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Nephro Combined For Quiz
Nephro Combined For Quiz
SYNDROME
PRESENTED BY
• OBJECTIVES
• REFERENCES
• DEFINITION OF TERMS
• BRIEF REVIEW OF
FILTERABILITY IN THE KIDNEYS
SCOPE OF PRESENTATION
• NEPHROTIC SYNDROME
• NEPHRITIC SYNDROME
• SUMMARY
OBJECTIVES
• TO PRESENT AND DISCUSS WITH
THE PARTICIPANTS THE
CLINICAL CONDITIONS CALLED
NEPHROTIC SYNDROME AND
NEPHRITIC CONDITION
• NEPHROLOGY : CLINICAL
CASES UNCOVERED BY
MENNA CLATWORTHY
REFERENCES
• RENAL AND ELECTROLYTE
DISORDER BY ROBERT SCHRIER
8TH EDITION
• TEXTBOOK OF MEDICAL
PHYSIOLOGY , 11TH EDITION BY
GUYTON AND HALL
REFERENCES
• CLINICAL ANATOMY BY REGIONS , BY
RICHARD S SNELL , 9TH EDITION
• DE GOWIN’S DIAGNOSTIC
EXAMINATION : THE COMPLETE GUIDE
TO ASSESSMENT EXAMINATION
DIFFERENTIAL DIAGNOSIS 8TH EDITION
DEFINITION OF A SYNDROME
SYNDROME *
A CONSTELLATION OF
SIGNS AND SYMPTOMS OR A
CONSTELLATION OF CONGENITAL
ANOMALIES BELIEVED TO BE
PATHOLOGICALLY RELATED , THAT
IS IN CONTRAST TO A SEQUENCE ,
CANNOT BE EXPLAINED ON THE
BASIS OF A SINGLE LOCALIZED ,
INITIATING DEFECT
IT IS CAUSED BY A SINGLE
ETIOLOGIC AGENT WHICH
SIMULTANEOUSLY AFFECTS
SEVERAL TISSUES
• PROTEINURIA
• HEMATURIA ( CAN PRESENT
AS TEA – COLORED URINE)
• EDEMA
• HIGH BLOOD PRESSURE
FILTERABILITY OF PROTEIN
• NEGATIVELY CHARGED LARGE
MOLECULES ARE FILTERED LESS EASILY
THAN POSITIVELY CHARGED
MOLECULES OF EQUAL SIZE
2. GLOMERULAR DYSFUNCTION
• A DEFECT IN THE GLOMERULAR
BARRIER THAT ALLOWS ABNORMAL
AMOUNTS OF PROTEINS OF
INTERMEDIATE MOLECULAR
WEIGHT TO ENTER BOWMAN’S
SPACE
• ALSO CALLED GLOMERULAR
PROTEINURIA
PROTEINURIA
MECHANISMS / CAUSES
OF PROTEINURIA
3. TUBULAR DYSFUNCTION
• ALSO CALLED TUBULAR
PROTEINURIA
• DISEASES RESULTING IN THE
INABILITY OF THE KIDNEY TO
REABSORB NORMALLY
PROTEINS PRESENTED TO THE
RENAL TUBULES
NEPHROTIC SYNDROME
NEPHROTIC SYNDROME
• A CONDITION CHARACTERIZED &
THAT RESULTS FROM
PROTEINURIA OF MORE THAN 3.5
GRAMS PROTEIN PER DAY AND IS
CHARACTERIZED BY EDEMA,
MINIMAL HEMATURIA,
HYPOALBUMINEMIA,
HYPERLIPIDEMIA AND
HYPERTENSION
DATA ARE DERIVED FROM ANALYSIS OF 9605 NATIVE KIDNEY BIOPSY SPECIMENS EVALUATED AT
THE UNIVERSITY OF NORTH CAROLINA NEPHROPATHOLOGY LABORATORY.
NEPHRITIC SYNDROME
NEPHRITIC SYNDROME
• PRODUCTION OF 1–2 G/24 H OF
PROTEINURIA, HEMATURIA WITH RED
BLOOD CELL CASTS, PYURIA,
HYPERTENSION, FLUID RETENTION
• HALLMARK IS HEMATURIA
NEPHRITIC SYNDROME
NEPHRITIC SYNDROME
• IT CAN OCCUR AS AN
ISOLATED RENAL PROCESS OR
AS A FEATURE OF A SYSTEMIC
DISEASE OR HEREDITARY
DISORDER
• IF GLOMERULAR
INFLAMMATION DEVELOPS
SLOWLY, THE SERUM
CREATININE WILL RISE
GRADUALLY OVER MANY
WEEKS
NEPHROTIC VS NEPHRITIC
SYNDROME
KEY POINTS ON THE CAUSES OF
NEPHROTIC SYNDROME & NEPHRITIC
SYNDROME
• DESPITE OF THE CAUSE OF
NEPHROTIC SYNDROME BE IT
PRIMARY GN OR SECONDARY
TO OTHER DISEASES , THE LOSS
OF SUBSTANTIAL AMOUNTS OF
PROTEIN IN THE URINE RESULTS
IN A SHARED SET OF
ABNORMALITIES THAT
COMPRISE NEPHROTIC
SYNDROME
GLOMERULAR
DISEASES GRAMS OF PROTEIN EXCRETED PER DAY ( G/DAY OR G/24H )
0.25 > 3.5
SPECTRUM OF GLOMERULAR
DISEASE
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
CLINICAL APPROACH TO
NEPHROTIC AND NEPHRITIC
SYNDROME
1.THOROUGH MEDICAL HISTORY AND
PHYSICAL EXAMINATION
• WITH THE OBJECTIVE OF IDENTIFYING
THE POSSIBLE CAUSE
2. LABORATORY EXAMINATION
• CBC
• BLOOD CHEMISTRY
• IMMUNOLOGIC STUDY (ANTI-NUCLEAR
ANTIBODY (ANA); COMPLEMENT
LEVELS (C3 AND C4), ANTI-DOUBLE-
STRANDED DNA ANTIBODY (DSDNA);
• HEPATITIS PROFILE
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
CLINICAL APPROACH TO
NEPHROTIC AND
NEPHRITIC SYNDROME
2. LABORATORY EXAMINATION
• ROUTINE URINALYSIS
✓ IT WILL SERVE AS AN INITIAL
SCREENING FOR PRESENCE
OF PROTEINURIA AND
APPROXIMATION OF ITS
AMOUNT
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
PROTEINURIA ON ROUTINE
URINALYSIS
THE DIPSTICK RESULTS OF ROUTINE
URINALYSIS HAVE THE FOLLOWING
APPROXIMATE CORRELATIONS WITH
PROTEIN CONCENTRATION:
RESULT OF AMOUNT OF PROTEIN
TEST STRIP
NEGATIVE <15MG/DL
TRACE 15 – 30 MG/DL
1+ 30 – 100 MG/DL
2+ 100 – 300 MG /DL
3+ 300 – 1000 MG /DL
4+ > 1000 MG /DL
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
CLINICAL APPROACH TO
NEPHROTIC AND
NEPHRITIC SYNDROME
2. LABORATORY EXAMINATION
• ROUTINE URINALYSIS
✓ IT WILL SERVE AS AN INITIAL
SCREENING FOR PRESENCE
OF PROTEINURIA AND
APPROXIMATION OF ITS
AMOUNT
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
CLINICAL APPROACH TO
NEPHROTIC AND
NEPHRITIC SYNDROME
2. LABORATORY EXAMINATION
• 24 HOUR TOTAL URINE
PROTEIN AND CREA
CLEARANCE
✓ IT WILL PROVIDE
QUANTITATIVE INFORMATION
AS TO THE AMOUNT OF
PROTEIN PRESENT IN THE
URINE FOR 24 HOURS
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
CLINICAL APPROACH TO
NEPHROTIC AND
NEPHRITIC SYNDROME
2. LABORATORY EXAMINATION
• 24 HOUR TOTAL URINE
PROTEIN AND CREA
CLEARANCE
✓ IT WILL PROVIDE
QUANTITATIVE INFORMATION
AS TO THE AMOUNT OF
PROTEIN PRESENT IN THE
URINE FOR 24 HOURS
CLINICAL APPROACH TO PATIENTS WITH
NEPHROTIC AND NEPHRITIC SYNDROMES
CLINICAL APPROACH TO
NEPHROTIC AND
NEPHRITIC SYNDROME
2. LABORATORY EXAMINATION
CHEST XRAY
ULTRASOUND OF KUB
3. KIDNEY BIOPSY
• TO INVESTIGATE AND
DIAGNOSE KIDNEY DISEASE AS
WELL AS FOR
PROGNOSTICATION
RESULT OF KIDNEY BIOPSY AMONG
PATIENTS WITH NEPHROTIC SYNDROME
GRAPH DEPICTING THE
FREQUENCIES OF
DIFFERENT FORMS OF
GLOMERULAR DISEASE
IDENTIFIED IN RENAL
BIOPSY SPECIMENS
FROM PATIENTS WITH
PROTEINURIA OF MORE
THAN 3 G OF PROTEIN
PER DAY EVALUATED AT
THE UNIVERSITY OF
NORTH CAROLINA
NEPHROPATHOLOGY
LABORATORY
COMPLICATIONS OF NEPHROTIC
SYNDROMES
COMPLICATIONS OF
NEPHROTIC SYNDROMES
• THROMBOEMBOLISM
✓ DVT +/- PULMONARY EMBOLISM
✓ THROMBOSIS OF RENAL VEIN
• INFECTION
• HYPERLIPIDEMIA
• MALNUTRITION
• ACUTE RENAL FAILURE
THERAPEUTIC APPROACH
• ONE OF THE MAIN GOALS OF
TREATMENT IS THE REDUCTION
OR ELIMINATION OF
PROTEINURIA
• TREAT THE UNDERLYING CAUSE
• LIMIT DIETARY SODIUM
• TREAT THE DYSLIPIDEMIA
• INSTITUTION OF
CORTICOSTEROID WITH
REGULAR MONITORING FOR
RESPONSE AND TAPERING OF
DOSE
• DIURETICS AND OTHER MEDS
SUMMARY
• NEPHROTIC SYNDROME IS A CONDITION
CHARACTERIZED & THAT RESULTS
FROM PROTEINURIA OF MORE THAN
3.5 GRAMS PROTEIN PER DAY AND IS
CHARACTERIZED BY EDEMA, MINIMAL
HEMATURIA, HYPOALBUMINEMIA,
HYPERLIPIDEMIA AND HYPERTENSION
• NEPHRITIC SYNDROME IS A
CONDUCTION CHARACTERIZED BY
PRODUCTION OF 1–2 G/24 H OF
PROTEINURIA, HEMATURIA WITH RED
BLOOD CELL CASTS, PYURIA,
HYPERTENSION, FLUID RETENTION
SUMMARY
• BOTH NEPHROTIC AND NEPHRITIC
SYNDROMES ARE CAUSED BY
EITHER PRIMARY RENAL DISORDER
OR SECONDARY CONDITIONS
WHEREIN THERE ARE CONDITIONS
THAT EVENTUALLY INVOLVED THE
KIDNEYS
• OBJECTIVES
• REFERENCES
• BRIEF REVIEW OF THE RENAL
ANATOMY AND FUNCTION
SCOPE OF PRESENTATION
• TEXTBOOK OF MEDICAL
PHYSIOLOGY , 11TH EDITION
BY GUYTON AND HALL
REFERENCES
• BATES’ GUIDE TO PHYSICAL
EXAMINATION AND HISTORY TAKING
12TH EDITION BY LYNN S BINCKLEY
• BLOOD IS CONSIDERED TO BE A
SEPARATE FLUID COMPARTMENT
BECAUSE IT IS CONTAINED IN A
CHAMBER OF ITS OWN, THE
CIRCULATORY SYSTEM
BODY FLUID COMPARTMENTS
BLOOD VOLUME
• THE BLOOD VOLUME IS ESPECIALLY
IMPORTANT IN THE CONTROL OF
CARDIOVASCULAR DYNAMICS
NONELECTROLYTES IN THE
PLASMA
SUBSTANCES IN THE ECF AND ICF
TYPES OF INTRAVENOUS FLUIDS
BROAD CATEGORIES OF
INTRAVENOUS (IV) FLUIDS
A. CRYSTALLOID IV FLUID B. COLLOID IV FLUID
TYPES OF INTRAVENOUS FLUIDS
BROAD CATEGORIES OF IV
FLUIDS
CRYSTALLOIDS
• BASICALLY CONTAINS WATER
WITH ELECTROLYTES AND SOME
WATER SOLUBLE MOLECULES
1. COST EFFECTIVINESS
2. SIMPLICITY
3. AVAILABLE IN
DIFFERENT
COMBINATIONS
4. NO IMMUNE
RESPONSE
TYPES OF INTRAVENOUS FLUIDS
CRYSTALLOIDS
THREE TYPES OF
CRYSTALLOIDS BASED
ON OSMOLALITY
1. ISOTONIC
2. HYPOTONIC
3. HYPERTONIC
TYPES OF CRYSTALLOIDS
THREE TYPES OF
CRYSTALLOIDS BASED ON
OSMOLALITY
1. ISOTONIC
• THESE ARE SOLUTIONS WITH THE
SAME OSMOTIC CONCENTRATION
OF PARTICLES AS THAT OF THE
ECF OR PLASMA. HENCE IT WILL
NOT CAUSE ANY SHIFT IN FLUID
OR CHANGE IN IONS BETWEEN
ICF AND ECF
• THEY CAN HAVE AN OSMOLALITY
OF 250 – 375 MOSM
TYPES OF CRYSTALLOIDS
THREE TYPES OF
CRYSTALLOIDS BASED ON
OSMOLALITY
2. HYPERTONIC
• THESE ARE SOLUTIONS HAVE
GREATER OSMOTIC
CONCENTRATION (> 375
MOSM)
• THIS WILL RESULT TO FLUID
BEING PULLED OUT FROM
THE CELL . FLUID MOVING OUT
OF ICF INTO ECF
TYPES OF CRYSTALLOIDS
THREE TYPES OF
CRYSTALLOIDS BASED ON
OSMOLALITY
3. HYPOTONIC
• THESE ARE SOLUTIONS WITH
LESS CONCENTRATION OF
PARTICLES , HENCE LESS
OSMOTIC CONCENTRATION
(< 250 )
ISOTONIC SOLUTIONS
COMMONLY USE IVF (CRYSTALLOIDS)
HYPOTONIC SOLUTIONS
HYPERTONIC SOLUTIONS
COMMONLY USE IVF (CRYSTALLOIDS)
• POTENTIATE IMMUNE
RESPONSE
• EXAMPLE OF COLLOID
FLUIDS
✓ ALBUMIN – AVAILABILITY 5% ,
25%
✓ DEXTRAN
POTASSIUM
POTASSIUM
• POTASSIUM PLAYS A KEY ROLE IN
MAINTAINING CELL FUNCTION
• THE MAJORITY (98%) OF THIS K+ IS
WITHIN CELLS WITH ONLY 2% IN THE
EXTRACELLULAR FLUID
• THE NORMAL CONCENTRATION OF
K+ IN THE EXTRACELLULAR FLUID IS
3.5 TO 5.3 MEQ/L
• APPROXIMATELY 90% OF THE DAILY
K+ INTAKE IS EXCRETED IN THE
URINE, WHILE 10% IS EXCRETED BY
THE GASTROINTESTINAL TRACT
POTASSIUM
FACTORS THAT CAN ALTER POTASSIUM DISTRIBUTION BETWEEN THE
INTRA- AND EXTRACELLULAR FLUID
FACTORS THAT SHIFT K+ INTO FACTORS THAT SHIFT K+ OUT OF
CELLS THE CELLS
(DECREASE EXTRACELLULAR K) (INCREASE EXTRACELLULAR K)
• HYPOKALEMIA DEFINED AS A
PLASMA POTASSIUM (K)
CONCENTRATION OF LESS
THAN 3.6 MMOL/L
HYPERKALEMIA AND
HYPOKALEMIA
CONSEQUENCES OF
HYPERKALEMIA
• HIGH LEVELS OF POTASSIUM CAUSE
ABNORMAL HEART AND SKELETAL
MUSCLE FUNCTION BY LOWERING
CELL-RESTING ACTION POTENTIAL
AND PREVENTING REPOLARIZATION,
LEADING TO MUSCLE PARALYSIS
• HYPOKALEMIA WORSENS
HYPERTENSION
• IT CAUSES MUSCLE
WEAKNESS AND
PARALYSIS
ARTERIAL BLOOD GASES (ABG)
IT ASSESSES THE
EFFECTIVENESS OF GAS
EXCHANGE OF THE HUMAN
BODY BY MEASURING THE
PARTIAL PRESSURES OF
OXYGEN AND CARBON
DIOXIDE IN A SAMPLE OF
BLOOD OBTAINED BY
ARTERIAL PUNCTURE
ARTERIAL BLOOD GASES (ABG)
IMPORTANCE OF ABG
1. HELP DETERMINE SEVERITY OF
DISEASES
2. INFORMATION ON OXYGENATION
3. ADEQUACY OF VENTILATION AND
PERFUSION
4. DETERMINE METABOLIC STATUS
5. HELP PLAN TREATMENT
2. RESPIRATORY SYSTEM
3. KIDNEYS
PRIMARY ACID-BASE DISTURBANCES
PRIMARY ACID-BASE
DISTURBANCES
• RESPIRATORY ACIDOSIS: LOW PH,
HIGH PaCO2, NORMAL OR HIGH
NORMAL BICARBONATE.
CAUSES: NEUROMUSCULAR
WEAKNESS, INTRINSIC LUNG
DISEASE - EG, COPD
NORMAL VALUES
PH - 7.35 - 7.45
PO2 - 85 – 100
PCO2 - 35 - 45
HCO3 - 22 - 26 MEQ
ARTERIAL BLOOD GASES (ABG)
PH - 7.35 – 7.45 / 7.38 - 7.42
DEGREE ACIDOSIS ALKALOSIS
MILD 7.33 – 7.37 7.43 – 7.47
MODERATE 7.30 – 7.32 7.48 - 7.52
SEVERE < 7.29 > 7.53
2. RESPIRATORY ALKALOSIS
( 40 –PCO2) X 0.5 – 24 + 2
3. METABOLIC ACIDOSIS
1.5 X HCO3 + 8.4 + 2
4. METABOLIC ALKALOSIS
24 – (HCO3) X (.5 & I ) + 40 + 2
SAMPLE PROBLEM
PH 7.10 ACIDOTIC
A 30 YEAR OLD PATIENT WAS
PCO2 22 ALKALOSIS
RUSHED TO ER DUE TO
TACHYPNEA & DYSPNEA. ABG HCO3 12 ACIDOTIC
DONE SHOWED THE FOLLWING
RESULTS: O2 75 LOW
PH 7.10
PCO2 22
HCO3 12 1. KNOW THE PH
=1.5 + 12 + 8.4 +2
= 21.9 +2
= 23.9 – 19.9