Nephrology + Urology

Question 1

What triad defines nephrotic syndrome?

Answer 1

1. Proteinuria (>3.5g/day)
2. Hypoalbuminaemia
3. Oedema

**+/- hyperlipidaemia (only assoc. with kidney cause of nephrotic syndrome) and hypercoagulable

Question 2

What are the risk factors of Nephrotic syndrome?

Answer 2

Immunological
Medications
Hodgkins Lymphoma

Asian Male
Minimal change disease dx is most common in kids.

Question 3

Nephrotic syndrome general Px (not triad)?

Answer 3

Oedema
Hypotension
Hypovolaemia (low urine output, tachycardia + absent peripheral pulses)
Possible abdo pain - hypovolaemia can cause mesenteric ischaemia or peritonitis

Question 4

Ix for nephrotic syndrome?

Answer 4

Urine dip (in morning, as by midday everyone has orthostatic proteinuria)
U&E, FBC, LFTs, Hep b, Bone Profile, Immunology

Varicella zoster status - this is because the mainstay Rx for nephrotic syndrome is steroids. If a pt has chicken pox this is v. bad (if this happens, give Aciclovir for 7-10 days)

Biopsy all adults, as worry about para-neoplastic syndromes

Question 5

Rx of thrombosis as a complication of nephrotic syndrome?

Answer 5

Pt on anti-coags for 3-6 months if thrombosis develops.

x7 risk of thrombosis if nephrotic syndrome

Question 6

Rx of nephrotic syndrome?

Answer 6

20% HAS (Human Albumin Solution) of hypovolaemia, pleural effusion or oedema causing skin breakdown (1g/kg).
High-dose steroids
Ranitidine
? Penicillin V
Cyclophospomide (Alkylating agents)given if frequently relapsing ( >4x a yr)

If steroid-resistant, give Cys A or Tacrolimus + biopsy, as 50% go into renal failure in 5-10yrs

Question 7

What is the Px of Nephritic Syndrome?

Answer 7

PHAROAH

P - proteinuria
H - haematuria
A - azotaemia
R - red cell casts
O - oliguria
A - anti-streptolysin O titres
H - hypertension

Question 8

Nephritic syndrome causes/types?

Answer 8

IgA
ANCA+
Anti-GBM
ASOT+

Question 9

What are the primary causes of nephrotic syndrome?

Answer 9

1. Minimal change disease
2. Membranous Glomerulonephritis
3. Focal segmental glomerulonephritis (FCGS)

Question 10

What are the secondary causes of nephrotic syndrome?

Answer 10

Nodular Glomerulonephritis (diabetic nephropathy and amyloidosis)

Question 11

What is minimal change dx?

Answer 11

Minimal change dx is the most common cause of nephrotic syndrome in children (90% of cases).

More common in boys

Question 12

What are the causes of minimal change disease?

Answer 12

Drugs (NSAIDs, Lithium, Rifampicin)
Glandular fever
Neoplastic (Hodgkin’s lymphoma, Thymoma)

Question 13

Minimal change disease Px?

Answer 13

Purely Nephrotic
- no haematuria or periorbital oedema.
Normal BP, renal function and complement levels

Question 14

Minimal change dx diagnosis Ix?

Answer 14

Renal biopsy!

On electron microscopy - podocyte foot effacement

Question 15

Minimal change dx Rx?

Answer 15

Prednisolone (if no response then ciclosporin)

Question 16

What age groups does membranous nephropathy affect?

Answer 16

Bimodal peak in 20s and 60s

Question 17

What is the most common cause of nephrotic syndrome overall?

Answer 17

Membranous neohropathy

Question 18

What are the causes of membranous nephropathy?

Answer 18

70% idiopathic
SLE (most common secondary cause)
Cancer - lung, colorectal, multiple myeloma
Haematological
Drugs - NSAIDs, Captopril, Penicillamine
Infection- Hep B + C, HIV, malaria
Gold

Question 19

Membranous Nephropathy Ix?

Answer 19

RENAL BIOPSY!
Light microscopy- thick GBM
Electron microscopy- IgG under podocytes and spike + dome pattern

Question 20

Membranous Nephropathy Rx?

Answer 20

1/3 fo into spontaneous remission - watch and wait

ACE-i/ ARB - stop proteinuria
Immunosuppression - induce remission