Approach to GN.pdf

Approach to Glomerulonephritis  Outline Anatomy Mechanisms of Injury Clinical Syndromes Clinical conditions Indications for Biopsy Conclusion Approach to Tygerberg Hospital Glomerular Disease  Anatomy Approach to...

Approach to Glomerulonephritis  Outline Anatomy Mechanisms of Injury Clinical Syndromes Clinical conditions Indications for Biopsy Conclusion Approach to Tygerberg Hospital Glomerular Disease  Anatomy Approach to Tygerberg Hospital Glomerular Disease  Anatomy Approach to Tygerberg Hospital Glomerular Disease  Mechanism of Injury Approach to Tygerberg Hospital Glomerular Disease  Clinicopathological Syndromes Glomerular Disease Asymptomatic Rapidly Nephrotic Haematuria/ Nephritic Syndrome Progressing Proteinuria Syndrome Glomerulonephritis Primary vs Primary vs Secondary Secondary Approach to Tygerberg Hospital Glomerular Disease  Asymptomatic Haematuria/Proteinuria Proteinuria 150mg – 3g/day Haematuria > 2 RBC’s per high-power field No clinical manifestations of nephrotic or nephritic syndrome Most haematuria not of glomerular origin (10%) Microscopic examination: Structural changes – lose biconcave configuration, multiple membrane blebs Presence of red blood cell casts and proteinuria > 2g/24hr Biopsy findings: 30% - No pathological abnormality 26% - Thin basement nephropathy 28% - Ig A nephropathy Approach to Tygerberg Hospital Glomerular Disease  Asymptomatic Haematuria/Proteinuria Approach to Tygerberg Hospital Glomerular Disease  Nephrotic Syndrome Proteinuria (heavy) (>3.5g/day) Oedema (anasarca) Hypoalbuminaemia Hyperlipidaemia Lipiduria Hypercoagulable state Approach to Tygerberg Hospital Glomerular Disease  Minimal Change Disease Pathology: fusion of foot processes of epithelial cells (seen only on electron microscopy) Does not lead to chronic renal failure Features: Proteinuria, oedema (especially facial) Associations: Occurrence in Hodgkin's lymphoma and leukaemia NSAID use Rx: High dose corticosteroid therapy Approach to Tygerberg Hospital Glomerular Disease  Focal Segmental Glomerulosclerosis Pathology: segmental glomerulosclerosis -> progresses to global sclerosis Variant 1 – classical – benign course and more favourable response to steroids Variant 2 – collapsing – seen in HIVAN Features: massive proteinuria, haematuria, HPT and renal impairment Associations: Hypertension, HIV, Obesity, Kidney loss Rx: Prednisone (6months before declaring poor response to steroids).Cyclosporine/Azathioprine/Cyclophosphamide if poor response 50% of patients will progress to ESRD Approach to Tygerberg Hospital Glomerular Disease  Membranous Glomerulopathy Pathology: thickened capillary walls with uniform capillary wall deposits of IgG and C3 Affects young and middle aged Males more that females 40% develop renal failure Presentation: Asymptomatic proteinuria +- microscopic haematuria and hypertension Approach to Tygerberg Hospital Glomerular Disease  Membranous Glomerulopathy Associations: 1. Idiopathic 2. Drugs (NSAIDS/captopril) 3. Autoimmune Disease (SLE/ thyroiditis) 4. Infectious Diseases (Hep B,C/ Plasmodium malariae/Schistosomiasis/Syphilis) 5. Carcinoma (lung, colon, stomach, breast, NHL) 6. Others (sarcoid/renal transplant/sickle cell) Approach to Tygerberg Hospital Glomerular Disease  Membranous Glomerulopathy Rx: Use cyclophosphamide Corticosteroids and azathioprine ineffective Use renal protective measures (control sugar/BP/decreased salt/statins/ACE-I/avoid nephrotoxins) Disease of 1/3s 1/3 spontaneous resolution 1/3 stay the same 1/3 get worse Approach to Tygerberg Hospital Glomerular Disease  Membranoproliferative GN Pathology: Glomerular capillary wall thickening with hypercellularity Features: Mixed nephrotic/nephritic picture, nephrotic syndrome +- haematuria +- HPT +-renal impairment 3 types: (decreased C3) Type 1: “tram-line” effect with subendothelial IC deposits Type 2: linear intermembranous deposits (Dense deposit disease) Type 3: Mixed features of 1 and 2 Approach to Tygerberg Hospital Glomerular Disease  Membranoproliferative GN Associations: Similar to those of membranous GN Rx: Idiopathic + Non-nephrotic range proteinuria = conservative management and follow up with BP control Adults with nephritic syndrome = aspirin Nephrotic range = prednisone Eventually ESRD Approach to Tygerberg Hospital Glomerular Disease  Nephritic Syndrome Oliguria Haematuria with red cell casts Proteinuria