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SPINE Semester 2 > Introduction to renal pathology > Flashcards

Introduction to renal pathology Flashcards

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1
Q

What structure should you want to include in a renal biopsy?

A

Glomeruli

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2
Q

What is the gold standard for diagnosis of glomerular disease?

A

Renal biopsy

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3
Q

What bedside investigations are done for suspected glomerulonephritis?

A

Urine dip
Urine albumin: creatinine ratio
Obs -> esp BP (high)

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4
Q

What bloods should be done in a suspected glomerulonephritis?

A

FBCs, U&Es, LFTs, bone panel, CRP
Lipid profile, Coagulation, HbA1c

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5
Q

What imagging should be done for suspected glomerulonephritis?

A

Ultrasound - size and morphology
CXR - fibrosis, pulmonary haemorrhage

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6
Q

What specialised investigations may be done for suspected glomerulonephritis?

A

Hep B, Hep C, HIV
ANCAs
Anti-GBM antibodies
ANAs
Anti-dsDNA antibodies
Complement screen
Immunoglobulins
Anti-PLA2R antibodies
Myeloma screen (serum free light chains, serum/urine electrophoresis)

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7
Q

What are the key histological features of this healthy glomerulus?

A

Mesangial cells
Capillary loop
Afferent arteriole
Bowmans capsule

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8
Q

What are the three layers of the glomerular filtration barrier?

A

Fenestrated endothelium
Basement membrane
Visceral epithelial cells (podocytes) - foot processes

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9
Q

What does the glomerular filtration barrier look like under an electron microscope?

A
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10
Q

What is the difference between a focal and diffuse disease of the glomeruli?

A

Focal - only some glomeruli
Diffuse - all glomeruli

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11
Q

What is the difference between a segmental vs a global disease of the glomeruli?

A

Segment - only fraction of the glomerulus
Global - the whole of the glomerus

Does not relate to the number of glomeruli affected

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12
Q

What is the key clinical syndrome of nephrotic syndrome?

A

Proteinuria 3-3.5g or more per day
Hypoalbuminemia - plasma albumin less than 35g/L
Generalized oedema
Hyperlipidemia and lipiduria

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13
Q

What are the key presentation features of nephrotic syndrome?

A

Periorbital/facial oedema
Hypertension
Proteinuria
Peripheral pitting oedema
Genital/sacral oedema
Ascites
Pleural effusion

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14
Q

What are the key features of nephrotic syndrome on urine dip?

A

Protein 2-3+
usually no blood

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15
Q

What are the key features of nephritic syndrome on urine dip?

A

Blood +
Protein +

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16
Q

What is the most common cause of nephrotic syndrome in children?

A

Minimal change disease

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17
Q

What are the difference causes of nephrotic syndrome in children?

A

Minimal change disease - 75%

Focal segmental glomerulosclerosis - 10%
Membranous nephropathy - 3%
IgA nephropathy - 2%

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18
Q

What is the most common cause of nephrotic syndrome in adults?

A

Focal segmental glomerulosclerosis - 35%
Membranous nephropathy - 30%

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19
Q

What are the key secondary causes of nephrotic syndrome?

A

Diabetes mellitus
Amyloidosis

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20
Q

What are all potential secondary causes of nephrotic syndrome?

A

DM
Amyloidosis
SLE
Drugs - NSAIDS, penicillamine, heroin
Infections - malaria, syphilis, hep B/C, HIV
Malignant disease -carcioma, lymphoma
Miscellaneous (bee-sting, herediatry)

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21
Q

What are the key pathological features of minimal change disease?

A

Primary disorder of the podocytes
Normal under-light microscopy
Immunofluorescence negative
Electron microscopy - effacement (dec height and wider width) fusion of the podocyte foot processes

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22
Q

Patient presents with neprhotic syndrome, this is the change in electron microscopy - what pathology is shown on the right?

Study These Flashcards
A

Flattened and effacement of podocyte foot processes - looks more like a grey blob surrounding
Shows minimal change disease

23
Q

What is the key treatment and prognosis for minimal change disease?

Study These Flashcards
A

Corticosteroid therapy
>90% respond rapidly to treatment

24
Q

What is the key pathology of Focal segmental glomerulosclerosis?

Study These Flashcards
A

Podocytopathy
Sclerosis of some glomeruli - affecting only portion of capillary tuft
Immunofluorescent negative
Light micscrope - picks up collagenous sclerosis.

25
What type of biospy (where in the kidney) is needed to ensure Focal glomerulosclerosis is not missed?
Cortico-medullary junction sampling
26
What are the different causes of focal segmental glomerulosclerosis?
Primary/idiopathic Secondary to HIV or adpative (compensatory hypertrophy of remaining tissue due to loss of renal tissue)
27
What is the typical management of FSGS?
Variable response to corticosteroids Children better prognosis that adults 50% will develop end stage renal disease within 10yrs 20% within 2years May recur in renal transplant
28
What are the key pathology of membranous nephropathy?
Immune mediated - antigen antibody complexes - typically subepithelial Diffuse process Complement C5b-C9 membrane attack complex injures glomeruli epithelial and mesangial cells Release proteases and oxidants Capillary wall injury Increased protein leakage
29
What is the key antigen inovled in primary membranous nephropathy?
This causes 75% of cases M type phospholipase A2 receptor (PLA2R) on epithelial/podocyte cells
30
What are the causes of secondary membranous nephropathy?
Drugs - penicillamin, captopril, NSAIDs Underlying malignancy - lung, colon, melanoma SLE Infections - chronic Hep B, hep C, syphilis, schistosomiasis malaria
31
What does membranous nephropathy look like on light microscopy?
Capillary loops are diffusely thickened and prominent Cellularity is not changed Silver stain - spikes - BM deposition between immune complexes
32
What does membranous nephropathy look like on immunofluorescence?
Immunofluorescence positive Granular IgG deposition - along glomerular capillary loops.
33
What does membranous glomerulopathy look like on electron microscopy?
Thickened basement membrane due to interleaved immune complex deposition Looks like snake
34
How does the location of immune complex deposition relate to the disease?
Subepithelial -> acute glomerulonephritis Membranous deposits -? membranous Subendothelial -> Lupus nephritis
35
What is the typical treatment for membranous nephrotic syndrome?
Low risk - conservative (watch and wait) High risk - in heavy proteinuria/declining renal function - immunosuppression such as steroids, cyclophosphamide, rituximab
36
What are the key pathological features of DM causing nephrotic syndrome?
Microvascular injury -> of the glomerular capillaries If marked proteinuria and retinopathy -> most likely diabetic nephropathy Significantly increased morbidity associated with cardiovascular complications
37
What are the key features of diabetic nephropathy on biopsy?
Initial diffuse glomerulosclerosis - increased mesangial matrix Later nodule formation -> called Kimmelstiel-Wilson lesions (N) -> these are dense deposits with rim of cells around nodules Thickened capillaries
38
What is the treatment for diabetic nephropathy?
SGLT2 inhibitors - dapagliflozin ACEi Supportive - statins
39
What are the key features of nephrotic syndrome secondary to amyloidosis on a light microscopy?
Pink deposits of amyloid in/around artieres, interstitium or glomeruli Note - unlike DM are NOT rimmed by cells
40
What is the pathology of nephrotic syndrome secondary to amyloidosis?
Extracellular deposition of protein fibrils with a characteristic Beta -pleated sheet confirmation primary - light chains - plasma cell secondary -AA - due to systemic chronic inflammatory conditions
41
What special stain can be used to identify amyloidosis in the glomeruli? What does this look like?
Congo red stain - deep red colour Can also be viewed under polarised light showing apple green refringence
42
What are the clinical features of nephritic syndrome?
Microscopic hematuria (rbcs and casts) Subnephrotic proteinuria with or without oedema Decline in kidney function Hypertension
43
What are the three main categories of nephritic syndrome?
Immune mediated GN (proliferative) Pauci-immune GN Anti-GBM
44
What are the different types of immune mediated nephritic syndrome?
IgA nephropathy SLE Post-infectious Membranoproliferative glomerulonephritis (MPGN)
45
What are the difference types of Pauci-immune glomerulonephritis?
ANCA associated microscopic vasculitis (wegners, Churg-strauss)
46
How does lupus relate to nephrotic and nephritis syndrome?
Stage 5 lupus = cause nephrotic syndrome All other stages are nephritis
47
What are the key features of rapidly progressive glomerulonephritis as a cause of nephritic syndrome?
Rapid deterioation in renal function Oliguria and nephritic -> death from renal failure within weeks to months Severe glomerular injury
48
What is the appearance of rapidly progressive glomerulonephritis on light microscopy?
Crescentic
49
What are the different causes of cresenteric glomerulonephritis?
SLE IgA nephropathy Post infectious ANCA associated microscopic vasculitis Anti-GBM disease
50
What are the key pathological features of anti_GBM disease?
Anti-body mediated nephritis against fixed glomerular antigens Most common in males 20-40yrs Presents with rapidly progressive glomerulonephritis and pulmonary haemorrhage (good pasture syndrome)
51
What glomerular antigens are targeted in Anti-GBM disease?
alpha 3 chain of type 4 collagen in GBM Also found in the lungs
52
What are the features of anti-GBM on light microscopy?
Segmental necrotizing lesions with capillary rupture Crescents
53
What does anti-GBM disease look like on fluorescence?
Crushed ribbon - linear fluorescence along the glomerular basement membrane

SPINE Semester 2 (31 decks)

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