GLOMERULAR DISEASES

Normal glomerular structure

There are about one million renal glomeruli in each kidney and each consists of a capillary plexus invaginating the blind end of the proximal renal tubule (Fig. 9.4). The glomerular capillaries are lined by a fenestrated endothelium, which rests on the glomerular basement membrane (GBM). External to the GBM are the visceral epithelial cells (podocytes) which only make contact with the GBM by finger-like projections, called foot processes, which are separated from one another by ‘filtration pores'. This unique structure of the glomerular membrane accounts for its tremendous permeability, allowing 125-200 mL of glomerular filtrate to be formed every minute (this is the glomerular filtration rate or GFR). The composition of the glomerular filtrate is similar to plasma but contains only small amounts of protein (all of low molecular weight), most of which is reabsorbed in the proximal tubule. Tubular reabsorption and secretion normally substantially alter the water and electrolyte composition of the glomerular filtrate until it reaches the renal pelvis as urine.

Pathogenesis and terms in glomerular disease

Glomerular disease includes glomerulonephritis, i.e. inflammation of the glomeruli, and glomerulopathies, i.e. when there is no evidence of inflamma-tion. There is an overlap between these terms. The kidneys are symmetrically involved and the renal lesion may be primary or part of a generalized disease, e.g. systemic lupus erythematosus.

Renal tissue, obtained at transcutaneous renal biopsy, is examined by light microscopy, electron microscopy and immunofluorescence to determine the extent and type of disease and to assess the type of immunological injury. The most commonly used terms are:

■ Focal: Some but not all the glomeruli contain the lesion.

■ Diffuse (global): Most of the glomeruli contain the lesion.

■ Segmental: Only a part of the glomerulus is affected (most focal lesions are also segmental, e.g. focal segmental glomerulosclerosis).

■ Proliferative: An increase in cell numbers due to hyperplasia of one or more of the resident glomerular cells with or without inflammation.

■ Membrane alterations: Capillary wall thickening due to deposition of immune deposits or alterations in basement membrane.

■ Crescent formation: Epithelial cell proliferation with mononuclear cell infiltration in Bowman's space.

Fig. 9.4 (A) Diagrammatic representation of the normal glomerulus. (B) Components of the glomerular membrane. (Adapted from Read et al. 1993 Essential Medicine. Churchill Livingstone, Edinburgh; Guyton 1987 Human Physiology and Mechanisms of Disease, 4th edn. WB Saunders, London.)

Classification and presentation of glomerulopathies

The presence of some form of glomerular disease, as opposed to tubulointer-stitial or vascular disease, is usually suspected from the history and from one or more of the following urinary findings: haematuria (particularly if the red cells are abnormally shaped or distorted, i.e. dysmorphic), red cell casts and proteinuria, which may be in the nephrotic range (>3.5 g/day). Glomerulop-athies are classified and discussed as they relate to four major glomerular syndromes:

■ Nephrotic syndrome: Massive proteinuria (>3.5 g/day), hypoalbumin-aemia, oedema, lipiduria and hyperlipidaemia.

■ Acute glomerulonephritis (acute nephritic syndrome): Abrupt onset of haematuria with casts or dysmorphic red cells, non-nephrotic range proteinuria, oedema, hypertension and transient renal impairment.

■ Rapidly Progressive glomerulonephritis: Features of acute nephritis, focal necrosis with or without crescents and rapidly progressive renal failure over weeks.

■ Asymptomatic haematuria, proteinuria (or both): These are usually inci-dental findings on urinary dipstick testing and may be an early indicator of renal disease. The causes and further investigation are discussed in the sections on haematuria (p. 358) and proteinuria (p. 357).

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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