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OS 214: Renal Dr.

Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

OUTLINE O2sat 92%) Severe


I. Introduction Uncompensated
II. Glomerulonephritis Metabolic acidosis (low
III. Pathogenesis of Glomerulonephritis pH, low HCO3;
IV. Approach to Patient with causes tachypnea)
CXR To rule out pneumonia Heart not enlarged but
Glomerulonephritis
with congestion
V. Forms of Glomerulonephritis Showed pulmonary
A. IgA Nephropathy edema
B. Poststreptococcal Glomerulonephritis EKG Check for hyperkalemia Peaked T waves
C. Membranous Glomerulonephritis (denotes hyperkalemia)
VI. Summary  you have to give
VII. Socioeconomic impact of calcium gluconate as
Glomerulonephritis treatment
VIII. Figures UTZ Visualize the kidney: Small shrunken kidney
If enlarged (e.g. 12 Cortex should at least be
cm)=acute GN, reversible 4.5cm thick
Note: The lecturer did not provide a powerpoint. Thank you to
If
Irving for sending pictures of the ppt for this trans. Please be
shrunken=ESRD,irreversi
reminded that the exam questions will come mainly from HPIM
ble
17th ed.; topics included are general information on glomerular
(Normal Filipino size:9.6
disease, GN, IgA nephropathy, PSGN and MGN.
cm in length; Normal
Caucasia:11-12 cm)
I. INTRODUCTION *Normal  globular, thick
A. Case of ER, presented with: cortex
o high BP (160/100), HR 104, RR 30/min Urinalysis “window to glomerular -low sp. gravity
o pale, sallow (in between pallor and jaundice) disease” -granular casts
o “peculiar fetor” – fruity smell -early morning urine -Increase RBC and
expected to have a dark, WBC
o evidence of cardiac damage (Grade II Av block intense color if kidney is -mucus threads rare
hypertensive) but not yet in CHF due to absence of able to concentrate urine denotes that urine was
s3 - concentrated (Sp. well collected
o no evidence of liver involvement gravity 1.020-1.030) -px has no fever but high
o ++ bipedal edema -Acute GN – red cell WBC may indicate
casts; RBCs degenerate sterile pyuria
o Dry skin, good and equal pulses
to fine/coarse granular
o Basal crepitant rales casts reflects chronicity
-Hyaline casts can be
B. Primary Impression: UREMIA (symptom diagnosis) found in a normal person
Symptoms seen in the ER -Most common cause of
o Vomiting pus cells non infective
o Tremors pyuria
o Anorexia
*if creatinine is high, BUN is expected to be abnormal; if BUN
o Weakness
is high, creatinine is not necessarily high
o SOB
*the presence of protein in the urine is not correlated with the
o Pruritus specific gravity of the urine since SG indicates the ability of
o Easy fatigability the kidneys to concentrate. Even if this is intact, the kidneys
o Irritability can still spill out urine.
*those in asterisks are the cheaper tests, so they are the most
Full blown Uremia (not seen in ER) economical and efficient in terms of information.
o Somnolence
o Seizures D. Final Diagnosis:
o Disorientation o Uremia secondary to ESRD (CKD Stage V)
o Coma secondary to Chronic Glomerulonephritis (CGN)

*Azotemia is a laboratory diagnosis Basis for diagnosis:


Uremia a clinical diagnosis CGN
o young adult, hypertension at age 19 (hypertensive
C. Labs Requested nephrosclerosis takes about 20 years to develop,
and so it is an unlikely ddx)
Lab Purpose Finding in ER o hematuria, pyuria
CBC Check for anemia due to Low Hg (7) o small kidneys (denotes a chronic problem, not acute)
pallor
BUN To asses kidney function, Elevated (60umol/L) ESRD
but creatinine is more
o shrunken kidneys
important
*Creatinine Single most important Increased (1800 umol/L) o uremia, anemia, low Ca
test for uremia (uremic if o Inc phosphorus
azotemic); if high, tells
you that px likely has *Single most important determinant of chronicity shrunken
kidney disease kidneys
Electrolytes To check for acidosis Decreased
Ca
Phosphorus *Severe renal failure Ca low, Phosphorus high
Elevated (6)
**K Needed if urgent action is Elevated (5.9)
required (can easily kill **ER is a UP student; inc BP at age 19 (140/90). ER was
the patient) erroneously treated as UTI for 3 years in a male with no
***ABG Needed if urgent action is (pH7.2; pCO235; symptoms and an abnormal urinalysis; ER passed
required pO294; HCO311; engineering boards 3 days before he underwent hemodialysis!

March 6, 2009/Friday Page 1 of 7


Seth, Ian
OS 214: Renal Dr. Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

*Immunofluorescence can be used to determine whether


immune complexes are in-situ or circulating

My Goals (which I guess have to be our goals) *Overlapping etiologies may produce similar glomerular
1. To be aware lesions display common patterns of injury (syndrome); this is
2. To be suspicious evident in microscopy:
3. To Set the Alarm IgA paramesangial; can still see spaces in glomerulus; most
common in Asians
II. Glomerulonephritis
-inflammation of the glomerular capillaries Poststrep GN (PSGN) – same pattern of injury can be seen in
lupus; immune-complex GN; most common post infectious
a. Normal Kidneys:
o smooth surface Membranous GN (MGN) –same pattern can be seen in
o pinkish cortex idiopathic, Hepatitis, and drug-induced; just hits the basement
o reddish medulla membrane, causing it to thicken; most common in men
o yellow calyces, pelvis
o In GN: kidneys are pale IV. Approach to Patient with Glomerulonephritis

*Kidney disease has 10 types but can manifest the same way. A. History and PE (what to look at)
But if you look inside the kidneys, the pathology is actually o confined to the kidneys or systemic? acute or
different. They hit different parts of the kidney thus histology chronic?
is important! o signs and symptoms (what to ask the px)
• dysuria – pain during urination?
b. Glomerulus • nocturia – urination at night?
o 600 thousand – 2 million (all in all) in a normal • hematuria – blood in the urine? (2 kinds gross
individual and microscopic)
*prematures have less glomeruli  higher tendency • retention/incontinence – incomplete
for hypertension  higher tendency for renal disease voiding?
at age 50 • frequency – urinating more often?
o is a ball of capillaries (“berries”) with afferent and • Sediments- may “latak” sa ilalim ang ihi?
efferent arterioles (histology: stalk – where efferent
• frothy urine – like beer?
and afferent arterioles run)
o glomerular capillaries filter 120-180 L/d of plasma • edema
water o last known urinalysis/creatinine
o filtration occurs through a physicochemical barrier o pregnancy status (preeclampsia); birth control pills
governed by pore size and negative electrostatic o last normal BP
charge o Blood pressure
o glomerulus is an imperfect barrier • must give exact value, not just saying
*e.g. albumin-despite its negativity, readily passes normal or high, because what is high for
through due to its small radius (3.6nm vs. 4nm radius one person may be normal for another
of glomerular basement mebrane (GBM) slit-pores); o Urinalysis
albumin is reabsorbed in the proximal tubules (urine • window to glomerular disease
normally contains only 8-10 mg) • Quality of urine: clear, cloudy or bloody
(gross hematuria)
*Glomerulonephritis can affect any part of the glomerulus *if with gross hematuria and is painless consider
(mesangium, parietal epithelium, basement membrane, malignancy until proven otherwise; if painful,
podocytes) and will manifest differently. consider urethritis
In GN: the glomeruli are full of scars
*Dilute urine  yellow concentrated
Pathogenesis:
*Cloudy tea colored
(1) (2) *Bloody gross hematuria
Circulating immune complexes In-situ immune complexes
Table 277-1. Urine assays for albumin/proteinuria (HPIM 17th ed)
T-cells (CD 4/8) activation 24Hr Albumin/ Dipstick 24Hh
Albumin creatinine proteinuri Urine
Loca activation of toll-like receptors on Glomerular Cells (mg/24h) ratio a Protein
(mg/G) (mg/24h)
Deposition of Immune Complexes
Normal 8-10 <30 - <150
Complement injury Microalbu 30-300 30-300 -/trace/1+ -
minuria
Glomerular injury Proteinuria >300 >300 Trace-3+ >150
Mononuclear infiltration
V. Forms of Glomerulonephritis (Patterns of Clinical GN)
Cytokine release

Attract more inflammatory cells Form Prototype Disease


Acute Nephritic IgA Nephropathy
Glomerular damage Infectious Disease PostStreptococcal GN
Associated; Nephritic (PSGN)
*In summary, GN may be caused by circulating or in situ Nephrotic Membranous GN
immune complexes, but whichever the cause is, they both
follow the path of inflammation via T-cell activation Basement membrane Alport’s syndrome
Glomerular Vascular Disease ANCA small vessel vasculits

March 6, 2009/Friday Page 2 of 7


Seth, Ian
OS 214: Renal Dr. Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

Pumonary-Renal Goodpasture’s disease o sometimes recur post transplant


o risk factors for renal failure: HPN, proteinuria,
*just focus on the first three as said by the lecturer, ayt? absence of episodic macroscopic hematuria,
male, older age of onset, sever renal biopsy
changes
A. IgA Nephropathy o “Point of no return” – stage where treatment is
CASE: insufficient usually when creatinine is at least 2
31 female o the clinical prognostic index (CPI) of GN–made
Routine annual Physical checkup in Verona, Italy; a scoring system that predicts
Urinalysis the prognosis of GN
- RBC –TNTC • 2pts for Serum Creatinine> 1.4mg/dl
- WBC – 0-3 • 1pt for Proteinuria> 1g/24 hrs
- Protein (-) • 1pt for presence of HPN
- Casts (-)
• 1pt patient > 30 years old
BP  120/70
o Score of 0-2*: higher 10-year renal survival; 3-5:
o immune complex mediated GN defined by the lower 10-year renal survival; most likely to end
presence of diffuse mesangial IgA deposits often up in dialysis; hence, creatinine is the single
associated with mesangial hypercellularity most impt predictors of survival since it
o circulating immune complexes get deposited in the automatically gives you 2pts if abnormal
mesangium or podocytes (not the basement
membrane [BM]) *Immunoflourescence  positive for IgA
o IgM, IgG, C3, or immunoglobulin light chains can be • Treatment
codistributed with IgA
o Evidence-based: ACEI-ARB, Steroids, fish oil
o Mild – do not undergo dialysis
(severe only), sequential, cyclophosphamide:
o RPGN (rapidly progessive)- end up in dialysis after 6
azathioprine (progressive only)
mos
o Non-evidence Based: azathioprine/MMF, CNI
• POSTstrep GN - tea colored urine happens 2
(CsA Tacro), IVIg, Leflunomide,
weeks after infection
heparin/warfarin/dipyridamole, tonsillectomy
• In IgA – happens with the infection
*IgA GN is common, progressive, but treatable
• Pathogenesis: defective immune response formation of
immune complex proinflammatory, proproliferative, B. PostStreptococcal Glomerulonephritis (PSGN)
proapoptotic, profibrotic + milieu in glomeruli
CASE:
mesangial/podocyte injury, capillary hypertension, altered
22 male
perm selectivity, glomerulosclerosis, tubulo-interstitial
1 month impetigo in L leg
fibrous hematuria, proteinuria, decreased GFR
Pus, crust, swelling, redness, fever  tea colored urine, dec
• Epidemiology outpu, puffy eyelids, anorexi, easy fatigability, inc BP
o most common form of GN worldwide
o 30% in Asia and Pacific RimEast > West o also known as Postinfectious GN
o 20% in southern Europe o prototype for acute endocapillary proliferative GN
o low prevalence in N. Europe & N. America o classically not a nephritic syndrome
o Male > Female
o peak incidence: 2nd-3rd decade of life • Pathogenesis: putative streptococcal antigens circulating
o rare familial clustering 1-C, activation of complement with cell mediated injury
• Presentation deposition in GBM
o most common presentations are: • Epidemiology
• recurrent episodic macroscopic hematuria o typically sporadic
following a respiratory infection in children o children between 2-14 yrs (10% in px>40yrs)
• asymptomatic microscopic hematuria seen o Males > Females
in adults o 10% pts>40yrs
o between episodes, urinalysis is normal o familial/cohabitant incidence is high-40%
o in persistent hematuria, increasing proteinuria is o M types of Streptococci (nephritogenic strains)
found o impetigo- M types 2, 47, 49, 55, 57, 60;
• Differentials PSGN develops 2-6 wks after a skin infection
o Henoch-Schonlein Purpura- can be
o Pharyngitis (nephritogenic strain)- M types
1,2, 3, 4, 12, 25, 49; PSGN develops 1-3 wks
distinguished for IgA Nephropathy by prominent
after strep upper respiratory infection
systemic sx, younger onset (<20yrs old),
(pharyngitis)
preceding infection and abdominal complaints
o Crohn’s disease, chronic lover disease, GI
adenocarcinoma, etc –also present with IgA • Labs
deposition in mesangium; can be differentiated o Decreased CH50, decreased C3
due to absence of significant glomerular o Inconsistently positive culture (10-70%)
inflammation. o Increased ASO titers (30%)
• Progression o Anti-DNase (70%)
o generally a benign disease, but 25-30% o Antihyaluronidone Ab (40%)
progress to renal failure over 20-25 yrs.
o 5-30% go into complete remission
• Presentation

March 6, 2009/Friday Page 3 of 7


Seth, Ian
OS 214: Renal Dr. Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

o classic presentation of acute nephritic px: HPN, • heavy proteinuria (24h urine total protein > 3g),
hematuria, RBC casts, pyuria, mild to moderate minimal hematuria, hypoalbuminemia,
proteinuria hypercholesterolemia, HPN
o oliguric renal failure • if untreated leads to progressive glomerular
o systemic symptoms include headache, malaise, injury, decline in GFR and renal failure
o anorexia, flank pain (swollen renal capsule) in 50%
of cases Edema
o in the 1st week of symptoms: 90% have depressed There are 2 theories for the cause of edema due to NS:
CH50, decreased C3 (because they are circulating
and get deposited in the GBM) 1. Underfill  protein spillage  low albumin
o positive strep cultures are inconsistent (albumin acts as the magnet that attracts fluid)
 low oncotic pressure  low intravascular
Renal Biopsy volume  secondary sodium retention 
o diffuse proliferative: little bowman’s space seen EDEMA
o hypercellularity of mesangial and endothelial cells 2. Overfill  low GFR  low RPF and low FF
o glomerular infiltrates of PMN leukocytes primary Na retention  Expanded ECF volume
o granular subendothelial immune deposits of IgG,  EDEMA
IgM, C3, C4, C5-9 Nephrotic syndrome (NS) is described as: 24hr total
o subepithelial deposits-“humps” Pr>3gm, hypertension, hypercholesterolemia,
o RPGN – with crescents hypoalbuminemia, edema/anasarca
• Diagnosis
*therapy of edema in NS: low Na diet, oral loop diuretic,
o renal biopsy is not necessary goal of 1-2lbs edema loss/day
o subclinical cases are reported to be more Renal Biopsy
common than clinical nephritis and o LM: uniform thickening of the BM along the
characterized by asymptomatic microscopic peripheral capillary loops
hematuria and low serum complement levels o Immunoflorescence: diffuse granular deposits of
• Treatment IgG and C3
o EM: electron dense subepithelial deposits
o supportive
• for HTN
• for Edema
• Progression
o some reports suggest that degree of tubular
• Dialysis if indicated (oliguric)
atrophy or interstitial fibrosis are better
o antibiotic tx for strep infection for px and predictors than the stage of glomerular disease
cohabitants o high recurrence rates
o no role for immunosuppressive tx even if o Abrupt onset of edema
crescents are present o spontaneous remission occur in 20-30% of
o good prognosis, rare recurrence, permanent
patients and occur late in the course after year
renal failure is very uncommon (1-3%) of NS
o complete resolution of hematuria and proteinuria o 1/3 have relapsing NS but maintain normal renal
in children occur in 3- 6 weeks of onset of functions
nephritis o 1/3 develop Renal failure of die of complications
of NS
C. Membranous Glomerulonephritis (MPGN/MGN)
o risk factors for worse prognosis: male, older age,
o also called Mebranous Nephropathy (MGN)
HPN, persistent proteinuria
o in situ formation of immune complexes with megalin-
o MGN has highest reported incidence of renal
receptor associated protein as the putative agent
vein thrombosis, pulmonary embolism and DVT
complications among NS
• Epidemiology
o 30% of nephrotic syndrome (NS) in adults • Treatment
o rare in children but most common NS in the elderly o symptomatic treatment: edema (oral loop
o peak incidence between 30-50 years diuretics, low Na diet, target is loss of 1-2lbs or
o Males > Females (2:1) fluid per day), HPN, dyslipidemia,
o 25-30% secondary to malignancy (tumors of lung, hypercholesterolinemia (lipid lowering agents to
breast, colon), infection (Hep B, malaria, decrease risk for CVS disease), proteinuria
schistosomiasis), rheumatologic disorders (lupus) (inhibition of RAS)
o other etiologies are Drug-induced MGN o immunosuppresive drugs (steroids and
o Unknown/Idiopathic is still the most common MGN cyclophosphamide, chlorambucil, cyclosporine,
tacrolimus, rituximab) for primary MGN and
Causes: persistent proteinuria (>3.0g/24hrs)
• Idiopathic o experience with mycophenolate mofetil or anti-
• Secondary: malignancy,infective Hep B, CD20 antibody is limited
Rheumatology (SLE), Drugs (Gold)  25-30% is o prophylactic anticoagulation (controversial but
secondary recommended) in px with sever proteinuria

• Presentation Low risk


o 80% with nephrotic syndrome (NS)* and Normal renal function
nonselective proteinuria Protein <4
o 50% with microscopic hematuria
Medium
Nephrotic Syndrome Normal fxn

March 6, 2009/Friday Page 4 of 7


Seth, Ian
OS 214: Renal Dr. Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

Protein >=4 <8

High
Abnormal fxn
Protein >= 8

VI. SUMMARY

Be aware
o Family History: HTN, DM, CVD, Gout, Dialysis,
ESRD

Be suspicious
o BP > 140/90
o Frothy/cloudy urine
o Crea > 1.5 mg/dL or 132 umol/L
o GFR < 60
o Nocturia
o Dysuria

Set the Alarm


o Urinalysis
o BP >130/80
o Crea 1.5mg/dl, 132 mmol/L

3 Syndromes and their signs


Form Prototype Disease Proteinuria Albuminuria
Acute IgA Nephropathy +/++ +++
Nephritic
Infectious PSGN +/++ +++
Disease
Associated;
Nephritic
Nephrotic MGN ++++ +

*the GFR should be greatly decreased before creatinine


manifests with an abnormality. Hence, be suspicious agad!

*A normal creatinine doesn’t mean there’s normal kidney


function, so always compute!
Therapeutic Intervention
o AntiInflammatory: Prednisone, tacrolimus, MMF, Postinfectious (poststreptococcal) glomerulonephritis.The
ritazimab glomerular tuft shows proliferative changes with numerous PMNs,
o Reduce Proteinuria: ACEI, ARB with a crescentic reaction in severe cases (A1). These deposits
e.g. FSGS-progression, remission, relapse if localize in the mesangium and along the capillary wall in a
mainatained on prednisone, but if given combination subepithelial pattern and stain dominantly for C3 and to a lesser
therapy of prednisone and mycophenolate, disease extent for IgG (A2). Subepithelial hump-shaped deposits are seen by
is kept in remission electron microscopy (A3).

VII. Socioeconomic impact of Glomerulonephritis


o Dialysis: Php40,000 per month
o Kidney transplant: Php1.2 M
o Maintenance medications: Php60,000 per month

*Hence: set the alarm! Because GN is a TREATABLE


disease; if treated early, there’s no need for these expensive
interventions.

VIII. Figures

March 6, 2009/Friday Page 5 of 7


Seth, Ian
OS 214: Renal Dr. Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

IgA nephropathy
There is variable mesangial expansion due to mesangial
deposits, with some cases also showing endocapillary proliferation or
segmental sclerosis (C1). By immunofluorescence, deposits are
evident (C2).

Membranous glomerulopathy. Membranous glomerulopathy is due


to subepithelial deposits, with resulting basement membrane reaction,
resulting in the appearance of spike-like projections on silver stain
(B1). The deposits are directly visualized by fluorescent anti IgG,
Hyaline Cast
revealing diffuse granular capillary loop staining (B2). By electron
microscopy, the subepithelial location of the deposits and early
surrounding basement membrane reaction is evident, with overlying
foot process effacement (B3)

Berry-like configuration of the glomeruli.

March 6, 2009/Friday Page 6 of 7


Seth, Ian
OS 214: Renal Dr. Agnes Mejia
Glomerulonephritis (GN) Exam 1&2

The mechanisms of glomerular injury have a complicated


Immunofluorescent staining of glomeruli with labeled anti- pathogenesis. Immune deposits and complement deposition
IgG demonstrating linear staining (D1) from a patient with anti- classically draw macrophages and neutrophils into the
GBM disease or immune deposits from a patient with glomerulus. T lymphocytes may follow to participate in the injury
membranous glomerulonephritis compared to IgG lumpy- pattern as well.
bumpy staining (D2). Preformed immune deposits can
preciptate from the circulation and collect along the glomerular *Amplification mediators such as locally
basement membrane (GBM) in the subendothelial space or
derived oxidants and proteases expand this
can form in situ along the subepithelial space.
inflammation, and depending on the location
of the target antigen and the genetic
polymorphisms of the host, basement
membranes are damaged with either
endocapillary or extracapillary proliferation

March 6, 2009/Friday Page 7 of 7


Seth, Ian