glomerulonephritis for gpvts

7/28/2019 Glomerulonephritis for GPVTS

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Nephritic Sx & Nephrotic Sx


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Case report 1

18 yr old man

Bilateral loin pain

Macroscopic haematuria

Sore throat started one day earlier

BP 140/90; euvolaemic

Creatinine 120 mol/l Proteinuria and haematuria on dipstix


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Case Report 2

20 yr old lady

Completely well

Haematuria on dipstix

No proteinuria

Normotensive


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Case Report 3

12 year old boy

Impetigo two weeks earlier

Headache

Oliguric

Frothy dark coloured urineHypertensive


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Case report 4

15yr old woman

3/12 ankle swelling; face and fingers

swollen in the am BP 130/80; JVP normal; Leg oedema

Creatinine 54 mol/l

Cr Cl 140 ml/min Albumin 18 g/l

24 hr u.protein 10 g


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Case Report 5

30 year old man,diabetic

Known hypertensive

Ankle oedema

Dipstix: ++++ proteinuria

Creatinine 124 mol/l (80120)

Albumin 30 g/l (3645)


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Case Report 6

50 year old obese man

Hypertension 10 years

NIDDM 3 years

No retinopathy

Creatinine 124 mol/l24 hr urine protein 2 g

HbA1 9.6%


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10

Structure of thefiltration barrier

Podocyte

Foot processes

Fenestratedendothelium


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Minimal change disease


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Glomerular changes in disease

ProliferationSclerosis

Necrosis

Increase in mesangial

matrix

Changes to basementmembrane

Immune deposits

Diffuse vs focal

Global vs segmental


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Common Syndromes

Nephrotic Syndrome

Nephritic Syndrome

Rapidly Progressive GN

Loin Pain Haematuria Syndrome


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Features of Glomerular Disease

Proteinuria

Haematuria

Renal Failure

Salt and Water Retention

Loin Pain


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Salt and Water Retention

Hypertension

Oedema

Oliguria


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Loin Pain

Rare
http://www.painhelp.com/back-pain.jpg


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Proteinuria

Marker of renal disease

Risk factor for

cardiovascular disease

Dyslipidaemia

Hypertension

Something more?

24 hr protein vs urine

protein:creatinine ratio


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Nephrotic syndrome

Proteinuria > 40 mg/m2*hr

Hypoalbuminaemia (


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Learning Points

Clinical features

Commonest types

Prognosis

Causes

Treatments


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Nephrotic Syndrome

Causes of primary idiopathic NS

Minimal change disease

Mesangial proliferation

Focal segmental glomerulosclerosis


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Minimal Change Disease

Usually children

Nephrotic syndrome withhighly selective

proteinuria andgeneralised oedema

Rarely hypertension orARF

T cell mediatedVPF

Steroid sensitive usually

Spectrum of disease toFSGS
http://www3.us.elsevierhealth.com/ajkd/atlas/33/3/slide/fig01.jpg


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Focal Segmental

Glomerulosclerosis

Juxtamedullary glomeruli

may be missed due to

sampling error

Older patients

Less sensitive to

immunosuppression

Hypertension,

haematuria, progressive

CRF
http://www3.us.elsevierhealth.com/ajkd/atlas/33/4/slide/fig04.jpg


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FSGS:

Familial

VUR

Drug abuse

Obesity


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Common types of GN

Primary

Thin membrane disease

IgA disease

Minimal Change / FSGS spectrum

Membanous Nephropathy

Secondary

PSGN & Diabetic Glomerulosclerosis


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Rarer Types

Diffuse endocapillary proliferative GN

(post infectious GN)Crescentic GN

Membanoproliferative / mesangiocapillary

GN


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Nephritic Syndrome

Haematuria

Hypertension

Oliguria

Edema


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Rapidly progressive GN

Nephritic or nephrotic onset

ESRF in six months


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General Treatment of GN

Control BP

Angiotensin blockade

Statin

Lose weight

Stop smoking

(pneumococcal prophylaxis)

(anticoagulation)


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Help!

I need a volunteer!


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30


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Case report 1

18 yr old man

Bilateral loin pain

Macroscopic haematuria

Sore throat started one day earlier

BP 140/90; euvolaemic

Creatinine 120 mol/l Proteinuria and haematuria on dipstix


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Case 1: indicative answers

IgA Disease

Renal failure, proteinuria, haematuria,

oedema, hypertension, oliguria, loin pain

All except oedema and oliguria


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Mesangial IgA disease

Classical BergersDisease

Microscopic haematuria

Proteinuria (rarelynephrotic)

Hypertension

Chronic renal failure

? Failure of hepaticclearance of IgA

Association with GIdisease

No specific treatment


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Ig A Nephropathy

Ig A nephropathy is the most common primary

GN worldwide

Usually present with hematuriaEpisodes of gross hematuria are precipitated by

flu like illness, exercise

Urinary protein excretion usually non-nephrotic

Associated with chronic liver ds, psoriasis, IBD

and HIV disease.


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Ig A Nephropathy

Only 30% of patients with IgA

nephropathy has progressive disease.

In progressive disease, use of fish oil maybe beneficial.

Immunosuppressive therapy in patients

with Ig A nephropathy has not consistentlyshown to be of benefit


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Case Report 2

20 yr old lady

Completely well

Haematuria on dipstix

No proteinuria

Normotensive


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Exclude menstruation!

Thin membrane disease (possibly IgA

disease)

Commonest cause of isolated microscopic

haematuria in this age group.

At this age, urological cause unlikely; nil

to suggest infection / urolithiasis


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Thin membrane disease

Most common GN

Microscopic haematuria

Familial

Benign

No treatment needed

Most young people with

isolated microscopichaematuria have thinmembrane disease


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Acute nephritic syndrome

Post-streptococcal glomerulonephritis

Diffuse proliferative endocapillary

glomerulonephritis

Due to salt and water retention, so salt

restriction or loop diuretic


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Acute Post-Infectious GN

Usually occur in children

Post-streptococcal GN is the most common cause of

post infectious GNOccurs after a streptococcal sore throat or impetigo

Caused by Group A, beta-hemolytic streptococci,

particularly nephritogenic strainsType 1,4,12

(throat) and 2,49(skin)


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Acute onset of gross hematuria (COLA

COLORED) or microscopic hematuria

after latent period of 10-14 days.Edema/hypertension

RBC casts on U/A

Elevated creatinine, increased ASO titer

Decreased complement level


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LMDiffuse proliferative and exudative

GN

IFIgG and C3 lumpy, bumpy

EMSub epithelial Hump or Flame

like deposits


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Diffuse Endocapillary Proliferative GN

(Post Streptococcal GN)

Diffuse endocapillaryproliferative GN

Post infectious; usually

Gp A Strep Acute nephritic syndrome

Uraemia rare

Self-limited; rarely death

from

BP Abnormal RUA for up to

2 yrs

Circulating immunecomplex mediated
http://medlib.med.utah.edu/WebPath/jpeg1/RENAL085.jpg


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Renal biopsy is generally not required.

Treatment is supportive and consist of

sodium restriction, control of BP and

dialysis if this become necessary.


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Complications of the Nephr itic Syndrome

Hypertensive encephalopathy (seizures, coma)

Heart Failure (pulmonary oedema)

Uraemia requiring dialysis


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Prognosis in the Nephr itic Syndrome

More than 95% of children make a complete recovery

Chronic renal impairment in the longer term is uncommon in

children

Bad prognostic features include severe renal impairment at

presentation and continuing heavy proteinuria and

hypertension

Adults more likely to have long term sequellae than children


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Case report 4

15 yr old girl

3/12 ankle swelling; face and fingers

swollen in the am BP 130/80; JVP normal; Leg oedema

Creatinine 54 mol/l

Cr Cl 140 ml/min

Albumin 18 g/l

24 hr u.protein 10 g


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Minimal changefocal segmentalglomerulosclerosis spectrum

Very nephroticAge and borderline BP make FSGS more

likely than MCN

Effect of loss of colloid osmotic pressuregradient across glomerulus causinghyperfiltration


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Case Report 5

30year old man,diabetic

Known hypertensive

Ankle oedema

Dipstix: ++++ proteinuria

Creatinine 124 mol/l (80120)

Albumin 30 g/l (3645)


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Nephrotic syndrome secondary to diabetes

/ membranous disease

Refer urgently to nephrology


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Diabetic glomerulosclerosis

Retinopathy

Hypertension

MicroalbuminuriaNephrotic syndrome

Renal failure

usually progressivePoor prognosis on

RRT


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What wed like!

Demography including tel no and occupation

Reason for referral: presenting complaint,expectations

Co-morbidities, incl other diagnoses, smoking,alcohol and BMI, social care needs

Examination

Medications (incl recently stopped), allergies etcTreatment and investigations to date

Special requirements (eg interpreter)


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Case Report 6

50 year old obese man

Hypertension 10 years

NIDDM 3 years

No retinopathy

Creatinine 124 mol/l

24 hr urine protein 2 g

HbA1 9.6%


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Obesity-related FSGS more likely than diabetic

nephropathy (duration diabetes, absence of

retinopathy)

Worsening nephrotic syndrome and progressive renal

failure; Death from cardiovascular cause before

reaches ESRF

Stop smoking, lose weight, improve glycaemic control,regular exercise, healthy diet, moderate alcohol in that

order


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Case 6: indicative answers contd

Lack of ownership of responsibility for own health

Withdrawal symptoms (smoking)

Denial of calorie intake

Difficulty exercising due to immobility

No!

Problems with MDRD equation

No evidence of benefit of ACE inhibitors in absence proteinuria Dangers of ACE inhibitors in patients with angioneurotic

oedema, hypotension or bilateral renal artery stenosis


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Lessons

Not all abnormal urinalysis is a UTI

Acute pyelonephritis is very rarely bilateral

H t i


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Haematuria

Urologist or Nephrologist?

Age

Other features

proteinuria etcUrine microscopy for

casts

Phase contrast

microscopy


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Non-dysmorphic vs dysmorphic
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RBC Cast


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AntiGBM disease

RPGN + Lunghaemorrhage

Destructive processmedical emergency!

Antibody-mediated

One hit

High doseimmunosuppression

Plasma exchange


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Any Questions?


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glomerulonephritis for gpvts

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