Glomerular Diseases Dr Rebecca Martin F2 - PowerPoint Presentation

Slide1

Glomerular Diseases

Dr Rebecca Martin F2

Learning objectives

Appreciate the fact that glomerular diseases fall onto a wide spectrum

Be able to define the nephritic and nephrotic syndromes

Understand the pathology of 4 key glomerular diseases which serve as archetypal examples of nephritic and nephrotic syndrome

Know how to assess and manage a patient with suspected glomerular disease

Exercise 1: Histology of the glomerulus

B

owman’s Capsule

C

apillaries

E

ndothelial cells

M

esangium

P

odocytes

(Foot processes)

(GBM)

Terminology

Glomerulonephritis = inflammation of the glomeruli‘Glomerulopathy’ is a more accurate term

NEPHRITIC SYNDROMECollection of symptoms and signs associated with inflammatory glomerular disorders Haematuria Hypertension Oliguria (Oedema)

NEPHROTIC SYNDROME

Collection of symptoms and signs associated with proliferative glomerular disorders

Overt proteinuria (> 3.5g/24h)

Hypoalbuminaemia

(< 30g/L)

Oedema

Proteinuria

Haematuria

SLE

IgA nephropathy

Minimal change nephropathy

Membranous nephropathy

Post-infective glomerulonephritis

Diabetic nephropathy

* Adapted from Davidson’s Principles and Practice of Medicine, 20

th

Edition

Spectrum of glomerular diseases

Presenting features of glomerular disease

SYMPTOMSAsymptomaticFatigue, lethargyHaematuriaFrothy urineSwellingOliguria

SIGNS

Hypertension

Oedema

Positive urine dipstick for protein/blood

Signs of related pathology

Exercise 2: Glomerular diseases

Match the conditions to their histological and clinical features

Glomerular diseases

CONDITION

HISTOLOGICAL FEATURES

CLINICAL FEATURES

Minimal

change nephropathy

Usually normal histology

Good response to steroids

Membranous nephropathy

Thickened GBM

Commonest cause

of nephrotic syndrome in adults

IgA

nephropathy

Increased mesangial matrix

Common cause

of ESRF

Post

-infective glomerulonephritis

Diffuse proliferation of endothelial/mesangial

cells, infiltration by neutrophils

Usually resolves spontaneously

Glomerular diseases 1

Minimal change nephropathy

Commonest cause of nephrotic syndrome in children

Accounts for 25% adult nephrotic syndrome

Proteinuria usually remits on high dose steroids

Does not progress to CKD

Issues: nephrotic syndrome and complications of treatment

Membranous nephropathy

Commonest cause of nephrotic syndrome in adults

1/3 spontaneous resolution, 1/3 remain in nephrotic state, 1/3 progress to CKD

Watch and wait/steroids/cyclophosphamide

Glomerular diseases 2

IgA nephropathyCommon cause of ESRFCommonest cause of nephritic syndromeAcute exacerbations can occur, particularly with respiratory infections Mild variant associated with HSP in children Poor response to immunosuppressive therapy

Henoch-Schonlein Purpura

Systemic vasculitis

3-10 years M:F 2:1

Skin rash, arthralgia, abdominal pain

40% glomerulonephritis (IgA nephropathy)

Glomerular diseases 3

Post-infective glomerulonephritis- More common in children, now rare in developed world10 day latency, usually after streptococcal throat infectionRenal function improves spontaneously after 10-14 daysManagement by fluid and sodium restriction

Rapidly progressive glomerulonephritisGeneral termExtreme inflammatory nephritisLoss of renal function over days to weeksBiopsy can show necrotising lesions in glomerulusGoodpasture’s disease > SLE > IgA nephropathy.

Diabetic nephropathy

Commonest cause of ESRF in UK30% with T1DM develop after 20 years Poor glycaemic control strongest risk factorMicroalbuminuria is earliest indicator Treatment with good glycaemic control and ACEi

Thickening of GBM

Increased mesangial matrix

Nodular deposits

Glomerulosclerosis and loss of glomeruli

Microalbuminuria (Albumin: creatinine ratio > 2.5 M > 3.5 F)

Heavy proteinuria

Exercise 3: Case based discussion

24 year old male presents to medical outpatient clinicMore tired than usualNo systemic symptoms on questioningOnly thing he has noticed is his urine is frothy

Group 1: What else would you like to ask in the history?

Group 2: What would you examine?

Group 3: What investigations would you perform?

Investigations in glomerular disease

Bedside testsUrine dip Laboratory testsFBC, U&E, CRP, ESR, HbA1C, complement, ANCA, ANA, anti-dsDNA, anti-GBM, ASOT Urine microscopy, urine albumin:creatinine ratio, 24h proteinThroat/skin swabsImagingRenal ultrasound Invasive testsRenal biopsy

Management of glomerular diseases

Refer to a nephrologist!Control hypertension (BP <130/80)Tight control of blood glucose if appropriateRestrict fluid and salt intake if proteinuriaWatch and wait?Steroids?Immunosuppressants?

Summary

Nephritic and nephrotic syndromesArchetypal diseases for eachKey investigations to perform Management principles

Learning at home

Please link this evening’s learning to rheumatology teachingSLE and Goodpasture’s disease (anti-GBM) are also causes of glomerulopathyThese are potential causes of rapidly progressive glomerulonephritis

Thank you

Any questions?