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92 Cards in this Set

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General Rule:
It is easier to rule out _______, so do this first unless your history or clinical suspicion dictates otherwise!
pre- or post- renal failure
These are epithelial cells on the basement membrane
Podocytes
These cells support the capillary wall
Mesangial Cells
Typically Non-inflammatory

Damage to basement membrane/epithelium=↑permeability

-↑ permeability= protein leakage >3.5g/day in urine
Nephrotic Syndrome
-↓ albumin

-↓ oncotic pressure --> 3rd spacing

-↓ effective circulating volume = activation of RAA

-loss of Antithrombin III -->hypercoaguable -->clots/emboli

-liver stimulated to make cholesterol
Nephrotic Syndrome
Characterized by:

proteinuria, edema, hyperlipidemia, hypercoaguability
Nephrotic Syndrome
Typically Inflammatory Process

Immune-mediated Damage

Infiltrates of neutrophils and phagocytes and/or proliferation of mesangium
Nephritic Syndrome
Infiltrates of neutrophils and phagocytes and/or proliferation of mesangium cause:

– Crescentic lesions

– Plugging up of Bowman‟s space

– Necrosis/Thinning of Glomerular Basement Membrane

– Rupture of GBM
Nephritic Syndrome
CLINICAL = hematuria, oliguria, HTN

LABS: urinalysis usually with (+) blood, RBC casts, and/or protein <3.5 g/day
Nephritic Syndrome
Proteinuria: >3.5 g/day

This is usually indicative of
Nephrotic Syndrome
Proteinuria: <3.5 g/day

This can be associated with _______
Nephritic Syndrome
You're looking at a urinalysis report and see: (+) blood, RBC casts,
and/or protein <3.5 g/day
Nephritic Syndrome
What are some typical symptoms of Glomerular Dz?
Edema*

weight gain

malaise

oliguria*

hematuria*

worsening HTN*
A Family Hx of kidney disease, DM, autoimmune diseases might make you think a patient's symptoms are due to _________
Glomerular Dz
Physical Exam Findings for Glomerular Dz?
– Signs of fluid overload
(edema, JVD, crackles)

– Hypertension

– Conjunctival pallor (anemia)

– Signs of Autoimmune Diseases

–Xanthomas
What are some physical exam findings
suggestive of autoimmune diseases?
**SLE**- malar rash, alopecia, apthous ulcers, peripheral edema, pallor

**RA**- nodules, joint effusions, ulnar deviation of fingers
What tests are used to help rule out
pre- and post-renal ARF?
PRE- FeNa, sp gravity, Una, Uosm

POST- bladder scan, Foley, renal US
Characterized by:

• Proteinuria > 3.5 g/day
(>50mg/kg/day for kids)

-Cholesterol in 300-400 mg/dL range
• Serum Albumin < 3.5 g/dL
Nephrotic Syndrome

**Low Sr Albumin b/c we're losing protein in urine**
If you see fatty casts (oval fat bodies) in urinalysis what are you thinking?
Nephrotic Syndrome

**high cholesterol in plasma**
Can see:

↓calcium due to ↓albumin, but also
due to loss of proteins which bind
vitamin D

• Anemia due to loss of transferrin and erythropoietin

• Hypercoaguability due to loss of
Antithrombin III (AT III)
Nephrotic Syndrome
BUZZWORDS FOR BOARDS:

Proteinuria
Hypoalbuminemia
Edema
Hyperlipidemia
Nephrotic Syndrome
Treatment usually always includes:

Statins, ACEI/ARBs, fluid and salt restriction
Nephrotic Syndrome
T/F

Nephrotic Syndrome is associated with 24-hr urine protein >3.5 g/day
True
Damage due to effacement/flattening of
podocytes
Minimal Change Disease
Minimal Change Disease is a subtype of __________
Nephrotic Syndrome
Minimal Change Disease can be associated with what 2 things?
Can be associated with:

– Medications (lithium, NSAIDs)

– *Lymphomas*
Most common type of nephrotic
syndrome in kids, accounting for 90%
of nephrotic cases < 10 years old
Minimal Change Dz
Why do you get nephrotic range
proteinuria with minimal change
disease?

**EXAM**
Effacement of podocytes

Disruption of filtration slits

proteins leak through "big holes"
Si/Sx: edema, massive proteinuria (Pr/Cr up to 9)

Dx: kidney biopsy shows effacement of podocytes
Mimimal Change Dz
Rx for Minimal Change Dz?
Steroids for 8 weeks
A previously healthy 32 year old female presents to your office after having swollen legs for the last 3 weeks.
She denies any recent illnesses, history of HIV or Hepatitis B or C, and does not endorse any symptoms of autoimmune diseases.

LABS:
Urinalysis: 3+ protein, no WBCs, RBCs or casts
Serum Albumin: 3.0 g/dL (normal 4.0 g/dL)
Serum Creatinine: 1.0 mg/dL (normal)

You decide to get a kidney biopsy. What would you expect to see?

A.Linear IgG deposition

B. Positive immunofloresence for GBM antibodies

C. Effacement of podocytes

D. No pathologic changes
C. Effacement of Podocytes

**Minimal Change Dz**
#1 cause of nephrotic syndrome in
African Americans
Focal Segmental Glomerulosclerosis
(FSGS)
HTN at level of glomerulus causes
hyperfiltration, which leads to
accumulation of extracellular matrix and eventual scarring and tamponade of glomerulus. EPITHELIAL cells are damaged.
Focal Segmental Glomerulosclerosis
(FSGS)

**Epithelial Cell (podocyte) damage d/t HTN**
What cells are damaged in FSGS?
Epithelial Cells are damaged due to HTN
(podocytes)
Associated with:
- HIV**
-Ureteral reflux (kids with posterior bladder valves
-Massive obesity
-Obstructive Sleep Apnea
-Chronic pyelonephritis
-Interstitial kidney disease
-IV Heroin**
Focal Segmental Glomerulosclerosis
(FSGS)
CLINICAL:

-indolent course; usually asymptomatic in early disease

-microscopic hematuria initially
Focal Segmental Glomerulosclerosis
(FSGS)
Prognosis: *50% progress to ESRD in 5 years*
Focal Segmental Glomerulosclerosis
(FSGS)
This is the exception to the rule that NEPHROTIC syndromes are not due to antibody problems, but is in keeping with the fact that NEPHROTIC is usually NONINFLAMMATORY
Membranous Glomerulonephropathy

**Results from antibody/IC deposition**
-Damage to mesangial matrix

• Although there are immune complexes associated with this disease, they can't cross basement membrane and, therefore, DO NOT cause inflammatory changes
Membranous Glomerulonephropathy
Associated with:

– ***Hepatitis B/C ***

– Syphilis

– Diabetes Mellitus

– **SLE, RA **

– ***Malignancies***
• Breast, colon, stomach, kidney, lung
Membranous Glomerulonephropathy
Workup:

-exclude SLE, RA

-Hepatitis serologies

***age appropriate cancer screenings***

Rx: steroids and cytotoxic agents
Membranous Glomerulonephropathy
A 45 year old male presents to the ED
because he has noted foamy urine for the
last several months. He also has gained
about 20 pounds in the last 3 months, which he says “must be water weight” because he has noted that his shoes are too tight from being swollen.
Pertinent past medical history is significant
for only osteoarthritis of his lower back.
Family history is significant for coronary artery disease, diabetes, and colon cancer in his father and paternal uncle at ages 50 and 48, respectively. Patient is a nonsmoker, and results of a recent HIV test were negative.

LABS
-Serum creatinine: 1.2 mg/dL
-Serum Albumin: 3.2 g/dL
-Urinalysis: 3+ protein; oval bodies, no RBCs
-Serum Cholesterol: 355 mg/dL
-Random Glucose: 126

Before proceeding to a kidney biopsy,what other tests would you like to order?
**Membranous Glomerulonephropathy**

ANA --> SLE, RA

Hepatitis B and C

**colonoscopy**

RPR --> Syphilis
Increased Prevalence in smokers, nonwhites, those with poor glycemic and/or BP control
Diabetic Glomerulosclerosis
Dx:
-urine microalbumin test: microalb/cr >30

-nodular sclerosis on biopsy (Kimmelstiel-Wilson nodules)
Diabetic Glomerulosclerosis
You are looking at a kidney biopsy and see nodular sclerosis.

(Kimmelstiel-Wilson nodules)
Diabetic Glomerulosclerosis
A urine microalbumin test reveals:

microalbumin/Cr > 30
Diabetic Glomerulosclerosis

**microalbuminuria**
Rx for Diabetic Glomerulosclerosis?
-Glycemic Control

-***ACEi/ARBs*** (even if there's no HTN)

-Intensive Cholesterol Control (LDL<100)
BUZZWORDS:

CLINICAL:
Hematuria
Oliguria
HTN

LAB:
Urinalysis: (+) blood, RBC casts

Urine protein < 3.5 g/day
Nephritic Syndrome
T/F

Protein on UA rules out nephritic glomerular diseases.
False
Which Immunoglobulin plays a critical role in mucosal immunity? (i.e. More is produced in mucosal linings than all other type of antibody combined)
IgA
#1 cause of glomerulonephropathy
worldwide

• 2-3 days post infection (URI, GI)

• IgA Deposition associated with
–Henoch-Schönlein Purpura
IgA Nephropathy
Upper respiratory tract or GI infection

Defective mucosal immunity

Overproduction and hence increased serum levels of partially degalactosylated polymeric IgA1 and IgA-immune complexes
(Pathogenic IgA)
IgA Nephropathy
IgA Symptoms due to inflammation:

-Focal, mesangial proliferative glomerular inflammation
Asymptomatic, MICROSCOPIC hematuria
IgA Symptoms due to inflammation:

-Diffuse, mesangial proliferative
glomerular inflammation
More acute nephritis with MACROSCOPIC hematuria
What type of hematuria is associated with IgA nephropathy in patients with a recent GI or UR infection?
Macroscopic hematuria (bloody urine)
Dx:
history, microscopic/macroscopic hematuria, normal C3, normal C4

Dx: ACEi/ARB2, steroids if pr/cr ratio >1
IgA Nephropathy
What are the levels of C3 and C4 like in IgA nephropathy?
Normal
Disease of Children

• Usually follows URI

• Abnormal IgA deposition in:
– Skin
– GI tract
– Kidney
– Joints
Henoch-Schönlein Purpura
CLINICAL FINDINGS:

• Lower extremity bruising (“palpable purpura”)

• Bloody diarrhea

• Hematuria and Hypertension

• Arthralgias (bleeding into joints)

Rx: Supportive
Henoch-Schönlein Purpura
You see a patient with:
Subendothelial antigen deposition

• 2-3 weeks post infection (strep
pharyngitis or cellulitis)

• Low C3, Low C4
Post-Infectious GN
T/F

Prompt treatment of strep infection
does not guarantee that post-infectious
GN will not develop
True
A 32 year old female with no PMH
presents to your office due to general malaise, runny nose and sore throat. She is also concerned because her urine has been dark. Her symptoms have been going on for about 3 days.
She has a slightly elevated BP at 146/88. The result of her rapid strep test is positive, urine pregancy test is negative, and moderate blood is noted on urine dipstick.

Based on what you know, what is the most likely diagnosis?

A. IgA Nephropathy
B. Post-Infectious GN
IgA Nephropathy
T/F

Prompt treatment of strep infection
does not guarantee that post-infectious
GN will not develop
True
A 32 year old female with no PMH
presents to your office due to general malaise, runny nose and sore throat. She is also concerned because her urine has been dark. Her symptoms have been going on for about 3 days.
She has a slightly elevated BP at 146/88. The result of her rapid strep test is positive, urine pregancy test is negative, and moderate blood is noted on urine dipstick.

Based on what you know, what is the most likely diagnosis?

A. IgA Nephropathy
B. Post-Infectious GN
IgA Nephropathy

**Timeframe is 2-3 days here.. Not 2-3 weeks which would make you think Post-Infectious GN**
What pattern of complement would you expect for IgA nephropathy?

A. Low C3, low C4
B. Low C3, normal C4
C. Normal C3, normal C4
D. Normal C3, low C4
Normal C3, Normal C4
Usually secondary to other diseases

• Associated with:
– Sjogren‟s Syndrome
– Systemic Lupus Erythematosis
– Hep B/C with cryoglobulinemia
– Infective endocarditis
Membranoproliferative GN
What are the two characteristic complaints in Sjogren's Disease?

What antibodies are positive in Sjogren's Disease?
Dry Mouth, Dry Eyes

Positive Anti-Ro, Anti-La

(Membranoproliferative GN)
LABS: UA with dysmorphic RBCs,
erythrocyte casts, LOW C3, NORMAL C4

• Rx: treat underlying cause, steroids,
antiplatelets
Membranoproliferative GN
C3 and C4 levels in Membranoproliferative GN?
C3=LOW

C4=NORMAL
• 10-20% of cases of Rapidly
Progressive GN

• Can be ANCA +

• Antibodies to type IV collagen
Anti-GBM/Goodpasture's Syndrome
CLINICAL
• Rapid Onset of HTN, oliguria
• Fatal if not treated promptly

Kidney only: more common in older women (anti-GBM syndrome)

– Kidney/Lung: more common in young men (Goodpasture‟s syndrome); 70% will have alveolar hemorrhage
Anti-GBM/Goodpasture's Syndrome
Can have isolated kidney involvement or kidney and lung involvement
Anti-GBM/Goodpasture's Syndrome

– Kidney only: more common in older women (anti-GBM syndrome)

– Kidney/Lung: more common in young men (Goodpasture‟s syndrome); 70% will have alveolar hemorrhage
Dx: anti-GBM antibodies, biopsy

• Rx: cyclophosphamide + steroids;
plasmapheresis if pulmonary
hemorrhage
Anti-GBM/Goodpasture's Syndrome
Tx for Goodpasture's patient with pulmonary hemorrhage?
PLASMAPHERESIS
• Prognosis depends on:

–promptness of diagnosis and
treatment

–Degree of kidney involvement (if Cr
> 5 or dialysis required, prognosis
poor)
Anti-GBM/Goodpasture's
2 Types of Small Vessel Vasculitis?
1. Wegener's Granulomatosis
-lung, kidney and sinus involvement

2. Microscopic Polyangiitis
Patient has a Small vessel vasculitis with:
-lung, kidney and sinus involvement
Wegener's Granulomatosis
CLINICAL: (non-specific)
-decreased appetite
-weight loss
-hematuria and/or proteinuria
-polymyalgia
Small Vessel Vasculitis
c-ANCA +

anti-PR3– Wegener's

anti-MPO– Microscopic Polyangiitis
Small Vessel Vasculitis
anti-PR3– ?
Wegener's
anti-MPO– ?
Microscopic Polyangiitis
A 50 year old female presents to the office with a chief complaint of coughing up blood. She has no significant past medical history and has not had any recent respiratory illnesses. A PPD placed 6 months ago was negative. She is a lifelong nonsmoker. Routine labs reveal an increase in serum creatinine from 0.8 to 3.2 mg/dL in 3 months.

Vital Signs are unremarkable except for a
BP of 150/80.
You are concerned that the hemoptysis may be part of a pulmonary-renal syndrome like Goodpasture‟s or Wegener‟s.

What one question about associatedsymptoms could help you differentiate between Goodpasture‟s Syndrome and Wegener‟s Granulomatosis?
History of recurrent sinusitis = Wegener's

*****
What labs could you order to help you differentiate between Goodpasture's Syndrome and Wegener's Granulomatosis?
c-ANCA (positive in Wegener's)

anti-PR3 (Wegener's)

anti-GBM (Goodpastures)
What is the treatment for pulmonary
hemorrhage in either Wegener's or
Goodpasture's?
Plasmapheresis
CLINICAL:
acute onset of hematuria, proteinuria and edema; can also see pancytopenia

• Diagnosis: anti-Sm, anti-DS DNA**
Lupus Nephritis
– III focal nephritis

– IV diffuse nephritis

– V membrane formation, nephrotic range proteinuria

– VI >90% of glomeruli sclerotic, chronic
Lupus Nephritis
This disease is *associated with both membranous and membranoproliferative GNs*
Lupus Nephritis

Nephrotic/Nephritic Syndrome
Rx: Class III and above: cyclophosphamide +/- steroids

• Px: Depends on
– Kidney function on presentation
– Histologic type
– Crescents (aggressive disease)
Lupus Nephritis
Know this summary slide
Know this algorithim
Nephritic or Nephrotic Diseases? :

-IgA Nephropathy

• Henoch Schönlein Purpura

• Post-Infectious Glomerulonephritis

• Membranoproliferative GN

• Anti-GBM/Goodpasture‟s Syndrome

• Small Vessel Vasculitis

• Lupus Nephritis
Nephritic
Nephritic or Nephrotic Diseases? :

-Minimal Change Disease

• Focal Segmental Glomerulosclerosis

• Membranous Glomerulonephropathy

• Diabetic Glomerulosclerosis
(aka Diabetic Nephropathy)

• Amyloid
Nephrotic