glomerulonephritis an overview for the generalist - rcp london
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GlomerulonephritisAn overview for the generalist
Dr Emma Vaux @VauxEmma
October 2019
What to do when blood & protein in urine?
What investigations should I do?
When do you refer ?
When do you
worry?
Chapter: Mechanisms of glomerular injuryoverviewAuthor(s): Neil TurnerFrom: Oxford Textbook of Clinical Nephrology
What treatments are you using?
Chapter: Mechanisms of glomerular injuryoverviewAuthor(s): Neil TurnerFrom: Oxford Textbook of Clinical NephrologyDownloaded from Oxford Medicine Online. © Oxford University Press
Case 1
• 50 year old
• Presents to ED
• 2 days D&V
• Clinically dehydrated
• BP 102/56
• Cr 154 mmol/l
• Urine dip 1+ blood
• Treated IV fluids
US KUB normal
Cr 66 mmol/l by day 2
What would you do next?
Q POLL OPEN
1 Discharge, no further follow up12.6%
2 Discharge, follow up with urologist3.15%
3 ‘Acute kidney screen’ & discharge18.9%
4 Discharge, GP follow up, repeat urine dip59.06%
5 Refer to nephrology6.3%
What would you do next?
A Discharge, no further follow up
B Discharge, follow up with urologist
C Acute kidney screen & discharge
D Discharge, GP follow up, repeat urine dip
E Refer to nephrology
Isolated non-visible haematuria
• ‘Trace' considered negative• 2 out of 3 dipsticks should be positive ≥ 1+ blood• Urine microscopy is rarely indicated • Proteinuria must be assessed
UrologyAge >45
NephrologyAge <45y
What do you do for isolated non-visible haematuria?
• Urology investigations appropriate for age
• Annual follow up with GP
– eGFR
– Urine ACR
– BP
Thin Basement membrane disease
When to refer with microscopic haematuria?
• Urine ACR > 30
• HT & age < 40yr
• FHx
• Progression CKD
Units eGFR = mL/min/1.73m2 ACR (albumin:creatinine ratio) = mg/mmol
Significant progression of CKD decline in eGFR of >5 within 1 year decline in eGFR >10 within five years
Urgent referral sustained decrease eGFR>25% within 12 monthsdecrease eGFR >15 within 12 months
IgA Nephropathy
• Commonest type of GN
• Frank haematuria following URTI,
isolated haematuria, proteinuria,
nephrotic syndrome, AKI, CKD
• Raised serum IgA ~50%
• Complement levels normal
• 20-40% eventually develop ESRD
• Can be secondary to liver disease
Normal
glomeruli
Mesangio
proliferative
GN
CrescenticGN
Global sclerosis
Treatment of IgAN
All patients Supportive treatment (ACEI/ARB
Mild disease Normal eGFR, proteinuria < 0.5g
Watch and wait
Moderate to severe disease urine protein>1g, eGFR >30 (KDIGO >50)
Corticosteroids for 6 months
Point of no returneGFR <30, severe chronic damage
Prepare for dialysis & transplantation
Crescentic IgA High dose steroid + cyclophosphamide
Alport Syndrome
When we would refer for genetic testing
• Family history
• Deafness
• Potential live kidney donor
Case 2
• Urgent referral by GP to AMU
• 34 yr female
• BP 176/92
• 2 days sore throat
• Urine dip 3+ blood 2+ protein
What is the most likely diagnosis?
Q POLL OPEN
1 Post streptococcal glomerulonephritis54.62%
2 Henoch Schönlein purpura25.21%
3 IgA nephropathy16.81%
4 Mesangiocapillary GN1.68%
5 SLE1.68%
What investigation would you do first?
Q POLL OPEN
1 ASOT titre24.8%
2 ANCA titre3.2%
3 Anti-GBM titre6.4%
4 ANA titre0.8%
5 Creatinine64.8%
What is the most likely diagnosis?
A Post streptococcal glomerulonephritis
B Henoch Schönlein purpura
C IgA nephropathy
D Mesangiocapillary GN
E SLE
What investigation would you do first?
A ASOT titre
B ANCA titre
C Anti-GBM titre
D ANA titre
E Creatinine
Henoch Schönlein Purpura
• IgA systemic vasculitis
• Purpuric rash, arthritis or arthralgia, & abdominal pain
• Most commonly seen in those <20 yr
• 10-30% ESRD at 15 yr
Differential diagnosis- hypersensitivity vasculitis- cryoglobulinemia,- SLE
TreatmentSupportiveSteroids – arthritis/abdo painKidney biopsy – active disease
Treatment of IgAN
All patients Supportive treatment (ACEI/ARB
Mild disease Normal eGFR, proteinuria < 0.5g
Watch and wait
Moderate to severe disease urine protein>1g, eGFR >30 (KDIGO >50)
Corticosteroids for 6 months
Point of no returneGFR <30, severe chronic damage
Prepare for dialysis & transplantation
Crescentic IgA High dose steroid + cyclophosphamide
Poststreptococcal GN
• Children & >60 yr
• Group A or C streptococci
• Acute nephritic syndrome
• Skin infection (several weeks) > throat infection (2 weeks)
• Raised ASOT, low C3
• Supportive treatment
• Unusual to need dialysis
Mesangioproliferative GN
• Young adults• ICX + complement mediated• Hypocomplementaemia, C3NF• HT
• Approximately 40% of patients progress to ESRD within 10 years of diagnosis
• Immune complex–mediated– Infections– Autoimmune diseases eg SLE– Monoclonal gammopathy (MGRS)
• Complement-mediated– Dense Deposit Disease– C3GN
• MPGN without immunoglobulin or complement deposition
– TTP/HUS– Antiphospholipid syndrome– Allograft nephropathy– Radiation nephritis– Malignant hypertension/sclerodema
Investigations blood & protein
• ANA, ANCA, anti-GBM, Rheumatoid Factor• Complement (low C3- post-infectious GN, MCGN,
SLE)• Immunoglobulins• CRP• ASOT• Infection…think IE, hepatitis C (& HIV)• (Cryoglobulins (HepC))
• Kidney biopsy
Case 3
• 68yr man• Respiratory clinic with obstructive sleep apnoea• c/o Swollen ankles
• No other PMHx; No other medication• Cr 96 mmol/l• BP 119/64• Urine dip 3+ protein• Urine ACR 340 mg/mol
What test would you do next?
Q POLL OPEN
1 US KUB16.67%
2 Kidney biopsy9.65%
3 Serum albumin60.53%
4 Echocardiogram5.26%
5 CXR7.89%
What test would you do next?
A US KUB
B Kidney biopsy
C Serum albumin
D Echocardiogram
E CXR
What would you not do next?
Q POLL OPEN
1 Start steroids64.42%
2 Refer nephrology0.96%
3 US KUB3.85%
4 Start diuretic therapy26.92%
5 Start VTE prophylaxis3.85%
What would you not do next?
• Start steroids
• Refer nephrology
• US KUB
• Start diuretic therapy
• Start VTE prophylaxis
What is the most likely diagnosis?
Q POLL OPEN
1 Minimal change GN20%
2 Diabetic nephropathy12.31%
3 Focal segmental glomerulosclerosis21.54%
4 Membranous GN43.08%
5 Hypertensive GN3.08%
What is the most likely diagnosis?
• Minimal change GN
• Diabetic nephropathy
• Focal segmental glomerulosclerosis
• Membranous GN
• Hypertensive GN
Membranous Nephropathy
Male; >40yr Young women ?SLE
Primary (associated with positive PLA2R)
Secondary (Hepatitis, SLE, drugs, tumours)
Patients with MN should have age-appropriate cancer screening
10-30% will develop ESRD within 10 years
Kidney International 2019 95, 268-280DOI: (10.1016/j.kint.2018.10.018)
Figure 3
Kidney International 2019 95, 268-280DOI: (10.1016/j.kint.2018.10.018)
Minimal Change Disease
• Commonest cause of NS in
children
• Primary vs Secondary
(Lymphoma, NSAID, Allergy)
• Response to corticosteroids
• Relapse 50-75%
Focal segmental glomerulosclerosis
• Histologic lesion• Primary – diagnosis of exclusion• Secondary – obesity, drugs,
infection• Familial• Variants eg collapsing –HIVAN
• High dose steroids• Renal survival
– Responders vs non-responders/untreated 80% vs <50% at 10 years
Risk of VTE: Increase with albumin < 28
Kidney International (2012) 81, 190
Case 4
52 yr man
Type I DM (aged 13yr), previous MI, heavy smoker
Increasingly SOBOE & ankle swelling
Diagnosed by GP with heart failure
Cr risen from 86mmol/l to 196 on diuretics
GP & community heart failure team worried about his management
What set of investigations would you do next?
Q POLL OPEN
1 U+Es, CXR, ECG, ECHO1.3%
2 U+Es, CXR, albumin, ECHO3.9%
3 U+Es, CXR, Urine ACR11.69%
4 U+Es, albumin, urine ACR, ECHO63.64%
5 U+Es, albumin, US KUB, ECHO19.48%
What set of investigations would you do next?
A U+Es, CXR, ECG, ECHO
B U+Es, CXR, albumin, ECHO
C U+Es, CXR, Urine ACR
D U+Es, albumin, urine ACR, ECHO
E U+Es, albumin, US KUB, ECHO
Case 4
52 yr man
Type I DM (aged 13yr), previous MI, heavy smoker
Increasingly SOBOE & ankle swelling
Diagnosed by GP with heart failure
Cr risen from 86mmol/l to 196 on diuretics
GP & community heart failure team worried about his management
Urine dip 3+ protein; ACR 290; albumin 29
Bp 189/92
What is the most likely cause of the nephrotic syndrome?
Q POLL OPEN
1 Heart failure1.06%
2 Diabetic nephropathy58.51%
3 Hypertensive nephropathy26.6%
4 Membranous Glomerulonephritis13.83%
What is the most likely cause of the nephrotic syndrome?
A Heart failure
B Diabetic nephropathy
C Hypertensive nephropathy
D Membranous Glomerulonephritis
50 yr man admitted the previous day with 2 day history severe arthralgias, fever, weight loss, epistaxis, and large painful purpuric lesions on his legs
• Creatinine 275 mmol/l not improving with intravenous fluid
• FBC: Hb 115; Plt 165• Urine dip 2+ blood 1+ protein• You learn that he has a history of cocaine abuse• Some of the acute screen is back – low C3 + C4
Case 5
Which ONE of the following is MOST likely to be found on renal biopsy?
POLL OPEN
1. Crescentic IgAN8.11%
2. Collapsing FSGS8.11%
3. Pauci-immune necrotising & crescentic GN37.84%
4. Thrombotic microangiopathy45.95%
A. Crescentic IgANB. Collapsing FSGSC. Pauci-immune necrotising & crescentic GND. Thrombotic microangiopathy
Which ONE of the following is MOST likely to be found on renal biopsy?
Chapter: Mechanisms of glomerular injuryoverviewAuthor(s): Neil TurnerFrom: Oxford Textbook of Clinical NephrologyDownloaded from Oxford Medicine Online. © Oxford University Press
It’s all about the protein….
Microscopic haematuria – age, urology, ACR >30, HT, FHx
Proteinuria - ACR >70; nephrotic
AKI +/- Progressive kidney disease
BP
Dear Dr
Please see this 33 year old lady whom I think might have nephrotic syndrome.
She has normal kidney function but her serum albumin is only 30.
Her liver function is normal.
Best wishes
Who to refer?Microscopic haematuria >40yr to urology
Significant proteinuria - ACR >30 with haematuria- ACR >70 (unless DM)- NephroticSignificant progression CKDPoor BP controlNon-resolving AKISystemic symptoms
TreatmentsStop thingsSupportive
Steroids
Calcineurin inhibitorsCyclophosphamideRituximabPlasma exchange
Renal replacement therapy