introduction to nephrology
DESCRIPTION
INTRODUCTION TO NEPHROLOGY. Jeffrey J. Kaufhold, MD. RID YOURSELF OF BOTHERSOME BRAIN TISSUE THE KAUFHOLD WAY !. DEFINITIONS. GFR - true function of the kidney best measured by Inulin, Nuc. Med CREATININE CLEARANCE - measurement is difficult in inpatients - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/1.jpg)
INTRODUCTION TONEPHROLOGY
Jeffrey J. Kaufhold, MD
RID YOURSELF OF BOTHERSOME BRAIN TISSUETHE KAUFHOLD WAY !
![Page 2: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/2.jpg)
DEFINITIONS
GFR - true function of the kidney best measured by Inulin, Nuc. Med
CREATININE CLEARANCE - measurement is difficult in inpatients
COCKCROFT EQUATION: (140 - age) X Kg wt Screat X 72
![Page 3: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/3.jpg)
NEPHROLOGY
SUMMARY DEFINITIONS
STRUCTURE FUNCTION CORRELATION
SPECTRUM OF GLOMERULAR DISEASE
SIMPLE, EASY, COVERS 85% OF CASES
WE GET PAID FOR THE OTHER 15%
![Page 4: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/4.jpg)
Hematuria
• T
• I
• G
• H
• T
• S
![Page 5: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/5.jpg)
Hematuria
• TUMOR
• I NFECTION
• G LOMERULONEPHRITIS
• H EMATOLOGIC
• T RAUMA
• S TONE
![Page 6: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/6.jpg)
![Page 7: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/7.jpg)
HEMATURIA
• Glomerular Causes:• IgA (Berger’s)• Mesangioproliferative GN• Hereditary GN’s, including • Alport’s, Thin Basement
Membrane
• Hallmark of Glomerular Disease is RBC cast
![Page 8: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/8.jpg)
![Page 9: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/9.jpg)
![Page 10: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/10.jpg)
![Page 11: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/11.jpg)
Mesangio-proliferative: mild mesangial hypercellularity
![Page 12: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/12.jpg)
Hereditary Nephritis
Alports Nail -Patella Thin Basement Mem.
![Page 13: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/13.jpg)
NEPHROLOGY
DEFINITIONS HEMATURIA - DIFFERENTIAL TIGHTS TUMOR, INFECTION GN’s, HEMATOLOGIC TRAUMA AND STONE
PROTEINURIA - normal up to 150 mg/24 h made up of tubular protein (Tamm Horsfal) ABnormal = albumin, >150 mg
![Page 14: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/14.jpg)
PROTEINURIA• LESS THAN 300 mg - normal
• 300 to 1200 think orthostatic or • interstitial• 1200-3000 mg talk to the patient
• OVER 3 Gm Consider Biopsy
![Page 15: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/15.jpg)
PROTEINURIA
• Glomerular Causes:– Minimal Change Disease - 25 %– Focal Segmental Glomerulo Sclerosis
• FSGS - 30 %– Membranous - 30 %
![Page 16: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/16.jpg)
PROTEINURIA Relative Frequency by Age.
0%10%20%30%40%50%60%70%80%90%
100%
Under12
12 to 20 20 to 60 over 60
OtherMemFSGSMCD
![Page 17: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/17.jpg)
Membranous GN
• Silver stain showing thickened basement membrane and “spiking” caused by subepithelial deposits in the membrane.
![Page 18: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/18.jpg)
Minimal Change Disease
Normal appearing Glomerulus. Normal appearing interstitium.
![Page 19: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/19.jpg)
Minimal Change EM
• Foot processes are completely effaced (no longer discreet).
![Page 20: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/20.jpg)
Focal Segmental Glomerular Sclerosis (FSGS)
• Segments of glom are preserved and segments are sclerosed (darker pink).
![Page 21: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/21.jpg)
NEPHROLOGY
DEFINITIONS
PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours:
<0.2 = normal
>3.0 nephrotic
![Page 22: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/22.jpg)
NEPHROLOGY
IDIOPATHIC GN'S• NEPHRITIC• HEREDITARY
• IgA (BERGER'S)
• MESANGIO-• PROLIF.
• ITIC/OTIC• MEMBRANO-• PROLIF.
• PSGN
NEPHROTICNIL
FSGS
MEMBRANOUS
![Page 23: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/23.jpg)
Post Infectious GN
• Proliferative with lots of PMN’s visible.
![Page 24: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/24.jpg)
PSGN Electron MicroscopySubepithelial Humps
![Page 25: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/25.jpg)
Membrano-proliferative GN
Lupus nephritis Class IV
![Page 26: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/26.jpg)
NEPHROLOGY
SYSTEMIC DZ• NEPHRITIC• LUPUS CLASS• II AND III
• CRYOGLOBULINS
• ITIC/OTIC• PSGN
• LUPUS IV• (DPGN)
NEPHROTICDMAMYLOIDMYELOMALUPUS V
![Page 27: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/27.jpg)
NEPHROLOGY
RPGN• CLASS I• ANTI-GBM
• CLASS 2• CIRCULATING• IMMUNE• COMPLEXES
R/O INTERSTITIAL DISEASE
CLASS 3PAUCI- IMMUNE (VASCULITIS)
CLASS 4
VASCULOPATHY
![Page 28: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/28.jpg)
Rapidly Progressive GN
• Clinical Syndrome• ARF• HTN• RBC Casts
• Mimicked by TIN
• TIN Tubulointerstitial Nephritis
• or• Crescents with
characteristic change on Immunoflurescence
![Page 29: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/29.jpg)
RPGN light Microscopy
• Interstitial Nephritis • Crescent
![Page 30: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/30.jpg)
RPGN Class I
• Linear Immunofluresence
• Due to Anti-GBM Antibody
• Goodpasture’s • Syndrome
![Page 31: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/31.jpg)
RPGN Class II
• Granular IF• Immune Complex• Deposition• Due to SLE, MPGN,
HSP, PSGN, Others
![Page 32: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/32.jpg)
RPGN III: Vasculitis
• Crescent with Focal Necrotizing GN
• Pauci-immune.• ANCA Positive.• Seen in Wegener’s
Granulomatosis, Churg-Strauss, PolyArteritis Nodosa (PAN).
Necrotizing area
![Page 33: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/33.jpg)
RPGN IV: Vasculopathy
• Hyaline thrombi• Endothelial cell
swelling and vacuolization
• Seen in TTP/HUS, Preeclampsia,
• Malignant HTN
![Page 34: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/34.jpg)
Old Definitions ACUTE RENAL FAILURE - acute deterioration
over hours to days of renal function
CHRONIC RENAL FAILURE - progressive loss of renal function over years
CHRONIC RENAL INSUFFICIENCY - A chronic, fixed loss of renal function due to a past insult.
![Page 35: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/35.jpg)
New TerminologyARF - RIFLE criteria
• Risk low uop for 6 hours, creat up 1.5 to 2 times baseline
• Injury creat up 2 to 3 times baseline, low uop for 12 hours
• Failure Creat up > 3 times baseline or over 4, anuria
• Loss of Function Dialysis requiring for > 4 weeks
• ESRD Dialysis requiring for > 3 months
![Page 36: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/36.jpg)
New Terminology Chronic Kidney Disease
CKD• Stage 1 Normal GFR with known
disease• Stage 2 GFR 60-80 ml/min• Stage 3 GFR 30-60• Stage 4 GFR 20-30• Stage 5 GFR 10-20• Stage 6 GFR < 10, ESRD.
![Page 37: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/37.jpg)
NEPHROLOGY
DEFINITIONS DEHYDRATION - STATE OF
FREE WATER LOSS
VOLUME DEPLETION - STATE OF SALT AND WATER LOSS
![Page 38: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/38.jpg)
DIALYSISDEFINITIONS
HEMODIALYSIS
PERITONEAL DIALYSIS
CAVHD
DIALYSIS ACCESS, FISTULA please don't say shunt or graft
ULTRAFILTRATION - removal of water with dissolved solute dragged along for the ride.
![Page 39: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/39.jpg)
TRANSPLANT
DEFINITIONS ALLOGRAFT
REJECTION
IMMUNOSUPPRESSION
![Page 40: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/40.jpg)
CORRELATIONS
• STRUCTURE
• Endothelium
• GBM
• Epithelium
• Mesangium
• FUNCTION• make vessel
• seive
• charge select.
• makes GBM
PATHkawasaki's
Alport's
proteinuriaMinimal Change
Berger's
![Page 41: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/41.jpg)
Glomerular Physiology
• Afferent. Art• AT II constrict
• ACE-i dilate
• PG's NET dilate
• TGF NET constrict
• NSAID's constrict
• Aminophylline dilate
• Diltiazem dilate
• Filt Press• maintained
• reduced
• increase
• parallels
• reduce
• increase
• reduced
Efferent Art.constrict
dilate
no effect
no effect
no effect
no effect
dilate
![Page 42: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/42.jpg)
Glomerular Physiology
Blood flow determinants
Afferent Efferent
Filtration
Systemic
PG'sTGF
Local
![Page 43: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/43.jpg)
Renal Physiology
OverviewDistal Tubule
Loop of Henle
Collecting duct
ADH +
ADH -
permeable to H2O
impermeable
solute exchange
reabsorption
filtration
impermeable toH2Osolute
imperm. to
Proximal Tubule
![Page 44: INTRODUCTION TO NEPHROLOGY](https://reader033.vdocuments.us/reader033/viewer/2022061612/56814afb550346895db80e5e/html5/thumbnails/44.jpg)
CORRELATIONS
• STRUCTURE
• Endothelium
• GBM
• Epithelium
• Mesangium
• FUNCTION• make vessel
• seive
• charge select.
• makes GBM
PATHkawasaki's
Alport's
proteinuriaMinimal Change
Berger's