of renal biopsy predict those who are more likely to progress

What is it important to discuss before renal replacement therapy is considered?

Answer 23

It is important to discuss treatment options, and to identify potential live donors if appropriate, before renal replacement therapy is required.