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Nephritic Syndromes.docx

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University of Calgary
NURS 203

Nephritic Syndromes Proliferative Glomerulonephritis All the glomeruli are diffuse, too many nuclei Post strep GN Example: scarlet fever 2 weeks ago, presents with hematuria, RBC casts, mild to moderate proteinuria, HP, periorbital puffiness. EM: lumen of capillary, bump on lumen is endothelial cell, underneath is BM (grayish), and epithelial cells under. Has boulders that are denser than the normal glomerular BM – these are immune complexes. In this case, it the bacteria is the Ag-Ab immune complexes. Which side are they closer to? Closer to epithelial side, therefore they are subepithelial deposits – hence post strep GMN. Lupus GN Example: 35 y/o female with “+” serum ANA with a rim pattern (meaning you have anti DNA Ab’s present). Lupus almost always involves the kidney. There are 6 types, and the important one to know is type IV, which is a diffuse proliferative glomerulonephritis, which is the MC overall one seen in Lupus. Has many nuclei, therefore proliferative; has wire loops. (orient to EM) deposits in BM are anti DNA deposits. Would you agree that they are in the endothelial cell? Yes. So what is this location? Subendothelial deposits. Podocytes with slit pores in btwn are not fused b/c if they were, it would be nephrotic syndrome. Also see lumen, endothelial cells and deposits. Immune complexes are so big they can’t get through the BM. Crescentic GN Glomerulus surrounded by proliferating cells that are parietal cells b/c not in the glomerulus, and has crescent shape, hence the name crescentic glomerular nephritis. This is the WORST glomerular nephritis to have b/c in 3 months; pts will go into acute renal failure and die unless pt is on dialysis. Many dz’s have a crescentic glomerulonephritis, but the only one I need to know is Goodpastures; this is a NEPHRITIC dz; this dz has crescentic glomerulonephritis on bx (therefore a BAD dx). Nephrotic Syndromes: Pt with casts (fatty casts), polarized specimen with maltese cross – this is cholesterol in the urine. When cholesterol is polarized, it looks like a maltese cross. These fatty casts are pathonognomic for nephrotic syndrome. Greater than 3. 5 grams protein for 24 hrs, fatty casts in the urine, ascites, pitting edema, risk of spontaneous peritonitis if you are a child. Organism? Strep pneumonia in kids, E coli in adults. Lipoid nephrosis aka Minimal Change Dz: Example: EM of 8 y/o boy that had an URI one week ago, and now is all swollen, has pitting edema throughout body (anasarca) and ascites, normo-tensive, no HTN; saw nothing on renal bx; but then did a EM – see RBC in glomerular capillary lumen. So, see endothelial cells, see BM (without electron dense deposits), podocytes (fused) – fusion of podocytes is ALWAYS seen in any cause of nephrotic syndrome. Maltese crosses in urine. Dx? Lipoid nephrosis. All pt with nephrotic syndrome have hypercholesteremia. Since they have glomerular dz and some of the cholesterol can get into the urine, some can form casts in the urine. Aka minimal change dz. Why is this happening? Has lost neg charge in GBM, therefore albumin can get through. These pts have a select proteinuria – the only protein in these pt’s urine is albumin, and it is greater than 3.5 grams per 24 hrs. Rx – corticosteroids (usually goes away in 1 year never to come back again). The MCC nephrotic syndrome in kids. Focal Segmental Glomerulosclerosis Example: pt that is HIV “+”, pitting edema – therefore look at urine and note that is greater than 3.5 grams over 24 hrs. Has fatty casts in urine and has HTN. Do bx, and already know what you are gonna see b/c it the MCC nephrotic syndrome in AIDs pt. On bx, some of the glomeruli are abnormal and others are normal, but only a part of the glomerulus is messed up. Therefore, it is focal segmental. B/c the renal bx with EM and immunofluorence did NOT show deposits, therefore it’s glomerulosclerosis. So, this is called focal segmental glomerulosclerosis. This is the MC lesion in AIDs pts and IVDA’s. Next to rapidly progressive crecentric glomerulonephritis, this is the next worse glomerular dz. Diffuse membranous glomerulonephritis Example: adult with pitting edema, over 3.5 gram per 24 yrs, fatty casts. Do a bx and see not many ‘dots’ therefore not a proliferative dz. However the BM is thicker. Dx? Diffuse membranous glomerulonephritis = MCC nephrotic syndrome in adults. This is subepithelial deposit. Epimembranous spikes – spike like lesion on the outside of GBM seen with silver stain = diffuse
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