Glomerulonephritis

Question 1

Strongest factor in IgA nephropathy leading to ESRF?

Answer 1

Proteinuria at least 1-2g
If question said BP of 180 as an answer and protein of 1g would probably go with BP as these are mostly related.
Biopsy score also important

Question 2

IgA nephropathy most common presentation.

Answer 2

Approximately 40 to 50 percent present with one or recurrent episodes of visible hematuria, usually following an upper respiratory infection. This has sometimes been called “synpharyngitic hematuria.”

40% have incidental finding of microscopic haematuria

Question 3

IgA nephropathy treatment

Answer 3

ACE or ARB if proteinuria over 0.5g/day

Question 4

What is the cumulative dose of cyclophosphamide that causes problems?

Answer 4

36g

Question 5

IV vs oral cyclo?

Answer 5

IV less toxic but higher risk relapse

Question 6

Evidence for plasmapheresis in Wegners?

Answer 6

Short term benefit plasmapheresis compared with steroids (MPEX trial)

Historically do in pulmonary haemorrhage and co-circulating anti-GBM ab

Question 7

MMF vs AZA in maintenance for Wegner’s?

Answer 7

MMF inferior (opposite of lupus)

Question 8

Ritux vs cyclophos in Wegner’s

Answer 8

At least as good ritux as cyclophos for mild-moderate

In more severe disease no obvious difference

Question 9

Membranous nephropathy antibody in 70%

Answer 9

anti-phospholipase A2 receptor - usually IgG4

Negative in secondary causes (ie cancer)

If negative, still a 30% chance of it being primary

predicts response to treatment . Higher titre less likely

Question 10

Which has highest risk of VTE of all the nephrotic syndromes?

Answer 10

Warfarin

Question 11

Treatment of idiopathic membranous nephropathy

Answer 11

steroids alone DOES NOT WORK

Some evidence for CNI + low dose steroids (be careful if worsening renal function)

Best evidence for pred and cyclophosphamide alternating for 6-12 months

Basically, if no nephrotic syndrome, supportive care (ACE, ARB, SALT RESTRICTION, BP control, diuretics if needed, anticoagulate if alb less than 25). if nephrotic syndrome or very high grade proteinuria over 4g or deterioration in renal function over 30% then start immunosupression. Pred and chlorambucil has best evidence. Cyclosporine quite reasonable if not getting better and just nephrotic syndrome no renal impairment

Question 12

Complement findings in GN

Answer 12

Cryglobulinaemic vasculitis- low C4 with normal or low C3
MCGN and post infectious GN- low C3, normal C4 (alternate pathway)
lupus nephritis- both low (classical pathway)

Question 13

HIV associated with what glomerulopathies

Answer 13

black- FSGS

white-IgA and lupus like syndrome

Question 14

Associations with IgA nephropathy?

Answer 14

HSP
Alcoholic cirrhosis
Coeliac disease/dermatitis herpetiformis
HIV

Remember that re: prognosis; frank haematuria is GOOD. male, protein over 2g/day, hypertension, smoking, high lipids, ACE genotype DD is bad

Question 15

How do you differentiate beween post strep GN and IgA nephropathy

Answer 15

1. Low complement in post strep GN
2. Main sx in PSGN is proteinuria but haaematuria can also happen
3. usually there is an interval between URTI and renal issues in PSGN, but IgA often synpharyngitic