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GLOMERULONEPHRITIS

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GLOMERULONEPHRITIS Powered By Docstoc
					GLOMERULONEPHRITIS
  MOHAMAD S .RABABA’H ;MD
               CLASSIFICATION
►   PRIMARY:
         Minimal Change Disease
         Membranous GN
         Membrano Proliferative GN
         Diffuse Proliferative GN
         Focal Segmental GS
         Rapidly Progressive GN
         Chronic GN
         IgA Nephropathy
         Anti GBM GN
         ANCA associated GN
► SECONDARY
      Diabetes Mellitus
      SLE ,Lymphoma ,Solid tumors
      Amyloidosis ,MM
      Malaria ,Endocarditis
          PRESENTATION
► NEPHRITIC   SYNDROME

► NEPHROTIC   SYNDROME

► MIXED


► ASYMPTOMATIC
 HEMATURIA/PROTEINURIA
     NEPHRITIC SYNDROME
► HEMATURIA
► OLIGURIA
► RENAL IMPAIRMENT
► HYPERTENSION
► OEDEMA
► PROTEINURIA
            SEQUENCE
► ACUTE GN
► RAPIDLY PROGRESSIVE GN
► CHRONIC GN
           INVESTIGATIONS
► URINALYSIS




► RENAL   PROFILE
           INVESTIGATIONS
► MAKE   3 SEROLOGIC INVESTIGATIONS

  1. IMMUNE CMPLEX MARKERS C3,C4
  2. ANTI GBM
  3.ANCA . ( c , p)
  IMMUNE COMPLEX MARKERS
► ANA…….    LUPUS GN


► ASO   TITER….. POSTSTREPT. GN


► OTHER   INFECTIVE MARKERS …AntiHCVAb,
                             HBsAg
                ANCA + GN
► No Extra Renal disease….. ANCA associated
                              crescentic GN
► Extra renal disease….
         1. Systemic vasculitis…
                     Microscopic polyangitis
         2. Respiratory granulomas…
                    Wegener’s Granulomatosis
         3. Asthma+ Eosinophilia…
                    Churg strauss syndrome
            ANTI GBM Ab +
► No   lung hemorrhage…
        Anti GBM GN



► Lung  Hemorrhage…
       Good Pasture Syndrome
► SERUM   IgA levels…. IgA nephropathy

► CRYOGLOBULINS…      CRYOGLOB. GN

► C3   NEPHRITIC FACTOR… MPGN
    OTHER INVESTIGATIONS


► RENAL   BIOPSY
          MANAGEMENT
► TREAT HTN
► RESTRICT FLUIDS
► DIURETICS
► DIALYSIS
► IMMUNOSUPP:
       CORTICOSTEROIDS
       CYTOTOXICS
       POST INFECTIOUS GN
► CAUSE:
    Nephritogenic group A β Hemolytic Sterpt
    Other like
         S.Aureus
         HBV,HCV etc
► PATTERN:
    Diffuse proliferative
► TREATMENT
      PENICILLIN or ERYTHROMYCIN
      ANTI HTN like ACEI
      SALT RESTRICT
      DIURETIC
      STEROIDS SHOW NO BENEFIT
► PROGNOSIS
   CHILD….FAVORABLE

   ADULT….
     <5%.... CRESCENT.. RPGN.. ARF
      5%.... ESRD
            IgA NEPHROPATHY

► IgA   deposits in mesangium

► CAUSE
         unknown
         assoc. CIRRHOSIS; CELIAC DISEASE
                HIV; CMV
► EPIDEMIO
       asia
       children….young
       male

► FEATURES
    1. URTI followed by GROSS HEMATURIA
    2. MICROSCOPIC HEMATURIA
    3. NEPHROTIC
► PROGNOSIS
   30% CLINICAL REMISSION
   40-50% PROGRESSIVE RENAL INSUFF.
   20% CHRONIC MICROSCOPIC HEMAT.
►   MANAGEMENT
       PROTEINURIA> 1G/DAY
             ACEI/ARB
       PROTEINURIA 2-3.5G/DAY
          ACEI/ARB +
          CORTICOSTEROIDS
             MP 1G/DAY IV fore 3 days
             predni 0.5 mg/kg alternate day for 6m
          FISH OIL 2-5G/DAY

         TRANSPLANT good but 30% recurrence
    HENOCH SCHONLEIN PURPURA
►   MOST COMMON SYSTEMIC VASCULITIS IN CHILDREN
►   CAUSE UNKNOWN
►   MALE MORE AFFECTED
►   FEATURES
         PALPABLE PURPURA more LL
         ARTHRALGIA
         ABDOMINAL PAIN
         NEPHRITIC FEATURES
►   PROGNOSIS
         SELF LIMITED; 1-6 WEEKS
►   NO WEL DEFINED ROLE OF THERAPY
        CRYOGLOBUL ASSOC GN
►   Usually with Polyclonal variety
►   CAUSE
       HBV; HCV;RA
►   FEATURES
       Necrotizing skin lesions
       Arthralgia
       Fever
       Hepatosplenomegaly
►   May lead to RPGN
►   TREATMENT
         TREAT UNDERLYING INFECTION
          STEROIDS+ PLASMAPHARESIS+CYTOTOXIC
          ANCA associated GN
► SMALL VESSEL VASCULITIS
► FEATURES
      Systemic inflammatory features
      Hematuria
      Proteinuria
      Purpura
      Mononeuritis Multiplex
      Wegener’s has U/L RT symptoms
      Churg strauss has Asthma and eosinophilia
► LAB
     c-ANCA…. WEGENER
     p-ANCA… MICR POLYANGITIS
► CAN LEAD TO RPGN…ARF
► TREATMENT
         HIGH DOSE CORTICOIDS
         CYTOTOXIC… cyclophosphamide
► PROGNOSIS
       without treatment poor
       with treatment remission 75%
             ANTI GBM GN
       GOOD PASTURE
► 2/3…..
► 1/3…… NO LUNG INVOLVEMENT


► 10-15%...RPGN


► EPIDEMIO
       MORE IN MALE
       10-30 YEARS
►   ASSOCIATION
    influenza A; hydrocarbon solvent
    HLA DR2,B7


►   LAB
     iron deficiency anemia
     normal complement levels
     CXR shows pulmonary infiltrates


►   TREATMENT
     Plasmapharesis
     Immunosupp …. Corticosteroids
                    cyclophosamide
     NEPHROTIC SYNDROME

► MASSIVE PROTEINURIA >50mg/kg
► HYPOPROTEINEMIA
► EDEMA
► HYPERLIPIDEMIA
► HYPERCOAGULABILITY
                 CAUSE
► 1/3… SYSTEMIC DISEASE
               DM
               AMYLOIDOSIS
               SLE
► 2/3… IDIOPATHIC
         MINIMAL CHANGE DISEASE
         FOCAL SEGMENTAL GLOMERULOSCLEROSIS
         MEMBRANOUS GN
         MEMBRANOPROLIFERATIVE GN
         COMPLICATIONS
► INCREASED   CHANCES OF INFECTION



► HYPERCOAGULABILITY ,[DVTs;Renal vein
 thrombosis;Thromboembolizations].
                LABS
► URINALYSIS
     DIPSTICK ONLY FOR ALBUMIN
     SULFOSALICYLIC ACID FOR OTHER
                             PROTEIN
     OVAL FAT BODIES
     MALTESE CROSS IN POLARIZED LIGHT
► BLOOD CHEMISTRY
► BIOPSY
                 MANAGEMENT
►   PROTEIN LOSS
         TOTAL DIETRY PROTEIN EQUALS URINARY LOSS
            ‘‘ IF GFR <25ML/MIN RESTRICT PROTEIN TO 0.6G/KG/DAY’’
► EDEMA
       SALT RESTRICTION
       DIURETIC
► HYPERLIPIDEMIA
       DIET
       EXERCISE
       STATINS
► HYPERCOAGULABLE STATE
       LMW heparines S/C
       MINIMAL CHANGE DISEASE
►   EPIDEMIO
          CHILDREN 70-75% , Adults 15- 20%

►   CAUSE
            IDIOPATHIC; VIRAL URTI;TUMORS
            DRUGS; HYPERSENSITIVITY to drugs,
                                bee sting

►   TREATMENT
         prednisolone 1mg/kg/day,tapering over 16 weeks
         rarely needs cyclophosphamide,CsA…..

►   PROGNOSIS
         Rarely …… ESRD
          MEMBRANOUS GN
► CAUSE
     PRIMARY
     SECONDARY
           Infections…HBV; Endocarditis
           Autoimmune… SLE
           Tumors
            Drugs… penicillamin , captopril
►   EPIDEMIO
               40-60 YEARS

►   TREATMENT
         TREAT UNDERLYING CAUSE

PROTEINURIA
      <3.5G/DAY
          low salt; control BP; ACEI
      3.5-8G/DAY
          Immunosupp with Steroids +\- cyclophosphamide
       >8G/DAY
          STEROIDS+ CYCLOPHOS or CYCLOSPORIN

TRANSPLANT
            FOCAL SEGMENTAL
          GLOMERULOSCLEROSIS
► CAUSE
         Idiopathic
         Secondary:
         Heroin use
         Obesity
         HIV
► DIAGNOSIS
          Biopsy shows fusion of epithelial foot
  processes and deposits of IgM & C3
► TREATMENT
   SUPPORTIVE
   STEROIDS….. Prednisolone 1-1.5 mg/Kg
 for 2-6 m
   CYTOTOXIC have only 20% remission

► PROGNOSIS
  VERY BAD
  FSGS + NEPHROTIC….ESRD IN 6-8 YRS
          3. IDIOPATHIC
    MEMBRANOPROLIFERATIVE GN
►   USUALLY IN YOUNG AGE

► TWO   TYPES
         TYPE I… recent URTI
                 Nephrotic
                 low complement
                 Thick and split GBM
                 Mesangial cell prolif.
► TYPE   II …… Nephritic
               less common
               C3 nephritic factor+,low C3&C4
               dense deposits in GBM

THERAPY
    CORTISONE
    ANTIPLATELET DRUGS like ASPIRIN

50% HAVE ESRD IN 10 YRS
 SYSTEMIC DISEASES CAUSING
        NEPHROTIC
AMYLOIDOSIS
     Define:

     Types:
    1.Primary Renal…(AL).. Idiopathic;
                          Multiple Myeloma
    2.Secondary Renal..(AA).. RA; IBD; FMF;TB

    Diagnosis:
       Biopsy and Congo red staining
► TREATMENT
   1. ALKYLATING AGENT.. Melphalan
     CORTICOSTEROIDS.. Prednisolone

   2. Melphalan + Stem cell transplant

   3. Renal transplant for sec. amyloid
        DIABETIC NEPHROPATHY
►   TYPE I… 40-45% CHANCE OF DN IN 20YRS
►   TYPE II.. 15-20% CHANCE OF DN IN 20YRS
►   MALE SEX HIGH RISK
►   RETINOPATHY INVARIABLY +
►   URINE EXAM FOR ALBUMINURIA
         ( >30 mg/day )
►   MANAGEMENT
      STRICT GLYCEMIC CONTROL
      CONTROL HTN
      ACE/ARB
►   KIDNEY ENLARGED ON U/S
              HIV NEPHROPATHY
► YOUNG BLACK MAN; IV DRUG ABUSER
  …HIGH RISK
► PRESENTS AS NEPHROTIC WITH NORMAL
  COMPLEMENT
► HAART can slow progress

►   PREDNISOLONE 1 mg/kg/day +CYCLOPHOSPHAMIDE +ACEI…… TRIALS
     DISEASES PRESENTING AS
     NEPHROTIC + NEPHRITIC
1. SLE
  Overt Renal Involvement 35-90%

► PRESENTATION
    GLOMERULAR
          nephrotic+nephritic
    NON GLOMERULAR
          Tubulointerstitial nephritis
          Vasculitis
► WHO CLASS
  I    Normal
  II   Mesangioproliferative GN
  III Focal segmental Proliferative
  IV Diffuse Proliferative
   V Membranous
► MANAGEMENT


   I ….. No treatment

   III, IV…. Aggressive Immunosupp
                      Steroi+Azathioprine vs MMF,
                      cyclophosphamide
            trials of Mycophenolate Mofetil
IN cases of ESRD
DIALYSIS…. FAVORABLE PROGNOSIS
TRANSPLANT…. 8% RECURRENCE
                  2. HCV
► HCV    causes three patterns
            Membranoproliferative GN
            Cryoglobulinic GN
            Membranous GN

► IFN-α IS INDICATED
► RIBAVIRIN IS CONTRAINDICATED

				
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posted:11/12/2011
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