Minimal change disease (MCD) is a histologic pattern seen on kidney biopsy that is characterized by nephrotic syndrome without immune deposits or inflammation. It is most common in children but can occur in adults. The pathogenesis involves circulating permeability factors that cause foot process effacement and proteinuria. MCD is highly responsive to steroids, with remission occurring in 80-85% of adults, though relapses are common. Treatment involves corticosteroids, with slower tapers needed in adults to minimize relapses. Refractory cases may require additional immunosuppression. The prognosis is generally excellent if the disease is steroid-responsive.
download link : https://www.dropbox.com/s/xc0fpdul47g1gu8/IgA%20Nephropathy.ppt?m
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Brief explanation of each *refer harrison textbook for details causes of TIN
Acute interstitial nephritis
Chronic interstitial nephritis
Reflux nephropathy
Papillary necrosis
Sickle-cell nephropathy
lupus nephritis is a autoimmune disease, commonly seen in adult and child and the medical or nursing care is also very important for this type of disease condition.
download link : https://www.dropbox.com/s/xc0fpdul47g1gu8/IgA%20Nephropathy.ppt?m
Join us on our facebook group: NephroTube...............Follow our blog: www.nephrotube.blogspot.com
Brief explanation of each *refer harrison textbook for details causes of TIN
Acute interstitial nephritis
Chronic interstitial nephritis
Reflux nephropathy
Papillary necrosis
Sickle-cell nephropathy
lupus nephritis is a autoimmune disease, commonly seen in adult and child and the medical or nursing care is also very important for this type of disease condition.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
Nephrotic syndrome is a clinical state characterized by : Massive proteinuria ( > 40 mg /m²/hour), Hypoalbuminaemia ( < 2.5 gm/dl), Generalized edema, Hyperlipidemia ( S. cholesterol >250 mg /dl). 60%-80% present before 6 years. MCNS most commonest type of nephrotic syndrome , about 85% of idiopathic nephrotic syndrome.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. introduction
First described in 1913 by Munk , who called it lipoid
nephrosis due to lipids in tubular epithelial cells and urine.
More common in children
-70-90% cause of nephrotic synd. In kids <10 yrs
- 50 % of nephrotic synd in kids 10-18 yrs
-10-25 % primary nephrotic synd in adults , 3rd most
common after FSGS and MN
Boys > girls
3. More common in asia then in europe and america.
MCD usually presents as a primary renal disease but can
be associated with several other conditions
- Hodgkin’s disease
- allergies
- use of nonsteroidal anti-inflammatory agent
4. Pathophysiology
Shalhoub, in 1974, proposed that MCD is caused by a
circulating factor, thought to be a cytokine, that
increases the permeability of the glomerular basement
membrane (GBM) to plasma proteins
5.
6. MCD might represent aT cell disorder based on
-the lack of immune deposits,
-the rapid response to corticosteroids,
-the association with Hodgkin disease (aT cell neoplasm),
- and the observation that remission often occurred during
resolution of measles infection, which is associated with a
transient inhibition of cell-mediated immunity
7. B cell disorder
initially thought to be uninvolved but recent studies
showing response to Rituximab (B20 monoclonal antibody)
suggest Bcell involvement producing permeability factors
in circulation.
8. Circulating Factor(s)
1. Cytokines - IL-8 , IL-13 . podocytes possess IL- 13R and
stimulation of cultured monolayer podocytes with IL-13
lead to decreased transepithelial electrical resistance.
IL13 expression is upregulated inT cells in children with
steroid sensitive nephrotic synd. in relapse.
9. 2. Hemopexin- synthesized in the liver and is present in
human plasma of patients with MCD which, when
infused into the isolated rat kidney, induced proteinuria
by increased glomerular permeability.
patients with relapse shows increased level hemopexin
proteinase activity.
10. 3. Microbial Products- 70% of MCD patients with relapse
have documented viral or bacterial respiratory infections.
-TwoToll-like receptor (TLR) ligands
- lipopolysaccharide (LPS)
- a component of the outer membrane of gram-negative
bacteria
- polyinosinic-polycytidylic acid (poly IC)
- viral-like particle
11. Bind toTLR-4 andTLR-3 on podocytes, respectively, and
cause proteinuria in animals with podocyte expression of
CD80 and increased urinary CD80 excretion, mimicking
findings observed in MCD patients during relapse.
12. Mechanisms of proteinurea
Loss of Anionic Charges in the Glomerular Filtration
Barrier as a Cause of Minimal Change Disease –
Heparan sulfate proteoglycans, which are the major
source of anionic sites in the GBM, are reported to be low
or normal in the GBM of MCD patients.
13. Podocyte Dysfunction as a Cause of Minimal Change
Disease –
- Alteration of slit diaphragm proteins such as reduced
nephrin phosphorylation 19 & alteration in integrin-mediated
podocyte adhesion .
-Podocyte expression of two molecules, CD80 (also known as
B7.1) andangiopoietin-like-4 (Angptl-4) also have been
proposed .
14.
15. 1. CD80
CD80 is a co-stimulatory molecule present on antigen-
presenting cells that was found to be expressed on podocytes
in children with MCD. It also can be induced in podocytes both
byTLR ligands, with the development of transient proteinuria
and focal foot process effacement. High levels of CD80 also can
be found in the urine of children with steroid-sensitive MCD
16. CD80 is regulated by cytotoxicT lymphocyte–associated
antigen 4 (CTLA-4) (expressed by podocytes)
viral components stimulateTLR-3 podocyte receptors,
resulting in overexpression of podocyte CD80. Because of an
inadequate CTLA4 response by the podocyte, the increased
expression of CD80, by interfering with phosphorylation of
nephrin, could lead to changes in podocyte shape affecting
the “size barrier “
17. 2. Angiopoietin-like-4 (Angptl-4) –
-glomerular over expression of angptl4 and podocin
marked loss of GBM heparan sulfate proteoglycans,
podocyte foot process effacement, and albuminuria .
18. MCD is the most common type of nephrotic syndrome in
patients with Hodgkin disease <1%.
-C-MIP is overexpressed in Reed-Steinberg cells and
podocytes. C-MIP appears to mediate podocyte injury by
preventing the interaction of nephrin with the tyrosine
kinase
-decreased phosphorylation of nephrin
-cytoskeleton rearrangement and proteinuria
20. Clinical features
Most frequently the presenting symptom of MCD is
nephrotic syndrome characterized by edema, periorbital, of
the scrotum or labia, and of the lower extremities.
Nephrotic Syndrome
-Edema
-Massive proteinuria (.40 mg/m2 per h in children, .3.5 g/d in
adults)
-Hypoalbuminemia (,2.5 g/dl)
- Hyperlipidemia
21. Anasarca may develop with ascites and pleural and
pericardial effusion (serum albumin levels below 2 g/dl),
leading to abdominal pain because of hypoperfusion
and/or thrombosis, dyspnea (rarely), and cold extremities
with low BP.
22. Intravascular volume depletion and oliguria are also present,
and concomitant factors (sepsis, diarrhea, diuretics) can lead
to AKI (common in adolescents and young adults )
Gross hematuria –rare (3%)
HTN (50% in adults)
Abdominal pain and nausea
23. AKI with MCD
-Mostly in adults older than age 40
-Marked decrease in glomerular permeability due to
extensive foot process effacement, tubular obstruction
from proteinaceous casts, and intrarenal hemodynamic
change and increased endothelin-1 expression in the
kidneys
-AKI with gross hematuria followed by anuria can also be
secondary to bilateral renal vein thrombosis.
24. Lab findings
Nephrotic range proteinuria is defined as greater than 3.5
g/24 h
Hypoalbuminemia serum level of albumin below 2.5 g/dl
Hyperlipidemia (elevated total cholesterol and low-density
lipoprotein[LDL] cholesterol)
acute kidney injury (AKI) with oliguria secondary to
reduction of intravascular compartment
Mild hyponatremia
25. Low serum calcium and vitamin D levels
Elevated hemoglobin and hematocrit levels and
thrombocytosis
Elevated srum c3 level.
27. Light microscopy
Usually normal
Sometime minimal focal segmental prominence limited
to 3-4 cells in matrix of segment may be seen
This mesangial prominence should have no more than
three or four cells embedded in the matrix of a segment,
and the matrix should not be expanded to the extent that
capillary lumens are compromised
28. Lipid and protien deposits in tubular cells stain with PAS stain
Areas of interstitial fibrosis and tubular atrophy raise possibilty
of FSGS
Focal proximal tubular epithelial flattening (simplification),
which is histologically identical to that seen with ischemic AKI,
occurs in patients who have the syndrome of MCD with AKI
29.
30. Immunoflourance
No staining with IgG , IgM, IgA, C3, C4 or C1q
Low level mesangial staining for IgM can be seen but
without mesangial electron dense deposits on EM
Effacement of foot process seen in EM which diminish as
diseases remits.
Due to increased lipid absorption intracytoplasmic
densities can be seen.
Findings non specific and seen in nephrotic range
protienuria.
31. Electron microscopy
During active nephrosis, the effacement often is very
extensive, with only a few scattered intact foot
processes. As the patient enters remission, the extent of
foot process effacement diminishes.
MCD is a diagnosis by exclusion that is made only when
there is no evidence by light, immunofluorescence, and
electron microscopy for any other glomerular disease
32.
33. MCD vs FSGS
Primary FSGS diagnosis requires biopsy findings of
segmental glomerusclerosis in at least 1 glomerulus in
addition to diffuse foot process effacement
Sclerotic changes appear first at the juxtamedullary
glomeruli, which may not be seen in a biopsy sample
containing only outer cortex or with <8 glomeruli on biopsy .
Patients responding poorly to steroids and progressing to
ESRD are thought to have been missed FSGS at initial
diagnosis.
34.
35.
36. Treatment
General considerations
-low sodium diet
- Avoid bed rest because of the increased risk for
thromboembolic events.
- diuretics are often used to control extracellular fluid
volume
- thrombosis prophylaxis
-statins for hyperlipidemia (rarely used)
37. MCD is highly steroid responsive and carries an
excellent prognosis
Steroid therapy leads to complete remission in 80-85 %
of adults with MCD
Corticosteroid exert direct protection of podocytes from
injury and/or promotion of repair
38. Adults are not considered steroid-resistant until after 4
months
The time course to a complete remission is prolonged,
with 50 % responding by four weeks and 10 to 25 %
requiring more than three to four months of therapy
relapses occurring in about 56%–76% of patients
39.
40. Steroid dependence is seen in 25 to 30 %
Remissions are typically abrupt, with the patient being
free of proteinuria within two to three weeks from the
time of initial response .
10%–20% of adults with MCD are resistant, and a repeat
renal biopsy in these patients may show FSGS
41.
42. Studies failed to show a significant benefit of intravenous
methylprednisolone (20 mg/kg per day for 3 days)
followed by reduced-dose oral steroids (prednisone 0.5
mg/kg per day) versus full-dose oral steroids alone
(prednisone 1 mg/kg per day).
43. Yeung et al
- of intravenous methylprednisolone (20 mg/kg per day
for 3 days followed by a 2-week steroid-free period and
oral prednisolone at 0.5 mg/kg)
- oral prednisolone (1 mg/kg per day for 4–6 weeks
followed by a taper).
44. N 18 @ 2 weeks
- IV methyl pred * 3day - 3 of 10 remission
- oral prednisolone – 5 of 7 remission
nonresponders in the iv m-pred- received oral
prednisolone (1 mg/kg per day) ---5 of 7 remission.
1 mth all patients on oral prednisolone – remission.
45. controversial issue for therapy since slow tapering may
increase cumulative steroid doses, but rapid tapering may
expose patients to the risk of relapses .
taper prednisone by 5–10 mg/wk after remission over 8
weeks for a total 24-week period of exposure to prednisone
48. The rate of dose tapering and total length of treatment
of the initial episode may need to be reduced in
individual patients if steroid toxicity is significant (e.g.,
uncontrolled diabetes, psychiatric complications, patient
with severe osteoporosis)
49. frequent replapsing/ steroid dependent
Rituximab may be effective therapy in adults
with frequently relapsing or glucocorticoiddependent
MCD. Its suggested rituximab therapy be attempted in
such patients who have also failed to attain a durable
remission with cyclophosphamide or calcineurin
inhibitors.
50. Steroid resistant MCD
Approx 10-20% of patients
-Re-evaluate patients who are corticosteroid resistant for
other causes of nephrotic syndrome
-IV steroid can be tried
-Cyclosporine can be started in combination
with steroid
51. Other Immunomodulatory Treatments for FR,
SD, orSteroid-Responsive Disease
use of levimasole not reported in adults
In MCD with AKI
- dialysis
-Albumin infusion may be considered if there is evidence
of severe intravascular volume depletion with severe
hypoalbuminemia
52. Take home message
MCD is a histologic picture than does not correspond to a
single disease entity
MCD is highly steroid responsive and carries an
excellent prognosis
With longer treatment duration and slower tapers
required compared with children to attain remission and
minimize relapses
Adults with MCD that are steroid resistant repeat renal
biopsy in these patients may show FSGS
54. Refrence
TheTreatment of Minimal Change Disease in Adults Jonathan Hogan and Jai
Radhakrishnan Division of Nephrology, Columbia University Medical Center, New
York, NewYork
Minimal Change Disease
MarinaVivarelli,* Laura Massella,* Barbara Ruggiero,† and Francesco Emma*
Harrison 20°
Comprehensive Clinical Nephrology 6e
KDIGO guidelines