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Glomerular Diseases

Glomerular Diseases. Dr. Atapour. Differential diagnosis and evaluation of glomerular disease. CLINICAL PATTERNS OF GLOMERULAR DISEASE . Nephrotic Nephritic. Nephrotic pattern . The nephrotic proteinuria that is usually above 3.5 g/day Lipiduria Edema Hyperlipidemia

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Glomerular Diseases

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  1. GlomerularDiseases Dr. Atapour

  2. Differential diagnosis and evaluation of glomerular disease

  3. CLINICAL PATTERNS OF GLOMERULAR DISEASE  • Nephrotic • Nephritic

  4. Nephrotic pattern  • The nephroticproteinuria that is usually above 3.5 g/day • Lipiduria • Edema • Hyperlipidemia • Some patients also have microscopic hematuria • Red cell casts

  5. Asymptomatic proteinuria • Full-blown nephrotic syndrome

  6. The bland sediment • Absence of immune complex deposition in most of these disorders: • Minimal change disease • Focal segmental glomerulosclerosis • Diabetic nephropathy • Amyloidosis.

  7. Lack of inflammation • The serum creatinine concentration

  8. Acute kidney injury in the nephrotic syndrome • Concurrent acute tubular necrosis • Usually in minimal change disease

  9. Nephritic pattern • Presence of red cells • White blood cells • Red cell • Dysmorphic appearance • Acanthocytes • Mixed cellular casts • Variable degrees of proteinuria

  10. dysmorphic RBCs muddy brown casts tubular cell casts oval fat body

  11. RBC cast Hyaline cast

  12. Pathologic classification  • Light microscopy  • Focal • Diffuse • This terminology is most often used in lupus nephritis • ANCA-positive vasculitis.

  13. Limitations of this classification  • Same pathology and multiple causes • Nonspecific nature of the histologic patterns

  14. MPGN Can be a systemic immune complex disease • To infective endocarditis • Systemic lupus erythematosus • Hepatitis C virus complement

  15. Membranous nephropathy • Systemic lupus erythematosus • Chronic hepatitis B virus infection • Underlying malignancy • Drugs

  16. Focal segmental glomerulosclerosis • Primary condition • Secondary change induced by intraglomerular hypertension or healing of previous glomerular injury.

  17. Nephrotic syndrome without a nephritic sediment • Mild hematuria • No red cell casts

  18. Depend on age What do you think?

  19. Less than 15 years : • Minimal change disease • Focal segmental glomerulosclerosis • Mesangial proliferative glomerulonephritis

  20. 15 to 40 years : • Minimal change disease • Membranous nephropathy • Focal segmental glomerulosclerosis • Diabetic nephropathy • Preeclampsia • Postinfectiousglomerulonephritis

  21. Greater than 40 years: • Focal segmental glomerulosclerosis • Membranous nephropathy • Diabetic nephropathy • Minimal change disease • IgA nephropathy • Primary amyloidosis • Benign nephrosclerosis • Postinfectiousglomerulonephritis

  22. Mild glomerulonephritis • Mild glomerulonephritis is defined as a nephritic sediment and: • Normal or near normal estimated GFR • Do not have the nephrotic syndrome

  23. Less than 15 years • Mild postinfectiousglomerulonephritis • IgA nephropathy • Thin basement membrane disease • Hereditary nephritis • Henoch-Schönleinpurpura • Mesangial proliferative glomerulonephritis

  24. 15 to 40 years • IgA nephropathy • Thin basement membrane disease • Lupus nephritis, hereditary nephritis • Mesangial proliferative glomerulonephritis

  25. Greater than 40 years • IgA nephropathy

  26. Moderate to severe glomerulonephritis • Moderate to severe glomerulonephritis is defined as a nephritic sediment • Reduced estimated GFR • Nephrotic syndrome ±

  27. Less than 15 years • Postinfectiousglomerulonephritis • Membranoproliferativeglomerulonephritis

  28. 15 to 40 years • Postinfectiousglomerulonephritis • lupus nephritis • RPGN (crescenticglomerulonephritis) • IgA nephropathy • Fibrillaryglomerulonephritis • Membranoproliferativeglomerulonephritis

  29. Greater than 40 years : • Rapidly progressive glomerulonephritis • Vasculitis • IgA nephropathy • Fibrillaryglomerulonephritis • Postinfectiousglomerulonephritis

  30. Effect of race

  31. In black patients : • Focal segmental glomerulosclerosis (57 percent) • Membranous nephropathy (24 percent) • Minimal change disease (14 percent) • Membranoproliferativeglomerulonephritis, IgA nephropathy, and immunotactoid nephropathy were each present in 1 to 2 percent.

  32. In white patients: • Membranous nephropathy (36 percent), • Focal segmental glomerulosclerosis (23 percent) • Minimal change disease (20 percent) • IgA nephropathy (8 percent) • Membranoproliferativeglomerulonephritis (6%) • Immunotactoidglomerulopathy (6 percent).

  33. Positive family history  • Thin basement membrane nephropathy • Hereditary nephritis (Alport syndrome) • Focal segmental glomerulosclerosis are examples:

  34. LABORATORY TESTING IN PATIENTS WITH SUSPECTED GLOMERULAR DISEASE • serum creatinine • serum albumin • complete blood count • Estimation of protein excretion in patients with proteinuria • serologic testing for disorders that cause glomerular disease • measurement of serum complement levels

  35. membranous nephropathy • The value of hepatitis B virus • Hepatitis C virus (HCV) infection • Congenital and secondary syphilis • HIV infection (FSGS)

  36. Chronic bacterial • Endocarditis • Shunt nephritis • Abscesses • Fungal • Parasitic infections can cause

  37. SUMMARY AND RECOMMENDATIONS • There are many causes of glomerular disease, • the characteristics of the urine sediment, • The degree of proteinuria • Patient’s age often

  38. Two different urinary patterns are seen: • Nephrotic • Nephritic.

  39. The nephrotic pattern = proteinuria > 3.5 g/day • Lipiduria

  40. The nephritic • Red cells • White blood cells • Red cell or mixed cellular casts • Acanthocytes • Some patients have the concurrent presence of two glomerular diseases,

  41. Approaching a patient • Urinalysis • Estimated glomerular filtration rate • Patient age help to identify • Race • Family history • Renal biopsy

  42. Standard laboratory testing • Serum creatinine • Serum albumin • Protein excretion in patients with proteinuria • Serologic testing for disorders that cause glomerular disease

  43. Serologic tests • Lupus • Amyloidosis • Hepatitis B (HBV) • Hepatitis C (HCV) • HIV infection • ANA • Anti-dsDNA • C3 • C4

  44. Primary amyloidosis and light chain deposition disease • Serum and urine immunofixation • Serum free light chain ratio analysis

  45. Glomerulonephritis Nephritic urine RBCs, RBC casts Low – mod proteinuria Nephrotic urine No casts, few RBCs Heavy proteinuria • Diabetes • Amyloid • Membranous Nephropathy • FSGS • Minimal Change Disease • Sometimes MPGN C3, C4 Low Normal • Postinfectious • Lupus nephritis • MPGN (often Hep C) ANCA (+) ANCA (-) • Vasculitis • Wegener’s • MPA • Churg-Strauss • IgA nepropathy • Anti-GBM/Goodpasture’s progress fast progress slow

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