The Kidney in Sistemic Disease

Zehra Eren M.D.Nephrology Department

LEARNING OBJECTIVESThe Kidney in: Congestive heart failure Liver disease Diabetes Mellitus Systemic Vasculitis İnfections Systemic Lupus Erythematosus Dysproteinemias and amyloidosis Hemolytic Uremic Syndrom /Thrombotic Thrombocytic Purpura Cancer and its treatment

Renal Function In Congestive Heart Failure

Heart Failure

Definition-complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability to supply blood to adequatly meet the metabolic needs of bodily tissues-it is characterized by specific symptoms, such as dyspnea and fatigue, and signs, such as fluid retention

Cardiorenal syndrome interactions between heart disease

and kidney disease the interaction is bidirectional as

acute or chronic dysfunction of the heart or kidneys can induce acute or chronic dysfunction in the other organ

Classification of Cardiorenal syndrome

Type 1 (acute) — Acute HF results in acute kidney injury (AKI, previously called acute renal failure)

Type 2 — Chronic cardiac dysfunction (eg, chronic HF) causes progressive chronic kidney disease (CKD, previously called chronic renal failure)

Type 3 — Abrupt and primary worsening of kidney function due, for example, to renal ischemia or glomerulonephritis causes acute cardiac dysfunction, which may be manifested by HF

Type 4 — Primary CKD contributes to cardiac dysfunction, which may be manifested by coronary disease, HF, or arrhythmia

Type 5 (secondary) — Acute or chronic systemic disorders (eg, sepsis or diabetes mellitus) that cause both cardiac and renal dysfunction.

Renal Function In Liver Disease

Acute RI

Hepatorenal syndrom

Cronic RI

Post transplantation

Hepatorenal syndromDefinitiondevelopment of acute kidney injury in a patient who usually has advanced liver disease due to cirrhosis, severe alcoholic hepatitis, or (less often) metastatic tumor, but can occur in a substantial proportion of patients with fulminant hepatic failure from any cause

DIABETIC NEPHROPATHY (DN)

DIABETIC NEPHROPATHY

Definitionprogressive decline in glomerular filtration rate (GFR) in context of long-standing diabetes, usually accompanied by nephrotic range proteinuria and other end-organ complications, such as retinopathy

DN PATHOLOGY

Diabetic kidneys generally increased in size

Light microscopy

-mesangial expansion

-glomerular basement membrane thickening

-glomerular sclerosis

DN PATHOLOGY

Kimmelstein-Wilson nodules

DN Pathogenesis glomerular hyperfiltration hyperglycemia and the increased

production of advanced glycation end products

increased plasma prorenin activity hypoxia-inflammation activation of cytokines

Risk factors for progression family history of diabetes black race higher systemic blood pressures evidence of hyperfiltration early in course

of disease poor glycemic control smoking obesity and older age

No one factor is predictive in the individual patient

Renal Involvement in Systemic Vasculitis

Types of vessels in the Chapel Hill Consensus Conference nomenclature system

Large vessels: aorta and its major branches and the analogous veins Medium vessels: main visceral arteries and veins and their initial branchesSmall vessels: intraparenchymal arteries, arterioles, capillaries, venules, and veins

2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides

Renal angiogram in polyarteritis nodosa

Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

Infection-Related Glomerulonephritis

Lupus Nephritis

Lupus Nephritis An abnormal urinalysis (hematuria and/or

proteinuria) with or without an elevated plasma creatinine concentration is observed in up to 75 percent of patients with systemic lupus erythematosus

The most frequently observed abnormality is proteinuria

Classification revised by the International Society of Nephrology (ISN) and the Renal Pathology Society (RPS)

Class I – Minimal mesangial lupus nephritis Class II – Mesangial proliferative lupus nephritis Class III – Focal lupus nephritis (active and chronic;

proliferative and sclerosing) Class IV – Diffuse lupus nephritis (active and chronic;

proliferative and sclerosing; segmental and global) Class V – Membranous lupus nephritis Class VI – Advanced sclerosis lupus nephritis

Renal Amyloidosis and Glomerular Diseases with Monoclonal

Immunoglobulin Deposition

Noninfiltrated purpuric macule

Renal İnvolvementn in Hemolytic- Uremic Syndrome (HUS) /

Thrombotic- Thrombocytopenic Purpura (TTP)

Clinic presentation of HUS/TTP

Microangiopathic hemolytic anemia Thrombocytopenic purpura Acute renal failure Fever Neurologic dysfunction

Etiology and pathogenesis of microangiopathy

Peripheral blood smear from a patient with HUS

Renal involvemen in cancer and its treatment

SUGGESTED READING Goldman's Cecile Medicine, Goldman L, Schafer AI

Case files Internal Medicine, Toy Patlan

Current Medical Diagnosis and Treatment, Maxine A. Papadakis, Stephen J. McPhee, Eds. Michael W. Rabow, Associate Ed.

Current Diagnosis & Treatment: Nephrology & Hypertension Edgar V. Lerma, Jeffrey S. Berns, Allen R. Nissenson