1. INTRODUCTION TO NEPHROLOGY
Jeffrey J. Kaufhold, MD
RID YOURSELF OF BOTHERSOME BRAIN TISSUE THE 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. NEPHROLOGY SUMMARY 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 S

5. Hematuria
TUMOR I G H T S

6. Hematuria
TUMOR
I NFECTION G H T S

7. Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS H T S

8. Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC T S

9. Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T RAUMA S

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

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

16. Class 2 - mild mesangial hypercellularity

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

18. 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

19. PROTEINURIA LESS THAN 300 mg - normal 300 to 1200 think orthostatic or
interstitial
mg talk to the patient
OVER 3 Gm Consider Biopsy

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

21. PROTEINURIA Relative Frequency by Age.

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

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

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

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

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

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

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

29. PSGN Electron Microscopy
Subepithelial Humps

30. Membrano-proliferative GN
Lupus nephritis Class IV

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

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

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

34. RPGN light Microscopy
Interstitial Nephritis
Crescent

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

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

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

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

39. 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.

40. New Terminology ARF - 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

41. New Terminology Chronic Kidney Disease CKD
Stage 1 Normal GFR with known disease
Stage 2 GFR ml/min
Stage 3 GFR 30-60
Stage 4 GFR 20-30
Stage 5 GFR 10-20
Stage 6 GFR < 10, ESRD.

42. NEPHROLOGY DEFINITIONS
DEHYDRATION - STATE OF FREE WATER LOSS
VOLUME DEPLETION - STATE OF SALT AND WATER LOSS

43. DIALYSIS DEFINITIONS 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.

44. TRANSPLANT DEFINITIONS
ALLOGRAFT
REJECTION
IMMUNOSUPPRESSION

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

46. 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
Efferent Art.
constrict
dilate
no effect

47. Glomerular Physiology Blood flow determinants
Systemic
Afferent
Efferent
PG's
Local
TGF
Filtration

48. Renal Physiology Overview
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

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