Glomerulonephritis Flashcards

(54 cards)

1
Q

What is glomerulonephritis?

A

Immune mediated disease of the kidney affecting the glomerulus with secondary tubulo-interstitial damage = 2nd commonest cause of end stage renal failure

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2
Q

What is the pathogenesis of glomerulonephritis?

A
Humoral (antibody mediated) = intrinsic or planted antigen, deposition of immune complexes
Cell mediated (T cells)
Inflammatory cells, mediators and complements
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3
Q

What does disruption to the glomerular capillary wall cause?

A

Size and charge selective barrier = disruption leads to haematuria and/or proteinuria

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4
Q

What does damage to the endothelial and mesangial cells lead to?

A

Proliferative lesion and red cells in urine

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5
Q

What does damage to the podocytes lead to?

A

Non-proliferative lesion and protein in urine

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6
Q

What are some features associated with damage to the mesangium?

A

Proliferative, release angiotensin 2, chemokine release, attract inflammatory cells

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7
Q

What are some features associated with damage to the podocytes and endothelial cells?

A

Podocytes = atrophy, loss of size/charge specific barrier

Endothelial cells = vasculitis

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8
Q

How is glomerulonephritis diagnosed?

A

Clinical presentation and blood tests
Examination of urine
Kidney biopsy

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9
Q

How can urine be examined?

A

Urinalysis = haematuria, proteinuria
Urine microscopy = RBC (dysmorphic), RBC and granular casts, lipiduria
Urine protein:creatine ratio/24hr urine collection = quantify proteinuria

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10
Q

What is the renal presentation of glomerulonephritis?

A

Haematuria, proteinuria, impaired renal function, hypertension, nephrotic/nephritic/nephrotic-nephritic syndrome

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11
Q

How may haematuria present?

A

Asymptomatic microscopic haematuria

Episodes of macroscopic haematuria

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12
Q

What are the different forms of proteinuria?

A

Microalbuminuria = 30-300mg albuminuria/day
Asymptomatic proteinuria = 1g/day
Heavy proteinuria = 1-3g/day
Nephrotic syndrome = >3g/day

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13
Q

How may impaired renal function present?

A

AKI = rapidly progressive GN-RPGN

CKD/ESRD

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14
Q

What are the features of nephritic syndrome?

A

Acute renal failure, oliguria, oedema/fluid retention, hypertension, active urinary sediment

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15
Q

What may urinary sediment consist of?

A

RBC, RBC and granular casts

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16
Q

What is nephritic syndrome indicative of?

A

A proliferative process affecting the endothelial cells

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17
Q

What are some features of nephrotic syndrome?

A

Proteinuria >3g/day (mostly albumin, also globulin)

Hypoalbuminaemia (<30), oedema, hypercholesterolaemia, usually normal renal function

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18
Q

What is nephrotic syndrome indicative of?

A

A non-proliferative process affecting podocytes

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19
Q

What are some complications of nephrotic syndrome?

A

Infection = loss of opsonising antibodies
Renal vein thrombosis and pulmonary emboli
Volume depletion = due to over-aggressive diuretics use, may lead to ARF (pre-renal)
Vitamin D deficiency
Subclinical hypothyroidism

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20
Q

What are the two classes of glomerulonephritis?

A

10 (idiopathic) = majority of cases

20 = caused by infection/drugs, associated with malignancy or as part of systemic disease

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21
Q

How is glomerulonephritis looked at histologically?

A

Renal biopsy, light microscopy, immunofluorescence, EM

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22
Q

What does proliferative and non-proliferative classification refer to?

A

The presence or absence of proliferation of mesangial cells

23
Q

What are the histological classifications of glomerulonephritis?

A

Proliferative and non-proliferative
Focal and diffuse = < or > 50% glomeruli affected
Global and segmental = all or part of glomeruli affected
Crescenteric = presence of crescents

24
Q

What causes a crescenteric appearance?

A

Epithelial cell extracapillary proliferation

25
What are the principles of glomerulonephritis treatment?
Reduce degree of proteinuria Induce remission of nephrotic syndrome Preserve long term renal function
26
What are some non-immunosuppressive treatment options?
Anti-hypertensives, ACE inhibitors/ARBs, statins, diuretics, omega 3 fatty acids/fish oil, anticoagulants, aspirin, anti-platelets
27
What is the target BP for patients with glomerulonephritis?
<130/80 mmHg or <120/75 mmHg if proteinuria present
28
What are some immunosuppressive drugs used in the treatment of glomerulonephritis?
Corticosteroids = prednisolone/methylprednisolone IV Azathioprine and mycophenolate mofetil (MMF) Alkylating agents = cyclophosphamide, chlorambucil Calcineurin inhibitors = cyclosporin, tacrolimus
29
What are the immunosuppressive treatment options for glomerulonephritis?
Immunosuppressive drugs Plasmapharesis = therapeutic plasma exchange IV immunoglobulin, monoclonal T/B cell antibodies
30
What is the treatment for nephrotic patients?
General = fluids, salt restriction, diuretics, ACEi/ARBs, anticoagulation, IV albumin (only if volume deplete) Immunosuppression
31
What is the aim of treatment for nephrotic patients?
Induce sustained remission: Complete remission = proteinuria < 300mg/day Partial remission = proteinuria < 3g/day
32
What are the main idiopathic (10) types of glomerulonephritis?
Minimal change, focal segmental glomerulosclerosis, membranous nephropathy, membranoproliferative, IgA nephropathy
33
What are some features of minimal change nephropathy?
Commonest cause of nephrotic syndrome in children | Doesn't cause progressive renal failure
34
What is a possible cause of minimal change nephropathy?
IL-3
35
How does minimal change nephropathy appear on biopsy?
Normal renal biopsy on LM and IF with foot process fusion on EM
36
How is minimal change nephropathy treated?
94% complete remission with oral steroids Some are steroid resistant/dependent or have relapses Second line agents = cyclophosphamide, CSA
37
What are some features of focal segmental glomerulosclerosis (FSGS)?
Commonest cause of nephrotic syndrome in adults 10 or 20 = HIV, heroin, obesity, reflux nephropathy Minimal Ig/complement deposition on IF
38
What is the prognosis of focal segmental glomerulosclerosis?
Remission with prolonged steroids in 60% | 50% progress to end stage failure after 10 years
39
What are some features of membranous nephropathy?
2nd commonest cause of nephrotic syndrome in adults | 10 or 20 = hep B, parasites, lupus, carcinoma, lymphoma, gold, penicillamine
40
How does membranous nephropathy appear on biopsy?
Subepithelial immune complex deposition in basement membrane
41
What is antibody is implicated in membranous nephropathy?
Anti-PLA2r antibody present in >70% of primary cases
42
How is membranous nephropathy treated?
Steroids, alkylating agent, B cell monoclonal antibody
43
What is the prognosis of membranous nephropathy?
30% progress to end stage renal failure in 10 years
44
What are some features of IgA nephropathy?
Most common form of GN in the world | 25% progress to end stage renal failure in 10-30 years
45
How does IgA nephropathy present?
Asymptomatic microhaematuria and non-nephrotic range proteinuria, AKI/CKD, macroscopic haematuria after resp/GI infection
46
What is IgA nephropathy associated with?
Henoch-Schonlein purpura = arthritis, colitis, purpuric skin rash
47
How does IgA nephropathy appear on biopsy?
Mesangial cell proliferation and expansion on light microscopy with IgA deposits in mesangium on IF
48
How is IgA nephropathy treated?
BP control, ACEi/ARBs, fish oil
49
What is rapidly progressive glomerulonephritis (RPGN)?
Rapid deterioration in renal function over days-weeks = may be part of systemic disease
50
What are some features of rapidly progressive glomerulonephritis?
Active urinary sediment | Associated with glomerular crescents on biopsy
51
What are some causes of rapidly progressive glomerulonephritis?
ANCA positive = GPA, microscopic polyangiitis | ANCA negative = Goodpasture's (anti-GBM), Henoch-Schonlein purpura (IgA), SLE
52
What are the aims of treatment for rapidly progressive glomerulonephritis?
Treatment should be prompt and consist of strong immunosuppression with supportive care
53
What is the treatment of rapidly progressive glomerulonephritis?
Immunosuppression and plasmapharesis
54
What immunosuppressive agents can be used to treat rapidly progressive glomerulonephritis?
``` Steroids = IV methylprednisolone, oral prednisolone Cytotoxics = cyclophosphamide, MMF, azathioprine ```