glomerulonephritis. acute or chronic immune dysfunction disease of kidneys with primary lesion of...

66
Glomerulonephritis

Upload: theodora-stanley

Post on 26-Dec-2015

234 views

Category:

Documents


5 download

TRANSCRIPT

Page 1: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Glomerulonephritis

Page 2: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive course with the consequent development of nefroscrerosis and chronic kidney disease.

Page 3: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

The main ethiological factor of Glomerulonephritis is streptococcus infection (tonsillitis pharyngitis, etc), particularly ß- haemolytic streptococcus of group A.

Page 4: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Apart from that, disease might develop after vaccination of introduction of serums, because of drugs, chemical substances intolerance, at hypersensitivity to insects poison, pollen, alcohol intoxication. Genetic predisposition plays a big role in Glomerulonephritis development.

Page 5: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

PathogenesisNowadays an infection-allergic theory of gromerulonehprites is

recognized, according to it occurrence and development of

this disease the major roles belong to immune processes..

Page 6: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Immuno-complex variant of development is more frequent. In this variant, in response of antigens of streptococcus getting in the organism antibodies are created and immune complex is formed. Immune complexes circulate in the blood vessels, and then accumulate in basic membrane of glomerulus capillaries or in mesangium.

Page 7: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

The second variant is less frequent and is called autoimmune. In this variant immune complexes are created immediately on the basic membrane of the walls of glomerulus capillaries. This mechanism is more frequent at glomerulonephritis with systematic diseases and also at fast

glomerulonephritis.

Page 8: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

After creation of these immune complexes or auto antibodies basic membrane of kidneys a compliment is activated, which at glomerulonephritis is humoral immunity mediator of inflammation. This results in basic membrane of glomerulus capillaries inflammation and attraction into this zone of neutrophils and monocytes.

Page 9: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Neutrophils phagocyte immune complexes and at this a lot of lysosomal proteolytic ferments are secreted, which affect the basic membrane and other components of glomerula. Neutrophiles produce the factor of trombocytes activation.

Page 10: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Activation of thromocytes helps the development of inflammation in kidneys. Permeability of glomerulus capillaries increases, it results in growth of thrombocytes aggregation and microthrombus formation.

Page 11: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Monocytes and macrophage produce biologically active substances, which result in proteinuria. Thus, activation of the compliment system, on the one hand, directly affects basic membrane of glomerulus, and on the other hand, helps include cellular factors of glomerulonephritis pathogenesis.

Page 12: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

In chronic GN formation the major role is given to genetic incompetence of T-cell immune chain, which results in insufficient lymphoid elements flow to a kidney.

Page 13: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Inflammatory process is lengthy, wavelike (acute and remission periods), which results in sclerosis, hyalinosis, glomerules desolation and CRF development.

Page 14: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

ClassificationClinical morphological

characteristics of Chronic GN.

Page 15: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Glomerulonephritis with minor alterations (lipoid nephrosis).Typical nephrotic syndrome which develops very quickly. 35 % of patients have elevation of blood pressure. In urine – proteinuria and hematuria is rare.

Page 16: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Membrane glomerulonephritis with main lesion of basic membrane of glomerulus. The initial stage of the disease is gradual, slow with development of nephrotic syndrome. Arterial blood pressure elevation is rare. Chronic kidney disease develops late. The level of protein in urine is more that 3,5 grams a day.

Page 17: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Mesangium glomerulonephritis. Mesangiums and endothelium of membrane of glomerulus capillaries are affected. Clinical picture of the disease is not representative. Nephrotic syndrome is rarely developed. General condition of patients is satisfactory. In urine – proteinuria mot more than 1 g/l,

microgematuria, cylinder-uria.

Page 18: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Mesangium capillaries. It is characterised by evident proliferation of mesangium cells and thickening of capillaries walls. It is more frequently developed with young women. Clinically: edema of face, extremities, , ache in the kidneys zone, general weakness. There is combination of nephrotic syndrome and high arterial pressure. In urine – incoming

macrohematuria.

Page 19: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Berger disease – an option of proliferative mesangium glomerulonephritis. Signs: recurrent macrohematuria. In clinic – dull pain in lumbar zone, arterial pressure elevation. On late stages the nephrotic syndrome and post

hemoragic anemia are developed.

Page 20: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Focal segmentary glomerula sclerosis and hyalinosis. Is rare, more often with men, in the base of pathogenesis there is disfunction of T-lymphocytes, hyalinosis and sclerosis of kidneys glomerulas. Clinical – evident nephritic syndrome and severe arterial hypertension. In urine – proteinuria and

microhematuria.

Page 21: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Sclerosing (fibro-plastic). This heterogeneous group, including all above-mentioned morphological forms at the final stage of the disease.

Page 22: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Acute GN ClinicsClinical manifestations. Is developed at young people after 2-3 weeks after sustained infection and is characterised by 4 main clinical syndromes:

Page 23: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

acute inflammation of glomerulus: pain lumbar zone on both sides, which does not depend on the intensiveness of physical activities and body position. Elevation of body temperature, olygouria, urine has the colour of “raw meat water”.

Page 24: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

edema syndrome: “pale edemas”, on the face and eye-lids, more frequent in the early morning hours. In severe cases – anasarca, hydrothorax, hydropericarditis, ascites. Some patients do not have evident edemas, but daily increase of body weight is observed, which is connected with retention of liquid in

body.

Page 25: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

edema syndrome Some patients have edemas due to reduction of glomerulus filtration, strengthening of renal tubule re-absorption of water and sodium, development of hypoalbuminemia and reduction of oncotic blood pressure, strengthening of aldesteron secretion.

Page 26: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Cardiovascular syndrome is manifested with shortness of breath, which reflect the severity of cardiovascular insufficiency or can be the consequence of nephrogenous lung edema. There is a possibility of development of acute left ventricular insufficiency with side effects of cardiac asthma, lung edema. Arterial hypertension is developed, resulting in increase of circulation blood, activation of rennin-aldesteron system. Lasting elevated hypertension – unfavourable predicted sign.

Page 27: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

cerebral syndrome – is conditioned by cerebrum edema. Its main manifestations – headaches, nausea, vomiting, reduction of visual acuity, insomnia, high irritability. In severe cases there can be developed angiopahtic encephalopathy. Patients have convulsions of extremities, respiratory muscles and diaphragm, can be loss of consciousness, face and neck cyanosis, jugular venous distention, loud breathing, slow pulse, high AP, muscles

rigidity.

Page 28: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Presence and intensity degree of the above syndromes

depends on clinical form of Acute GN

Page 29: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

1.Acute cyclic form. Is characterized by a stormy beginning, expressed renal and nonrenal symptoms. It finishes with recovery.

Page 30: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

2.Lingering (acyclic) form. Is characterized by gradual beginning with slowly growing edemas, minor arterial hypotension and other symptoms. It lasts from 6 to 12 months.

Page 31: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

3)Unfolded (triad) or classical form. Is characterized by edemas, hypotension, urine syndrome.4)Bi-syndrome form. Is characterized by the urine syndrome along with the arterial pressure elevation.

Page 32: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Clinical diagnosis of chronic GN totally depends on morphological option of the disease. Renal biopsy is thus carried out, it is only possible in specialized wards.

Page 33: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

It is common experience to distinguish 5 clinical forms of chronic glomerulonephritis. 1.Latent – its course is characterised by isolated urine syndrome and is the most frequent. It is diagnosed, as a rule, accidentally, and very often at the stage of chronic renal disease. Urine modifications are minor-

proteinuria , minor cylindruria.

Page 34: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

2.Nephrotic form. In the basics of diagnosis there lay evident edemas: morning and upper body. In more severe cases – it is possible that hydrothorax, hydropericarditis, ascites and anasarca development. Arterial pressure is usually normal. In urine – massive proteinuria, cylindruria and microhematuria. In blood tests – anaemia, increase of erythrocyte

sedimentation rate, ESR.

Page 35: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

3.Hypertensive form – elevation of arterial blood pressure and its consequences. Patients complain about intensive headaches, dizziness, visual acuity reduction, ear noise, flashing in the eyes, pains in the heart zone, shortness of breath and dyspnea. At examination – heart borders are displaced to the left, auscultation, systolic noise at apex of heart, accent of the 2nd tone on aorta. In urinalasis: proteinuria, microhematuria, reduction of urine density, at fundus of eye – phenomenon of “chiasm”, hemorrhage, etc. and in blood – signs of reduction of glomerulus filtration.

Page 36: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

4. Form hemorrhagica – more often with young males (Berger Disease). In clinical picture urine syndrome dominates: macrohematuria, microhematuria, but frequent and lasting – proteinuria is not big, normal arterial pressure, minor edema or its absence.

Page 37: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

5.Mixed – makes 10% of patients. Combines signs of nephrotic and hypertensive form. Its course is progressive.

Page 38: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Laboratory data

Page 39: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

- In general blood test – leukocytosis, increase of erythrocyte sedimentation rate, anaemia.

Page 40: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

- In urinalysis – proteiuria, microhematuria, cylindruria (hyaline and granular), decrease of specific weight of urine, nicturia. (urine test by Zemnitsky – density and amount of urine; urine test by Necheporenko – amount of erotrocytes, leucocytes and cylinders in 1 ml of urine)

Page 41: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

- Biochemical blood test - proteinogram: elevation of α2 and γ – globulins; coagulagramm – shortening of thromboplastic time, increase of prothrombine index, suppression of fibrinolytic activity of blood; increase of creatinine and urea

Page 42: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

- immunological blood test: content of immunoglobulin, compliment activity, B and T lymphocytes

Page 43: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

- Reberg-Gareev test – determination of glomerular filtration and renal tubule re-absorption

Page 44: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

- kidney biopsy - fundus of eye analysis - ECG at elevation of arterial blood pressure – diffuse modifications of myocardium (decrease of wave-T amplitude in several leads) - US, ultrasonic scanning of kidneys

Page 45: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Differentiated diagnosis

Page 46: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

The main task of the differential diagnosis at making diagnosis CGN is the exception of other renal diseases which are revealed by AH, proteinuria, hematuria and also systemic connective tissue diseases, especially those which initiate with kidneys lesion.

Page 47: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

At AH prevalence it is necessary it necessary first of all to exclude the hypertensive disease, hypertensive form of chronic pyelonephritis.

Page 48: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

In patients with HD the urine syndrome is preceded by a lengthy period of AP elevation without any changes in urine.

Page 49: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

At chronic pyelonephritis (CPN) in urinary sediment there are mostly leucocytes, bacteriuria is revealed, deformation of renal calicial-pelvic system is revealed, early anemia combined with fever and shivering.

Page 50: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

At predominance in the clinic of the nephrotic syndrome it is essential to make differentiated diagnostics with renal amyloidosis, diabetic nephropathy and myelomatosis.

Page 51: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

myelomatosis. This disease is different from CGN with osteoarticular pains, hepatosplenomegaly, spontaneous breaks, particular bone defect (flat bones), which are revealed by X-ray. Electrophoresis of proteins in urine, detection of protein Bens-Jones in urine favour making diagnosis.

Page 52: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Nephrotic syndrome can be revealed by diabetic glomeruloscrerosis.

Page 53: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

At hematuric form of CGN differential diagnosis with urologic pathology is conducted: urolithiasis, renal tuberculosis, kidney tumors, nephroptosis and others.

Page 54: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

An essential stage of differential diagnosis is exclusion of the link between GN with connective tissue diseases: SLE, periarteritis nodosa and hemorrhagic vasculitis.

Page 55: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Data about anamnesis, results of objective studies will allow to specify clinical variant of a disease. On the basis on the study results of glomerular filtration, kidneys concentration function, detection of urine and creatinin in blood, CRF is diagnosed.

Page 56: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

ComplicationsAcute renal insufficiency, acute cardiac insufficiency. Chronic renal insufficiency.

Page 57: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

The most dangerous complication of the Acute GN, arising in the severe cases, are: encephalopathy (eclampsy), Acute Cardiac Failure and acute Renal failure.

Page 58: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Chronic renal failure (CRF)It is a symptomonocomplex, specified by a permanent renal function disorder as a result of irreversible decrease of functioning nephrons mass.

Page 59: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Major homeostasis disorders at CRFRetention of nitrogen compounds in the organism.Renal function loss at CRF.Early polyuric stagesAt CRF kidneys are unable to regulate acid-base balanceErythropoietin generation aggregation and toxic actionlose their ability to retain potassium.

Page 60: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

Stages of CRFLaboratory dynamics:1st stage - - latent, minimal clinical manifestations.

hypersthenuria – decreased urine density

Kreatenin – not more than 0.35 millimole/l

(N 0,07-0,13)

Page 61: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

2nd stage – azotemic, kreatenin 0,35-0,65Polyuria (increased diuresis)Nicturia (mostly night

diuresis)Hyperazotemia HypocalcinemiaHypoisosthenuria

(decreased urine density) Clinically: patients have expressive weakness, edema, hemorrhagic rash, skin itch, elevation of bloodpressure.

Page 62: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

3rd stage - uremic, kreatenin increased to 0,65

Anaemia, nicturia, oligouria or anuria.Clinically patients have insomnia, headaches, myocarditis and pleurisy, urinary syndrome(nicturia, oligouria or anuria).

Page 63: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

TreatmentDiet - table No 7. Restrictions on salt, liquids. Exclusion of spices and spicy food, restriction on food containing proteins and animal fats.1.Antibiotics. At chronical infection focus it is recommended to take antibiotics which do not have toxic effect on kidneys.2.Hluco-corticosteroids - have anti-inflammatory and immunosuppressive action.

Page 64: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

3. Сytostatics - also have anti-inflammatory and immunosuppressive action and depress proliferation processes.4. Anticoagulants and antiaggregants. Anticoagulants suppress autoimmune inflammation due to its anticomplimentary action. Reduces penetrability of glomerular capillaries, which reduces proteinuria. Prevents creation of thrombi and improves microcirculation.Antiaggregants - they suppress aggregation of thrombocytes, intravascular hemocoagulation.

Page 65: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

5.Nonsteroid anti-inflammatory means - suppress action of inflammation mediator, inhibits synthesis of anti-inflammatory prostaglandin, restricts migration of leucocytes in the focus of inflammation.

Page 66: Glomerulonephritis. Acute or chronic immune dysfunction disease of kidneys with primary lesion of glomerulus. Chronic glomerulonephritis has progressive

6. Aminoquinoline has anti-inflammatory action, restricts migration of thrombocytes, has a minor immunodepressive action.7. Symptomatic treatment - it is the treatment of arterial hypertension, obesity syndrome, heart insufficiency, chronic renal insufficiency