Lecture – 3 – Major renal syndromes Dr.Hazem.K.Al-Khafaji MBCHB.D.M.FICMS

The clinical presentation of renal diseases include:- 1- Nephritic syndrome 2-Nephrotic syndrome 3- Acute kidney injury(AKI),the old name acute renal failure. 3- Chronic kidney disease, previously chronic renal insufficiency ̸ failure. 4- Tubulointerstitial nephritis ̸ defects. 5- Urinary tract infection. 6- Urolithiasis. 7- Renovascular hypertension. The clinical presentation of renal diseases include:- 1- Nephritic syndrome 2-Nephrotic syndrome 3- Acute kidney injury(AKI),the old name acute renal failure. 3- Chronic kidney disease, previously chronic renal insufficiency ̸ failure. 4- Tubulointerstitial nephritis ̸ defects. 5- Urinary tract infection. 6- Urolithiasis. 7- Renovascular hypertension.

INFLAMMATION OF THE GLOMERULI, THIS ALLOW PASSAGE OF PROTEIN& RED BLOOD CELLS IN THE URINE WITH REDUCTION IN AMOUNT OF URINE. IF LEFT UN TREATED CAN LEADS TO SCARRING & IRREVERSIBLE LOSS OF RENAL FUNCTION(CHRONIC GN).AFFECTING ALL AGES BUT IT IS MORE COMMON IN CHILDREN & YOUNG ADULTS. CLASSIFIED ACCORDING TO HISTOPATHOLOGICAL FINDINGS.E.G FOCAL,DIFFUSED.SEGMENTAL & CRESCENTIC (CRESCENT MEANS ACCOMULATION OF LARGE PALE CELLS WITHIN THE BOWMAN”S CAPSULE FORMING SEMICIRCULAR STRUCTURE & THIS INDICATE THE WORST PROGNOSIS.THE DISEASE MAY BE PRIMARY ( MOSTLY DUE TO IMMUNOLOGICAL INJURY ) OR MAY BE SECONDARY ; ASSOCIATED WITH OTHER DISEASES AS SLE, HEPATITIS, MALARIA & OTHERS. TREATMENT IS AIMED TO DECREASEING THE INFLAMMATION,CORTICOSTEROIDS IS THE PRIMARY AGENTS IN MOST CASES, OTHER DRUGS ;MYCOPHENOLATE MOFETIL( CELL CEPT ),CYCLOSPORINE, AZOTHIOPRIME. GLOMERULOPATHY : THE TERM USED WHEN THERE IS NO FEATURES OF INFLAMMATION AS IN MORBID OBESITY, DRUGS,& HIV INFECTION Glomerulonephritis

Nephritic syndrome   Presence of glomerular disease mostly due to immunological injury. Characterestic features:-   Haematuria (especially dysmorphic red cells)   Active sediments in the urine as red cell casts& ̸ or dysmorphic RBCs.   Oliguria.   Hypertension.   Oedema.   Proteinuria ( in the range of >3.5 g/24hours).   Impaired renal function; raised b.urea & creatinine

Nephrotic syndrome متلازمة التناﺫر الكلوي Definition of Nephrotic Syndrome (NS) · NS is characterized by heavy proteinuria, hypoproteinemia, generalized edema and hyperlipidemia. Heavy proteinuria- when urinary protein excretion more than 40mg/m2/hour or 1g/m2/24hours. Or ≥3.5gm/day Hypoproteinemia- serum albumin < 3g/dl (adult) or 2.5g/dl(children). Hyperlipidemia-serum cholesterol>250mg/dl. BP may be normal,decreased or increased. Other consequences are hypercoaguable state & depressed immunity.

15 times more common in children than adults

THE UNDERLYING PRIMARY DEFECT IS INCREASED IN THE PERMEABILITY. THE CAUSE OF THE INCREASED PERMEABILITY IS NOT WELL UNDERSTOOD. IN MINIMAL CHANGE DISEASE, IT IS POSSIBLE THAT T-CELL DYSFUNCTION LEADS TO ALTERATION OF CYTOKINES, WHICH CAUSES A LOSS OF NEGATIVELY CHARGED GLYCOPROTEINS WITHIN THE GLOMERULAR CAPILLARY WALL.

CAN BE DUE TO SYSTEMIC(SECONDARY) OR LOCAL RENAL DISEASE(PRIMARY) DIABETIC NEPHROPATHY MOST COMMON CAUSE OTHER COMMON CAUSES INCLUDE MINIMAL CHANGE DISEASE, FOCAL SEGMENTAL GLOMERULOSCLEROSIS, MEMBRANOUS NEPHROPATHY, MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS,AMYLOIDOSIS OFTEN SECONDARY TO MULTIPLE MYELOMA), LIGHT CHAIN DEPOSITION DISEASE. Nephrotic syndrome

Blood plasma v Filtrate ComponentPlasma / mg 100cm -3 Filtrate / mg 100cm -3 Urea0.03 Glucose0.10 Amino acids0.05 Salts0.72 Proteins8.000

Urine Dip Protein +++

Acute kidney injury previously known as acute renal failure, encompasses a wide spectrum of injury to the kidneys, not just kidney failure. The definition of acute kidney injury has changed in recent years, and detection is now mostly based on monitoring creatinine levels, with or without urine output. Acute kidney injury is increasingly being seen in primary care in people without any acute illness,

AKI (Acute Kidney Injury) Definition and diagnostic Criteria  An abrupt (within 48hr) reduction in kidney function currently defined as an absolute increase in serum creatinine of either >0.3 mg/dL( over the baseline) or a percentage increase of >50% or a reduction in UOP (documented as oliguria of 6hr)

Acute kidney injury is seen in 13– 18% of all people admitted to hospital

Acute Versus Chronic  Acute  sudden onset  rapid reduction in urine output( days – weeks )  Usually reversible  Tubular cell death and regeneration  Chronic  Progressive( 3 months & more )  Not reversible  Nephron loss  50% of function can be lost before its noticeable

Acute kidney injury/Acute Renal Failure  Causes:-  Pre-renal = 55%  Renal parenchymal (intrinsic)= 40%  Post-renal = 5-15%

Chronic renal failure  Chronic renal failure(Chronic kidney disease)  Progressive & irreversible renal loss ( structural or functional ) ≥ 3 months.

1-KIDNEY DAMAGE FOR ≥ 3MONTHS, AS DEFINED BY STRUCTURAL OR FUNCTIONAL ABNORMALITIES OF KIDNEY, WITH OR WITHOUT DECREASED GFR,MANIFEST BY EITHER: PROLONGED ABNORMALITIES; OR MARKERS OF KIDNEY DAMAGE INCLUDING ABNORMALITIES IN COMPOSITION OF THE BLOOD OR URINE, OR ABNORMALITIES IN IMAGING TEST. OR 2- GFR ˂ 60ML ̸ MIN ̸ 1.73 M 2 WITHIN ≥ 3 MONTHS WITH OR WITHOUT STRUCTURAL RENAL DAMAGE Definition of chronic kidney disease Criteria

GFR ˂ 60ml ̸ min ̸ 1.73 m 2 within ≥ 3 months with or without structural renal damage

Chronic Renal Failure A. Definitions 1.Azotemia - elevated blood urea nitrogen (BUN >28mg/dL) and creatinine (Cr>1.5mg/dL) 2.Uremia - azotemia with symptoms or signs of renal failure 3.End Stage Renal Disease (ESRD) - uremia requiring RRT : transplantation or dialysis 4.Chronic Renal Failure (CRF) - irreversible kidney dysfunction with azotemia >3 months 5.Creatinine Clearance (CCr) - the rate of filtration of creatinine by the kidney (GFR marker) 6.Glomerular Filtration Rate (GFR) - the total rate of filtration of blood by the kidney

Interstitial nephritis  Refers to group of diseases(acute & chronic) characterised by presence of an inflammatory cell infiltrate in the renal interstitium and tubules & fibrosis in chromic condition.  Sparing of vasculatures & glomeruli.  Immune-mediated cause of acute renal failure

Pyelonephritis  Invasive kidney infection  Usually ascends from UTI  Fever, flank pain  Organisms: E. coli, Proteus

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