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Renal 10 Acute/sub R
Thomas: Acute/subacute Renal Failure: Glomerular Disease
| Question | Answer |
|---|---|
| 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
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