Transcript BOARD REVIEW

BOARD REVIEW
NEPHROLOGY 2
Renal imaging
• X Ray- all renal stones show up except uric acid
• Renal US- size, obstruction, masses, screening for
Polycystic dz, stones> 5 mm
• IVP- non glomerular hematuria, renal stones, voiding
disease, unexplained flank/ abdominal pain
• Spiral CT without contrast- stones, perirenal hrg
• CT with contrast- staging of renal masses
• Radionuclide scan- to assess renal perfusion
• Renal arteriography- renal artery disease
• MRI- renal vein thrombosis
• Renal bx- glomerular disease
Glomerulopathy
Pearl to remember-when glomerulus affected- urine should have 3 things!
Dysmorphic RBC, RBC casts, proteinuria
• 1. subepithelial- small
deposits of membranous
GN,
• 2. subendothelial-lupus
• 3. mesangial-Ig A
nephropathy
• 4. basement membrane
deposits: Good Pasture,
hump appearance of
deposits in
poststreptococcal GN on
the epitelial side of GBM
Presentation of glomerular disease
Urinary findings
proteinuria
hematuria
Clinical features
Histopath
presentation
Nephrotic
syndrome
Fatty casts, oval fat
bodies
> 3 g/day
+/-
Generalized
edema, periorbital
edema, HTN
Minimal change
……
Nephritic
syndrome
RBC casts, cola,
smoky urine
<2.5 g/day
+
HTN
Post strep GN
….
Glomerular disease with nephrotic sdr
Primary
Secondary
Minimal change disease
Focal segmental
glomerulosclerosis
Membranous glomerulopathy
DM
SLE
Amyloidosis
Vasculitis
Glomerular disease with nephritic sdr
Low serum C
Normal serum C
Post streptococcal
SLE
Cryoglobulinemia
Idiopathic
membranoprolipherative
IgA nephropathy( Berger’s
disease)
Goodpasture’s srd
Systemic vasculitis( Wegener,
PAN, Henoch Schonlein
Purpura)
TTP/HUS
Minimal change disease
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Etio: mostly idiopathic
sec: Hodgkins/ Leukemia/NSAIDs/ Lithium
Bx: normal
IM: normal
EM: diffuse effacement of the epit foot processes
Complement: normal
Tx: steroids
Best prognosis of nephrotic syndromes
Focal segmental glomerulosclerosis
• Etio: Most common cause of idiopathic nephrotic
syndrome in African Americans
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Sec causes: heroin use, HIV, sickle cell disease,
obesity, urinary reflux
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Heroin has been associated with this condition but
this association has waned in the past decade(MKSAP 13)
• Bx: sclerosis of part of glomerulus in few glomeruli
• IM: IgM + C3
• C: normal
• Tx: steroids /cyclophos
Question
• 1. 31 year old AA male comes with BP of 150/90. His father has HTN.
Patient has history of drug abuse in the past. Urine check up reveals
hematuria + proteinuria> 3g/day. What is the most likely renal lesion:
• A) Focal segmental glomerulosclerosis
• B) minimal change disease
• C) HTN nephropathy
• D) Membranous glomerulopathy
• 2. A 33 year old male with Hodgkin’s disease has 2 months h/o edema
of the feet. He now comes to you with acute SOB. O/E lungs are clear,
CXR is normal. ABG: ph 7.56, pCO2 20, pO2 62, urine 4+ prot, 24 h
urine prot 5g. What is the possible diagnosis?
Membranous glomerulopathy
• Etio hep B, C, syphilis, tumors( solid), NSAIDs, SLE,
captopril
• Gold, penicillamine
• Bx: thickened capillary loops
• IM: granular IgG+ C3
• EM: subepitelial deposits( wire loop changes)
• C: normal
• Tx: steroids, cyclophosphamide
Membranoproliferative GN
• Etio: hep B, C, malaria, SLE, cryoglobulinemia, subacute
bacterial endocarditis
• Bx: tramtrack appearance
• IM: mesangial deposits
• EM: ribbon, sausaging of membrane
• C: low
• Tx: steroids, Cyclophosp
Complications of nephrotic sdr
• Prot> 3g/day  hypoalbuminemia edema
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hypogammaglobulinemia infections
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loss of antithrombin III thrombosis, PE
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loss of transferrin iron def anemia
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 fat bodies, fatty casts in
urine, hyperlipidemia
• Tx: ACE inhibitors
• Low salt
• Loop diuretics
• HMG CoA reductase inh
Diabetic glomerulopathy
• DM is the commonest secondary cause of nephrotic sdr in
adults
• Sequence of events are microalbuminuria( not detected by
urine dipstick) decline in renal function diabetic
microvascular retinopathy gross proteinuria( detected by
dipstick)
• Nephropathy that is diffuse and nodular, develops slowly
and dialysis or transplant is required
Diabetic glomerulopathy- questions
• 1. a patient with DM has proliferative changes in the
fundus. He also has prot-uria. Would you expect him to
have DM nephropathy?
• 2. When would you do kidney bx in a patient with DM and
nephropathy?
• 3. Under a light microscope, a kidney bx shows large
appearing nodular masses in the glomerulus. What is the
differential diagnosis?
• Next- do congo red and examine under the polaring
microscope
Amyloidosis
• 1. AL type is the primary disease( macroglossia) and is also
associated with MM. It is due to the overproduction of
light chains- mostly lambda chains. Dg can be made from
gingival, rectal, fat pad, renal bx
• Al type is congo red positive Renal failure occurs in 1-2
years. Treatment with melphalan and prednisone.
• 2. AA type is the secondary form-due to chronic
inflammation and it occurs in chronic drug abusers where
amyloid nephropathy follows the chronic skin infection
resulting from skin popping. It is treated by correcting the
underlying inflammatory condition- some patients respond
to colchicine
Skin popping
Glomerulopathy following URI
• An 18 year old male Asian male has gross hematuria
developing over few days after URI. BUN and creatinine
are normal. Serum C is normal. Urine is conc with specific
gravity of 1030. There is 2+ prot-uria and 4+ blood. Urine
sediment shows dysmorphic RBC and RBC casts. What is
the possible diagnosis?
• Post strep GN or IgA nephropathy?
Post streptococcal( post
inf nephritis)
IgA nephropathy
(Berger’s disease)
Latent period
Occurs within 3 weeks
It occurs within 3 days
after URI or impetigo
after URI and is the
with nephritogenic strains commonest cause of acute
GN
pathogenesis
Entire glomerulus with
many glomeruli are
involved causing oliguria,
azotemia, HTN
Subepitelial humps( IgG,
C3)
It is the mesangial
hypercellularity( mesagial
proliferative GN) in few
glomeruli and causing
hematuria- which
commonly occurs either
during a viral illness or
after execise
Lab findings
CH50 and C3 level are
low, ASLO positive
Serum C is normal
Serum IgA elevated
treatment
antibiotics
None. ACE inhib slow
the progression of disease
Question
• 1. A 24 year old female presents with arthralgias, low grade fevers,
Raynaud’s phenomenon. Malar rash+, bilateral pedal edema+. BUN/
creatinine 35/2.2. Serum complement decreased. ANA anti dsDNA
increased.
• UA 15-20 RBC, RBC casts+, prot 4+
• 24 h urine prot- 4 g/day
• Renal bx will most likely show:
• A) mesangial lupus nephritis
• B) membranous nephritis
• C) focal proliferative GN
• D) membranoproliferative( diffuse proliferative)
Question
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All of the following will have low complement except?
A) post streptococcal GN
B) SLE
C) SBE
D) cryoglobulinemia
E) MPGN
F) minimal change disease
Question
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1. All of the following have normal complement except?
A) minimal change disease
B) focal segmental glomerulosclerosis
C) membranous nephropathy
D) IgA nephropathy
E) Henoch Schonlein nephropathy
F) Cryoglobulinemia
Question
• A patient is admitted with massive hemoptisis. Workup
reveals severe renal failure. There is no past history of
renal disease. A renal bs shows diffuse glomerulonephritis
with giant cell granuloma. What is the most probable
diagnosis?
• You are shown a biopsy of the glomerulus with linear
deposits ( IgG in linear fashion along the capillary loop)
What Ab would you order in serum?
• Anti glomerular basement membrane
Question
• A 17 year old male homosexual having a single partner,
comes with hemoptysis 2 days after an URI. Chest Xray
shows bilateral interstitial infiltrates. Urine exam shows
gross hematuria, modest proteinuria, and on microscopy,
dysmorphic RBCs and red cell casts. A kidney biopsy
shows IgG deposits in linear fashion along the capillary
loop. What is the possible diagnosis?
• A) Good Pasture
• B) Wegener’s
• C) Kaposi’s sarcoma
• D) HIV nephropathy
Question
• A 65 year old woman is referred to you for evaluation of HTN. Six
months ago, initial serial blood pressure readings range from 160/110
to 170/120 mmHg. BP was brought under control with three
antihypertensive agents. The patient has been asymptomatic. There is
no family history of HTN. On exam BP 170/105 in both arms, and
similar readings are recorded in both legs. Fundoscopy reveals
hemorrhages and exudates. A systolic and diastolic bruit is heard in the
left mid abdomen and through the back. Serum creatinine is 2.3 mg/dl,
K is 3.9. UA shows 1+ prot-uria. An EKG shows LVH. What is the
most appropriate noninvasive screening test for possible renal artery
stenosis in this patient?
• A) pre and post captopril peripheral plasma renin activity?
• B) CT angiography with contrast
• C) rapid sequence iv urography
• D) magnetic resonance angiography