- A 55-year-old woman presented with swelling of the face and lower limbs for one month, as well as shortness of breath on exertion for 20 days and decreased appetite.
- Investigations showed nephrotic range proteinuria, hypoalbuminemia, and a renal biopsy consistent with minimal change disease.
- Minimal change disease should be considered and treatment involves corticosteroids, with frequent monitoring due to the risk of relapses.
Nephrotic syndrome made easy, it can help you a lot to learn the basics about Nephrotic Syndrome and for more information I recommend the Dr. Najeeb videos about nephrotic and nephritic syndrome.
Nephrotic syndrome made easy, it can help you a lot to learn the basics about Nephrotic Syndrome and for more information I recommend the Dr. Najeeb videos about nephrotic and nephritic syndrome.
Presented at Belfast City Hospital Physician's Meeting.
Topic - A case of Focal Segmental Glomerulosclerosis with all the complications of nephrotic syndrome and transplant recurrence of FSGS.
Nephrotic syndrome happens when damage to your kidneys causes these organs to release too much protein into your urine.
Nephrotic syndrome isn’t itself a disease. Diseases that damage blood vessels in your kidneys cause this syndrome.
Nephrotic syndrome is characterized by the following:
A high amount of protein present in the urine (proteinuria)
high cholesterol and triglyceride levels in the blood (hyperlipidemia)
Low levels of a protein called albumin in the blood (hypoalbuminemia)
Swelling (edema), particularly in your ankles and feet, and around your eyes.
Presented at Belfast City Hospital Physician's Meeting.
Topic - A case of Focal Segmental Glomerulosclerosis with all the complications of nephrotic syndrome and transplant recurrence of FSGS.
Nephrotic syndrome happens when damage to your kidneys causes these organs to release too much protein into your urine.
Nephrotic syndrome isn’t itself a disease. Diseases that damage blood vessels in your kidneys cause this syndrome.
Nephrotic syndrome is characterized by the following:
A high amount of protein present in the urine (proteinuria)
high cholesterol and triglyceride levels in the blood (hyperlipidemia)
Low levels of a protein called albumin in the blood (hypoalbuminemia)
Swelling (edema), particularly in your ankles and feet, and around your eyes.
This presentation focuses on main and most common oncological emergencies that are required by any stagiaire or junior doctor.
This presentation based on three books mainly, Davison’s principles and practice of medicine, pocket guide to oncological emergencies and ESMO hand book of oncological emergencies, in addition to some researches.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Nephrotic syndrome, Characterized by heavy proteinuria>3.5g/m/day in adults,>...FarsanaM
Nephrotic syndrome, in paediatric patients(children), mainly Minimal change nephrotic syndrome (MCNS),Characterized by heavy proteinuria>3.5g/m/day in adults,>1g/m/day in children, hypoalbuminemia <2.5g/dL, oedema, hyperlipidemia 200mg/dL, Pathogenesis of MMCNS injury to the glomerular visceral epithelial cell( Podocyte) foot processes
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
2. • A 55 yr old lady ms. Manju who is a known case
of hypertension since 8yrs and hypothyroidism
since 6 yrs was on tab. Losartan once daily and
tab thyronorm 50mcg once daily
• Admitted with a chief complaint of
• swelling of face and followed by swelling of both
the lower limbs since one month
• Dyspnea on exertion since twenty days
• Decrease in appetite
5. • D/d
• CHF
• Chronic liver disese
• Loss of protein in urine(? nephrotic synd )
• Protein losing enteropathy
• Decreased absorption of protein in the gut
11. • Renal biopsy description :
• Sections of renal tissue core show 8 glomeruli,
one of which appears sclerosed. The remaining
glomeruli show congestion and mild mesangial
expansion.
• Any segmental sclerosis, hypercellularity or
capillary basement membrane thickening is not
seen.
• No significant fibrosis is present.
• Few tubules are dilated and show presence of
hyaline casts
12. igG , igA, igM, C3, C1Q, fibrinogen : all
negative
Comments :
Minimal change disease needs to be considered
13. Approach to proteinuria
• The magnitude of proteinuria and its
composition in the urine depend on the
mechanism of renal injury that leads to
protein losses.
14. • Normally healthy individuals excrete <150
mg/d of total protein and <30 mg/d of
albumin.
15. MECHANISM OF PROTEINURIA
• Filtration of blood occurs in glomerulus.
• Glomerular filtration barrier consists of :
• -capillary endothelium
• -glomerular basement membrane
• -visceral epithelium with foot process
17. • 1) Glomerular :
• Predominantly selective loss of albumin (
mininal change disease)
• Loss of albumin and other plasma proteins (
immune complex deposition)
18. • 2) Tubular :
• Secreted by tubules , tamm horsfall, IgA,
urokinase , beta2 microglobulin , apoproteins ,
enzymes, and peptide hormones .
• Excessive production of abnormal protein in
• Multiple myeloma, amyloidosis, lymphomas
19. Detecting and quantifying proteinuria
• 1) DIPSTICK MEASUREMENT
• Detects only albumin.
• False positive :
• With Alkaline urine
• With highly concentrated urine
• With gross hematuria
• False negative :
• Dilute urine
20. • Proteinuria that is not predominantly due to
albumin will be missed by dipstick screening.
• Eg : bence jones proteins in patients with
multiple myeloma
21. • 2) albumin to creatinine ratio :
• Spot urine sample ( ideally from a first
morning void)
22. • 24-Hour Protein Excretion
• The 24-hour urine collection for protein excretion remains the reference
• (gold standard) method. It is based on chemical assay (e.g.,
• biuret or Folin-Lowry reaction), turbidimetric technique (e.g.,
trichloroacetic acid, benzethonium chloride, ammonium chloride), or
• dye-binding technique (e.g., ponceau S, Coomassie brilliant blue
• G-250, pyrogallol red molybdate), which quantify total proteins
• rather than simply albumin.
• The 24-hour protein excretion averages the variation of proteinuria
caused by the circadian rhythm and is the most accurate for monitoring of
proteinuria during treatment.
• However, it can be impractical in some settings (e.g., children, outpatients,
• elderly patients) and is subject to error from overcollection
• or undercollection.
23. • Microalbuminuria Defined as the presence of albumin in the urine
• in a range of 30 to 299 mg/24 h, microalbuminuria identifies
diabetic
• patients at increased risk of developing overt diabetic nephropathy.
• Also, in the general population, microalbuminuria identifies patients
• at increased risk of chronic kidney disease, cardiovascular
morbidity,
• and overall mortality.
• The 24-hour urine collection, initially considered
• the gold standard method for the detection of microalbuminuria,
• currently has been replaced by the use of early-morning urine,
• which minimizes the changes caused by diurnal volume variations.
• .
24. • A number of semiquantitative dipstick tests
are available to screen for microalbuminuria.
• Once microalbuminuria is found by dipstick, a
standard quantitative method is then used for
confirmation, usually immunoassay.
• Because of its great simplicity,
immunoturbidometry is the method most
frequently used
25. • Tubular Proteins
• Low-molecular-weight tubular proteins such as α1-
microglobulin, retinol-binding protein, and β2-
microglobulin are identified by a qualitative analysis of
urine proteins, using electrophoresis on cellulose acetate or
agarose after protein concentration
• or using very sensitive stains such as silver and gold.
• Sodium dodecyl sulfate–polyacrylamide gel electrophoresis
(SDS-PAGE) can be used to identify tubular proteins in the
urine of patients with glomerular diseases, which may have
therapeutic and prognostic implications.
26. • Selectivity of Proteinuria
• Selectivity can be assessed in nephrotic patients
by the ratio of the clearance of IgG (molecular
weight of 160,000 d) to the clearance of
transferrin (88,000 d).
• Although now used infrequently, highly selective
proteinuria (ratio <0.1) in nephrotic children
suggests the diagnosis of minimal change disease
and predicts corticosteroid responsiveness
31. Treatment of nephrotic syndrome
• Treat specific cause
• Treatment of complications
Hypertension
Proteinuria
Nephrotic edema
Thrombosis
Risk of infections
32. Minimal change disease in adults
• Most frequent cause of nephrotic syndrome in
children, but it is less common in adults
• Diffuse effacement of foot processes of
epithelial cells
• Dramatic response to corticosteroid therapy
33. Pathogenesis
• ?immune mediated
• ANGPTL (angiopoietin like protein) – having
high positive charge – deposited in Podocytes
• Secondary MCD – hodgkins lymphoma ,
NSAIDS
• Finnish type – nephrin mutations
34. Clinical course
• 75% of adults with MCD are steroid responsive
• >50% of adult MCD patients will experience
relapses
• Up to a third of patients may become FR or
SD.
• 10% of adult MCD patients are steroid-
resistant
35. • Steroid resistance – failure to achieve remission after 16 weeks of
steroid therapy
• Steroid dependence- Two consecutive relapses during
corticosteroid therapy, or within 14 days of ceasing therapy
• Frequent relapsers –not defined in adults
• Remission -uPCR <200 mg/g or <1+ of protein on urine dipstick for
3 consecutive days
• Relapse -uPCR >2000 mg/g or >3+ protein on urine dipstick for 3
consecutive days
38. FSGS
• Lesion is characterized by sclerosis of some,
but not all, glomeruli (thus, it is focal); and in
the affected glomeruli, only a portion of the
capillary tuft is involved (thus, it is segmental)
• IDIOPATHIC
• SECONDARY
40. HISTOPATHOLOGY
• Light microscopy - In the sclerotic segments-
collapse of basement membranes, increase in
matrix, and segmental insudation of plasma
proteins
• Electron microscopy-Both sclerotic and
nonsclerotic areas - diffuse effacement of foot
processes & focal detachment of the
epithelial cells with damage to underlying
GBM
42. Treatment
• Complete remission-↓ proteinuria to 300mg/d
or 300 mg/g of ACR
• Relapse - Proteinuria >3.5 g/d or >3500 mg/g of
ACR after complete remission has been obtained
• Steroid-dependent -Two relapses during or within
2 weeks of completing steroid therapy
• Steroid-resistant --Persistence of proteinuria
despite prednisone 1 mg/kg/d or 2 mg/kg every
other day for >4 months
43. Rx of Idiopathic FSGS
Initial treatment
• Prednisone - 1 mg/kg/d ( max 80 mg/d) or
A/D prednisone 2 mg/kg (up to 120 mg)
• For at least 4 weeks and for max of 4 months
• In case of a complete remission, taper
prednisone: e.g., reduce dose by 10mg per 2
weeks down to 0.15 mg/kg/d, then taper dose
every 2–4 weeks by 2.5 mg.
44. Rx of SR FSGS
• Therapy for SR FSGS
• Cyclosporine
• 3–5 mg/kg/d: in two divided doses (initial target levels 125–175 ng/ml
[104–146 nmol/l]); in case of a remission continue treatment for 1 year
then try to slowly taper cyclosporine: reduce cyclosporine dose by 25%
every 2 months. If no remission by 6 months, discontinue cyclosporine
treatment.
• Or
• Tacrolimus
0.1–0.2 mg/kg/d in two divided doses (initial target levels 5–10 ng/ml
[6–12 nmol/l]); in case of remission see advice for cyclosporine.
• And
• Prednisone
0.15 mg/kg/d for 4–6 months, then taper off over 4–8 weeks.
45. Membranous nephropathy
• Common cause of the nephrotic syndrome in
adults. ( 25-30% of cases)
• MC cause of Nephrotic syndrome in elderly
• Diffuse thickening of the glomerular capillary
wall and the accumulation of electron-dense,
Ig deposits along the subepithelial side of the
basement membrane
46. • Peak incidence – 30-50 years
• M:F -2:1
• 70-75% of cases idiopathic or primary
• 25-30 % of cases associated with malignancies
, infections, autoimmune diseases
47. Pathogenesis
• Immune complex mediated
• Resembles experimental model of heymann
nephritis
• Newer studies – Idiopathic MGN – antibodies
to phospholipase A2 receptor
48. Histopathology
• Light microscopy- Thickening of the basement
membrane along the peripheral capillary
loops
• Electrom microscopy-Electron-dense
subepithelial deposits
• Immunoflorescence-diffuse granular deposits
of IgG and C3
• IgG 4 predominant in Idiopathic MGN
49. Course
• 20-33% of cases – spontaneous remission
• 30% - relapsing with normal renal function
• 30% - renal failure
• MGN – highest incidence of thrombotic
complications
50. Treatment of Idiopathic MGN
• First 6 months – supportive with
antihypertensives & antiproteinuric drugs
• Monitoring of serum creatinine, eGFR, urine
protein excretion , for other compliactions of
NS
51. Indications of immunosuppression
• urinary protein excretion persistently exceeds
4 g/d AND remains at over 50% of the
baseline value, AND does not show
progressive decline, during antihypertensive
and antiproteinuric therapy of at least 6
months
• The presence of severe, disabling, or
lifethreatening symptoms related to the
nephrotic syndrome
52. Indications of immunosuppression
• SCr has risen by 30% or more within 6 to 12
months from the time of diagnosis AND this
change is not explained by superimposed
complications.
53. Immunosuppression
• Initial therapy consist of a 6-month course of
alternating monthly cycles of oral and i.v.
corticosteroids, and oral alkylating agents
• Manage conservatively for at least 6 months
following the completion of this regimen
before being considered a treatment failure if
there is no remission,
54.
55. • Complete Remission: Urinary protein
excretion<0.3 g/d (uPCR<300 mg/ g ),
confirmed by two values at least 1 week apart,
accompanied by a normal serum albumin
concentration, and a normal SCr.
56. Alternate regimen
• Cyclosporine: 3.5–5.0 mg/kg/d given orally in two
equally divided doses 12 hours apart, with
prednisone 0.15 mg/kg/d, for 6 months.
• Tacrolimus: 0.05–0.075 mg/kg/d given orally in
two divided doses 12 hours apart, without
prednisone, for 6–12 months.
• *Discontinue CNIs in patients who do not
achieve complete or partial remission after 6
months of treatment.
57. Treatment of resistant cases
• In case of relapse – we can use primary
regimen which induced remission
• In case of resistance – we can use alternate
regimen
58. • Patients with IMN and nephrotic syndrome,
with marked reduction in serum albumin (<2.5
g/dl ) and additional risks for thrombosis, be
considered for prophylactic anticoagulant
therapy, using oral warfarin.
59. MPGN
• Characterized histologically by alterations in
the basement membrane, proliferation of
glomerular cells, and leukocyte infiltration
• Also called as mesangiocapillary GN
• Accounts for 10% to 20% of cases of nephrotic
syndrome in children and young adults
61. Pathogenesis
• Type 1 is mainly due to ag-ab complex mediated
• Type 2 & 3 – due to activation of alternate
pathway of complement
• Light microscope – GBM thickening & mesangial
proliferation in both types & double contour
/tram track app in type 1
• Electron microscopy- subendothelial deposits in
type 1 & dense deposits along GBM in type 2
62. Treatment
• Idiopathic MPGN with nephrotic syndrome
AND progressive decline of kidney function -
oral cyclophosphamide or MMF plus low-dose
alternate-day or daily corticosteroids with
initial therapy limited to less than 6 months.
• There is very low–quality evidence to suggest
the benefit
63. Diabetic nephropathy
• Diabetic nephropathy is the single most
common cause of chronic renal failure
accounting for 45% of patients receiving RRT
• 40% of patients with types 1 or 2 diabetes
develop nephropathy
• Risk factors -Hyperglycemia, hypertension,
dyslipidemia, smoking, a family history of
diabetic nephropathy
65. Pathogenesis
• Thickening of the glomerular capillary
basement membrane
• Diffuse increase in mesangial matrix. There
can be mild proliferation of mesangial cells.
• Kimmelstiel-Wilson disease OR nodular
glomerulosclerosis
67. • Screening for microalbuminuria -5 years after
diagnosis in type 1 DM, at the time of
diagnosis in type 2 DM
• More than 90% of patients with type 1
diabetes and DN have DR
• Only 60% of patients with type 2 diabetes
with nephropathy have DR
• Patients with advanced DN have normal to
enlarged kidneys
68. Treatment
• (1) Normalization of glycemia
• (2) Strict blood pressure control
• (3) Administration of ACE inhibitors or ARBs