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INTRODUCTION TO NEPHROLOGY

INTRODUCTION TO NEPHROLOGY. Jeffrey J. Kaufhold, MD. RID YOURSELF OF BOTHERSOME BRAIN TISSUE THE KAUFHOLD WAY !. DEFINITIONS. GFR - true function of the kidney best measured by Inulin, Nuc. Med CREATININE CLEARANCE - measurement is difficult in inpatients

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INTRODUCTION TO NEPHROLOGY

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  1. INTRODUCTION TONEPHROLOGY Jeffrey J. Kaufhold, MD RID YOURSELF OF BOTHERSOME BRAIN TISSUETHE KAUFHOLD WAY !

  2. 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

  3. NEPHROLOGYSUMMARY • DEFINITIONS • STRUCTURE FUNCTION CORRELATION • SPECTRUM OF GLOMERULAR DISEASE • SIMPLE, EASY, COVERS 85% OF CASES • WE GET PAID FOR THE OTHER 15%

  4. Hematuria • T • I • G • H • T • S

  5. Hematuria • TUMOR • I NFECTION • G LOMERULONEPHRITIS • H EMATOLOGIC • T RAUMA • S TONE

  6. HEMATURIA • Glomerular Causes: • IgA (Berger’s) • Mesangioproliferative GN • Hereditary GN’s, including • Alport’s, Thin Basement Membrane • Hallmark of Glomerular Disease is RBC cast

  7. Mesangio-proliferative: mild mesangial hypercellularity

  8. Hereditary Nephritis Alports Nail -Patella Thin Basement Mem.

  9. NEPHROLOGYDEFINITIONS • 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

  10. 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

  11. PROTEINURIA • Glomerular Causes: • Minimal Change Disease - 25 % • Focal Segmental Glomerulo Sclerosis • FSGS - 30 % • Membranous - 30 %

  12. PROTEINURIA Relative Frequency by Age.

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

  14. Minimal Change Disease Normal appearing Glomerulus. Normal appearing interstitium.

  15. Minimal Change EM • Foot processes are completely effaced (no longer discreet).

  16. Focal Segmental Glomerular Sclerosis (FSGS) • Segments of glom are preserved and segments are sclerosed (darker pink).

  17. NEPHROLOGYDEFINITIONS • PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours: • <0.2 = normal • >3.0 nephrotic

  18. NEPHRITIC HEREDITARY IgA (BERGER'S) MESANGIO- PROLIF. ITIC/OTIC MEMBRANO- PROLIF. PSGN NEPHROLOGYIDIOPATHIC GN'S NEPHROTIC NIL FSGS MEMBRANOUS

  19. Post Infectious GN • Proliferative with lots of PMN’s visible.

  20. PSGN Electron Microscopy Subepithelial Humps

  21. Membrano-proliferative GN Lupus nephritis Class IV

  22. NEPHRITIC LUPUS CLASS II AND III CRYOGLOBULINS ITIC/OTIC PSGN LUPUS IV (DPGN) NEPHROLOGYSYSTEMIC DZ NEPHROTIC DM AMYLOID MYELOMA LUPUS V

  23. CLASS I ANTI-GBM CLASS 2 CIRCULATING IMMUNE COMPLEXES NEPHROLOGYRPGN CLASS 3 PAUCI- IMMUNE (VASCULITIS) CLASS 4 VASCULOPATHY R/O INTERSTITIAL DISEASE

  24. Clinical Syndrome ARF HTN RBC Casts Mimicked by TIN TIN Tubulointerstitial Nephritis or Crescents with characteristic change on Immunoflurescence Rapidly Progressive GN

  25. Interstitial Nephritis Crescent RPGN light Microscopy

  26. Linear Immunofluresence Due to Anti-GBM Antibody Goodpasture’s Syndrome RPGN Class I

  27. Granular IF Immune Complex Deposition Due to SLE, MPGN, HSP, PSGN, Others RPGN Class II

  28. Crescent with Focal Necrotizing GN Pauci-immune. ANCA Positive. Seen in Wegener’s Granulomatosis, Churg-Strauss, PolyArteritis Nodosa (PAN). RPGN III: Vasculitis Necrotizing area

  29. Hyaline thrombi Endothelial cell swelling and vacuolization Seen in TTP/HUS, Preeclampsia, Malignant HTN RPGN IV: Vasculopathy

  30. 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.

  31. 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

  32. 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.

  33. NEPHROLOGYDEFINITIONS • DEHYDRATION - STATE OF FREE WATER LOSS • VOLUME DEPLETION - STATE OF SALT AND WATER LOSS

  34. 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.

  35. TRANSPLANTDEFINITIONS • ALLOGRAFT • REJECTION • IMMUNOSUPPRESSION

  36. STRUCTURE Endothelium GBM Epithelium Mesangium FUNCTION make vessel seive charge select. makes GBM CORRELATIONS PATH kawasaki's Alport's proteinuria Minimal Change Berger's

  37. 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 Glomerular Physiology Efferent Art. constrict dilate no effect no effect no effect no effect dilate

  38. Glomerular PhysiologyBlood flow determinants Systemic Afferent Efferent PG's Local TGF Filtration

  39. Renal PhysiologyOverview Proximal Tubule Distal Tubule filtration solute exchange reabsorption Collecting duct impermeable to imperm. to H2O solute ADH + permeable to H2O Loop of Henle ADH - impermeable

  40. STRUCTURE Endothelium GBM Epithelium Mesangium FUNCTION make vessel seive charge select. makes GBM CORRELATIONS PATH kawasaki's Alport's proteinuria Minimal Change Berger's

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