Transcript OVERVIEW glomerular disease 2008

INTRODUCTION TO
NEPHROLOGY
Jeffrey J. Kaufhold, MD
RID YOURSELF OF BOTHERSOME BRAIN TISSUE
THE KAUFHOLD WAY !
DEFINITIONS

GFR - true function of the kidney
best measured by Inulin, Nuc. Med

CREATININE CLEARANCE - measurement is
difficult in inpatients

COCKCROFT EQUATION:
(140 - age) X Kg wt
Screat X 72
NEPHROLOGY
SUMMARY

DEFINITIONS

STRUCTURE FUNCTION CORRELATION

SPECTRUM OF GLOMERULAR DISEASE

SIMPLE, EASY, COVERS 85% OF CASES

WE GET PAID FOR THE OTHER 15%
Hematuria
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Hematuria
TUMOR
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Hematuria
TUMOR
I NFECTION
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T RAUMA
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T RAUMA
S TONE
HEMATURIA
Glomerular Causes:
IgA (Berger’s)
Mesangioproliferative GN
Hereditary GN’s, including
Alport’s, Thin Basement Membrane
Hallmark of Glomerular Disease is RBC cast
Class 2 - mild mesangial hypercellularity
Hereditary Nephritis
Alports
Nail -Patella
Thin Basement Mem.
NEPHROLOGY
DEFINITIONS

HEMATURIA - DIFFERENTIAL TIGHTS
TUMOR, INFECTION
GN’s, HEMATOLOGIC
TRAUMA AND STONE

PROTEINURIA - normal up to 150 mg/24 h
made up of tubular protein
(Tamm Horsfal)
ABnormal = albumin, >150 mg
PROTEINURIA
LESS THAN 300 mg - normal
300 to 1200
think orthostatic or
interstitial
1200-3000 mg talk to the patient
OVER 3 Gm
Consider Biopsy
PROTEINURIA
Glomerular Causes:
Minimal Change Disease - 25 %
Focal Segmental Glomerulo Sclerosis
FSGS - 30 %
Membranous - 30 %
PROTEINURIA Relative
Frequency by Age.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Other
Mem
FSGS
MCD
Under 12 12 to 20 20 to 60 over 60
Membranous GN
Silver stain showing
thickened basement
membrane and
“spiking” caused by
subepithelial deposits
in the membrane.
Minimal Change Disease
Normal appearing
Glomerulus. Normal
appearing interstitium.
Minimal Change EM
Foot processes are
completely effaced (no
longer discreet).
Focal Segmental Glomerular
Sclerosis (FSGS)
Segments of glom are
preserved and segments
are sclerosed (darker
pink).
NEPHROLOGY
DEFINITIONS

PROTEIN/CREATININE RATIO
based on assumption of 1 Gm of
creatinine excreted per 24 hours:

<0.2 = normal

>3.0 nephrotic
NEPHROLOGY
IDIOPATHIC GN'S
NEPHRITIC
ITIC/OTIC
NEPHROTIC
HEREDITARY
MEMBRANOPROLIF.
NIL
PSGN
MEMBRANOUS
gA (BERGER'S)
MESANGIOPROLIF.
FSGS
Post Infectious GN
Proliferative with lots of
PMN’s visible.
PSGN Electron Microscopy
Subepithelial Humps
Membrano-proliferative GN
Lupus nephritis Class IV
NEPHROLOGY
SYSTEMIC DZ
NEPHRITIC
ITIC/OTIC
NEPHROTIC
LUPUS CLASS
II AND III
PSGN
DM
AMYLOID
MYELOMA
LUPUS V
CRYOGLOBULINS
LUPUS IV
(DPGN)
NEPHROLOGY
RPGN
CLASS I
CLASS 2
CLASS 3
ANTI-GBM
CIRCULATING
IMMUNE
COMPLEXES
PAUCIIMMUNE
(VASCULITIS)
CLASS 4
VASCULOPATHY
R/O INTERSTITIAL DISEASE
Rapidly Progressive GN
Clinical Syndrome
ARF
HTN
RBC Casts
Mimicked by TIN
TIN Tubulointerstitial
Nephritis
or
Crescents with
characteristic change on
Immunoflurescence
RPGN light Microscopy
Interstitial Nephritis
Crescent
RPGN Class I
Linear
Immunofluresence
Due to Anti-GBM
Antibody
Goodpasture’s
Syndrome
RPGN Class II
Granular IF
Immune Complex
Deposition
Due to SLE, MPGN,
HSP, PSGN, Others
RPGN III: Vasculitis
Crescent with Focal
Necrotizing GN
Pauci-immune.
ANCA Positive.
Seen in Wegener’s
Granulomatosis, ChurgStrauss, PolyArteritis
Nodosa (PAN).
Necrotizing area
RPGN IV: Vasculopathy
Hyaline thrombi
Endothelial cell swelling
and vacuolization
Seen in TTP/HUS,
Preeclampsia,
Malignant HTN
Old Definitions

ACUTE RENAL FAILURE - acute deterioration
over hours to days of renal function

CHRONIC RENAL FAILURE - progressive loss
of renal function over years

CHRONIC RENAL INSUFFICIENCY - A chronic,
fixed loss of renal function due to a
past insult.
New Terminology
ARF - RIFLE criteria
Risk low uop for 6 hours, creat up 1.5 to 2 times baseline
Injury creat up 2 to 3 times baseline, low uop for 12 hours
Failure Creat up > 3 times baseline or over 4, anuria
Loss of Function Dialysis requiring for > 4 weeks
ESRD Dialysis requiring for > 3 months
New Terminology
Chronic Kidney Disease
CKD
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Normal GFR with known disease
GFR 60-80 ml/min
GFR 30-60
GFR 20-30
GFR 10-20
GFR < 10, ESRD.
NEPHROLOGY
DEFINITIONS

DEHYDRATION - STATE OF
FREE WATER LOSS

VOLUME DEPLETION - STATE
OF SALT AND WATER LOSS
DIALYSIS
DEFINITIONS

HEMODIALYSIS

PERITONEAL DIALYSIS

CAVHD

DIALYSIS ACCESS, FISTULA
please don't say shunt or graft

ULTRAFILTRATION - removal of water
with dissolved solute dragged along
for the ride.
TRANSPLANT
DEFINITIONS

ALLOGRAFT

REJECTION

IMMUNOSUPPRESSION
CORRELATIONS
STRUCTURE
FUNCTION
PATH
Endothelium
make vessel
kawasaki's
GBM
seive
Alport's
Epithelium
charge select.
proteinuria
Minimal Change
Mesangium
makes GBM
Berger's
Glomerular Physiology
Afferent. Art
AT II
constrict
ACE-i
dilate
Filt Press
Efferent Art
maintained
constrict
reduced
dilate
PG's
NET dilate
increase
no effect
TGF
NET constrict
parallels
no effect
reduce
no effect
Aminophylline dilate
increase
no effect
Diltiazem
reduced
dilate
NSAID's
constrict
dilate
Glomerular Physiology
Blood flow determinants
Systemic
Afferent
Efferent
PG's
Local
TGF
Filtration
Renal Physiology
Overview
Proximal
Tubule
Distal Tubule
filtration
solute exchange
reabsorption
impermeable to
solute
imperm. to
H2O
Collecting duct
ADH +
permeable to H2O
Loop of Henle
ADH -
impermeable
CORRELATIONS
STRUCTURE
FUNCTION
PATH
Endothelium
make vessel
kawasaki's
GBM
seive
Alport's
Epithelium
charge select.
proteinuria
Minimal Change
Mesangium
makes GBM
Berger's