Week 14 - Nephrology

• Hypertension
• Haematuria
• Reduced GFR
• Nephrotoc syndrome
• Nephritic Syndrome
• Rapid progressing GN → 6wks to ESKD

• Nephrotic Syndrome
• Heavy proteinuria
• Hypoalbuminaemia
• Oedema
• Hyperlipidaemia → side effect of liver ^^protein

• HOHO?
• Hypoalbuminaemia, prOteinuria, Hyperlipidaemia, Oedema

• Nephritic
• Haematuria [with casts]
• Oliguria [<400ml/day]
• Hypertension
• Ureamia

• A.k.a PHARAOH
• Proteinuria
• Hematuria
• Azotemia
• RBC casts
• Anti-strep titres (if post-strep)
• Oliguria
• Hypertension

• IgA nephropathy → commonest
• Membraneous GN
• Minimal Change Disease
• RPGN [Rapidly progressing GN]
• Wegeners Granulomatosis
• Post infectious GN

• CF
• Haematuria, Proteinuria, hypertension & renal impairment
• ~Nephrotic Syndrome

• Patho
• Deposition of IgA in mesangium → activation of mesangial
• scar formation
• loss of capillary integrity

• CF
• Proteinuria, Nephrotic syndrome, hypertension, renal impairment
• Commonest cause of nephrotic syndrome in adults

• Patho
• Deposition of immune complexes in GBM & Mesangium [tumours, lupus]
• Alters GBM charge
• Altered permeable selectivity
• Thickens GBM

• CF
• Acute, Normal GFR, Nephrotic syndrome [puffy eyes]
• commonesst cause of nephrotic in kids

• Patho
• EM shows podicyte fusion, T cell associated

• CF
• Rapid onset, haematuria, roteinuria, hypertension, renal impairment, haemoptysis, systemic symptoms [malaise, fever]
• e.g. Wegeners/ Goodpastures

• Patho
• Goodpastures → anti GBM disease, cellular destruction & crescent formation
• Wegeners Granulomatosis → necrotising vasculitis, nasal, pulmonary & renal symptoms ANCA +ve

• Serum biochem → Cr & Albumin
• FBC → Hb, CRP, WCC
• Immunology → antibodises & electrophoreisis → ANCA, RhF, ANF & Anti-GBM
• U/O → Dipstix, PCR, Microscopy & MSSU
• Imaging → CXR, Renal U/S

• Infancy [<1yo]
• Abn Urinary tract [congenital malformation]
• Female → esp pregnant
• Bladder dysfunction/ incomplete emptying → ^^prostate
• Foreign bodies in tract → stones, catheters
• DM

• Bacteruria & fever >38 = Pyelonephritis
• Systemic symptoms [fever, malaise, lethargy]
• vomiting, loin pain

• Bacteruria & abscence of systemic features = cystitis
• Non-specific abdo pain
• urgency, frequency, wetting, frank haematuria

• Ascending infection
• urethral colonisation by infective org
• multiplication in bladder
• reflux to kidneys [pathophysiological]
• VUR → vesicoureteral reflux
• Female > male

• Haematogenous Infection
• Infection includes renal parenchyma
• Gram +ve infection more common

Chronic can lead to scarring

• Dx
• Urinalysis → leucocytes + Nitrites = UTI
• Microscopy/ Flow cytometry → neutrophils & bacteria
• Urine C+S

• Usually single org infection
• ?multiple → change catheter

• Gram neg → Proteus, E coli, Klebsiella & psuedomonas
• Gram pos → enterococcus, staph aureus [red flag]

?anaerobes → bladder cancer

• 3-7d course of;
• Amoxicillin
• or trimethoprim
• or Nitrofurantoin

• Renal [Clear] cell Ca
• Patho → adenocarcinoma of PCT, can ascend IVC

Pc → loin pain, palpable mass, Frank haematuria

Mx → radical nephrectomy/ nephron sparing surgery

Pc → painful micturation, cant initiate urination easily, recurring UTI

Patho → Adenocarcinoma [peripheral zone of prostate], central zone = benign adenoma

Tx → watchful waiting, PSA ea 3m [not tumour specific], Rt/ radical prostectomy

RF → smoking, rubber/ dye industry, schistosomiasis

Pc → frank haematuria [usually painless]

Pathology → majority = transitional cell Ca, some SCC

Tx → transurethral resection, radical cystectomy

• OBSTRUCTION
• Calyceal diverticulum
• Pelviureteric junction obstruction [congenital]
• Ureteric stricture
• Foreign body
• UTI
• Proteus infection → urease, change pH ^^stones

• Obstruction → urine superconcentration
• particle gets fixed to renal papilla [seed crystal]
• Growth of stone

pH dependant → works better at low pH [Proteus infection]

• Staghorn → infection, calyceal location
• Calyceal
• Renal Pelvis
• Ureteric Calculi

• Small stones → watch & wait
• Lithotripsy → shockwave degradation of stone
• Open surgery → large/complicated stone
• Laproscopic

• ^^[Glucose] & HBP mediated damage to glomerulus
• ^^mesangium
• Sclerosed nodules
• Thickened Glycated GBM
• Podocytes absent

• Pc
• Proteinuria [microalbuminuria]
• HBP
• retinopathy
• worsening oedema
• Uraemic coma

• Mx
• <120sys → ACEi
• eventually dialysis

• HBP
• carotid & femoral bruits
• asymmetrical kidnys
• excretory renal impairment

AKI/CKD

Light chains [Bence-jones protein] are toxic to proximal tubule

• Pre-renal
• hypoperfusion → haemorrhage, pump failure, antihypertensives
• hypovolaemia
• Sepsis

• Renal [Intrinsic]
• Glomerular [vasculitis] → acute GN [e.g. IgA nephropathy etc]
• Tubular → acute tubular necrosis [ATN], myeloma, rhabdomyolysis
• Large BV?

• Post renal
• obstruction; renal pelvis → urethral meatus

• Acute Tubular necrosis
• Damage to renal tubular cells by iscaemia [hypoperf/hypovolaemia] or nephrotoxins [contrast, gentamicin, amphotericin B, myoglobin]

Histological → tubules occluded by cellular debris

• 1. Acute/ Chronic
• Comorbidities suggest chronic e.g. DM
• Previously abn blood tests, small kidneys → chronic
• Abscence of anaemia, low Ca & ^^phos → acute

2. Rule out obstruction

• 3. Rare causes of AKI?
• GN → urgent renal referral

• Monitor & correct K+ dereangements
• Restore perfusion
• remove causes → drugs/ sepsis
• Exclude obstruction
• Consider renal causes → GN screen [ANCA, ANA, electrophoreisis, aGBM, urine Bence jones (myeloma)]

1 → Kidney dam but normal function, GFR>90

2→ Kidney dam, mild drop in GFR 60-89

3→ moderate dec in GFR 30-59

4 → severly low GFR 15-29

5 → kidney failure/ dialysed, GFR <15

• Salt loser
• Medulla [tubular] damage → lose concentration/ acidification
• salt loss → water loss

Pc → dehydration, hypotension, acidosis

• Salt Retaining
• Cortex [Glomerular] damage → lose filtration ability
• Salt retention → water rentention

Pc → oedema, hypertension

FBC → anaemia [no EPO production]

pH → Acidotic salt losing Pts

Ca & PO4 → ^^PO4, low Ca, not hydroxylating vit D cant abs Ca, stim of PTH → release of Ca & phos from bone