Nephrology in Images presentation of nephro

Nephrology

1. Nephrology in Images Dr. Srinath.CHANDRAMANI

2. Renal artery stenosis : Causes

3. Renal angiography

4. “String of Beads” appearance : FMD

5. Osteitis Cystica Fibrosa

6. RBC in Urine

7. Casts in urine

8. Worst finding in urine

9. Glomerulonephritis Out of 1000 cases of AKI, only 4-6 cases are due to GN . But Mortality in ICU & NEET - HIGH !!!

10. Case 1 : 25years, Male Detected to have proteinuria and  microscopic hematuria   during an employment health examination.

11. Causes : Hematuria Most common cause is UTI and calculi. However,1-5% have Glomerulonephritis. Next Step ? HISTORY !!!

12. Past History The employee reported passing blood in urine a month ago, which had coincided with an attack of acute tonsillitis. The urinary analysis at that time had revealed numerous red blood cells/high power field . Significant Hematuria ?

13. IS THIS GN ? WELL,………NOT YET ? NEED URINE ANALYSIS TO HELP !

14. Dysmorphic RBC in urine

15. Renal function Test showed : BUN level -15 mg/dL, S.Creat - 0.9 mg/dL, eGFR - 83.7 mL/min. HOW? Cockroft Gault Formula : ( estimatedGFR /eGFR) For Males : (140-Age) * Weight(kgs)/72 * S.Creat For Females : Multiply above formula by 0.85 In addition, USG was normal.

16. Post-URTI : GN Focus on Latent period in such cases. IgA nephropathy Within 1 st week Henoch Schloein Purpura of the URTI Post-Streptococcal GN(PSGN)

17. Further History However, he had no other symptom, including abdominal pain, arthralgia, purpura, erythema or fever. EXCLUDES HSP For IgA vs PSGN : Serology & IF studies on the Biopsy

18. IgA nephropathy/Berger’s disease (Syn- pharyngitic nephropathy) Serological test in the present patient showed : an elevated serum IgA level of 456 mg/dL (N: 110–410 mg/dL), Complement activity titers were normal. The level of serum C3 was 140 mg/dL (N : 86–160 mg/dL).

19. Anti-IgA staining revealed Granular depositions of IgA in the glomerular mesangial areas consistent with IgA nephropathy. Treatment : 99% are Self-limiting. <1% Progress to RPGN requiring Plasmapheresis. Prognosis : Best among GN

20. PSGN 70% cases are positive for Anti- DNAase (Most sensitive anibody ) Renal Biopsy revealing deposition of IgG and C3 in the glomerular mesangium would confirm the diagnosis. Treated with Penicillin therapy to eradicate the residual infection. Long-term prophylaxis not required as relapse rates are low.

21. IF - Post Streptococcal GN Granular pattern. Bumpy appearance “Starry sky” appearance Predominant IgG and C3 deposits on the GBM

22. IF Pattern : Granular IgA nephropathy : IgA staining PSGN : IgG staining

23. Case 2 25 year-old Male, smoker presented to the clinic with cough and hemoptysis . H/O sore throat, fever 2 weeks ago. On examination his BP was 160/100mm of Hg. Urine Analysis revealed dysmorphic hematuria with 100-120RBC/ hpf and 2.5g/d of Proteinuria. His Serum creatinine levels were 4.1mg/dl.

24. NEPHRITIC Syndrome Along with Lung involvement – it constitutes PULMONARY RENAL SYN – D/D : Goodpasture’s syndrome ANCA positive Vasculitis syndromes. Henoch Schloein Purpura

25. IF to the Rescue – Again ! Serology reveals presence of Anti-GBM and ANCA. Serum C3 levels are normal.

26. Linear Pattern of IF GOODPASTURE’S SYNDROM E Antibody against Alpha-3 subunit Type IV Collagen Lung involvement more in Smokers Rx : Plasmapheresis Poor Prognosis : >70% mortality

27. Pauci-immune Pattern VACULITIS SYNDROMES : WEGENER’S GRANULOMATOSIS MICROSCOPIC POLYANGITIS CHURG STRAUSS SYNDROME Rx : Plasmapheresis

28. Case 3 A previously healthy 25-year-old woman presented with leg swelling. Only mild pretibial edema was detected in her physical examination. Laboratory workup revealed that an erythrocyte sedimentation rate 110mm/h, a serum creatinine concentration of 1.2mg/dL and albumin level of 2g/dL. Urinalysis revealed microscopic hematuria and a proteinuria of 9g/day.

29. NEPHROTIC Syndrome Minimal change disease Focal Segmental Glomerulosclerosis (FSGS) Membranous nephropathy Membrano -Proliferative GN (MPGN)

30. Microscopy confirms MPGN “ Double Basement Membrane ” appearance of the GBM due to Intra-GBM mesangial proliferation. (at 6 o’clock position on the biopsy) IF studies showing predominant C3 deposits are now termed C3GN (C3 Glomerulopathy)

31. C3GN Mesangiocapillary deposits of C3 enhanced on IF staining.

32. Summary of GN All Hematuria are not GN Dysmorphic hematuria favours diagnosis of GN Based on clinical features and proteinuria, there are 2 types of GN Preceding H/O gives clue to differential diagnosis Biopsy with IF studies is confirmatory. Once, RPGN occurs, best treatment is Plasmapheresis.

33. Crescentric GN

34. FSGS

35. Diabetic nephropathy

36. Alports syndrome

37. Basket weave appearance

38. APKD

39. Amyloid deposits – B2 MG

40. Well done !!! You have become a Nephrologist !!!