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Flashcards in Glomerulonephritis Deck (50):
1

What is glomerulonephritis?

Inflammatory disorder of the kidney

2

What percentage of end stage kidney disease is glomerulonephritis responsible for?

Up to 30%

3

Give some of the many ways glomerulonephritis can present

Proteinuria
Renal Failure
Hypertension

4

How is glomerulonephritis classified?

Morphology:
-Proliferative
-Non-proliferative

5

What do we mean by proliferative glomerulonephritis?

Characterised by excessive numbers of cells in glomeruli

These include infiltrating leucocytes

6

What do we mean by non-proliferative glomerulonephritis?

Glomeruli look normal or have areas of scarring.

They have normal numbers of cells

Tubules and interstitium may be damaged

7

What are the different types of proliferative glomerular nephritis?

Diffuse proliferative
-Post infective nephritis

Focal proliferative
-Mesangial IgA disease

Focal necrotising (crescentic) nephritis

Membrano-proliferative nephritis

8

How do you differentiate diffuse and focal proliferative glomerulonephritis?

Decided on percentage of glomeruli effected

9

How do you diagnose diffuse proliferative (post infective) glomerulonephritis?

Microscopy
Electron microscopy
Immunoflourescence

10

When does diffuse proliferative glomerulonephritis present?

Follows 10-21 days after infection typically of throat or skin

11

What organism is diffuse proliferative glomerulonephritis most commonly associated with?

Lancefield group A Streptococci

12

How does acute nephritis present?

(typical of post infective glomerulonephritis)

Fluid retention with oedema

Normal serum albumin

Little proteinuria

Hypertension

Renal impairment

13

What is the treatment for Post infective glomerulonephritis?

Antibiotics for infection

Loop diuretics such as frusemide for oedema

Vasodilator drugs (e.g. amlodipine) for hypertension

Consider immunosupression for severe disease

14

If someone presents with what looks like post infective glomerulonephritis when would you do a biopsy?

Test urine and bloods

If it looks like post infective treat as such

If they get better then great

If not biopsy
-Invasive

15

What is the commonest cause of glomerulonephritis?

IgA nephropathy

16

How does IgA nephropathy present?

Typically occurs in the young

Presents with macroscopic haematuria
-Very occassionally microscopic

Provoked by inter current infection

Usually not hypertensive

17

What are the investigative tests like in IgA nephropathy?

Laboratory tests reflect renal function

No characteristic serology

Diagnosed by renal biopsy

18

How does the renal biopsy in IgA nephropathy appear?

Microscopy
-Mesangia expansion
(mesangio-proliferative)

Immunoflourescence
-IgA deposits seen

Electron-Microscopy

19

how does IgA nephropathy present in adults?

Often have an insidious onset

Prognosis of IgA nephropathy is worse in adults - 25% develop renal failure

20

How do you treat IgA nephropathy?

Non-specific with ACE inhibitors and other hypotensives

21

What is segmental necrosis?

Such an intense proliferation that the capillaries rupture

(morphological appearance -> not diagnosis)

22

How does crescentic glomerulonephritis present?

Rapidly progressive glomerulonephritis

May occur in isolation or complicate other diseases e.g. chronic nephritis, vasculitis

MEDICAL EMERGENCY

23

What 3 main settings does focal necrotising (crescentic) glomerulonephritis occur?

In the presence of anti-glomerular basement membrae antibodies (Goodpastures syndrome)

Associated with systemic vasculitis (e.g. Wegener's granulomatosis, Microscopic polyangiitis)

As a complication of other types of glomerulonephritis including post-streptococcal glomerulonephrotos and mesangial IgA disease

24

What is goodpasture's syndrome?

Rare disease caused by autoimmunity to the Glomerular basement membrane

Typically presents as nephritis with or without lung haemorrhage

Diagnosed by demonstrating anti-GBM antibodies in serum and kidney

Treated by plasma exchange and immunosupression

25

How do you treat crescentic glomerulonephritis?

immunosuppression:
-Prednisolone
-Cytotoxic drugs (e.g. cyclophosphamide)
-Plasma exchange

26

Summerise Proliferative glomerulonephritis

Presents with nephritic syndrome

Blood on dipstix
-None or minimal proteinuria

Can be medical emergency with rapidly progressive glomerulonephritis

27

What are the different types of non-proliferative glomerulonephritis?

Minimal change disease

Focal glomerulonephritis

Membranous nephropathy

CAUSE NEPHROTIC SYNDROME

28

What is the clinical triad of nephrotic syndrome?

Pitting Oedema

Proteinuria (>5G)

Hypoalbuminaemia (

29

What is the definition of nephrotic syndrome?

A clinical syndrome in which severe oedema is caused by hypoalbuminia due to loss of protein in the urine.

Specifically there is:
-Serum albumin (5G/25hrs
-(normal

30

What additional features may be seen in nephrotic syndrome?

Hyperlipidaemia

Hypercoagulable state

Increased risk of infection, especially with pneumococcus

31

What is the differential diagnosis of nephrotic syndrome?

Congestive Heart Failure
-JVP raised,
-Normal albumin
-Minimal proteinuria

Hepatic disease
-Abnormal LFTs
-No proteinuria

32

What are the principles of management of nephrotic syndrome?

Specific management

Treatment of oedema

Prophylaxis against complications

33

What is the specific management of nephrotic syndrome?

1. Make specific diagnosis, e.g. by renal biopsy

2. Specific treatment when indicated

3. Consider Rx with prednisolone if severe

34

How do you treat oedema in nephrotic syndrome?

1. Fluid and sodium restriction

2. Normal to high protein diet

3. Rx " loop diuretics" such as frusemide

4. Infusion of albumin with frusemide IV for resistant oedema

35

What prophylaxis against complications do you use in nephrotic syndrome?

1. Penicillin V (250mg qds) as prophylaxis against infection

2. Consider heparin as prophylaxis against thrombosis

3. Treat hyperlipidaemia in those with persistent nephrotic syndrome

36

What is minimal change nephrotic syndrome?

Commonest form in children

Sudden onset of oedema - days

Complete loss of proteinuria with steroids

Two thirds of patients relapse

37

Explain the morphology of minimal change nephrotic syndrome

Normal microscopy

Normal immunofluorescence

Only see small change on EM
-Slight change to podocytes

38

What is the treatment of minimal change nephrotic syndrome?

Prednisolone
-60mg/M2 per day with rapid tapering dose after a max of 8 weeks

Initial relapse treated in the same way

Subsequent relapses treated with 8 week course on cyclophosphamide or with continuous cyclosporin

39

What are the complications of steroid responsive (minimal change) nephrotic syndrome?

Bacterial infection, especially with pneumococcus

Thrombosis, especially in adults

40

What is the prognosis of steroid responsive (minimal change) nephrotic syndrome?

Resolves eventually and the long term prognosis is good: patients so not develop renal failure

NB in the pre-antibiotic and pre-steroid era, 60% of patients died

41

What are the clinical features of focal glomerulosclerosis (steroid resistant nephrotic syndrome)?

Severe nephrotic syndrome, especially in men in their 4th decade

Symptoms very disabling

At best an incomplete response to steroids

Progresses to renal failure over 2-3 years

Can recur in renal transplants

42

What is the morphology of focal segmental sclerosis?

Immunohistology negative

Adhesion seen at edge of bowman's

43

What is the treatment of focal glomerulosclerosis (steroid resistant nephrotic syndrome)?

Initial trial of steroids
-If responds completely the prognosis as for minimal change; if not poor prognosis

Continue steroids if clinically useful response

Try cyclophosphamide or cyclosporin if steroids fail

Use non-specific drugs to reduce proteinuria
-ACE inhibitors and NNSAIDs (indomethacin)

Give non specific treatment for nephrotic oedema, and prophylaxis against nephrotic complications

44

What is the commonest cause of nephrotic sundrome in adults?

Membranous nephropathy

About half the cases occur in isolation (idiopathic) and about half are associated with another disease

45

What diseases are associated with membranous nephropathy?

Cancers
SLE
Rheumatoid arthritis

46

What drugs are associated with membranous nephropathy?

Hypersensitivity to drugs
-e.g. gold and penicillamine

47

What is the morphology of membranous nephropathy?

All glomeruli

IgG deposits with spikes around them
-These spikes are the hallmark and can be seen on EM

48

What is the management of membranous nephropathy?

Control nephrotic symptoms

Immunosuppression for those with deteriorating renal function

Prednisolone and Chrorambucil alternating monthly for 6 months

Cyclosporin probably ineffective

49

What is the prognosis of membranous nephropathy?

Resolves spontaneously in 25% over 5-10 years

Prognosis good in treated patients whose proteinuria resolves

About 25% are on dialysis at 10 years

Can recur in renal transplants

50

Once you have diagnosed membranous nephropathy what must you rule out?

How do you do this?

Cancer

Tumour markers
-CEA

Search for likely places (according to history)
-e.g. Chest X-ray, barium enema etc