INTRODUCTION TONEPHROLOGY

Jeffrey J. Kaufhold, MD

RID YOURSELF OF BOTHERSOME BRAIN TISSUETHE KAUFHOLD WAY !

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

NEPHROLOGYSUMMARY

DEFINITIONS

STRUCTURE FUNCTION CORRELATION

SPECTRUM OF GLOMERULAR DISEASE

SIMPLE, EASY, COVERS 85% OF CASES

WE GET PAID FOR THE OTHER 15%

Hematuria

T

I

G

H

T

S

Hematuria

TUMOR

I

G

H

T

S

Hematuria

TUMOR

I NFECTION

G

H

T

S

Hematuria

TUMOR

I NFECTION

G LOMERULONEPHRITIS

H

T

S

Hematuria

TUMOR

I NFECTION

G LOMERULONEPHRITIS

H EMATOLOGIC

T

S

Hematuria

TUMOR

I NFECTION

G LOMERULONEPHRITIS

H EMATOLOGIC

T RAUMA

S

Hematuria

TUMOR

I NFECTION

G LOMERULONEPHRITIS

H EMATOLOGIC

T RAUMA

S TONE

HEMATURIA

Glomerular Causes:

IgA (Berger’s)

Mesangioproliferative GN

Hereditary GN’s, including

Alport’s, Thin Basement Membrane

Hallmark of Glomerular Disease is RBC cast

Class 2 - mild mesangial hypercellularity

Hereditary Nephritis

Alports Nail -Patella Thin Basement Mem.

NEPHROLOGYDEFINITIONS

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

PROTEINURIA

LESS THAN 300 mg - normal

300 to 1200 think orthostatic or

interstitial

1200-3000 mg talk to the patient

OVER 3 GmConsider Biopsy

PROTEINURIA

Glomerular Causes:

Minimal Change Disease - 25 %

Focal Segmental Glomerulo Sclerosis

FSGS - 30 %

Membranous - 30 %

PROTEINURIA Relative Frequency by Age.

0%10%20%30%40%50%60%70%80%90%

100%

Under 12 12 to 20 20 to 60 over 60

OtherMemFSGSMCD

Membranous GN

Silver stain showing thickened basement membrane and “spiking” caused by subepithelial deposits in the membrane.

Minimal Change Disease

Normal appearing Glomerulus. Normal appearing interstitium.

Minimal Change EM

Foot processes are completely effaced (no longer discreet).

Focal Segmental Glomerular Sclerosis (FSGS)

Segments of glom are preserved and segments are sclerosed (darker pink).

NEPHROLOGYDEFINITIONS

PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours:

<0.2 = normal

>3.0 nephrotic

NEPHROLOGYIDIOPATHIC GN'S

NEPHRITICHEREDITARY

IgA (BERGER'S)

MESANGIO- PROLIF.

ITIC/OTICMEMBRANO- PROLIF.

PSGN

NEPHROTICNIL

FSGS

MEMBRANOUS

Post Infectious GN

Proliferative with lots of PMN’s visible.

PSGN Electron MicroscopySubepithelial Humps

Membrano-proliferative GN

Lupus nephritis Class IV

NEPHROLOGYSYSTEMIC DZ

NEPHRITICLUPUS CLASS II AND III

CRYOGLOBULINS

ITIC/OTICPSGN

LUPUS IV(DPGN)

NEPHROTICDMAMYLOIDMYELOMALUPUS V

NEPHROLOGYRPGN

CLASS IANTI-GBM

CLASS 2CIRCULATINGIMMUNECOMPLEXES

R/O INTERSTITIAL DISEASE

CLASS 3PAUCI- IMMUNE (VASCULITIS)

CLASS 4

VASCULOPATHY

Rapidly Progressive GN

Clinical Syndrome

ARF

HTN

RBC Casts

Mimicked by TIN

TIN Tubulointerstitial Nephritis

or

Crescents with characteristic change on Immunoflurescence

RPGN light Microscopy

Interstitial Nephritis Crescent

RPGN Class I

Linear Immunofluresence

Due to Anti-GBM Antibody

Goodpasture’s

Syndrome

RPGN Class II

Granular IF

Immune Complex

Deposition

Due to SLE, MPGN, HSP, PSGN, Others

RPGN III: Vasculitis

Crescent with Focal Necrotizing GN

Pauci-immune.

ANCA Positive.

Seen in Wegener’s Granulomatosis, Churg-Strauss, PolyArteritis Nodosa (PAN).

Necrotizing area

RPGN IV: Vasculopathy

Hyaline thrombi

Endothelial cell swelling and vacuolization

Seen in TTP/HUS, Preeclampsia,

Malignant HTN

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.

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

New Terminology Chronic Kidney Disease

CKDStage 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.

NEPHROLOGYDEFINITIONS

DEHYDRATION - STATE OF FREE WATER LOSS

VOLUME DEPLETION - STATE OF SALT AND WATER LOSS

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.

TRANSPLANTDEFINITIONS

ALLOGRAFT

REJECTION

IMMUNOSUPPRESSION

CORRELATIONS

STRUCTUREEndothelium

GBM

Epithelium

Mesangium

FUNCTIONmake vessel

seive

charge select.

makes GBM

PATHkawasaki's

Alport's

proteinuriaMinimal Change

Berger's

Glomerular Physiology

Afferent. ArtAT II constrict

ACE-i dilate

PG's NET dilate

TGF NET constrict

NSAID's constrict

Aminophylline dilate

Diltiazem dilate

Filt Pressmaintained

reduced

increase

parallels

reduce

increase

reduced

Efferent Art.constrict

dilate

no effect

no effect

no effect

no effect

dilate

Glomerular Physiology

Blood flow determinants

Afferent Efferent

Filtration

Systemic

PG'sTGF

Local

Renal PhysiologyOverview

Distal Tubule

Loop of Henle

Collecting duct

ADH +

ADH -

permeable to H2O

impermeable

solute exchange

reabsorption

filtration

impermeable toH2Osolute

imperm. to

Proximal Tubule

CORRELATIONS

STRUCTUREEndothelium

GBM

Epithelium

Mesangium

FUNCTIONmake vessel

seive

charge select.

makes GBM

PATHkawasaki's

Alport's

proteinuriaMinimal Change

Berger's