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Internal Diseases
Propedeutics Department
Professor T.A. Dronova
Lecture
GLOMERULONEPHRITIS
GLOMERULONEPHRITIS
3rd most common cause (after diabetes &
GLOMERULONEPHRITIS
Nomenclature
Inflammation with leukocyte infiltration,
antibody deposition, &/or compliment
activation
Primary - when major problem starts in
the glomeruli
Secondary - when involvement is part of
systemic disease (SLE, diabetes mellitus,
amyloidosis)
GLOMERULONEPHRITIS
Nomenclature
Glomerular injury
Acute over days or weeks
Subacute or rapidly progressive - over weeks
or few months
Chronic - over many months or years
Glomeruli involvement
Focal minority (< 50%)
Diffuse majority (> 50%)
Segmental - part
Global almost all
GLOMERULONEPHRITIS
Nomenclature
Proliferative increase in glomerular cell
number (due to infiltration by leukocytes or
resident glomerular cells proliferation)
Proliferation of resident glomerular cells:
Intracapillary / endocapillary endothelial or
mesangial cells
Extracapillary Bowmans space (most
proximal portion of renal tubule)
GLOMERULONEPHRITIS
Nomenclature
Crescent half-moon-shaped collection of cells
in Bowmans space
Crescentic glomerulonephritis associated
with rapid progression of renal failure (weeksmonths) = rapidly progressive glomerulonephritis
Membranous expansion of glomerular
basement membrane by immune deposits
GLOMERULONEPHRITIS
Essentials of diagnosis
Hematuria, dysmorphic red cells, red
GLOMERULONEPHRITIS
Primary
Minimal change glomerular disease
Membranous glomerulonephritis
Membranoproliferative glomerulonephritis
Ig A nephropathy (Bergers disease)
Crescentic rapidly progressive
GLOMERULONEPHRITIS
Secondary
Common
SLE
Polyarteritis nodosa
Diabetes mellitus
Amyloidosis
Schonlein-Henoch disease
Malarial nephropathy
GLOMERULONEPHRITIS
Secondary
Uncommon
Pre-eclampsia & eclampsia
Malignancy associated paraproteinemia
Cryoglobulinemia
Rheumatoid artritis
Scleroderma
Hemolitic uremic syndrome
Wegeners granulomatosis
Cytomegalovirus nephropathy
AIDS nephropathy
GLOMERULONEPHRITIS
Pathogenesis (2 main processes )
Circulating immune complex deposition
most common
GLOMERULONEPHRITIS
Secondary mechanisms
Circulating immune complex deposition &
GLOMERULONEPHRITIS
Pathogenesis
Antigens
Exogenous:
Bacteria
Viruses
Parasites
Drugs
Endogenous:
Host antigens
Immune complex-mediated
glomerulonephritis - causes
Bacteria:
Beta-hemolitic streptococcus group A
Streptococcus viridans (in endocarditis)
Streptococcus pneumoniae
Staphylococcus
Treponema pallidum (syphilis)
Gonococcus
Salmonella
Meningococcus
Immune complex-mediated
glomerulonephritis - causes
Viruses:
Hepatitis B & C
Epstein-Barr virus
Coxsackie virus
Varicella
HIV
Mumps
Measles
Immune complex-mediated
glomerulonephritis - causes
Parasites:
Plasmodium malariae
Schistosomatosis
Filariasis
Toxoplasmosis
Drugs:
Penicillamine
Host antigens:
DNA in SLE
Malignant tumors
GLOMERULONEPHRITIS
Macroscopic appearances
Kidneys in acute glomerulonephritis:
Size - normal or enlarged & edematous
Surface punctate haemorrhages
cortical scarring
GLOMERULONEPHRITIS
Histological types & clinical features correlation
Histological types
Clinical features
Subtypes of proliferative
glomerulonephritis:
Diffuse
Acute nephritic
Focal segmental
syndrome
Haematuria,
proteinuria
GLOMERULONEPHRITIS
Histological types & clinical features correlation
Histological types
Subtypes of proliferative
glomerulonephritis:
With crescent formation
(rapidly progressive
glomerulonephritis)
Mesangiocapillary
(membranoproliferative)
Clinical features
Progressive renal
failure
Haematuria,
proteinuria, acute
nephritic or nephrotic
syndrome
GLOMERULONEPHRITIS
Histological types & clinical features correlation
Histological types
Clinical features
Membranous
Nephrotic syndrome
glomerulonephritis
Minimal-change
nephropathy
Ig A nephropathy
in adults
Nephrotic syndrome
especially in children
Asymptomatic
haematuria
Focal glomerulonephritis Proteinuria or
nephrotic syndrome
There is not complete correlation between histological types & clinical features
GLOMERULONEPHRITIS
Clinical picture
1 of 5 clinical presentations:
Asymptomatic proteinuria &/or
microscopic hematuria
Acute nephritic syndrome
Nephrotic syndrome
Rapidly progressive glomerulonephritis
Chronic glomerulonephritis
glomerulonephritis
Poststreptococcal glomerulonephritis
leading cause of acute nephritic
syndrome
(most common)
Ig A nephropathy
Schonlein-Henoch purpura
Wegeners granulomatosis
Goodpastures syndrome
Polyarteritis nodosa
Acute interstitial nephritis
Essential mixed cryoglobulinemia
Poststreptococcal glomerulonephritis
After pharyngeal or cutaneous infection with
Poststreptococcal glomerulonephritis
Latent period b/w earliest infection
Poststreptococcal glomerulonephritis
Diagnosis at least 2 of 3 features:
Group A beta-hemolytic streptococcus (nephritic
Poststreptococcal glomerulonephritis
Diagnosis:
Poststreptococcal glomerulonephritis
ESR usually elevated
C reactive protein normal
Rheumatoid factor normal or
undetectable
Post-streptococcal glomerulonephritis
ACUTE NEPHRITIC SYNDROME
Age: common in childhood (2-6 years of age)
Sex: > males
Nature of disease: post-streptococcal
swelling)
Decreased diuresis sometimes anuria
(may be frequent tenesmus)
Facies nephritica
Brights face
Edematous face
Bed rest
Salt free diet
Protein restriction in ureamia
Daily record of fluid intake & excretion
Daily weighing (body fluid status change)
Regular measurement of blood pressure
Diuretics (reduce hypertension & edema)
Anti-hypertensive drugs
Antibiotics (in poststreptococcal
glomerulonephritis positive culture)
NEPHROTIC SYNDROME
Features
Heavy proteinuria (> 3g/24 hours)
Hypoalbuminemia (serum albumin
<30g/l)
Edema
Hyperlipidemia (due to increased
hepatic lipoprotein synthesis)
Hypercoagulability
NEPHROTIC SYNDROME
PATHOGENESIS
Proteinuria: capillary wall injury of glomeruli
NEPHROTIC SYNDROME
PATHOGENESIS
Generalized edema:
Salt & water retention
Hypoalbuminemia - decrease colloid
NEPHROTIC SYNDROME
PATHOGENESIS
Hypercoagulability:
Increased urinary antithrombin III loss
Altered levels &/or activity of protein C &
protein S
Hyperfibrinogenemia increased hepatic
synthesis
Impaired fibrinolysis
Increased tendency of platelet
aggregation
NEPHROTIC SYNDROME
1.
2.
3.
4.
5.
6.
NEPHROTIC SYNDROME
CLINICAL FEATURES
Edema:
Peripheral oedema involving upper &
lower limb
Intense edema of scrotum or vulva
may occur
May be bilateral hydrothorax
NEPHROTIC SYNDROME
Clinical Features
Edema of intestine causes anorexia,
NEPHROTIC SYNDROME
Clinical Features
Hypercoagulability: peripheral arterial
NEPHROTIC SYNDROME
INVESTIGATIONS
Urine - proteinuria
24 hours urinary proteins: usually > 3 g/day
Serum albumin: < 3g/day (total serum protein <6
mg/dl)
Low density lipoprotein - elevated,
high density lipoprotein - normal
Raised ESR due to increased serum fibrinogen
Urine red cells & red cell cast
Blood sugar for diabetes & antinuclear factor for
SLE
Hepatitis B serology, serum complements
NEPHROTIC SYNDROME
INVESTIGATIONS
Renal biopsy: confirms diagnosis
Renal biopsy contraindicated:
Children under 10 years
Known diabetes mellitus
Patient on drug (penicillamine)
NEPHROTIC SYNDROME
COMPLICATIONS
Protein malnutrition
Hypercoagulability - due to rise in
NEPHROTIC SYNDROME
MANAGEMENT
Diet: low salt diet, moderate
NEPHROTIC SYNDROME
COMPLICATION MANAGEMENT
A. Venous thrombosis due to
hypercoaguloability
Prolonged bed rest should be avoided
In renal vein thrombosis - anticoagulants
B. Sepsis
Aggressive treatment of infection with
antibiotics
C. Oliguric renal failure
Maintain blood pressure & fluid volume
Albumin infusion, mannitol may initiate
diuresis
NEPHROTIC SYNDROME
MANAGEMENT
Specific therapy:
Minimal change disease (most common cause of
nephrotic syndrome in children, 20% in adult) prednisolone
Membraneous gloumerolunephritis (most
common cause of nephrotic syndrome in adult
after 30 age [5th-6th decade], high incidence of
renal vein thrombosis, in 50% - occult neoplasm
of lung, stomach & colon) - prednisolone &
azathioprine, chlorambucil or cyclophosphamide
Other causes - SLE: prednisolone & azathioprine
Preeclampsia-eclampsia
Toxemia syndrome
BP
Preeclampsia
Clinical picture
Rapid BP rise (preeclampsia-related
Eclampsia
Clinical picture
After cry or noisy deep inhalation convulsions (tonic
& clonic)
Cyanotic face
Swollen neck veins
Firm eyeballs (aside or up) with dilated pupils (without
light reaction)
Bitten tongue
Foam from mouth
PS tense, slow
Temperature may be rised
Involuntary defecation & urination
CHRONIC
GLOMERULONEPHRITIS
Persistent proteinuria &/or hematuria & renal
insufficiency with slow progression over years
Diagnosis:
upon routine urinanalysis
routine blood tests with unexplained anemia
elevated blood urea nitrogen & creatinine
discovery of bilateral small kidneys on abdominal
imaging
5. during evaluation for secondary causes of
hypertension
6. during clinical exacerbation of glomerulonephritis
triggered by pharyngitis or other infections
1.
2.
3.
4.
CHRONIC
GLOMERULONEPHRITIS
Manifestation of virtually all of major
glomerulonephritis
Renal biopsy typically reveals a variable
combination of proliferative, membranous,
sclerotic changes, depending on the causative
glomerulopathy
CHRONIC
GLOMERULONEPHRITIS
Arteriosclerosis, induced by secondary
CHRONIC
GLOMERULONEPHRITIS
2 periods:
I. Renal compensation stage (nitrogen
CHRONIC
GLOMERULONEPHRITIS
I. Renal compensation stage (signs &
CHRONIC
GLOMERULONEPHRITIS
I. Renal compensation stage:
Increased BP
Left ventricular hypertrophy
Urinalysis: proteinuria, cylindruria (waxy casts)
Leached erythrocytes (usually - small qauntity)
Increased serum cholesterol
Hypoproteinemia due to permanent proteinuria
CHRONIC
GLOMERULONEPHRITIS
II. Renal decompensation stage (nitrogen
disease
Osteosclerosis
Renal osteodystrophy
Osteomalacia: kidney failure to convert
Renal osteodystrophy
Hyperparathyroid bone disease: secondary
Amenorrhea in females
Loss of libido in both sexes
5. CVS Disorders
Hypertension
Atherosclerosis
Pericarditis
8. Skin abnormalities
Yellow brown pigmentation due to accumulation
of urinary pigment in skin especially urochromes
9. Neuromuscular disturbances
a. Neuropathy
sensory neuropathy
motor neuropathy
autonomic neuropathy
b. Myopathy
anemia
3. Ultrasound examination describes renal
size & defines or excludes obstructions
4. IVP size, shape & position of kidney &
calculi
replaced by dialysis
The endocrine & metabolic functions renal transplantation
Pyelonephritis
kidney infection
Possible causes of kidney infection:
infections in the bladder
use of a catheter to drain urine from the bladder
use of a cystoscope to examine the bladder and
urethra
surgery on the urinary tract
conditions such as prostate enlargement and
kidney stones that prevent the efficient flow of
urine from the bladder
defects or abnormalities in the urinary tract that
block the flow of urine
Symptoms
of pyelonephritis
back, side, and groin pain
urgent, frequent urination
pain or burning during urination
fever
nausea and vomiting
pus and blood in the urine
Complications
of pyelonephritis
Severe or recurrent infections may cause
Diagnosis
of pyelonephritis
Urine test to identify bacteria and
Chronic pyelonephritis
Renal injury induced by recurrent or persistent renal
infection
It occurs almost exclusively in patients with major
anatomic anomalies, including urinary tract
obstruction, struvite calculi, renal dysplasia, or, most
commonly, vesicoureteral reflux in young children.
Radiologic evidence
Vesicoureteral reflux - congenital defect that results in
incompetence of the ureterovesical valve due to a
short intramural segment (present in 30-40% of young
children with symptomatic urinary tract infection and
in almost all children with renal scars.
Vesicoureteral reflux may also be acquired by patients
with a flaccid bladder due to spinal cord injury
Chronic pyelonephritis
pathophysiology
associated with progressive renal scarring can lead to end-
Approximate
frequency
68%
Proteus mirabilis
12 %
Klebsiela
aerogens
4%
Approximate
frequency
Streptococcus
faecalis
6%
Staphylococcus
saprophyticus
or epidermidis
10%
Approximate
frequency
68%
Proteus mirabilis
12 %
Klebsiela
aerogens
4%