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Renal 10 Acute/sub R

Thomas: Acute/subacute Renal Failure: Glomerular Disease

Nephrotic Syndrome Non-inflammatory Damage to the basement membrane Increased permeability Proteinuria >3.5 g/d
Increased premeability leads to... ↓ albumin ↓ oncotic pressure ↓ effective circulating volume Loss of Antithrombin III
Nephritic Syndrome Inflammatory Immune-mediated damage Infiltrates of neutrophils and phagocytes -Crescentic lesions -Rupture of GBM
Clinical and lab findings with nephritic syndrome Hematuria Oliguria HTN RBC casts Proteinuria <3.5g/d
Glomerular diseases: Symptoms Edema Weight gain Malaise Oliguria Hematuria Worsening HTN
Glomerular diseases: Past Medical Hx HTN DM Hep B/C HIV Hyperlipidemia DVT/PE
Glomerular diseases: Family Hx Kidney disease DM Autoimmune Dz
Glomerular diseases: Physical exam Edema, JVD, crackles HTN Conjunctival pallor Signs of autoimmune dz Xanthomas
General labs/workup Rule out pre/post-renal Urine protein/Cr ratio UA specifically for casts Cholesterol panel Albumin
What tests are used to help rule out pre/post-renal ARF? Bladder scan UA Specific gravity FeNa Uosm
Nephrotic syndrome findings Proteinuria >3.5 Serum albumin <3.5 Cholesterol >300 mg/dL Oval fat bodies on UA
Nephrotic syndrome findings (cont.) ↓Ca due to ↓albumin Anemia due to loss of transferrin and erythropoietin Hypercoaguability due to loss of Antithrombin III
Nephrotic Syndrome Tx Statins ACEI/ARBs Fluid and salt retention
Nephrotic Syndrome **BUZZWORDS** Proteinuria Hypoabluminemia Edema Hyperlipidemia
Nephrotic syndromes Minimal change disease Focal segmental GS Membranous GN Diabetic GS Amyloid
Minimal Change Disease Most common type in kids 90% of nephrotic cases <10 Sudden onset Usually idiopathic
Minimal Change Disease: Association and Damage A: Medications Lymphomas D: effacement of podocytes
Why do you get the nephrotic proteinuria with MCD? Uniform thinning of GBM Subepithelial accumulation of immune complexes Disrupted filtration slits
Minimal Change Disease Clinical and Dx Edema Proteinuria (up to 9g/d) Dx: biopsy shows effacement of podocytes
Minimal Change Disease Tx and prognosis Tx: High dose steroids for 8 weeks Prognosis: Very good, few progress to ESRD
Focal Segmental Glomerulosclerosis (FSGS) #1 cause of nephrotic syndrome in African Americans ~30% of adult nephrotic
FSGS Mechanism HTN causes hyperfiltration Accumulation of ECM Leads to scarring and tamponade Epithelial cells damaged
FSGS Associations ***HIV*** IV heroin Urethral reflux Massive obstruction Chronic pyelonephritis Interstitial kidney dz
FSGS Clinical Usually asymptomatic Microscopic hematuria initially
FSGS Tx and prognosis Tx High dose steroids Treat underlying cause Prognosis 50% → ESRD in 5 yrs
Membranous Glomerulonephropathy From antibody/antigen deposition Up to 1/3 adult nephrotic 2:1 M:F Typical age 30-50
Membranous Glomerulonephropathy Mechanism Damage to mesangial matrix Immune cells can't cross GBM so it's non-inflammatory
Membranous Glomerulonephropathy Causes Usually idiopathic **Malignancies** -Breast, colon, stomach, kidney, lung Hepatitis B/C Syphilis, DM, SLE
Membranous Glomerulonephropathy Workup and Tx Exclude SLE, RA Hepatitis serologies **age appropriate cancer screenings** Tx: Steroids and cytotoxic agents
Diabetic Glomerulosclerosis Developes within... 5-10yrs in DM II 10-20yrs in DM I ~50% diabetics
Diabetic Glomerulosclerosis Increased prevalence in... Smokers Non-whites Pts with poor glycemic and BP control
Diabetic Glomerulosclerosis Dx Urine microslbumin test -microalb/Cr >30 Nodular sclerosis on biopsy **Kimmelstiel-Wilson nodules**
Diabetic Glomerulosclerosis Tx Glycemic control BP control with ACEI/ARBs Intensive cholesterol control (LDL<100)
Nephritic disease Inflammatory responce Immune mediated damage Crescentric lesions Plug up Bowman's Capsule Necrosis/thinning of GBM Rupture of GBM
Nephritic disease Clinical *********** *Hematuria* *Oliguria * * HTN * ***********
Nephritic disease Labs UA: Hematuria RBC casts Protein <3.5g/d
Nephritic Diseases IgA Nephropathy Henoch Schonlein Purpura Post-infectious GN Membranoproliferative GN Anti-GBM/Goodpasture's Syndrome
What immunoglobulin plays a critical role in mucosal immunity? IgA
IgA Nephropathy #1 cause of GN worldwide 2-3 days post infection
Causes of IgA nephropathy URT and GI infxn Causes defective mucosal immunity Overproduction and increased serum IgA
How does a pt with IgA nephropathy present? 1. Macroscopic or gross hematuria 2. Microscopic hematuria 3. High BP or kidney failure
IgA nephropathy Clinical findings, Dx and Tx Macroscopic hematuria 40% have asymptomatic microscopic hematuria Normal complement (C3&4) Tx ACEI/ARBs, steroids
Henoch-Schonlein Purpura Disease of kids Follows URI IgA in: -skin, GI tract, kidney, joints
Henoch-Schonlein Purpura Clinical findings and Tx Lower extremity bruising Bloody diarrhea Hematuria/HTN Arthalgias Tx: supportive
Post-Infectious GN Subendothelial antigen deposition 2-3 weeks post infxn Low C3 and C4
How is streptococcal pharyngitis diagnosed? Rapid strep test ASO titer
Post-Infectious GN Dx and Tx Dx: Hx, ASO titer, anti-DNAase B Tx: none, self-resolving
Membranoproliferative GN Idiopathic cases uncommon Usually secondary to other dz
Membranoproliferative GN Associated with Sjogren's Syndrome SLE Hep B/C WITH cryoglobulinemia Infective endocarditis
Membranoproliferative GN Labs and Tx UA with dysmorphic RBCs, RBC casts, low C3 and normal C4 Treat underlying cause, steroids, antiplatelets
Anti-GB/Goodpasture's Syndrome 10-20% of cases of rapidly progressive GN Can be ANCA+ Antibodies to type IV collagen
Anti-GB/Goodpasture's Syndrome Clinical Rapid onset of HTN Oliguria **Fatal if not treated promptly**
Anti-GB/Goodpasture's Syndrome Kidney and lung involvement Kidney only More common in older women (Anti-GBM) Kidney/lung More common in young men (Goodpasture's syndrome)
Goodpasture's Syndrome 70% will have alveolar hemorrhage (hemoptosis)
Anti-GB/Goodpasture's Syndrome Dx and Tx Dx Anti-GBM antibodies, biopsy Tx Cyclophosphamide+steroids Plasmapheresis if pulmonary hemorrhage
Anti-GB/Goodpasture's Syndrome Prognosis depends on... Promptness of Dx and Tx Degree of kidney involvement
Small Vessel Vasculitis Wegener's Granulomatosis -Lung, kidney, sinus Microscopic Polyangiitis
Small Vessel Vasculitis Clinical Decreased appetite Weight loss Hematuria/proteinuria Polymyalgia
Small Vessel Vasculitis Dx and Tx c-ANCA+ anti-PR3- Wegener's anti-MPO- Microscopic Cyclophosphamide+steroids Plasmapheresis for Wegener's
Nephrotic/Nephritic Lupus Nephritis WHO classifications III focal nephritis IV diffuse nephritis V Membrane formation VI >90% of glomeruli sclerotic
Nephrotic/Nephritic Lupus Nephritis Clinical and Dx Acute onset of hematuria Proteinuria Edema Pancytopenia Dx: anti-Sm, anti-Ds DNA
Nephrotic/Nephritic Lupus Nephritis Tx and prognosis >Class III Cyclophosphamide+/-steroids Prognosis depends on Kidney fxn Histologic type Crescents
Created by: bcriss