Nephritic Sx & Nephrotic Sx

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Nephritic Sx & Nephrotic Sx. Case report 1. 18 yr old man Bilateral loin pain Macroscopic haematuria Sore throat started one day earlier BP 140/90; euvolaemic Creatinine 120 μmol/l Proteinuria and haematuria on dipstix. Case Report 2. 20 yr old lady Completely well - PowerPoint PPT Presentation

Text of Nephritic Sx & Nephrotic Sx

  • Nephritic Sx & Nephrotic Sx

  • Case report 118 yr old manBilateral loin pain Macroscopic haematuriaSore throat started one day earlierBP 140/90; euvolaemicCreatinine 120 mol/lProteinuria and haematuria on dipstix

  • Case Report 220 yr old ladyCompletely wellHaematuria on dipstixNo proteinuriaNormotensive

  • Case Report 312 year old boyImpetigo two weeks earlierHeadacheOliguricFrothy dark coloured urineHypertensive

  • Case report 415yr old woman3/12 ankle swelling; face and fingers swollen in the amBP 130/80; JVP normal; Leg oedemaCreatinine 54 mol/lCr Cl 140 ml/minAlbumin 18 g/l24 hr u.protein 10 g

  • Case Report 530 year old man,diabeticKnown hypertensiveAnkle oedemaDipstix: ++++ proteinuriaCreatinine 124 mol/l (80 120)Albumin 30 g/l (36 45)

  • Case Report 650 year old obese manHypertension 10 yearsNIDDM 3 yearsNo retinopathyCreatinine 124 mol/l24 hr urine protein 2 gHbA1 9.6%

  • *Structure of the filtration barrierPodocyte

    Foot processes

    Fenestrated endothelium

  • Minimal change disease

  • Glomerular changes in diseaseProliferationSclerosisNecrosisIncrease in mesangial matrixChanges to basement membraneImmune depositsDiffuse vs focalGlobal vs segmental

  • Common SyndromesNephrotic Syndrome

    Nephritic Syndrome

    Rapidly Progressive GN

    Loin Pain Haematuria Syndrome

  • Features of Glomerular DiseaseProteinuriaHaematuriaRenal FailureSalt and Water RetentionLoin Pain

  • Salt and Water RetentionHypertension

    Oedema

    Oliguria

  • Loin PainRare

  • ProteinuriaMarker of renal diseaseRisk factor for cardiovascular diseaseDyslipidaemiaHypertensionSomething more?24 hr protein vs urine protein:creatinine ratio

  • Nephrotic syndromeProteinuria > 40 mg/m2*hrHypoalbuminaemia (
  • Learning PointsClinical features Commonest typesPrognosisCauses Treatments

  • Nephrotic SyndromeCauses of primary idiopathic NSMinimal change diseaseMesangial proliferationFocal segmental glomerulosclerosis

  • Minimal Change DiseaseUsually childrenNephrotic syndrome with highly selective proteinuria and generalised oedemaRarely hypertension or ARFT cell mediated VPF Steroid sensitive usuallySpectrum of disease to FSGS

  • Focal Segmental GlomerulosclerosisJuxtamedullary glomeruli may be missed due to sampling errorOlder patients Less sensitive to immunosuppressionHypertension, haematuria, progressive CRF

  • FSGS:

    Familial

    VUR

    Drug abuse

    Obesity

  • Common types of GNPrimaryThin membrane diseaseIgA diseaseMinimal Change / FSGS spectrumMembanous NephropathySecondaryPSGN & Diabetic Glomerulosclerosis

  • Rarer TypesDiffuse endocapillary proliferative GN (post infectious GN)Crescentic GNMembanoproliferative / mesangiocapillary GN

  • Nephritic SyndromeHaematuria

    Hypertension

    Oliguria

    Edema

  • Rapidly progressive GNNephritic or nephrotic onset

    ESRF in six months

  • General Treatment of GNControl BPAngiotensin blockadeStatinLose weightStop smoking(pneumococcal prophylaxis)(anticoagulation)

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  • Case report 118 yr old manBilateral loin pain Macroscopic haematuriaSore throat started one day earlierBP 140/90; euvolaemicCreatinine 120 mol/lProteinuria and haematuria on dipstix

  • Case 1: indicative answersIgA Disease

    Renal failure, proteinuria, haematuria, oedema, hypertension, oliguria, loin pain

    All except oedema and oliguria

  • Mesangial IgA diseaseClassical Bergers DiseaseMicroscopic haematuriaProteinuria (rarely nephrotic)HypertensionChronic renal failure? Failure of hepatic clearance of IgAAssociation with GI diseaseNo specific treatment

  • Ig A NephropathyIg A nephropathy is the most common primary GN worldwideUsually present with hematuriaEpisodes of gross hematuria are precipitated by flu like illness, exerciseUrinary protein excretion usually non-nephroticAssociated with chronic liver ds, psoriasis, IBD and HIV disease.

  • Ig A NephropathyOnly 30% of patients with IgA nephropathy has progressive disease.In progressive disease, use of fish oil may be beneficial.Immunosuppressive therapy in patients with Ig A nephropathy has not consistently shown to be of benefit

  • Case Report 220 yr old ladyCompletely wellHaematuria on dipstixNo proteinuriaNormotensive

  • Case 2: indicative answersExclude menstruation! Thin membrane disease (possibly IgA disease)Commonest cause of isolated microscopic haematuria in this age group. At this age, urological cause unlikely; nil to suggest infection / urolithiasis

  • Thin membrane diseaseMost common GNMicroscopic haematuriaFamilialBenignNo treatment neededMost young people with isolated microscopic haematuria have thin membrane disease

  • Case Report 312 year old boyImpetigo two weeks earlierHeadacheOliguricFrothy dark coloured urineHypertensive

  • Case 3: indicative answersAcute nephritic syndromePost-streptococcal glomerulonephritisDiffuse proliferative endocapillary glomerulonephritisDue to salt and water retention, so salt restriction or loop diuretic

  • Acute Post-Infectious GNUsually occur in childrenPost-streptococcal GN is the most common cause of post infectious GNOccurs after a streptococcal sore throat or impetigoCaused by Group A, beta-hemolytic streptococci, particularly nephritogenic strains Type 1,4,12 (throat) and 2,49(skin)

  • Acute Post-Infectious GNAcute onset of gross hematuria (COLA COLORED) or microscopic hematuria after latent period of 10-14 days.Edema/hypertensionRBC casts on U/AElevated creatinine, increased ASO titerDecreased complement level

  • Acute Post-Infectious GNLM Diffuse proliferative and exudative GNIF IgG and C3 lumpy, bumpy

    EM Sub epithelial Hump or Flame like deposits

  • Diffuse Endocapillary Proliferative GN (Post Streptococcal GN)Diffuse endocapillary proliferative GN Post infectious; usually Gp A StrepAcute nephritic syndromeUraemia rareSelf-limited; rarely death from BPAbnormal RUA for up to 2 yrsCirculating immune complex mediated

  • Acute Post-Infectious GN

    Renal biopsy is generally not required.

    Treatment is supportive and consist of sodium restriction, control of BP and dialysis if this become necessary.

  • Complications of the Nephritic SyndromeHypertensive encephalopathy (seizures, coma)

    Heart Failure (pulmonary oedema)

    Uraemia requiring dialysis

  • Prognosis in the Nephritic SyndromeMore than 95% of children make a complete recovery

    Chronic renal impairment in the longer term is uncommon in children

    Bad prognostic features include severe renal impairment at presentation and continuing heavy proteinuria and hypertension

    Adults more likely to have long term sequellae than children

  • Case report 415 yr old girl3/12 ankle swelling; face and fingers swollen in the amBP 130/80; JVP normal; Leg oedemaCreatinine 54 mol/lCr Cl 140 ml/minAlbumin 18 g/l24 hr u.protein 10 g

  • Case 4: indicative answersMinimal change focal segmental glomerulosclerosis spectrumVery nephrotic Age and borderline BP make FSGS more likely than MCNEffect of loss of colloid osmotic pressure gradient across glomerulus causing hyperfiltration

  • Case Report 530year old man,diabeticKnown hypertensiveAnkle oedemaDipstix: ++++ proteinuriaCreatinine 124 mol/l (80 120)Albumin 30 g/l (36 45)

  • Case 5: indicative answersNephrotic syndrome secondary to diabetes / membranous diseaseRefer urgently to nephrology

  • Diabetic glomerulosclerosisRetinopathyHypertensionMicroalbuminuriaNephrotic syndromeRenal failure usually progressivePoor prognosis on RRT

  • What wed like!Demography including tel no and occupationReason for referral: presenting complaint, expectationsCo-morbidities, incl other diagnoses, smoking, alcohol and BMI, social care needsExaminationMedications (incl recently stopped), allergies etcTreatment and investigations to dateSpecial requirements (eg interpreter)

  • Case Report 650 year old obese manHypertension 10 yearsNIDDM 3 yearsNo retinopathyCreatinine 124 mol/l24 hr urine protein 2 gHbA1 9.6%

  • Case 6: indicative answersObesity-related FSGS more likely than diabetic nephropathy (duration diabetes, absence of retinopathy)Worsening nephrotic syndrome and progressive renal failure; Death from cardiovascular cause before reaches ESRFStop smoking, lose weight, improve glycaemic control, regular exercise, healthy diet, moderate alcohol in that order

  • Case 6: indicative answers contdLack of ownership of responsibility for own healthWithdrawal symptoms (smoking) Denial of calorie intakeDifficulty exercising due to immobilityNo! Problems with MDRD equationNo evidence of benefit of ACE inhibitors in absence proteinuriaDangers of ACE inhibitors in patients with angioneurotic oedema, hypotension or bilateral renal artery stenosis

  • LessonsNot all abnormal urinalysis is a UTI

    Acute pyelonephritis is very rarely bilateral

  • Haematuria Urologist or Nephrologist?AgeOther features proteinuria etcUrine microscopy for castsPhase contrast microscopy

  • Non-dysmorphic vs dysmorphic

  • RBC Cast

  • AntiGBM diseaseRPGN + Lung haemorrhageDestructive process medical emergency!Antibody-mediatedOne hitHigh dose immunosuppressionPlasma exchange

  • Any Questions?

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