introduction to nephrology jeffrey j. kaufhold, md rid yourself of bothersome brain tissue the...
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INTRODUCTION TONEPHROLOGY
Jeffrey J. Kaufhold, MD
RID YOURSELF OF BOTHERSOME BRAIN TISSUETHE KAUFHOLD WAY !
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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
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NEPHROLOGYSUMMARY
DEFINITIONS
STRUCTURE FUNCTION CORRELATION
SPECTRUM OF GLOMERULAR DISEASE
SIMPLE, EASY, COVERS 85% OF CASES
WE GET PAID FOR THE OTHER 15%
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Hematuria
T
I
G
H
T
S
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Hematuria
TUMOR
I
G
H
T
S
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Hematuria
TUMOR
I NFECTION
G
H
T
S
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H
T
S
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T
S
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T RAUMA
S
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Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T RAUMA
S TONE
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HEMATURIA
Glomerular Causes:
IgA (Berger’s)
Mesangioproliferative GN
Hereditary GN’s, including
Alport’s, Thin Basement Membrane
Hallmark of Glomerular Disease is RBC cast
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Class 2 - mild mesangial hypercellularity
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Hereditary Nephritis
Alports Nail -Patella Thin Basement Mem.
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NEPHROLOGYDEFINITIONS
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
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PROTEINURIA
LESS THAN 300 mg - normal
300 to 1200 think orthostatic or
interstitial
1200-3000 mg talk to the patient
OVER 3 GmConsider Biopsy
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PROTEINURIA
Glomerular Causes:
Minimal Change Disease - 25 %
Focal Segmental Glomerulo Sclerosis
FSGS - 30 %
Membranous - 30 %
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PROTEINURIA Relative Frequency by Age.
0%10%20%30%40%50%60%70%80%90%
100%
Under 12 12 to 20 20 to 60 over 60
OtherMemFSGSMCD
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Membranous GN
Silver stain showing thickened basement membrane and “spiking” caused by subepithelial deposits in the membrane.
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Minimal Change Disease
Normal appearing Glomerulus. Normal appearing interstitium.
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Minimal Change EM
Foot processes are completely effaced (no longer discreet).
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Focal Segmental Glomerular Sclerosis (FSGS)
Segments of glom are preserved and segments are sclerosed (darker pink).
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NEPHROLOGYDEFINITIONS
PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours:
<0.2 = normal
>3.0 nephrotic
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NEPHROLOGYIDIOPATHIC GN'S
NEPHRITICHEREDITARY
IgA (BERGER'S)
MESANGIO- PROLIF.
ITIC/OTICMEMBRANO- PROLIF.
PSGN
NEPHROTICNIL
FSGS
MEMBRANOUS
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Post Infectious GN
Proliferative with lots of PMN’s visible.
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PSGN Electron MicroscopySubepithelial Humps
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Membrano-proliferative GN
Lupus nephritis Class IV
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NEPHROLOGYSYSTEMIC DZ
NEPHRITICLUPUS CLASS II AND III
CRYOGLOBULINS
ITIC/OTICPSGN
LUPUS IV(DPGN)
NEPHROTICDMAMYLOIDMYELOMALUPUS V
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NEPHROLOGYRPGN
CLASS IANTI-GBM
CLASS 2CIRCULATINGIMMUNECOMPLEXES
R/O INTERSTITIAL DISEASE
CLASS 3PAUCI- IMMUNE (VASCULITIS)
CLASS 4
VASCULOPATHY
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Rapidly Progressive GN
Clinical Syndrome
ARF
HTN
RBC Casts
Mimicked by TIN
TIN Tubulointerstitial Nephritis
or
Crescents with characteristic change on Immunoflurescence
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RPGN light Microscopy
Interstitial Nephritis Crescent
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RPGN Class I
Linear Immunofluresence
Due to Anti-GBM Antibody
Goodpasture’s
Syndrome
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RPGN Class II
Granular IF
Immune Complex
Deposition
Due to SLE, MPGN, HSP, PSGN, Others
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RPGN III: Vasculitis
Crescent with Focal Necrotizing GN
Pauci-immune.
ANCA Positive.
Seen in Wegener’s Granulomatosis, Churg-Strauss, PolyArteritis Nodosa (PAN).
Necrotizing area
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RPGN IV: Vasculopathy
Hyaline thrombi
Endothelial cell swelling and vacuolization
Seen in TTP/HUS, Preeclampsia,
Malignant HTN
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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.
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New TerminologyARF - 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
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New Terminology Chronic Kidney Disease
CKDStage 1 Normal GFR with known disease
Stage 2 GFR 60-80 ml/min
Stage 3 GFR 30-60
Stage 4 GFR 20-30
Stage 5 GFR 10-20
Stage 6 GFR < 10, ESRD.
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NEPHROLOGYDEFINITIONS
DEHYDRATION - STATE OF FREE WATER LOSS
VOLUME DEPLETION - STATE OF SALT AND WATER LOSS
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DIALYSISDEFINITIONS
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.
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TRANSPLANTDEFINITIONS
ALLOGRAFT
REJECTION
IMMUNOSUPPRESSION
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CORRELATIONS
STRUCTUREEndothelium
GBM
Epithelium
Mesangium
FUNCTIONmake vessel
seive
charge select.
makes GBM
PATHkawasaki's
Alport's
proteinuriaMinimal Change
Berger's
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Glomerular Physiology
Afferent. ArtAT II constrict
ACE-i dilate
PG's NET dilate
TGF NET constrict
NSAID's constrict
Aminophylline dilate
Diltiazem dilate
Filt Pressmaintained
reduced
increase
parallels
reduce
increase
reduced
Efferent Art.constrict
dilate
no effect
no effect
no effect
no effect
dilate
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Glomerular Physiology
Blood flow determinants
Afferent Efferent
Filtration
Systemic
PG'sTGF
Local
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Renal PhysiologyOverview
Distal Tubule
Loop of Henle
Collecting duct
ADH +
ADH -
permeable to H2O
impermeable
solute exchange
reabsorption
filtration
impermeable toH2Osolute
imperm. to
Proximal Tubule
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CORRELATIONS
STRUCTUREEndothelium
GBM
Epithelium
Mesangium
FUNCTIONmake vessel
seive
charge select.
makes GBM
PATHkawasaki's
Alport's
proteinuriaMinimal Change
Berger's