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Glomerular Disease Flashcards

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1
Q

How does blood enter to the glomerulus?

A

Via the afferent arteriole

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2
Q

What will NOT be filtered by the glomerulus and will stay in the plasma?

A

All proteins equal to or larger than albumin (including immunoglobulins)

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3
Q

Layers of the filter barrier

A
  1. Endothelial cell cytoplasm
  2. Basal lamina
  3. Podocytes
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4
Q

How many layers does the glomerular membrane / filter have?

A

3

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5
Q

What are mesangial cells?

A

Tree like group of cells (pericytes) which support capillaries

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6
Q

Where does filtrate go?

A

Into bowmans space then into the proximal tubule

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7
Q

What does the efferent arteriole contain?

A

Plasma

Unfiltered proteins e.g. albumin and antibodies

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8
Q

Classification of glomerulonephritis

A

Primary

Secondary

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9
Q

What is primary glomerulonephritis?

A

Only affects the glomerulus

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10
Q

What is secondary glomerulonephritis?

A

Other parts of the body are affected also e.g. Wegeners, SLE

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11
Q

What is glomerulonephritis a disease of?

A

The glomerulus

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12
Q

What are the 4 presentations of glomerulonephritis?

A

Haematuria
Heavy proteinuria (causing nephrotic syndrome). Very suddenly comes on
Slowly increasing proteinuria
Acute renal failure

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13
Q

Definition of haematuria

A

Blood in urine

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14
Q

4 most common causes of haematuria (in order of most to least common)

A
  1. UTI
  2. Urinary tract stone +/- infection
  3. Urinary tract tumour
  4. Glomerulonephritis
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15
Q

What must always be checked before a renal biopsy?

A

Clotting

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16
Q

Types of glomerulonephritis

A

IgA Glomerulonephritis
Membranous Glomerulonephritis
Diabetic Nephropathy
Crescentic Glomerulonephritis

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17
Q

Presentation of IgA Glomerulonephritis

A

Discoloured urine - dipstick +ve for blood

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18
Q

What would be seen in IgA Glomerulonephritis on kidney biopsy?

A

IgA immunoglobulins and complement C3 in mesangial area of all glomeruli

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19
Q

What would be seen in IgA glomerulonephritis on electron microscopy?

A

Deposits of IgA with prominent mesangial cells

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20
Q

Is there excess antibody produced in IgA glomerulonephritis?

A

Sometimes present in the serum however this is also sometimes true for people without the IgA glomerulonephritis - so no

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21
Q

Pathology of IgA glomerulonephritis

A

IgA gets stuck within the mesangium

IgA irritates the mesangial cells and causes them to proliferate and produce more matrix

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22
Q

Prognosis of IgA nephropathy

A

Usually self limiting i.e. return to normal

Small % go onto chronic renal failure due to continued deposition of the matrix

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23
Q

Presentation of membranous glomerulonephritis

A 
Feeling generally unwell 
Swollen legs 
Low albumin 
Dipstick proteinuria 
Haematuria
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24
Q

Pathology of membranous glomerulonephritis

A

Thickened glomerular basement membrane
Spikes of new basement membrane matrix material underneath podocytes (matrix tries to surround and remove the deposit)
Deposit of IgG. IgG is too big to be filtered into the urine but activates complement (C3) which punches holes in the filter.
Damage to basal lamina
End up with leaky basal lamina - leaking albumin into the urine (nephrotic syndrome)

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25
Is albumin filtered out of the plasma?
No
26
What is stuck in the membrane in membranous glomerulonephritis?
IgG
27
Prognosis of membranous glomerulonephritis
1/4 chronic renal failure within 10 years
28
What would be seen on a renal biopsy in diabetic nephropathy?
Glycated molecules -> matrix deposition in basal lamina underlying endothelium and in mesangial matrix -> thickened but leaky basement membranes and mesangial matrix compresses capillaries (no immune complexes)
29
Pathology of diabetic nephropathy
Thickened capillary wall which is leaking albumin Increased mesangial matrix (which compresses capillaries) Thickened, narrowed arterioles reduce blood flow to the glomerulus Adhesions to Bowmans capsule are glomerulus attempt to stop massive leakage of albumin into the urine Gross excess of mesangial matrix forming nodules
30
What are the nodules of the mesangial matrix in diabetic nephropathy called?
Kimmel-steil Wilson Lesion
31
When is there inevitable decline of diabetic nephropathy?
Established diabetic nephropathy AND Continued poor glycaemic control
32
What does rapidly rising creatinine indicate?
Acute renal failure
33
Pathology of crescentic glomerulonephritis
Cellular proliferation and influx of macrophages (=crescent) around glomerular tuft, within bowmans space Endothelial damage with fibrin deposition Crescent often ends up with a C shape
34
Causes of the pattern of injury seen in crescentic glomerulonephritis
Wegeners granulomatosis Microscopic polyarteriits Antiglomerular basement membrane disease Other forms of glomerulonephritis
35
What is another name for wegeners granulomatosis?
Granulomatosis with polyangitis
36
What is wegeners granulomatosis?
A form of vasculitis which affects the vessels in kidneys, nose and lungs
37
Definition of vasculitis
Primary inflammation of the vessels
38
Investigation for wegeners
Serum ANCA
39
What does ANCA stand for?
Anti-neutrophil cytoplasmic antibodies
40
Is ANCA deposited in the kidney?
No
41
How does ANCA cause damage?
Antibodies directed against proteinase 3 and myeloperoxidase, 2 enzymes in primary granules of neutrophils Antibodies product tissue damage via interactions with primed neutrophils and endothelial cells
42
Prognosis of wegeners
Fatal (mean survival 6 months) if untreated
43
Treatment of wegeners
Cyclophosphamde (chemotherapy) - 75% complete remission
44
Types of haematuria
Macroscopic | Microscopic
45
What is macroscopic haematuria?
Tea or cold coloured or frank blood in the urine
46
What is microscopic haematuria?
> 5 RBCs per high power field
47
What can be the source of haematuria?
``` Kidney Ureter Bladder Prostate Urethra ```
48
What type of haematuria is seen in glomerulonephritis?
Persistent microscopic haematuria | Microscopy shows dysmorphic RBCs (mickey-mouse like)
49
Types of proteinuria
Glomerular or tubular | Albumineria or proteinuria
50
Which of nephritis and nephrotic syndrome presents with haematuria more?
Nephritis > nephrotic
51
Which one of nephritis or nephrotic syndrome presents with haematuria more?
Nephritis = Nephrosis
52
What type of proteinuria is present in glomerulonephritis?
Persistent | Proteinuria of more than 1 gram/mmol creatinine
53
What % of end stage kidney disease does glomerulonephritis make up?
30%
54
What is glomerulonephritis classified based on?
Morphology
55
What are the majority of glomerulonephritis attributed to?
Autoimmune aetiologies
56
Features of glomerulonephritis
Haematuria Proteinuria Hypertension Renal insufficiency
57
Which of nephrotic syndrome and nephritic syndrome is there mostly HTN?
Nephritis > Nephrotic
58
Features of the nephritic state
``` Active urine sediment - haematuria - dysmorphic RBCs - cellular casts HTN Renal impairment ```
59
Features of nephrotic state
Oedema Proteinuria >3.5g/day Hypoalbuminemia Hyperlipidaemia
60
Differential diagnosis of nephrotic syndrome
``` CHF (raised JVP, normal albumin, minimal proteinuria) Hepatic disease (abnormal LFTs, no proteinuria) ```
61
Causes of glomerulonephritis
``` Autoimmune Infection Malignancy Drugs Others ```
62
Types of glomerulonephritis
Primary; kidney alone | Secondary; part of a multisystem disease
63
Morphological types of glomerulonephritis
Proliferative | Non-proliferative
64
Features of proliferative glomerulonephritis
Excessive numbers of cells in glomeruli - these include infiltrating leucocytes
65
Features of non proliferative glomerulonephritis
Glomeruli look normal or have areas of scarring | They have normal numbers of cells
66
What can nephrotic syndrome cause?
Minimal change disease | Membranous nephropathy
67
What can nephritic state cause?
ANCA associated glomerulonephritis | Post infection glomerulonephritis
68
Is minimal change disease caused by nephrotic or nephritic disease?
Nephrotic
69
Is diffuse proliferative GN and crescenteric GN more nephrotic or nephritic?
Nephritic
70
Is membranoproliferative GN more nephrotic or nephritic?
Nephrotic 2 > 3 Nephritic
71
Is mesangioproliferative GN more nephrotic or nephritic?
Both the same
72
Examples of proliferative glomerulinephritis
Diffuse proliferative - post infection nephritis Focal proliferative - mesangial IgA disease Focal necrotising (crescentic) nephritis Membrano-proliferative nephritis
73
Treatment of post infective glomerulonephritis
Antibiotics for infection Loop diuretics such as furesimide for oedema Vasodilator drugs (e.g. amlodipine) for HTN
74
When does post-streptococcal glomerulonephritis occur?
10 - 21 days after an infection typically of throat or skin
75
What is the post streptococcal glomerulonephritis most common organism?
Lancefield Group A streptococci
76
What is the genetic predisposition to post strep glomerulonephritis?
HLA-DR
77
What is the most common cause of glomerulonephritis worldwide?
IgA nephropathy
78
Pathology of IgA Nephropathy
IgA deposition in the mesangium and mesangial proliferation
79
What decade of life does IgA nephropathy present? What gender?
2nd and 3rd | M > F
80
What % of IgA nephropathy can progress to end stage kidney disease?
40%
81
Presentation of IgA nephropathy
Microscopic haematuria Microscopic haematuria + proteinuria Nephrotic syndrome IgA Crescentic glomerulonephritis
82
Treatment for Focal necrotising glomerulonephritis
High dose steroids Cyclophosphamide Plasma exchange
83
Treatment of crescentic glomerulonephirits
Immunosuppression - corticosteriods - plasma exchange - cyclophosphamide - B cell therapy e.g. rituximab - complement inhibitors
84
Treatment of crescentric GN
High dose steroids Cyclophosphamide Plasma exchange
85
What is anti-GMB disease?
Rare disease caused by circulating anti-GBM
86
What % of crescenteric glomerulonephritis does anti-GMB make up?
10-20%
87
Presentation of anti-GMB disease
Nephritis (anti-GMB GN) | Nephritis + lung haemorrhage (goodpastures syndrome)
88
Peak ages for anti-GMB disease
3rd decade
89
Investigations for anti-GMB disease
Anti-GBM antibodies in serum and kidneys
90
Treatment of anti-GMB disease
Aggressive immunosuppression - steroids - plasma exchange - cyclophosphamide
91
What do proliferative GNs present with?
Nephritic syndrome
92
Types of non proliferative GN
Minimal change disease Focal and segmental GN Membranous nephropathy
93
Treatment of nephrotic syndrome
``` Salt restriction Loop diuretics RAAS blocker Heparin or warfarin Reduce infection e.g. pneumococcal vaccine Statins Specific therapy to the cause ```
94
What is the commonest form of nephrotic syndrome in children?
Minimal change
95
Presentation of minimal change disease
Sudden onset of oedema - days | Nephrotic syndrome
96
Response of minimal change disease to steroids
Complete loss of proteinuria with steroids
97
How many patients with minimal change disease relapse?
2/3
98
Treatment of minimal change disease
``` Prednisolone 1mg/kg for up to 16 weeks Once remission slow taper over 6 months Subsequent relapse can be treated with - cyclophosphamide - cyclosporin - tacrolimus - mycophenolate mofetil - rituximab ```
99
Prognosis of minimal change disease
Despite relapsing behaviour, prognosis Is favourable Risk of end stage kidney disease is low Steriods toxicity as multiple exposure
100
What is focal and segmental GN?
Not a single disease, a syndrome with multiple causes
101
What does focal and segmental GN present with?
Nephrotic syndrome
102
Histology of focal and segmental GN
Tip lesion Collapsing Cellular Perihillar
103
What is an important feature of focal and segmental GN?
Steriod resistant
104
Chance of progression of focal and segmental GN to end stage kidney disease
High chance
105
Treatment of focal and segmental GN
``` General measures Steroids Alternative - cyclosporin - cyclophosphamide - rituximab ```
106
What is the commonest cause of nephrotic syndrome in adults?
Membranous nephropathy
107
Most common cause of membranous nephropathy
Idiopathic
108
Serological markers of membranous nephropathy
Anti-phospholipase A2 receptor (PLA2R) antibody +ve in 70% of idiopathic cases Thrombospondin type 1 domain containing 7A (THSD7A)
109
Causes of membraneous nephropathy
``` Idiopathic Malignancies SLE RA Drugs - NSAIDs - Gold - Penicillamine ```
110
Treatment of membraneous nephropathy
``` General measures for at least 6 months Immunosuppression if - symptomatic nephropathic syndrome - rising proteinuria - deteriorating renal function Cyclophosphamide and steroids (alternate months) for 6 months Cyclosporine Rituximab ```
111
In how many people with membraneous nephropathy resolve spontaneously?
1/3
112
What % of patients with membraneous glomerulonephritis are on dialysis at 10 years?
25%
113
In what patients can membranous glomerulonephritis can recur?
Renal transplants
114
What does non proliferative GN present with?
Nephrotic syndrome
115
What is the triad of nephrotic syndrome?
Proteinuria Hypoalbuminuria Oedema
116
What is minimal change disease very susceptible to?
Steriods
117
What is creatinine?
A breakdown product from skeletal muscles
118
Is creatinine toxic?
Not toxic, just used as a measurement
119
Features of goodpastures syndrome
Rapidly progressive GN | Lung haemorrhage
120
Pathology of goodpastures syndrome
anti-GBM antibodies against collagen type IV
121
Who gets goodpastures?
M > F | 20 - 30 + 60 - 70
122
Association of goodpastures
HLA-DR2
123
Factors which increase the likelihood of pulmonary haemorrhage
``` Smoking LRTI Pulmonary oedema Inhalation of hydrocarbons Young males ```
124
Investigations of goodpastures
``` Renal biopsy (linear IgG deposits along basement membranes) Raised transfer factor (secondary to pulmonary haemorrhages) ```
125
Management of goodpastures
Plasma exchange Steroids Cyclophosphamide
126
Post strep GN vs IgA nephropathy WHEN they present
IgA - 1 - 2 days after URTI | Post strep - 1 - 2 weeks after URTI
127
Presenting factor (mostly) IgA vs post strep GN
IgA - macroscopic haematuria | Post strep - proteinuria
128
What kind of state is membraneous GN?
Hypercoagulable state
129
How is nephrotic syndrome a hypercoagulable state?
Loss of antithrombin III via the kidneys
130
What is the pneumonic to remember the variables for eGFR and what do they stand for?
CAGE - creatinine - age - gender - ethnicity

Renal Pathology (13 decks)

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