INTRODUCTION TONEPHROLOGY

Jeffrey J. Kaufhold, MD

RID YOURSELF OF BOTHERSOME BRAIN TISSUETHE KAUFHOLD WAY !

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

NEPHROLOGY

SUMMARY DEFINITIONS

STRUCTURE FUNCTION CORRELATION

SPECTRUM OF GLOMERULAR DISEASE

SIMPLE, EASY, COVERS 85% OF CASES

WE GET PAID FOR THE OTHER 15%

Hematuria

• T

• I

• G

• H

• T

• S

Hematuria

• TUMOR

• I NFECTION

• G LOMERULONEPHRITIS

• H EMATOLOGIC

• T RAUMA

• S TONE

HEMATURIA

• Glomerular Causes:• IgA (Berger’s)• Mesangioproliferative GN• Hereditary GN’s, including • Alport’s, Thin Basement

Membrane

• Hallmark of Glomerular Disease is RBC cast

Mesangio-proliferative: mild mesangial hypercellularity

Hereditary Nephritis

Alports Nail -Patella Thin Basement Mem.

NEPHROLOGY

DEFINITIONS 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

PROTEINURIA• LESS THAN 300 mg - normal

• 300 to 1200 think orthostatic or • interstitial• 1200-3000 mg talk to the patient

• OVER 3 Gm Consider Biopsy

PROTEINURIA

• Glomerular Causes:– Minimal Change Disease - 25 %– Focal Segmental Glomerulo Sclerosis

• FSGS - 30 %– Membranous - 30 %

PROTEINURIA Relative Frequency by Age.

0%10%20%30%40%50%60%70%80%90%

100%

Under12

12 to 20 20 to 60 over 60

OtherMemFSGSMCD

Membranous GN

• Silver stain showing thickened basement membrane and “spiking” caused by subepithelial deposits in the membrane.

Minimal Change Disease

Normal appearing Glomerulus. Normal appearing interstitium.

Minimal Change EM

• Foot processes are completely effaced (no longer discreet).

Focal Segmental Glomerular Sclerosis (FSGS)

• Segments of glom are preserved and segments are sclerosed (darker pink).

NEPHROLOGY

DEFINITIONS

PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours:

<0.2 = normal

>3.0 nephrotic

NEPHROLOGY

IDIOPATHIC GN'S• NEPHRITIC• HEREDITARY

• IgA (BERGER'S)

• MESANGIO-• PROLIF.

• ITIC/OTIC• MEMBRANO-• PROLIF.

• PSGN

NEPHROTICNIL

FSGS

MEMBRANOUS

Post Infectious GN

• Proliferative with lots of PMN’s visible.

PSGN Electron MicroscopySubepithelial Humps

Membrano-proliferative GN

Lupus nephritis Class IV

NEPHROLOGY

SYSTEMIC DZ• NEPHRITIC• LUPUS CLASS• II AND III

• CRYOGLOBULINS

• ITIC/OTIC• PSGN

• LUPUS IV• (DPGN)

NEPHROTICDMAMYLOIDMYELOMALUPUS V

NEPHROLOGY

RPGN• CLASS I• ANTI-GBM

• CLASS 2• CIRCULATING• IMMUNE• COMPLEXES

R/O INTERSTITIAL DISEASE

CLASS 3PAUCI- IMMUNE (VASCULITIS)

CLASS 4

VASCULOPATHY

Rapidly Progressive GN

• Clinical Syndrome• ARF• HTN• RBC Casts

• Mimicked by TIN

• TIN Tubulointerstitial Nephritis

• or• Crescents with

characteristic change on Immunoflurescence

RPGN light Microscopy

• Interstitial Nephritis • Crescent

RPGN Class I

• Linear Immunofluresence

• Due to Anti-GBM Antibody

• Goodpasture’s • Syndrome

RPGN Class II

• Granular IF• Immune Complex• Deposition• Due to SLE, MPGN,

HSP, PSGN, Others

RPGN III: Vasculitis

• Crescent with Focal Necrotizing GN

• Pauci-immune.• ANCA Positive.• Seen in Wegener’s

Granulomatosis, Churg-Strauss, PolyArteritis Nodosa (PAN).

Necrotizing area

RPGN IV: Vasculopathy

• Hyaline thrombi• Endothelial cell

swelling and vacuolization

• Seen in TTP/HUS, Preeclampsia,

• Malignant HTN

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.

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

New Terminology Chronic Kidney Disease

CKD• Stage 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.

NEPHROLOGY

DEFINITIONS DEHYDRATION - STATE OF

FREE WATER LOSS

VOLUME DEPLETION - STATE OF SALT AND WATER LOSS

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.

TRANSPLANT

DEFINITIONS ALLOGRAFT

REJECTION

IMMUNOSUPPRESSION

CORRELATIONS

• STRUCTURE

• Endothelium

• GBM

• Epithelium

• Mesangium

• FUNCTION• make vessel

• seive

• charge select.

• makes GBM

PATHkawasaki's

Alport's

proteinuriaMinimal Change

Berger's

Glomerular Physiology

• Afferent. Art• AT II constrict

• ACE-i dilate

• PG's NET dilate

• TGF NET constrict

• NSAID's constrict

• Aminophylline dilate

• Diltiazem dilate

• Filt Press• maintained

• reduced

• increase

• parallels

• reduce

• increase

• reduced

Efferent Art.constrict

dilate

no effect

no effect

no effect

no effect

dilate

Glomerular Physiology

Blood flow determinants

Afferent Efferent

Filtration

Systemic

PG'sTGF

Local

Renal Physiology

OverviewDistal Tubule

Loop of Henle

Collecting duct

ADH +

ADH -

permeable to H2O

impermeable

solute exchange

reabsorption

filtration

impermeable toH2Osolute

imperm. to

Proximal Tubule

CORRELATIONS

• STRUCTURE

• Endothelium

• GBM

• Epithelium

• Mesangium

• FUNCTION• make vessel

• seive

• charge select.

• makes GBM

PATHkawasaki's

Alport's

proteinuriaMinimal Change

Berger's