Week 4 - I(2) - Glomerulonephritis lecture - treatment part

Question 1

What is the first and second most common causes of end stage renal failure?

Answer 1

Dibetes - 1st Chronic glomerulonephritis - 2nd

Question 2

Acute GN is an important treatable cause of Acute Renal Failure What is glomerulonephritis?

Answer 2

Immune mediated disease of the kidneys affecting the glomeruli

Question 3

What happens secondary to the glomeruli being damaged by glomerulonephritis?

Answer 3

secondary tubulointerstitial damage

Question 4

What is the yellow shown in the picture?

Answer 4

These are the podocytes - specialized cell of the bowmans capsule that wrap around the capillaries

Question 5

What are the three layers of the glomerular membrane?

Answer 5

Fenestrated capillaries Basemant membrane (lamina propria) Podocytes with filtration slits

Question 6

The glomerular membrane is a size and charge selective barrier What does glomerulonephritis do to the barrier?

Answer 6

It causes damage to the barrier allowing blood and protein to leak through - haematuria and proteinuria

Question 7

There is proliferative and nonproliferative lesions occuring during gloerulonephrtiis What does damage to the podocytes lead to?

Answer 7

Damage to the podocytes leads to a non-proliferative lesion and protein in the urine

Question 8

Damage to what leads to a proliferative response from the kidneys? What is in the urine?

Answer 8

Damage to the endothelium or mesagnial cells leads to a proliferative response and red blood cells in the urine

Question 9

What is the function of the mesangial cells?

Answer 9

They are supporting cells between capillaries holding the matrix together Secrete phagocytes if there is antigen

Question 10

Why is it that protein will appear in the urine if there is damage to the podocytes?

Answer 10

This is because the negative charge of the podocytes ill be lost and the large proteins will not be repelled The size/charge specific barrier is lost

Question 11

Damage to the mesangium and endothelial results int he release of what?

Answer 11

Results in proliferation, and attracts inflammatory cells

Question 12

24 year old man incidentally found to have ++ blood and + protein on dip, BP 148/92. Protein quantified at 0.7g/day. Creat 72. What glomerular cells are most likely to be injured? (endothelial, mesangial or podocytes)

Answer 12

The cell mot likely to be injured is the mesangial cells If damage endothelial cells – the creatinine would not be normal as the filtration rate would be damaged

Question 13

When carrying out urinalysis, what is suggestive of glomerular disease? One thing in particular

Answer 13

Proteinuria

Question 14

How is the amount of protein quantified?

Answer 14

24hour urine preotein or protein:creatinine ratio

Question 15

What aounts of proetin suggest nephrotic syndrome? What is done after quantifying the protein to find out the cause?

Answer 15

24 hour urine protein - 3g/day Protein:creatinine ratio - 300mg/mmol

Question 16

Nephrotic syndrome will also present with hypoalbuminaemia, what level of albumin is this?

Answer 16

Less than 25g/l

Question 17

When looking at urine microscopy of the red blood cells, how can this help to identify where the urine came from?

Answer 17

Urine microscopy of red blood cells are dysmorphic is the bleed is coming from the glomerulus - have to be squashed through isomorphic if lower urinary tract

Question 18

A patient’s urinary casts can also be looked at on microscopy What does a red cell cast inidcate?

Answer 18

This indictes nephritic syndrome - glomerulonephritis

Question 19

What does granular casts indicate?

Answer 19

Inidcates chronic kidney disease or acute tubular necrosis (muddy brown casts)

Question 20

Which type of casts indicate nephrotic syndrome?

Answer 20

Fatty catsts in the urine

Question 21

What are the features of nephritic syndrome?

Answer 21

Acute renal failure Oliguria Haematuria High blood pressure RBCs and granular casts Oedema/fluid retention Azotemia

Question 22

What type of process is nephritic syndrome indicative of? What is azostemia?

Answer 22

It is highly suggestive of a non-proliferative process affecting the endothelial/mesangial cells Azostemia is abnormally elevated levels of nitrogen in the blood using due to renal dysfunction preventing filtration

Question 23

What is oliguria defined as?

Answer 23

it is a urinary output of less than 400ml/day

Question 24

What is the typical triad of nephritic syndrome features then?

Answer 24

Hameaturia Oliguria Hypertension (azotemia)

Question 25

What type of process affecting what is seen in nephrotic syndrome ?

Answer 25

This would be a non-proliferative proces causing podocyte disruption

Question 26

What are the clinical features of nephrotic syndrome?

Answer 26

Proteinuria - greater than 3g/day Hypoalbuminaemia - less than 25g/l Oedema Hyperlipidaemia Usually renal function is normal

Question 27

Does kidney function usually decline in nephrotic or nephritic syndrome?

Answer 27

Kidney function usually declines in nephritic syndrome

Question 28

What are complications of nephrotic syndrome?

Answer 28

Renal vein thrombosis Infections Volume depletion - if overuse of diuretics

Question 29

How does GN differ from a non glomerular disease like Interstitial Nephritis?

Answer 29

intersitial nephritis is a disease affecting the interstitium

Question 30

What is the main cause of glomerulonephritis?

Answer 30

Idiopathic

Question 31

What is next most common cause of glomerulonephritis after idopathic?

Answer 31

This would be due to post streptococcal inflammation - streptoccoal antigen will circulate and deposit in the glomerulus

Question 32

What are the investigations carried out to check for glomerulonephritis?

Answer 32

Renal biopsy and then - A renal biopsy is carried out and then a light microscopy – then immunofloursecne (stained the kindey for IgG), and then electon microspy – good to see the glomerular membrane

Question 33

HISTOLOGICAL CLASSIFICATION in GN What does proliferative or non proliferative usually refer to?

Answer 33

usually refers to the presence or absence of mesangial cell proliferation

Question 34

What does focal or diffuse glomerulonephritis refer to?

Answer 34

Less than or greater than 50% of the glomeruli are affected

Question 35

Global/Segmental (all or part glomerulus affected) What does crescent shapes on histology mean?

Answer 35

Rapid progressive glomerulonephritis - epithelial cell extracapillary proliferation

Question 36

What is the aims of treatment for glomerulonephritis?

Answer 36

Decrease proteinuria Induce remission of nephrotic syndrome Preserve long term renal function

Question 37

Treatment of glomerulonephritis is NON-IMMUNOSUPPRESSIVE and IMMUNOSUPPRESSIVE What are non-immunosupressive treatments aimed at?

Answer 37

Aimed at lowering the blood pressure of the patient

Question 38

What is the target blood pressure in GN? What is given?

Answer 38

Target blood pressure is 130/80 Give ACEi/ARBS to try maintain this blood pressure

Question 39

What can be given for the oedema and the hyperlipidaemia in glomerlonephrtiis?

Answer 39

Hyperlipidaemia - statin Oedema - diuretic for symptoms - increases fluid excretion

Question 40

Omega 3 fatty acids/ Fish oil What should you watch the intake of in GN?

Answer 40

Watch the intake of salt

Question 41

Non immunosuppressive treatment is usally given for nephrotic syndrome as it is non proliferative and does not require it What is the treatment given for nephritic syndrome?

Answer 41

This owould be immunosuppressants - corticosteroids and cyclophosphamide

Question 42

What is the main dietary and pharmacological treatment of glomerulonephritis then?

Answer 42

Dietary - fluid restrict and salt restrict ACEI/ARBS Diuretics for oedema Anticoagulants? IV alumin if completely depleted

Question 43

the aim of treatment is to control proteinuria and induce sustained remission What is remission in nephrotic syndrome?

Answer 43

Complete remission - proteinuria <300mg/day Partial remission <3g/day

Question 44

What are the risks of immunosuppressing a patient who is nephrotic?

Answer 44

Infection is the main risk