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medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
medicine.Renal 3.(dr.kawa)
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medicine.Renal 3.(dr.kawa)

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  • 1. Nephrotic syndrome with bland urine sediment ( (pure nephrotic
  • 2. Minimal Change Nephrotic ( Syndrome. MCNS (Nil lesion It‘s the most common type of NS. in children- < 90% of all children with NS have this conditionusual age : 2 – 6 years, with a male –female ratio of 2:1Account for about 15 - 25% of adult patients with-NS with equal male-female ratio .some adultswith malignant neoplasm have developed.MCNS. as Hodgkin‘s lymphoma.Usually present as sudden onset of NS in children
  • 3. MCNS does not progress to renal •impairement ,the main problems are thoseof nephrotic syndrome & complications of (treatment (steroid • Histopathology.( Light microscopy is normal ( nil lesion-Electron microscopy shows fusion of-.podocyte foot processes.
  • 4. Teatment A-.treatment of proteinuria B-.treatment of complications of NS.C- steroid & other immunosupressant drugs.( no need for nenal biopsy( NS in children-most children with NS have good response to-steroid( prednisolone 1 mg/kg/day for 6wks ,then tapered.( over 4-6 monthsIf the patient have no response to sreroid do renalbiopsy(may be other pathology as focal segmental.( glomerulosclerosisPrognosis. : good
  • 5. Membranous Glomerulopathy.It‘s the most common cause of NS in adultsThere is nephrotic range proteinuria with bland.urinary sedimentHistopathologyThickening of GBM with granular deposits of IgG & complement.
  • 6. Aetiology •.A- Primary ( Idiopathic ( :The most common cause • B- Secondary •nfection.: hepatitis B , syphilisI- •Neoplasm: carcinoma of lung, stomach- • breastDrugs: captopril , gold , D-penicillamine- •disease:SLE,rheumatoidCollagen vascular- • . arthritis •
  • 7. Prognosisone-third remit spontaneously( spontaneous - (remission. one-third remain in nephrotic state -.one-third show progressive loss of renal function - -
  • 8. Management -A-good prognostic features)need )conservative manag - .children- -adults with non-nephrotic range proteinuria- -women younger than 40 years old with NS but with- -)normal renal function.&modest proteinuria)>9gm/d - B-poor prognostic features)need specific treatment -) like steroid & cytotoxic agents -) persisting severe proteinuria )<9gm/day- -.men older than 40 years with symotomatic NS- - . progressive renal failure- -
  • 9. Management of membranous Glomerulopathy A- Treatment of proteinuria .B- Treatment of complications of NS C- Steroid & other immunosupressant drugs
  • 10. Focal Segmental Glomerulosclerosis, Can occurs in children & adultsHistopathologyFocal & segmental collapse of capillary loops&mesangial sclerosisAetiology.A-primary (idiopathic (,collapsing glomerulopathyB-secondary, -Heroin abuseAIDS-.Reflux nephropathy -
  • 11. Collapsing Glomerulopathy.more common in black people-.massive proteinuria-.rapid progression to renal failure-.Prognosis of focal segmental glomerulosclerosis.Have poor prognosisprogress to chronic renal failure.(by about 10 60-70%) years
  • 12. Management of membranous Glomerulopathy A- Treatment of proteinuria .B- Treatment of complications of NS C- Steroid & other immunosupressant drugs
  • 13. Diabetic Nephropathy
  • 14. Diabetic Nephropathy:Renal complications of diabetes mellitus.diabetic nephropathy-1.frequent urinary tract infection-2autonomic neuropathy,may impaire bladder-3function& increase the risk of ascending.infection
  • 15. : Effects of renal impairment on DMdiabetic control become more difficult in renal-1impairment.( may develop hypoglycemia more.( frequently Isuline requirement decrease in diabetic patiens-2 with renal impairment , due to decrease tubular.metabolism of insulineIn renal failure it‘s better to avoid using metformine-3. & long acting sulphonylurea
  • 16. Diabetic NephropathyDiabetic nephropathy is an important cause of morbidity&mortality,&is among the most common cause of ESRDAbout 30% of patients with type 1 diabetes have.developed diabetic nephropathy after 20 years Risk factors for developing diabetic nephropathy.poor control of blood sugar -1.long duration of diabetes -2presence of other microvascular complications-3.pre-existing hypertention-4 family history of diabetic nephropathy-5.family history of hypertention-6
  • 17. Phases of diabetic nephropathy: There are 5 phases of diabetic nephropathyPhase 1Hyperfiltration , with an increased glomerularfiltration rate (GFR( & renal hypertrophy .the GFR then return to normalThis phenomenon is associated with an increasein intraglomerular pressure ( if persist may cause.( proteinuria in the future
  • 18. .Phase 2In this phase the patient may gradually develop glomerulosclerosis , with thickening of the glomerular capillary basement membrane & expantion of the collagen matrix within the mesangial region . Albumin excretion remains normal (< 30 mg/24 hr.( .Many diabetic patiens develop this , but, Progression to ESRD occur in those with poor glycemic control .
  • 19. Phase 3 In this phase there is.microalbuminuriaMicroalbuminuria is defined as an albumin excretion rate of.30 – 300 mg/ 24 hrDuring this phase of nephropathy , patients usually initiallyhave a normal GFR, which begins to fall as the.microalbuminuria increasesApproximately 80% of patients with sustainedmicroalbuminuria will develop clinical diabetic nephropathy. over the next 7 to 14 years: The decline into renal failure can be slowed by.good control of blood glucose level -1.good control of hypertention -2.use of angiotensin-converting enzyme inhibitors -3
  • 20. Phase 4, In this phase there isdipstick positive proteinuria . ( this correlates with an albumin excretion rate <300 mg/24hr( & During this phase , a progressive fall in GFR occurs. hypertension is common: Progression to renal failure can be slowed by. good control of hypertention-1.use of ACE-inhibitors-2 low – protein diet (0.6 to-3.) 0.8 g./kg./daymaintenance of near-euglycemia for prevention of diabetic*nephropathy is of less benefit ,since diabetic nephropathy is.now well established
  • 21. Phase 5End-stage renal disease . Occurs in mostpatients who develop clinical proteinuria due to. diabetic nephropathy.Dialysis is usually started at a GFR of 15 ml/minDiabetic patients should be referred to anephrologist when the serum creatinine risesabove 3mg/dl.(discussion regarding the need forhemodialysis versus peritoneal dialysis versus.( transplantation
  • 22. Histopathologically there are 2 types of: diabetic nephropathy.Diffuse glomerulosclerosis-1Nodular glomerulosclerosis-2.(kimmelstiel – wilson nodule(
  • 23. :Natural history of diabetic nephropathyIn the first few years of DM there is hyperfiltration-which declines to return to normal at about 10.years. After about 10 years there is sustained proteinuria-By approximately 14 years it has reached nephrotic-.range proteinuria. ESRDAt approximatelly 16 years it reach-
  • 24. Screaning for microalbuminuriaIn type 1 DM screaning for microalbuminuriashould be started annually from 5 years after.diagnosisIn type 2 DM screaning should be started annually.from time of diagnosis Other causes of proteinuria should be excluded asfever , exercise , heart failure , UTI ,prostatism ,. menstruation
  • 25. `Progression of diabetic nephropathy can: be reduced by.improve control of blood glucose -1Aggressive reduction -2 .of blood pressure Use ACEI therapy .(calcium channel blockers -3.( are the alternativesMicroalbuminuria in type 1 DM indicate thepresence of diabetic nephropathy & should betreated with ACE inhibitors regardless of wether. blood pressure is elevated or not

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