Week 14 - Nephrology
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What are the Pc of Glomerulonephritis?
- Reduced GFR
- Nephrotoc syndrome
- Nephritic Syndrome
- Rapid progressing GN → 6wks to ESKD
What are the features if NEPHROTIC syndrome?
- Nephrotic Syndrome
- Heavy proteinuria
- Hyperlipidaemia → side effect of liver ^^protein
- Hypoalbuminaemia, prOteinuria, Hyperlipidaemia, Oedema
What are the features of the NEPHRITIC syndrome?
- Haematuria [with casts]
- Oliguria [<400ml/day]
- A.k.a PHARAOH
- RBC casts
- Anti-strep titres (if post-strep)
Give 4 types of GN?
- IgA nephropathy → commonest
- Membraneous GN
- Minimal Change Disease
- RPGN [Rapidly progressing GN]
- Wegeners Granulomatosis
- Post infectious GN
Outline the clinical & pathological features of IgA nephropathy?
- Haematuria, Proteinuria, hypertension & renal impairment
- ~Nephrotic Syndrome
- Deposition of IgA in mesangium → activation of mesangial
- scar formation
- loss of capillary integrity
What is the CF & Patho of Membraneous GN?
- Proteinuria, Nephrotic syndrome, hypertension, renal impairment
- Commonest cause of nephrotic syndrome in adults
- Deposition of immune complexes in GBM & Mesangium [tumours, lupus]
- Alters GBM charge
- Altered permeable selectivity
- Thickens GBM
What are the CF & patho of minimal change disease?
- Acute, Normal GFR, Nephrotic syndrome [puffy eyes]
- commonesst cause of nephrotic in kids
- EM shows podicyte fusion, T cell associated
For Rapidly progressing glomerulonephritis give the CF & pathology.
- Rapid onset, haematuria, roteinuria, hypertension, renal impairment, haemoptysis, systemic symptoms [malaise, fever]
- e.g. Wegeners/ Goodpastures
- Goodpastures → anti GBM disease, cellular destruction & crescent formation
- Wegeners Granulomatosis → necrotising vasculitis, nasal, pulmonary & renal symptoms ANCA +ve
Outline the features f a GN screen?
- Serum biochem → Cr & Albumin
- FBC → Hb, CRP, WCC
- Immunology → antibodises & electrophoreisis → ANCA, RhF, ANF & Anti-GBM
- U/O → Dipstix, PCR, Microscopy & MSSU
- Imaging → CXR, Renal U/S
Give 5 risk factors for UTI?
- Infancy [<1yo]
- Abn Urinary tract [congenital malformation]
- Female → esp pregnant
- Bladder dysfunction/ incomplete emptying → ^^prostate
- Foreign bodies in tract → stones, catheters
What are the CF of Pyelonephritis?
- Bacteruria & fever >38 = Pyelonephritis
- Systemic symptoms [fever, malaise, lethargy]
- vomiting, loin pain
What are the CF of a lower UTI/ Cystitis?
- Bacteruria & abscence of systemic features = cystitis
- Non-specific abdo pain
- urgency, frequency, wetting, frank haematuria
Outline the pathology of Pyelonephritis?
- Ascending infection
- urethral colonisation by infective org
- multiplication in bladder
- reflux to kidneys [pathophysiological]
- VUR → vesicoureteral reflux
- Female > male
- Haematogenous Infection
- Infection includes renal parenchyma
- Gram +ve infection more common
Chronic can lead to scarring
Outline the diagnostic tests for suspected UTI?
- Urinalysis → leucocytes + Nitrites = UTI
- Microscopy/ Flow cytometry → neutrophils & bacteria
- Urine C+S
What are the common orgs for UTI?
- Usually single org infection
- ?multiple → change catheter
- Gram neg → Proteus, E coli, Klebsiella & psuedomonas
- Gram pos → enterococcus, staph aureus [red flag]
?anaerobes → bladder cancer
How would a UTI be treated?
- 3-7d course of;
- or trimethoprim
- or Nitrofurantoin
For renal cell carcinoma give
- Renal [Clear] cell Ca
- Patho → adenocarcinoma of PCT, can ascend IVC
→ loin pain, palpable mass, Frank haematuria
→ radical nephrectomy/ nephron sparing surgery
For Prostate Ca give
Pc → painful micturation, cant initiate urination easily, recurring UTI
Patho → Adenocarcinoma [peripheral zone of prostate], central zone = benign adenoma
Tx → watchful waiting, PSA ea 3m [not tumour specific], Rt/ radical prostectomy
For bladder cancer give
RF → smoking, rubber/ dye industry, schistosomiasis
Pc → frank haematuria [usually painless]
Pathology → majority = transitional cell Ca, some SCC
Tx → transurethral resection, radical cystectomy
Give 4 causes of urinary calculi?
- Calyceal diverticulum
- Pelviureteric junction obstruction [congenital]
- Ureteric stricture
- Foreign body
- Proteus infection → urease, change pH ^^stones
Outline the mechanism of calculi formation
- Obstruction → urine superconcentration
- particle gets fixed to renal papilla [seed crystal]
- Growth of stone
pH dependant → works better at low pH [Proteus infection]
What are the 4 types of calculi?
- Staghorn → infection, calyceal location
- Renal Pelvis
- Ureteric Calculi
Outline the Mx of Renal Calculi?
- Small stones → watch & wait
- Lithotripsy → shockwave degradation of stone
- Open surgery → large/complicated stone
Give the histopathology of Diabetic nephropathy?
- ^^[Glucose] & HBP mediated damage to glomerulus
- Sclerosed nodules
- Thickened Glycated GBM
- Podocytes absent
Outline the Pc & Mx of diabetic nephropathy?
- Proteinuria [microalbuminuria]
- worsening oedema
- Uraemic coma
- <120sys → ACEi
- eventually dialysis
What would the signs of renal artery stenosis be?
- carotid & femoral bruits
- asymmetrical kidnys
- excretory renal impairment
What are the renal presentations of myeloma?
Light chains [Bence-jones protein] are toxic to proximal tubule
What are the causes of AKI?
- hypoperfusion → haemorrhage, pump failure, antihypertensives
- Renal [Intrinsic]
- Glomerular [vasculitis] → acute GN [e.g. IgA nephropathy etc]
- Tubular → acute tubular necrosis [ATN], myeloma, rhabdomyolysis
- Large BV?
- Post renal
- obstruction; renal pelvis → urethral meatus
What is ATN?
What are the histological features of ATN?
What are the causes of ATN?
- Acute Tubular necrosis
- Damage to renal tubular cells by iscaemia [hypoperf/hypovolaemia] or nephrotoxins [contrast, gentamicin, amphotericin B, myoglobin]
Histological → tubules occluded by cellular debris
Outline the diagnostic process in the Pt w AKI?
2. Rule out obstruction
- 1. Acute/ Chronic
- Comorbidities suggest chronic e.g. DM
- Previously abn blood tests, small kidneys → chronic
- Abscence of anaemia, low Ca & ^^phos → acute
- 3. Rare causes of AKI?
- GN → urgent renal referral
Outline the management of AKI?
- Monitor & correct K+ dereangements
- Restore perfusion
- remove causes → drugs/ sepsis
- Exclude obstruction
- Consider renal causes → GN screen [ANCA, ANA, electrophoreisis, aGBM, urine Bence jones (myeloma)]
What are the stages of Chronic Kidney Disease? [CKD]
1 → Kidney dam but normal function, GFR>90
2→ Kidney dam, mild drop in GFR 60-89
3→ moderate dec in GFR 30-59
4 → severly low GFR 15-29
5 → kidney failure/ dialysed, GFR <15
What is a 'salt losing' CKD Pt?
- Salt loser
- Medulla [tubular] damage → lose concentration/ acidification
- salt loss → water loss
→ dehydration, hypotension, acidosis
What is a 'salt retaining' CKD Pt?
- Salt Retaining
- Cortex [Glomerular] damage → lose filtration ability
- Salt retention → water rentention
→ oedema, hypertension
What would the blood results for the following be in a CKD Pt?
-Ca & PO4
FBC → anaemia [no EPO production]
pH → Acidotic salt losing Pts
Ca & PO4 → ^^PO4, low Ca, not hydroxylating vit D cant abs Ca, stim of PTH → release of Ca & phos from bone
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