nephrology - dr abo-elasrar - by el azhar medical students 2012 ( للطباعة )
DESCRIPTION
nephroTRANSCRIPT
-
( BETA EDITION)
With
Prof. Dr Mohammed Abo El-Asrar
Edited By El-Azhar Medical students 2012
-
Nepgrology Dr. Abo-Asrar
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Nephrology INDEX
Total pages = 47
Total time = about 9.5 hours
Lecture number Pages
1- lecture 11 4 - 5
Introduction ( page 4 )
inheritance 6 ( Autosomal inheritance 6 )
2- lecture 12 5 - 12
cont. Introduction ( page 5 )
3- lecture 13 12 19
Nephrotic $ ( page 12 )
4- lecture 14 19 - 25
cont. minimal change ( page 19 )
congenital nephrotic ( page 21 )
5- lecture 15 25 - 32
cont. post str. GN ( page 25 )
introduction to RF ( page 26 ) ..
6- lecture 16 32 - 38
cont. introdiction to RF ( page 32 )
chronic RF ( page 34 )
7- lecture 17 39 - 47
acute RF ( page 39 )
Urinary Hues ( page 44 )
Hematuria ( page 45 )
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72:1 .... 11
YGOLORHPEN
4
) $ ( emordnys citorhpen -1
) $ ( emordnys citirhpen -2
eruliaf laner -3
airutameh -4
tfut yrallipac iluremolg + eluspac s'nammuoB iluremolg -
tnereffe tnenreffa -
.ffE .ffA -
eluspac .B suluremolg erusserp
nietorp amsalp amsalp -
-
: ) ( sreyal 3 etaretlif -
) ( yendik fo enarbmem tnemesab -1
) ( seirallipac fo muilehtodne -2
) ( eluspac .B fo muilehtipe -3
seirallipac muilehtodne etaretlif -
eluspac .B muilehtipe artsanef enarbmem tnemesab
sreyal -
) MB ( enarbmem tnemesab eht :
muilehtipe muilehtodne
MB -
artsenef lacimotana dellac MB -
egrahc ev )elbazianoi( nietorp olais -
artsanef lacimotana dleif citengam
artsanef lacigoloisyhp dleif citengam
-
eniru nietorp .p -
suluremolg .. -
selubut fo sllec revoc taht nietorpocum fo gnidehs
srh 42 / gm 03 < eniru
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Nephrology Prof. Dr. Abo El -Asrar
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glomerulus
:
1- if > anatomical fenestra
- anatomical
high molecular weight protein globulin haptoglobine
2- if < physiological fenestra
- physiological
. As crystalloids as Na, K, etc
3- if > physiological but < anatomical :
- physiological anatomical
So, should pass through the magnetic field
A - So, if +ve charged
- Hb intravascular hemolysis Hb
And leading to acute tubular necrosis
B but if ve :
- ve charge LMW protein ( ve )
As albumin , transferring , IgG , tuftsin , lipoprotein lipase ( which destruct cholesterol ) , protein C ,
protein S & antithrombin iii
- sialo protein LMW protein
urine ( HMW protein ) selective proteinuria
selective sialprotein
- BM LMW+HMW
non selective proteinuria
11 12
12
- afferent efferent
And aff. : eff. = 7:1 WHY ?? To increase the pressure inside the glomerular capillaries
( pressure (
-
- glomerular filterate plasma protein
- sialoprotein selective proteinuria
1- in the most common type of nephrotic $ minimal change nephrotic
2- also, in congenital nephrotic $
- 1 2 selective proteinuria
- BM non selective proteinuria
-
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airunietorp -
eniru ... eniru -
:
42 eniru srh 42/gm 051 => eniru ni nietorP
051 03 .. 03 -
) gm 051 ( airunietorporcam yb detacilpmoc ro elbataert eb yam airunietorporcim dellaC
airunietorp fo sedarG -
airunietorp dlim eniru srh 42/gm 005-051 eniru ni nietorp fi -1
srh 42/ mg 1 sa etaredom 0002 < & 005 > fi -2
evissam ro yvaeh ) mg 2 ( gm 0002 => fi -3
) ( -
snorhpen MB fo noitcurtsed nietorpalis -
aimnetorpopyh airunietorp yvaeH -1
?? stceffe eht si tahw
aimenietorpopyh nietorp amsalp eniru ni nietorp amsalp -
edis suonev edis lairetra seirallipac -
traeh
stcudorp etsaw stneirtun 2o yrallipac -
retaw .. .. -
-
ecaps laititsretni ecaps laititsretni -
gHmm 52 erusserp citomso ) ( -
nietorp amsalp
erusserp citatsordyh -
gHmm 23 edis lairetra ni -
gHmm 21 edis suonev -
retaw fo retil 1 gHmm 1 -
23 = * 52 = 1 X 52 = dne lairetra -
ecaps laititsretni 7 = 52- 23 =
) ( stneirtun 2O 7 -
-
) 31 = 21-52 ( 21 = * 52 = 52 1 = edis suonev -
-
Nephrology Prof. Dr. Abo El -Asrar
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( ) 13 blood waste products
7 13
13 / 7 = 1.5 .. interstatium arterial end 1.5 venous end (
)
- interstitial space
odema
- hypoproteinemia :
2- generalized massive odema :
Due to :
A - osmotic pressure say 15 ( not 25 as normal )
- arterial side 17 ( 32 -15 = 17 ) interstitial space ( )
- venous side 3 ( 15-12 = 3 )
- interstatium 14 ( ) massive odema generalized
osmotic pressure
- odema
B - ADH :
- arterial side venous side 14 ( interstatium )
- atria volume receptors atria
hypothalamus ADH kidney to collecting tubules urine
reabsorption
- .. osmotic
pressure
- ADH urine
osmotic pressure .
C - renine aldosterone
- VR COP
- VR COP renal Bl. Flow
- afferent columnar cells juxtaglomerular apparatus
if RBF secrete renine hormone convert angiotensongen to angiotensen I then to ii to suprarenal
that secrete aldosterone to distal tubules reabsorption of Na then Na take water to
intravascular
- osmotic pressure
odema
-
3- hyperlipedemia or hypercholestremia :
-
Nephrology Prof. Dr. Abo El -Asrar
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- osmotic pressure liver
synthesis of albumin as a compensation
- kidney urine
- liver cells marked hyperactivity over compensation albumin ..
lipoproteins cholesterol
- intake
- liver
( liver) NB.
- liver
need lipoprotein lipase which is one of LMW protein that lost in urine
- ( ) so, hyperlipedemia or hypercholestremia
- nephrotic $ :
clinical $ that characterized by heavy proteinuria , hypoprotenmia , massive generalized odema with or
without hypercholetremeia ) heavy proteinuria = >= 2 gm/24 hrs )
-
- grades proteinuria adult child
- nephrotic
-: aldosterone osmotic pressure
-: osmolarity osmotic pressure
- osmolarity
Na urea ( ) intravascular extravascular
body fluids
NB. All called extracellular fliud
- but osmotic pressure depends on plasma protein that only intravascular
-: lymphatic system odema as a drainage system
-: .. arm lymphatic odema
:
- :
- :
1- odema of BM
- fenastra
2 - proliferation of endothelium 3
3 - proliferation of epithelium of B. capsule 2
-
-
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noitartlif raluremolg -
airugilo , os -1
-
42 eniru -
airugilo = srh 42/aera ecafrus 2m / lm 004 < fi -
= aera ecafrus 2m
aera ecafrus -
-
snmuloc 3 trahc -
thgieh aera ecafrus -
-
aera ecafrus
) ( -
) etarucca ton ( tW + 09 / ) tW 4 ( + 7
004 aera ecafrus -
..... 002 -
airugilo
yad / AS 2mm / lm 081 < airunA -
noitaniru ON airuna etulosba -
: noisnetrepyH -2
aimelovrepyh .. -
erusserp ralucsavartni noisnetrepyh
: .. citatsordyh erusserp citomso -
51 yas edis suonev - * 63 yas edis lairetra -
.. -
: amedo dliM -3
. retaw retil 11 = 52-63 edis lairetra eht ta -
retaw retil 01 = 51-52 edis suonev eht ta -
amedo dlim ) 41 ( 1 -
saera tnadneped ni ylno sraeppa taht
noitisop woble & eenk -
sdileye eht fo seniffup - : sa saera tnadneped -
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Nephrology Prof. Dr. Abo El -Asrar
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- ..
- odema dorsum of the hands & foots
-
4- Hematuria :
- intravascular pressure capillaries
so, may epistaxis
- capillaries pressure (
) bleeding ( .. ) Hematuria
5- mild proteinuria :
- plasma protein
as here there is hematuria that contain not only RBCs but also plasma
mild proteinuria
- selective non selective : non-selective both H&LMW protein
- nephritic $
- that defined as clinical $ characterized by oliguria , hypertension , hematuria , mild odema & mild
proteinuria
- ( )
- ( nephritic ) surface area 1 m2 200
/ 160 that indicate severe hypertension
- urine 200 ml/day ( oliguria .. ) criteria nephritic
- 2 nephrons .. 200,000 BM capllaires
( 10% of nephrons ) :
- hematuria become frank + protein heavy proteinuria ( > 2 gm / day )
+ urine output 350 ml ( still oliguric )
+ Bl. Pressure become 160/120 but still hypertensive
+ osmotic pressure so, massive odema ( due to heave proteinuria )
- :
1- still oliguria
2- still hypertension
3- hematuria
4- odema
5- preoteinuria
- called nephritic nephrotic $ 4 5
- causes & Pathogenesis :
- nephrotic nephritic
-
Nephrology Prof. Dr. Abo El -Asrar
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WHAT IS THE ETIOLOGY ?
1- congenital congenital nephrotic $
sialoprotein
- so, heavy selective proteinuria hypoproteinemia massive generalized odema
& if healthy liver hypercholetremia but if diseased liver no hypercholestremia
2- immunemediated
A- direct antigen antibody reaction part of the kidney is antigenic reaction
- : Abs sialoprotein selective heavy proteinuria
one of nephrotic called minimal change nephrotic $
B- destruction of the basement membrane ( BM )
non selective proteinuria and other manifestations of nephrotic
- as in membranous glomerulonephritis ( GN ) or rapidly progressive GN
C- also, antigen antibody reaction proliferation in the kidney
- so, proliferation of endothelium or epithelium of B. capsule or odema of BM
Nephritic $ or may complicated by nephrotic
D- Immune complexes
- antigen-antibody .. complement
c1-c9 kidney and cause nephritc,nephrotic or both
-
- investigations
- C3...
- classic pathway so, consumed in any complement aggregations
So, 1- if C3 means immune complex mediated pathology
2- if normal
- : congenital nephrotic $ C3 normal
minimal change nephrotic C3 normal
post.streptococcal GN C3 immune complexes
- complement immuno fluorescein biopsy slide
light microscope slide fluorescence
- fluorescein complement
- washing slide fluorescein immune complex
- so, if C3 so, +ve immuno fluorescein test
- so, in congenital -ve * in minimal change -ve * post. Strept. +ve
- EM Fl
-
Nephrology Prof. Dr. Abo El -Asrar
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- linear on glomeruli or lumbi deposition
1- if linear depositions on tha whole BM
- kidney antigenic
2- if lumbi depositions
- immune complex kidney
-
- ( linear ) end stage RF
- linear
- but if lumbi
100
12 13
Nephrotic syndrome
Definition
Clinical condition that characterized by 1- heavy protenuria
2- hypoproteinemia
3- massive genarlized odema
4- +/- hypercholetremia
Etiology : 1ry & 2ry
1ry
- 1ry pathology ( : )
1- congenital Nephrotic $
2- minimal change nephrotic $
3- membranous GN.
4- focal GN.
5- membrano-proliferative GN.
6- rapidliy progressive GN.
2ry causes : due to systemic diseases
1- collagen diseases as SLE ( multi systems affection )
- lupus kidney affected
2- Endocrine diabetic nephropathy 5
3- allergic vasculitis blood
- as Henoch shoneline purpura
-
Nephrology Prof. Dr. Abo El -Asrar
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4- sickle cell anemia immune complex formation
5- lymphoma 6- shistsoma mansoni & malaria
7- drugs as gold , penicllin etc
-
- congenital & minimal change pure nephrotic only & the rest either nephritic , nephrotic or both
-
- ascities , scrotal odema , puffiness of the eyelid
generalized odema
- urine analysis albumin + 4 ( means about 2.5 gm / 24 hrs )
- total protein 3 gm - serum albumin 2 gm ( hypoproteinemia )
- nephrotic
Q : enumerate causes & discuss how to diagnose one of them ??
- puffiness odema dorsum of hand & foot
- urine analysis RBCs in urine
- urine output < 400 ml / m2 + headache
- nephritic
- 1- congenital 2- minimal change
NB . most common cause of nephrotic minimal change = 70 % of all pediatric nephrotic
- ..
-
- minimal change nephrotic
Minimal change nephrotic
- Cause autoimmune
- antibodies against sialoprotein selective heavy proteinuria
- improves by measles infection due to suppression of T-cells all autoimmune process
measles infection TB
1- male > female 2:1
2- most common cause of nephrotic $
3- age of onset 2-7 years
- range rare rare
- Clinically
-
( !!! .. ) ( ) :
1 - ONLY massive generalized odema
-
Nephrology Prof. Dr. Abo El -Asrar
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- eyelid .. ..
- puffiness of eyelid then extremites ( dorsum of hand & foot )
- then genetalia ( scrotal in male labial in female ) + L.L odema
- abdominal & chest wall + ascites , pleural effusion & pericardial effusion
- causes of this odema
1- osmotic pressure due to plasma protein
2- ADH odema
3- aldosterone Na & water retention more & more odema
2- important ve data :
- No oliguria No hematuria No hypertension
- nephritic
- :
nephrotic manifestations generalized odema
- odema renal by exclusion of other causes of odema :
1- cardiac L.L then ascites then allover the body
2- liver disease ascites then L.L then allover the body
3- nutritional odema with loss of Wt
+ no history of cardiac or liver diseases
-
Either nephrotic or nephritic-nephrotic
- nephrotic
- :
..
NB hypertension may occurs in 10-20% of minimal change N
complications
- may present with complication of nephrotic $
- 2 complications
A - incidence of infections
1- odema precipitating factor for infection
- .. " "
organism ..
2- loss of 2 important immuno components in urine
-
Nephrology Prof. Dr. Abo El -Asrar
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- loss of IgG & tuftsin ( opsonin ) that help in phagocytosis of capsulated organisms
3- use of immuno suppressive drugs in the ttt as cortisone
B - risk of thrombosis 3
a- blood viscosity
- .. thrombosis
b- coagulation factors
- liver
c- coagulation factors
- antithrombin iii active factor iiia fibrinogen
Convert fibrinogen to fibrin
- antithrombin III lost in urine
d- loss of protein C & S in urine
- inactivation coagulation factors
- WHY blood viscosity ??
1- odema
interstitum
2- in ttt diuretics used shift water from intravascular to urine
3- cholesterol viscosity
4- polycyathemia due to using os steroids for long term & polycyathemia is one of
the most importrant side effect of steroid
- laboratory diagnosis ( investigations ) :
- odema
- heavy proteinuria
1- urine analysis 24
For measurement of total amount of proteins + type of proteins in urine by elsectrophoresis of urine
- :
- protein > 2 gm / 24 hrs ( heavy proteinuria )
- protein electrophoresis low molecular Wt protein so, selective ( albumin , trasnsferrin , & IgG ) ( no
globulin , no etc all HMW protein (
2- for hypoproteinemia total protein & serum albumin
- normal serum level protein = 6-8 gm %
- normal abumin = 4.5 5 gm % ( here < 2.5 gm / dl ) WHY ??
a- loss of protein in urine
-
Nephrology Prof. Dr. Abo El -Asrar
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b- gut wall odema gut secretions which is mucous which is protein in nature
- stool
c- catabolism of protein WHY ??
- odematous BMR
consumption
3- serum cholesterol > 300 mg / dl ( normal level = 150-250 mg % ) WHY ??
a- synthesis by the liver
b- metabolism due to lipoprotein lipase enz.
4- C3 Normal ( not immune complex )
5- renal functions normal
6- U/S for detection of ascites chest X ray for detection of pleural effusion
7- renal biopsy ( not a routein investigation )
- steroid
- light microscope every thing is normal
- fluorescein -ve
- EM fusion of foot processes
- epithelium of B. capsule BM foot process fusion
sialprotein Abs adhesion
- minimal change nephrotic $ normal ..
EM fusion of foot process
- TTT :
- nephrology ttt :
complete rest in bed + 3 D
1- complete bed rest
- BMR catabolism
- RBF glomerular capillaries pressure erect position ( ) flat position( )
- so, flat proteinuria so, loss of protein
2- Diet
- :
Protein fat CHO + minerals + vitamins + water
- :
a- CHO
-
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nietorp erup -
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.. ) ( .. -
taf .. .. -
.. .. -
. loretselohc
D tiv D tiv .. stekcir .. !!! -
) .. ( -
mg 003 mg 001 .. 3 -
.. -
.. -
) ( .. .. .. .. !!! -
..
stlas slarenim -d
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retaw & snimativ -e
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-
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+ K evig ,os ssol +K
kaew enotcadla -
enoretsodla kcolb
) K ( enotcadla xisal
VI lotinnam sa sciteruid citomso -
xisal tceffe ..
: nimubla eerf tlas -
erusserp citomso
-
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aimelovrepyh .. yendik
FH evitsegnoc
XISAL .. eniru -
noitasnepmoc revil amedo .. -
srotcaf noitalugaoc & loretselohc
.. pets sciteruid -
enummiotua .. sciteruid - 1
) 02 .. 62 ( amedo - 2
hgih .. gK sgurd evisserppusonummi -
amedo .. esod
.. noisufrep laner .. slessev laner seticsa - 3
sgurd evisserppusonummi esnopser
snoitcefni suoires ot noisulcxe .. evisserppusonummi - 4
BT erutluc eniru -
nilubolg nietorp WML GgI :
tWMH nilubolg :
.. sciteruid .. .. -
sgurd evisserppusonummi sgurD -4
) yad / 2m / gm 06 xam ( yad / gk / gm 2 ) enosinderp ( enositroc -
-
) airunietorp fo tset ( noitalugaoc
.. eerf nimubla -
) (
enositroc .. nimubla -
nwodtuhs lanerarpus
% 07
eniru ) ( nimubla htnom 1 -
yspoib laner .. yspoib laner
.. enositroc .. egnahc laminim -
) (
) .. ( respaler tneuqerf sisorelcsoluremolg lacof -
.. enositroc -
enosistroc .. stceffe edis enositroc gurd cixototyc -
-
Nephrology Prof. Dr. Abo El -Asrar
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- 6 ( 2 2 2 ) .. 6
single dose cortisone in the early morning every other day ) (
- cytotoxic drug (as cyclophosphamide endoxan ) 6 3 ..
3 ..
- membrano - proliferative GN incidence of thrombosis
- . cytotoxic ( 3 )
anticoagulant
- membranous
- & its prognosis :
10 % renal failure
90 % death from complications
13 14
- :
D.D. of minimal change
nephrotic syndrome in 1st year if life
post streptococcal GN
D.D. of minimal change NS
1- congenital nephrotic $
- autosomal recessive gene ( )
- sialoprotein ( age of onset since birth ) generalized odema
neonatal period .. minimal change 2-7 years
- selective proteinuria .. congenital (has no ttt (bad prognosis
2- Focal glomerulosclerosis :
- minimal change presentation cortisone
- .. frequent relapsing ( )
3- membranous glomerulonephritis
- age of onset not common in pediatrics 10
- non-selective ( BM )
- .. prognosis ( 10% & 90% )
4- membrano-proliferative GN :
- immune complex .. immune complex :
C3 + +ve immunoflourscentstydy + EM finding
- BM
proliferation of endothelium of capillary tuft & epithelium of B. capsule
- .. nephritic nephritic nephrotic
-
Nephrology Prof. Dr. Abo El -Asrar
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( hypertension , oliguria , hematuria )
- bad prognosis age of onset mainly > 10 years ( )
5- 2ry to systemic diseases :
- .. other criteria of systemic disease
-: ( cortisone
heavy proteinuria , selective ..)
- +
+ diuretics + cortisone urine ..
2/3 ( 6 4 ) .. 6 (
)
- 6 cortisone
- focal G.sclerosis cytotoxic (
)
- 3
presented with puffy eyelid & generalized odema , protein in urine 3 gm / 24 hrs
, serum albumin 1.5 gh / dl serum choletreol 400 mg / dl
( nephrotic ( ) 4 criteria )
- enumerate causes & how to diagnose one of them ??
- .. 3 ( congential nephrotic .. )
- 15
A causes of nephrotic $ in 1st year of life :
a- 1ry :
1- congenital nephrotic $ ( common )
2- minimal change NS not common ( 2-7 years )
3- membranous GN of idiopathic cause
4- focal g. sclerosis
b- 2ry :
1- 2ry to infection
a- congenital toxoplasmosis
- 2ry to infection
b- syphilis membranous GN 2ry type
- .. idiopathic
2- 2ry to teratogens :
-
Nephrology Prof. Dr. Abo El -Asrar
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- lead poisoning arsenic poisoning
- kidney
3- 2ry to genetic disease as :
- Nail-Patella $ charectrized by nephrotic + nail atrophy + absent patella
- gene factor .. 1ry kidney 2ry
4- Nephroblastoma ( embryogenic tumor )
5- Hemolytic uremic $
- bleeding disorders E-Coli verotoxin ( GIT ) coagulation +
immune complexes deposition kidney nephritic + hemolysis in
RBCs
- ....
B Discuss diagnosis of one of them :
- congenital nephrotic $ ( ) :
congenital nephrotic $
1- Etiology :
autosomal recessive gene abscent of sialoprotein
2- C/P :
- massive generalized odema :
- puffiness UL & LL genetalia ascites pleural effusion pericardial effusion
- odema nephritic complications
- infection ..
immunosuppressive
( odema loss of IgG & tuftsin ) ..
- thrombosis ..
steroids ( congenital)
3- Investigations :
1- urine analysis : heavy proteinuria > 3 gm / 24 hrs
2- total serum protein & serum albumin
- choletrerol
3- normal renal function
4- renal biopsy ( diagnostic )
4- TTT :
1 - rest
2 - diet .. special milk formula protein , CHO , low fat , low salt
-
Nephrology Prof. Dr. Abo El -Asrar
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3 - diuretics
4 - curative ttt RENAL TRANSPLANTATION
Post streptococcal GN
clinical
Etiology & pathogenesis
- streptococcal strain ( 12 pharyngitis ) ( 49 skin infection )
- 2 strains Abs complement immune complexes
glomeruli deposition filter .. irritation proliferation
of endothelium & epithelium of B. capsule ( irritation ) also,
juxta glomerular appartus, mesyngemal cells Diffuse proliferatve GN
- immune complexs subendothelium between endothelium & BM
- EM lumbi deposition not in kidney antigenic part
- odema of BM fenestra GFR oliguria or even anuria
etc
- then hypervolemia hypertension hysdrostatic pressure mild odema
- then some rupture of some capillaries hematuria
- nephritic ...
C / P
1- oliguria & hematuria :
- < 400 ml .. ( RBCs ) frank or smoky
2- hypertension :
- headache hypertension
a- due to GFR
b- also due to proliferation of juxta- glomerular appartus
renine aldosterone salt & water retention volume of the blood hypertension
c- peripheral vasculitis :
immune complexes deposition on endothelium of peripheral vessles irritation & proliferation lumen
peripheral resistance hypertension ( called peripheral vasculitis )
3- mild odema :
- mild odema ..
odema of dorsum of the hand & foot
- .. hydrostatic pressure ( hypertension )
- odema generalized
1- if complicated with nephrotic
-
Nephrology Prof. Dr. Abo El -Asrar
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2- may associated with HF.
3- acute RF without restriction of fliud
- complications :
1- HF
a- hypertension ( congestive HF )
b- toxic myocarditis immune complexes
c- volume overload
2- hypertensive encephalopathy
a- brain odema ICT headache not relived by usual analgesic .. only
relived by morhine.
b- projectile vomiting not precided by nausea
c- convulsion may occur
3- acute RF
- Investigations :
1- Nephritic or not ?? ( glomerular bleeding or not ?? ) so, do urine analysis
a- volume < 400 ml 24
b- specific gravity
- .. specific gravity ..
c- proteinuria mild
d- RBCs casts ( diagnostic )
- hematuria .. glomerular hematuria .. nephiritis ..
RBCs
But bilharziasis separated RBcs
UTI separated RBcs
stone separated RBcs
tumor separated RBcs
- .. ..
:
1 - RBCs tubule ( ) mucoprotein tubule ..
2 - RBCs biconcave ..
2- poststreptococcal or not ?? markers
- in winter antistreptolysin O titre ( ASOT) due to throat infections
-
Nephrology Prof. Dr. Abo El -Asrar
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- in summer antihyalouridinase due to skin infections
- immune complexes in blood
- C3 level
3- Renal biopsy :
- LM proliferation ( as it is diffuse proliferative GN )
- immunoflourscen + ve
- EM subendothelial depositions ( lumpi form )
NB complications or not ?? clinically ( ) as hypertensive encephalitis or not ( clinically )
4- Reanl failure or not ?? do renal function tests
- ttt :
- streptococci
1- eradication of streptococcal infection give penicillin for 10 days ( )
2- Diet ( )
a- CHO b- fat
RF .. urea suppression to lipoprotein lipase enz. so, cause
hypercholestremia
c- protein as urea from protein
: renal impairment .. liver impairment protein
d- Na e- K+
f- water so, fluid restriction
- fluid chart ( ) .. :
- volume of urine / 24 hrs ( ) + 400 ml / m2 ( for extrarenal water loss through
respiration , sweat etc (
-
( )
3- ttt of hypertension ( antihypertensive drugs )
..
4- for hyperkalemia
-
( k K
)
- K- citrate ..
- normal serum K 3.5-5 mEq / L
-
Nephrology Prof. Dr. Abo El -Asrar
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- 7 dialysis arrhythemia of heart ..
so the toxic level is very very narrow
-
1- glucose + insulin
- ( )
so, give glucose + insulin
2- bronchodilators :
- smooth ms of bronchus stimulation B2 bronchodilators
hypokalemia smooth ms of bronchus so, give B2 agonist by inhalation
3- Ca gluconate
- Ca gluconate :
- Ca brasyarrythemia ( cardioprotective against tachyarryrhemia of K + )
- gluconate give K-gluconate wcich is fat slouble to liver excreted in bile
4- ion exchange resin :
- ion exchange resin electrolyte disturbance
5- peritonial dialysis & its indications are :
- persistent hyperkalemia
- hypervolemia , urea , creatinine
14 15
:
- DD of poststreptococcal GN
- introduction to renal failure
- BM transplant & renal transplant
- RF ( )
- DD of poststreptococcal GN
- typical poststreptococcal GN.
- nephritic oliguria , hypertension , hematuria , mild odema
1 - nephritic $ or acute GN
2 - hematuria microscopic or macroscopic poststreptococcal or acute GN
3 - mild odema mild odema as cardiac or hepatic or nutritional
4 - hypertension
- 1 .. 2
- other causes of acute GN :
A - alport $ = heridiatry nephritis
gene factor mainly autusomal dominant
-
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autosomal recessive or X linked
- age of onset 1st 6 months or max. 1st 12 months
- :
1- nephritic $
2- other manifestations as :
- SNHL ..
- Keratoconus
- ..
kidney ( transplantation)
B - IgA nephropathy
- IgA mucosa
- infection ( viral ) IgA mucosa ( 1st protective mechanism ) serum
- IgA serum .. kidney
( immune complexes .. ) deposition odema of BM ..
- proliferation so, all manifestations of neohritic $ but severe hematuria
- infection nephritis so, recurrent nephritis
..
.. IgA with any infection ( hematuria )
-
- IgA in serum , normal C3 ( also in alport C3 is normal )
- biopsy deposites IgA
- kidney transplant .. kidney kidney
IgA deposites
avoid infections
C - hemolytic uremic $
D - rapidly progressive GN
Renal failure
INTRODUCTION
- organ failure
- so, we must 1stly know functions of the kidney 3
A Endocrinal functions :
1- erythropiotein
- RF .. stem cells of BM RBCs RBCs anemia
-
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2- thrombopiotein
- receptors stem cells megakaryocytes mother cells of platlets
- RF thrmbocytopenia
3- as kidney activate vit D so, if failure Rickets ( if still growing bone )
- vit D .. vit D3 ultra violet
rays
convert cholestreol to vit D3 ( cholecalcifirol ) wcich is non-functioning vit.
functioning vit 2 hydroxylations:
- in liver at C25 give 25 hydroxy cholecalcifirol
- in kidney hydroxylation at C1 ( parathyroid hormone dependant )
kidney receptors parathrmone active form ( 1-25
dihydroxycholecalcifirol)
- 1-25 dihydroxy . 1-hydroxy ( 1 alpha ) liver
1-25 dihydroxy ( vit D . )
4- kidney secrets renine from juxtaglomerular appartus ( )
from columnar cells at the end of afferent arterioles just befors glomerular capllaries
- if irrtative pathology renine hypertension
- if destructive pathology renine hypotension
- RF hypertension ..
.. hyper hypo
B Excretory functions :
- .. toxins .. endogenous toxins
.. :
1- macrotoxins :
- failure toxic effect appears so early acute & chronic & include
- urea , acetotic materials ( organic acid ) , K+ , phosphorus & uric acid
2- microtoxins :
- failure acute RF
chronic
- & include urochrome pigment, phenolic materails , aluminium
- RF
1- urea = Azot so, uremia = azotemia
- urea ( kidney main site of excretion ) (
.. ) :
1 ) through saliva :
salivation
-
rarsA- lE obA .rD .forP ygolorhpeN
82 | e g a P
2102 " " " : ,, : " "
gniht yna fo etsat dab ) ( .. aeru -
) .. (
.. .. sdub etsat noitcurtsed .. -
llems ainoma ro llems cimeru -
snoiterces TIG hguorht ) 2
hcamots -a
nrub traeh sitirtsag asocum cirtsag noitatirri -
) .. (
sisemetameh .. .. reclu cirtsag sitirtsag -
gnitimov .. sitirtsag
)loots kcalb ( anelem .. -
sitiloc ot gnidael snoiterces noloc -b
srotpecer hcterts niatnoc noloC .BN
lanios .. xelfer lanips .. noitalumits .. llaw noloc loots -
droc
loots .. noitcartnoc loots tnemges
suna & mutcer
)xelfer noitacefed (
ot erised .. noloc fo ytilitom .. srotpecer hcterts ) ( noitatirri -
. yrtnesyd ) .. reclu ( .. etacefed
) yrtnesyd cimeru tub .. yrtnesyd ) allegihs ( yrallicab ton .. yrtnesyd cibeoma ton (
: taews hguorht ) 3
noitatirri .. .. -
tceffe gnihcti )enimatsih fo srotpecer ( 1H ot
.. .. -
..
.. -
) ( tsorf aeru dellac
snoiterces .pseR hguorht ) 4
.. yawria .. suhcnorb fo snoiterces aeru -
)hguoc ( .. yawria tsehc
)tsehc .. eerf tsehc (
) ( .. -
sisytpomeh gnideelb .. noitareclu -
-
Nephrology Prof. Dr. Abo El -Asrar
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- bronchospasm .. ( wheezing .. ) chest
asthma ( wheeze asthma )
- kidney ( manifestations
)
- .. ..
1- suppression to cyclooxygenase Enz. Inside the platlet ( ) leading to thrombathenia
- RF thrombocytopenia .. purpura RF ..
.
2- deposition on cell membrane of RBCs rupture hemolysis ( due to deformity of cell membrane )
3- suppression to lipase enz. cholesterol hypercholestremia in RF
liver F hypochole.
- post. Strept. GN excess fat RF
4- if urea reach brain leading to
a- irritation of vomiting center ( chemoreceptor triger zone )
- RF :
A local cause gastritis B central cause irritation of vomiting center
b- to arousal center ( reticular formation )
- drousy coma
- manifestations of azotemia .. ..
5 - .. serosal membranes
1- pericardium dry pericarditis
2- pleura dry pleursy
3- peritoneum dry peritonitis
1,2 & 3 all leading to stitching pain
2- organic Acid :
- kidney
organic acids .. PH
( acidic .. alkaline PH )
- organic acids active process .. reabsorption bicarbonate PH
acidosis
... kidney
-
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acidosis :
a- failure of excretion of organic acid
b- loss of bicarb. In urine
- acidosis
1- Kussmaul respiration ( air hunger ) : WHY ??
- PH resp. system .. organic acids lung .. CO2 + H2O
- CO2 irritate respi.center leading to deep respiration
.. Kussmaul respiration ( air hunger )
- CO2 .. Acidosis
so, air hunger is a compensation for acidosis .
2- rickets if still growing bone ( due to melting of bone )
- bicarb
- bone bicarb .. bone Ca-carbonate .. Ca
bone Rickets
- so, Rickets has 2 causes in RF :
a- failure of activation of vit D
b- Ca from as a compensation to bicarb level ( )
3- K+ in RF K+ level
- normal level 3.5 5
- manifestations of K+ level :
a- irritation of SA node SA node tachycardia .
b- motility of GIT
- K+ motility
- motility colic .. diarrhea ( absorption )
- :
a- urea colitis dysentry
b- K+ motility of GIT
NB . effect of K+ on skeletal Ms is the opposite of of its effect on smooth Ms
K+ tone skeletal Ms hypotonia ..
4- Phosphate :
- RF no excretion of Ph WHY ??
- Ph Ca .. parathyroid hormone
Parathormone leding to excretion of Ph & reabsorption of Ca
-
rarsA- lE obA .rD .forP ygolorhpeN
13 | e g a P
2102 " " " : ,, : " "
aC .. ) .. enomrohtarap srotpecer ( yendik -
hP
) ( hP & aC eniru ni ,os -
.. .. .. hP aC dnalg dioryhtarap -
: .. enomroh dioryhtarap
yendik -a
enoB -b
tsalcoetso & tsalboetso .. -
( aC & hP enob .. tsalcoetso ytivitca enomrohtarap -
tsalboetso )
hP .. enomrohtarap dioryhtarap dnalg -
yendik .. hP .. hP & aC enomrohtarap
aC hP
hP .. hP aC .. .. yendik -
enomrohtarap ... elcric suocsiV .. enomrohtarap ..
.. hP & aC stsyc yar X .. stekciR
acitsyc asorbif siteitso ) tsyc ton ( aera dezialrenimed
: 3 .. FR stekciR -
enomrohtarap -3 enob fo gnitlem ot gnidael sisodica -2 noitavitca D tiV -1
dica cirU -5
sitirhtra -
: snixotorciM
: slairetam cilonehP -1
) .. ( -
) ( noitalucicsaf sCHA noitatirri .. FR -
) ( pucciH mgarhpaid fo noitcartnoc suonitnops .. n cinerhp noitatirri -
) FR fo % 03 ni rucco puccih ( FR
stnemgip emorhcoru noitadarged eninalem -2
eniru -
.. tnemgip .. .. .. -
.. .. .. -
raelc ( .. ..
)eniru
tnemgip -
-
rarsA- lE obA .rD .forP ygolorhpeN
23 | e g a P
2102 " " " : ,, : " "
muinomulA -3
) ( ) ( -
.. yreviled ) erup .. (
.. yendik -
: .. FR -
ecnabrutsid yromem noitceffa ebol latnorf -1
ainepotycnap yam MB ni setisoped -2
:FR ainepotycobmorht -
yticixot muinomula -b nietoipobmorht -a
: FR ni aruprup fo sesuac -
ainehtabmorht aeru -2 ainepotycobmorht fo sesuac -1
61 51
.. yendik eht fo snoitcnuf enircoxe & enircodne -
yendik noitcnuf
: noitulid & noitartnecnoc fo rewoP - C
) ( ytivarg cificeps -
0301 5101 = yllamron eniru fo ytivarg cificeps -
5201
.. 5101 0301
amsalp ro eniru ytivarg cificeps -
.. .. ytiralomso ytivarg cificeps -
aN
0101 = amsalp fo ytivarg cificeps lamron -
( amsalp etartlif raluremolg .. -
ytivarg cificeps nietorp amsalp ) .. nietorp amsalp
0101 amsalp etartlif raluremolg ytivarg cificeps -
.. retaw & aN noitprosbaer elubut detulovnoc lamixorp etartliF .lG -
.. ytivarg cificeps .. TCP
..
0101 = elneh fo pool ta ytivarg cificeps ,oS
retaw fo noitprosbaer .. aN fo noitprosbaer elneh fo pool -
0101 ytivarg cificeps etaretlif ..
aN fo noitrosbaer .. enoretsodla no tnadneped selubut detulovnoc latsid -
ytivarg cificeps ..
-
rarsA- lE obA .rD .forP ygolorhpeN
33 | e g a P
2102 " " " : ,, : " "
laitatsretni .. .. HDA yb delortnoc ) .. setag ( .. selubut gnitcelloc -
) tlas ton ( ylno retaw fo noitprosbaer alludem
eniru ytivarg cificeps .. ytivarg cificeps -
eniru fo noitartnecnoc =
.. .. HDA -
ytivarg cificeps + tuptuo eniru HDA fi TUB ytivarg cificeps + tuptuo eniru
) eniru fo noitartnecnoc fo rewop noitulid & ( yendik -
.. 21-8 .. -
) ekatni retaw (
.. HDA .. .. ekatni retaw -
:
) ( 0301 .. ytivarg cificeps +
ekatni retaw ) .. 2 ( -
) 5101 ( ytivarg cificeps + tuptuo eniru level lasab ot HDA
( .. 5101 0301 lamron ytivarg cificeps -
) 0301 ( ) .. 5101
) ( noitulid & noitartnecnoc fo rewop lamron dellac si siht
ytivarg cificeps : -
.. :-
) (
.. .. .. -
.. -
) .. ( ..
) (
: -
.. gnitsaf gnirud retaw fo noitprosbaer yendik
. noitardyh revo retaw fo noitprosbaer
.. -
) ti ni ytiralomso hgih ot eud ( alludem laitatsreti -1
HDA -2
-
Nephrology Prof. Dr. Abo El -Asrar
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- RF
- interstitial medulla .. .. ADH
glomerular filterate ..
with specific gravity 1010 as plasma ( in acute & chronic RF ) (low specific gravity)
- .. glomerular filterate .. urine volume .. specific gravity
1010 .. fixed
so, in RF urine has Low fixed specific gravity
Chronic RF
- Definition :
- inability of the kidney to maintain body homeostatsis ( )
- Causes :
1- in child < 5 years :
- Ch. RF 5 .. renal anomalies :
- Hypogenesis , agenesis ( aplasia of the kidney ) or urinary tract anomalies
acute chronic
- or any obstructive uropathy ( )
2- If child > 5 years
- may congenital as polycystic kidney & alport's $
- may acquired as GN or hemolytic iremic $
- clinical manifestations :
1- manifestations of azotemia( urea )
a- saliva as bad taste ..etc
b- bad odour of mouth
c- stomach d- colon e- sweat f- bronchial secretions
g- chest pain or abdominal pain h- CNS affection
- 3 4
( .. )
2- Air hunger ( rapid deep resp. ) due to acidosis ( metabolic ) due to :
a- loss of HCO3 in urine b- failure to excrete acidic materials
3- urine volume :
- kidney ( 2 )
- glomerular filterate 24 180 = 180 000 ml / 24 hrs
- urine output = 500 1500 ml / m2 / 24 hrs
-
Nephrology Prof. Dr. Abo El -Asrar
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400 oliguria .. 180 anuria .. 1500 polyuria
- urine
- renal impairment if nephrons < 0.5 milion ( )
: ( .. )
2 000 000 nephrons give 180 000 ml
So, 200 nephrons give 18 ml & 100 nephrons give 9 ml
- chronic RF 0.5 .. 100 000
..
As 100 9 so , 100 000 give 9000 ml
9 .. urine volume 9 .. polyuria ..
- .. .. 2- 3 .. 10 000
10 000 900 ml urine output
..
- .. 1000
So, 1000 90 ml ( oliguria even anuria according to surface area )
- urine volume chronic RF :
Polyuria normal oliguria or anuria or even absolute anuria
- complications : ( )
1- Racketic manifestations = renal osteodystrophy ..
a- no hydroxylation of vit. D in kidney
b- acidosis melting of bone Ca
c- Ph parathotmone osteitits fibrosa cystica
2- pallor or manifestations of anemia : WHY ??
a- production of RBCs due to :
1- erythropiotein
2- BM suppression by alumonium toxicity
3- iron & folic acid as a requirements ( )
- iron & folic acid ..
ammonia .. iron & folic acid.
b- loss :
1 ) hemolysis of RBCs by urea & other toxins .
-
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2 ) He due to bleeding tendancy
3 ) bleeding tendancy :
a- thrombocytopenia
b- thrombathenia
c- Coagulopathies as urea prevent activation of coagulation factors
4- Growth failure ( dwarfism short stature )
a- renal osteodystrophy HOW ??
- deformity bone
b- restriction of protein in diet .
c- anemia ( chronic )
d- uremia suppress GH receptors leading to end organ resistance to GH .
5- CVS complications :
A- Hypertension WHY ??
1- renin ( if irritative pathology ) Na & water retention .
2- End stage renal failure volume overload ( )
3- cholesterol ( hyperlipedemia )
B Pericarditis
C HF WHY ??
1- hypertension
2- end stage RF hypervolemia
3- anemic HF
4- toxic mycarditis ( due to uremia or other toxins )
6- Neuropsychatric disorders : due to :
a- urea
b- hypertensive encephalopathy
c- trace elements & vitamins
d- Aluminium toxicity
7- recurrent infections due to suppression of immune system by uremic toxins .
- Investigations :
-
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1- urine analysis :
- Low fixed specific gravity ( 1010 )
- volume
2- urea & creatinine elevated .
3- CBC
normocytic normochromic
or microcytic hypochromic ( iron )
or macrocytic normochromic ( folic acid )
4- Bl. Gases metabolic acidosis
5- Electrolytes :
- Na if renin ( irritative pathology ) & Na if renin ( destructive pathology )
- K+
excretion active process ..
- Ca ++ decreased - Ph increased
- alkaline phosphatase as he has RICKETS .
6- ECHO
7- assessment of nutritional state
Level of serum albumin , transferring , zinc , iron , folic acid , lipid ..etc
8- assess tone
9- investigations to detect etiology
.. ..
( heridatry )
- ttt :
1- Diet ( )
chronic RF
a- CHO
- .. ..
b- Fat give digested fat
- medium chain triglycerides
- fat .. .. 1 gm 9 ..
renal transplant
-
Nephrology Prof. Dr. Abo El -Asrar
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c- protein
... urea
d- minerals
- Na or is there salt loss or retention ??
- K +
- Ca
- ( skimmed milk .. ) fat
- Ph
- .. ..
- .. .. ..
- Ph excretion .. as Posphate binder
e- vitamins
- increase fat soluble Vit.
- increase water soluble vit . ( )
dialysis .. water soluble vit ..
f- water :
- if oligurai or anuria give urine volume + 400 ml / m2 / day ( fliud chart )
2- ttt of complications :
- hypertension
- anemia by dialysis ( aluminium ) + give iron & folic acid + erythropiotein
- Rickets :
give active vit D
correct acidosis
if resistant cases parathyroidectomy
3- dialysis : ??
- if GFR = 10 ml / minute
- or severe manifestations of azotemia
- or K+ reach 7 tachyarrythmia
- .. manifestations .. dialysis
4- Renal transplantation
5- social & psychological ttt
6- Drug dosage
-
Nephrology Prof. Dr. Abo El -Asrar
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- .. kidney
16 17
Acute renal failure
written
Definition
acute renal failure
: stop of filteration kidney waste products .
ARF
- may be reversible .. chronic
- filteration .. urine output
- .. oliguria .. chronic
- .. ARF
Causes :
- :
- filteration .. filteration
filteration
1- glomerular capillary pressure
- ( plasma protein )
- ( afferent ) diameter .. efferent ( ) .
Afferent diameter : efferent diameter = 7 : 1
capillary pressure .
2- Bowman's capsule
- filterate pressure .
3- basement membrane & the whole nephron :
( )
- ARF .. ARF
A - glomerular capillary pressure : ( called prerenal causes )
1- Dehydration ( Blood volume )
- dehydration :
a- loss of fliud ( as in diarrhea , vomiting , polyuria , excessive sweating )
b- intake of fluid as in fasting
dehydration
Dehydration Blood volume renal blood flow ( RBF ) glomerular capillary pressure
filteration that may leading to ARF according to severity of dehydration
-
Nephrology Prof. Dr. Abo El -Asrar
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2- loss of blood as Hge same mechanism as dehydration .
3- shock as
- hypovolemic shock or other tyoes of shock that leading to VD of peripheral bl vessels
renal arterial pressure .. RBF........................ etc
4- post surgery cardiac surgery
- .. motility intestine ..
paralytic ileus
- IV fluids .. motility
..
- oral intake ( passing Flatus .... ) not stool ..
( !!)
- .. .. auscultation motility .
- IV fluids .. dehydration
.. .. renal functions urea creatinie
.. renal impairment
- .. ..
motility
5- Nephrotic $ :
- urine .. osmotic pressure .. vessels
intrerstatium
- severe cases .. blood volume ... .......
- interstatium intravascular
- pre renal causes there is Hypotnsion
B - Bowman's capsule pressure ( called post renal causes )
- obstruction pathway urine .. :
1- Acquired :
- as stricture pf urethra or stone .
2- congenital :
- posterior urethral valve
- fold of mucosa urination urethra
- obstruction
- obstruction .. retention of urine bladder .. back pressure ureter
pelvis of kidney
then back pressure to all nephron's parts then to Bowman's capsule
filteration .. blood volume so, hypervolemia & hypertension
-
Nephrology Prof. Dr. Abo El -Asrar
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" " : ,, : " " " 2012
- .. obstruction urethra ( .. ) back pressure 2
kidneys
unilateral obstruction ( .. ureter .. ) kidney
.. renal impairment ..
- ARF unilateral obstruction .. single
functioning kidney
C Renal causes as :
1- filter closure ( )
- acute GN .. nephritic ..
odema or proliferation of cells of BM ..
..
2- nephrons destruction ( )
- as in severe anoxic tubular necrosis
- dehydration ( diarrhea ) ..
renal ischemia .. nephrons .. pre renal cause .
3- toxins as all nephrotoxic drugs as
- all anesthetic drugs
- aminglycosides
- gastroenteritis dehydrated .. aminoglycosides pre
renal cause
- carbon tetrachloride
4- infarction as an effect of embolus
5- congenital anomalies :
- agenesis ( ) or hypogenesis
- renal .. bl. Volume .. Hypertension
-: ARF .. pre , post or renal
- pre renal
- post or renal do catheterization .. ..
- bladder .. renal
- ( ) urine post renal
Clinical picture :
- acute renal failure .. macrotoxins
1- oliguria or anuria
-
Nephrology Prof. Dr. Abo El -Asrar
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" " : ,, : " " " 2012
- ..
- magor toxins :
2- urea manifestations of azotemia
3- metabolic acidosis manifestations as air hunger
- acidosis acute RF retention of organic acid .. loss of bicarb ..
filteration ( )
- chronic .
4- manifestations of hyperkalemia as :
- tachycardia due to stimulation os SA node .
- abdominal colic & diarrhea ( motility of intestine )
- generalized ms. Weakness & hypotonia
NB. NO manifestations of hyperphosphatemia or hyperuricemia
chronic
Investigations :
1- urine analysis
- 2 3 cm urine ( 24 )
a- volume oliguria ( < 400 ml / m2 / 24 hrs )
b- low fixed specific gravity ( 1010 )
- urine .. specific gravity ..
1 - ARF specific gravity
2 - end stage chronic renal failure ..
c- RBCs casts
- RBCs mucoprotein
d- Na
2- serum analysis :
- urea & creatinine - K & uric acid ( all major toxins increased )
- Na dilutional hyponatremia
- post & renal pre dehydration
- .. container 200 ml water .. ..
130 mEq / L
NB. mEq = milliequivalents
-
rarsA- lE obA .rD .forP ygolorhpeN
34 | e g a P
2102 " " " : ,, : " "
.. 2 + retaw lm 006 .. reniatnoc -
.. % 003 ( ..
) % 001
retaw & tlas .. noitaretlif .. laner & laner tsop -
lanoitulid .. tlas deniater aN .. noitneter
aimertanopyh
) .. ( GCE -3
. ygoloite gniylrednu fo noitagitsevni -4
: tnemtaerT
cinorhc .. .. .. etuca -
FR
: -
. srotcaf gnitatipicerp fo yrotsih -a
cirugilo -b
noitaripser peed dipar -c
ttt FO SENIL
: wol fi erusserP .lB erusaem -1
.. laner erp wol ... .. -
etatcal regnir .... erusserp yrallipac ralurmolg
sisodica .. etanobracib revil etatcal
.. )ycnegreme ( gK / lm 02 esod -
) emuloV .lb (
.. eniru .. noitaretlif ..
.. lotinnam .. siseruid citomso eniru -
.
.. xisal -
cinorhc .. .. .. eniru -
) sisorcen ralubut cixona snorhpen ( FR
laner tsop ro laner ,os : erusserP .lB hgiH fI -2
.. .. laner tsop .. -
. noitcurtsbo .. snoitcnuf laner
: laner fi -3
noitaretlif laner .. eniru -
-
rarsA- lE obA .rD .forP ygolorhpeN
44 | e g a P
2102 " " " : ,, : " "
K trahc duilf ( NG laccocotpertS .tsop -
) sisylaid snoitacilpmoc
.. xisal .. laner erp :
xisal : -
seuH yranirU
nettirw
eniru -
: eniru kraD - A
: -
: eniru deniater -a
tnemgip emorhcoru .. eniru deniater -
stnemgip elib -b
. .. niburilib tcerid J evitcurtsbo -
: eniru der B
eniru der -
airutameh -1
airunibolgomeh -2
eniru ni nibolgoym -3
sm .. .. -
) bH ( nibolgoym
niryhprop -4
niryhropotorp + nori bH -
aimena citylomeh cinorhc ni norI -5
.. stnega gnitalehc -
nori enimsaxorrefsed .. ..
eniru
setaru -6
) natcamir ( nicipmafir sgurD -7
steeb sa sdooF -8
.. .. -
) (
: eniru kcalb ro nworb kraD C
-
Nephrology Prof. Dr. Abo El -Asrar
P a g e | 45
" " : ,, : " " " 2012
1- melanine deposites as in melanoma
2- homogentisic acid
- tyrosine :
- Tyrosin give para hydroxy phenyl pyruvate by tyrocinase .
- then para hydroxy phenyl pyruvate give homogentisic acid by para hydroxy phenyl pyruvate oxidase .
- then homogentisic acid give succinic acid by homogentisic acid oxidase .
- then succinic acid excreted in urine .
- homogentisic acid oxidase .. homogentisic acid urine
- cartilage .. sclera ..
alkaptonuria
Hematuria
- RBCs urine > 5 RBCs / high power field of microscope ( HPF )
.. urine RBCs ..
Types
2 types
1- Microscopic ..
2- Macroscopic
Causes
A Glomerular causes :
ALL CAUSES OF NEPHRITIC $
-:
- Alport's , IgA nephropathy , SLE , anaphylactoid purpura , Post streptococcal GN , proliferative GN ,
progressive GN etc
B Non glomerular causes
- urinary tract pelvis od the kidney urethra
1- Congenital anomalies as :
a- polycystic kidney
- cyst .. hematuria
b- hemangioma in kidney pelvis leakage hematuria .
2- Infections in urinary tract :
- acute pyelonephritis or cystitis
- infections .. / UTI .
3- Tumors as wilms tumor
-
Nephrology Prof. Dr. Abo El -Asrar
P a g e | 46
" " : ,, : " " " 2012
- hematuria .. very late ( advanced)
- hypernphroma .. hematuria ( early)
wilms cortex .. medulla ( hematuria )
hypernephroma medulla
4- Drugs : as cyclophsphamide that cause Hemorrhagic cystitis .
5- Vascular cause :
as renal infarction , renal vein thrombosis , leading to congestion of the kidney
hematuria
6- trauma :
- extrenal trauma
- internal trauma as stones
: ( ) C I N D V T ( .. )
- C
- I
- N
- D
- V
- T
7- exercise induced hematuria :
- heavy exercise .. hematuria
a- erect position congestion of kidney
exercise
b- during exercise may minir trauma
DD between glomerular & non glomerular causes :
1 -
- glomerular .. .
- non ..
2 - .. relation to micturation .. ..
- glomerular .. .
- non :
* urinary bladder
* urethra
-
rarsA- lE obA .rD .forP ygolorhpeN
74 | e g a P
2102 " " " : ,, : " "
noisnetrepyh & amedo , iarugilo - 3
citirhpen .. raluremolg -
: .. non -
.. arhteru *
noifer cibuparpus .. reddalb *
niap niol .. sitirhpenoleyp *
) .. (
..... .. .. .. *
sisylana eniru - 4
2+ => nietorp , stsac raluremolg -
2+ < airunietorp , stsac on raluremolg non fi -
.. + ..
ymotsorhpen :
yendik eht fo sivlep .. .. reteru :-
) (
71 02