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Flashcards in Nephrotic syndrome Deck (60):

The glomerulus is a specialized capillary network which interacts with both (1) cells

1. visceral and parietal epithelial


The (1) cells interact with the glomerular capillary (2) to form (3) with specialized foot processes that contribute to the filtration barrier

1. visceral epithelial
2. basement membrane
3. podocytes


The (1) cells line the urinary space which becomes the (2) for each nephron

1. parietal epithelial
2. proximal convoluted tubule


Because the glomerulus is designed to filter large quantities of blood, it has a three part filtration barrier. The first is the (1) (essentially holes) within (2) in the glomerular capillaries. Next is the glomerular (3) and the third is the (4)

1. fenestrations
2. endothelial cytoplasm
3. basement membrane
4. foot processes/slit diaphragm design of the epithelial podocytes.


This triple barrier is designed for high volume filtration of blood which allows (1) in the filtrate in the urinary space but keeps (2) in the blood stream

1. water, ions, and small molecules
2. proteins


Ions, water, and small molecules present in the urinary space can be (1) from the tubular system into the post-glomerular blood stream. Certain ions and small molecules can also be (2) from the post-glomerular blood into the tubules

1. reabsorbed
2. secreted


The charge barrier is primarily the (1), which consists of (2) as well as (3)

1. basement membrane
2. Type IV collagen
3. negatively charged glycosaminoglycans such as heparan sulfate.


This strong negative charge prevents negatively charged proteins like (1) from being filtered into the urinary space

1. albumin


In constrast to the charge barrier, the size barrier is primarily determined by the (1), which have a complex structure of (2) which may represent an actual pore for entry of certain molecules

1. epithelial podocytes
2. foot processes and a slit diaphragm


Specific mutations in genes whose gene products are components of the slit diaphragm (such as (1), can lead to (2), providing some evidence that the slit diaphragm has an important role in maintaining the filtration barrier.

1. nephrin or podocin
2. proteinuria


(1) can also increase the size exclusion barrier by allowing some larger molecules to enter the urinary space

1. Fenestrations in capillary endothelial cell cytoplasm


Although (1) may not directly contribute to the filtration barrier, they are very important supportive cells (2), which provide both mechanical support and key functions.

1. mesangial cells
2. modified smooth muscle cells


The mesangial cells process (1) so they are important for elimination of immune damage. They also provide the (2) functions of the glomeruli and generate (3) and other modulators

1. plasma proteins and immune complexes by endocytosis
2. contractile
3. cytokines


Immunological damage to the glomeruli can either produce predominantly (1) (nephrotic symptoms and signs) or predominantly (2) (nephritic symptoms and signs).

1. protein loss
2. bleeding and more severe injury


Clinically, patients with heavy proteinuria have the (1) syndrome which consists of proteinuria (usually 3.5 grams of protein in a 24 hour urine collection), (2)

1. nephrotic
2. hypoalbuminemia, edema, hyperliipidemia, and lipiduria


The proteinuria leads directly to the (1) because the kidney is excreting the protein from blood into urine.

1. hypoalbuminemia or low serum albumin


The hypoalbuminemia causes (2) because of the decreased plasma oncotic pressure from decreased serum proteins.

2. edema (fluid within tissues)


The hyperlipidemia occurs because the (1) produces more (2) in the generalized response to produce more (3).

1. liver
2. lipoproteins
3. albumin


(1) happens because of the increased lipoproteins carrying lipid and because of loss of the filtration barrier.

1. Lipiduria (lipid in urine)


There can be extensive (1) in patients without any histopathological changes that can be seen by light microscopy

1. proteinuria


However, ultra-structural changes can be seen by electron microscopy generally show (1) in nephrotic syndrome.

1. fusion of the epithelial podocyte foot processes


There also can be pathologic changes identified by immune microscopy which identifies whether certain (1) are present in the glomeruli.

1. immunoglobulins or complement


Minimal change disease (also called (1) is the most common cause of nephrotic syndrome in children and also can cause nephrotic syndrome in adults. Children who do not develop any complications have a completely normal life span without any later renal disease.

1. nil lesion


Examination of a renal biopsy by light microscopy in minimal change disease show no pathologic changes, but (1) can be identified by electron microscopy

1. fusion of foot processes in visceral epithelial cells (podocytes)


The epithelial cells in minimal change disease can have some secondary changes such as (1) or the development of (2) on the cell surface

1. retraction of the podocyte cytoplasm from the basement membrane
2. microvilli


Although the cause of minimal change disease is unknown, it is thought to be the result of (1) occurring within the (2) and the symptoms are rapidly reversed by (3) treatment in children (although (3) can take longer to produce remissions in some adults who can have a more prolonged course).

1. antigen-antibody reactions
2. podocyte and the basement membrane
3. steroid


(1) is a relatively more common cause of nephrotic syndrome in adults than it is in children

1. Membranous nephropathy


Membranous nephropathy can be either primary (due to an unknown cause) or secondary from a disease which is producing (2) within the kidney

2. antigens or immune complexes


Some of the secondary causes of secondary membranous nephropathy include inflammation disorders like (1)

1. SLE, infections (hepatitis B is a classic example although others can as well), drugs, and neoplasms


There has been some controversy in the literature whether membranous nephropathy and other renal diseases which have immune complexes in the kidney are due to (1) or whether the antigen arrives first and the antibodies come later, producing (2) at the site in the kidney.

1. circulating immune complexes (type 3 hypersensitivity)
2. immune complexes


Neoplasms can be a fairly common cause of (1) and should be considered in cancer patients with proteinuria

1. membranous nephropathy


An experimental animal model called Heymann nephritis suggest that (1) are more often present first in the (2) or surrounding cells before the (3) arrive to form immune complexes.

1. antigens
2. basement membrane
3. antibodies


Light microscopy can show (1) in membranous nephropathy (silver stains show (2) material so they can show immune complexes as areas where the silver stain is lost)

1. thickened basement membranes
2. basement membrane


Electron microscopy of membranous nephropathy shows antigen-antibody complexes present in either the (1) or the subepithelial region between the (2)

1. basement membrane
2. basement membrane and the podocyte


In (1), the immune complexes can be found in (2) as well, although this is usually not the case in primary membranous nephropathy.

1. SLE
2. mesangial cells


The course of membranous nephropathy is variable, and spans from (1)

1. resolution to end stage renal disease


Another fairly common cause of nephrotic syndrome is (1) but that will be discussed in the nephritic presentation since it can present either way

1. focal segmental glomerulosclerosis (FSGS)


Immune microscopy in membranous nephropathy can show the presence of (1) antibody or (2) components including (3) and the components of the (4) which actually causes the injury

1. IgG
2. complement
3. C3
4. membrane attack complex (C5b, C6-C9)


parietal epithelium, situated on the ____, lines the ___, the
cavity in which plasma filtrate first collects

Bowman capsule; urinary space


Stain used to see the glomerular basement membrane (GBM)

Masson trichrome stain


In glomerulus, lumen refers to ____; bowman's space is where the ___ is; aka Endothelial side: vascular
Epithelial (podocyte) side: urinary

Blood; urine;


Outer BM is covered by foot processes from the
podocyte lining ___

urinary space (Bowman's)


The glomerular filter:
Molecules pass from capillary lumen to the _____;
1. Cross ____ of the endothelial cell;
2. ____
(lamina rara interna, lamina densa, and lamina rara externa),
3. ____ connects podocyte foot processes

urinary space;
trilaminar basement membrane (BM);
Slit pore diaphragm


GBM predominantly of _____
2. Also laminin, fibronectin, and glycosaminoglycans.
Relative exclusion of negatively charged molecules such as albumin due to _____

type IV collagen;
polyanionic glycosaminoglycans, (heparan sulfate).


Glomerular endothelial cells are on the ___ side and _____ by numerous 60- to 100-nm pores

vascular; fenestrated


Podocytes: outer side GBM: cytoplasmic projections (foot processes) onto _____ of GBM

lamina rara externa


central electron-dense zone is ____
___ and ___ are inner and outer electron lucent zone;

Lamina densa of GBM;
Lamina rara interna
Lamina rara externa:


slit diaphragm of podocyte foot processes consist of ____; mutation would lead to ____

nephrin and podocin;


modified smooth muscle cells situated in
the center of the glomerular tuft between capillary loops

Mesangial cells


Mesangial cells
Endocytosis and processing of ___and ____
Generation of ____

plasma proteins; immune complexes;
prostaglandins and cytokines


How is edema caused in nephrotic syndrome: 2 causes

Dec. _____ due to loss of albumin;
1. fluid escapes into tissues causing edema;
2. Dec. onc. pressure leads to dec. ____ --> dec. ____ --> INC. _____--> fluid retention--> edema

Dec. plasma oncotic pressure due to loss of albumin; 1. fluid escapes into tissues causing edema; 2. Dec. onc. pressure leads to dec. plasma volume --> dec. GFR --> INC. aldosterone--> fluid retention--> edema


Min. change disease aka Nil
Occasional association with ___
and with ____ has led to the
speculation that it is a T lymphocytes disorder

Hodgkin disease; T cell lymphomas


Minimal change disease
Light microscopy:
Immunofluoresence for immunoglobulins (IF) and complement:

Light microscopy: Normal
Electron microscopy: diffuse obliteration of podocyte foot processes
IF--> negative


In intermediate disease stages, silver stains (which demonstrate basement membrane
material) reveal multiple projections or “spikes” on the epithelial surface of BM

Membranous nephropathy


Membranous nephropathy progression: capillary lumens narrow -----> glomerular sclerosis---> ___

tubular atrophy
and interstitial fibrosis (end stage kidney)


M embranous Nepropathy

Immunofluorescence microscopy reveals ____ staining of capillary walls for IgG and C3. There is intense staining for terminal complement components, including
the _____, which induces glomerular injury

diffuse granular; membrane attack complex;


Membranous glomerulopathy. Caused by the ____ accumulation of immune complexes and the accompanying changes in the ____.

subepithelial; basement membrane (BM)


Membranous glomerulopathy.
Stage I exhibits ____ deposits. The outer contour of the basement membrane remains smooth.

scattered subepithelial


Membranous glomerulopathy.
Stage II disease has ____of basement membrane material adjacent to the deposits

projections (spikes)


Membranous glomerulopathy.
In stage III disease, newly formed basement
membrane has surrounded the deposits.

With stage IV disease, the immunecomplex
deposits lose their electron density, resulting in an _____ with irregular electron-lucent areas.

irregularly thickened basement membrane