Membranous nephropathy

RENAL FEATURES OF SLE/SLE NEPHRITIS. Lupus nephritis is inflammation of kidneys caused by SLE.Systemic lupus erythematosus is an auto immune disease in which the body's immune system attacks the body's own cells and organs.SLE nephritis gets worse over time and leads to renal failure. Lupus is more common in woman than in men. 9 out of 10 lupus patients are women.It most often strikes during child bearing years.Lupus is also more common in poeple of asian or african background. SYMPTOMS OF LUPUS NEPHRITIS. 1.Sudden ,unexplained swelling ,especially in the extremities-feet,ankles,legs,fingers,arms or eyes. 2.Hematuria. 3.Elevated blood pressure. 4.Foamy appearance in urinedue to proteinuria 5.Increased urination ,especially at night. HYPERTENSION,HEMATURIA,PROTEINURIA, EDEMA &WEIGHT GAIN CLASSIFICATION OF LUPUS NEPHRITIS. Lupus nephritis is staged according to the classification revised by the international society of nephrology (ISN) amd Renal pathology society (RPS).in 2003.The classification is based on light microscopy, immunoflorescence and electron microscopy findings from renal biopsy specimens. ISN/RPS CLASSIFICATION CLASS I : MINIMAL MESANGIAL LUPUS NEPHRITIS. Histological features. *Normal glomeruli on light microscopy. *Mesangial immune deposits on immunoflorescence. CLASS II : MESANGIAL LUPUS NEPHRITIS. Histological features. Mesangial hypercellularity with mesangial immune deposits on immunoflorescence. CLASS III : FOCAL PROLIFERATIVE. LUPUS NEPHRITIS. Histological features. Focal proliferative glomerulonephritis involving <<50% of glomeruli.,typically with focal sub- endothelial immune deposits and leucocyte infiltration. CLASS IV : DIFFUSE PROLIFERATIVE LUPUS NEPHRITIS. Histological features. Diffuse proliferative glomerulonephritis involving >>>50 % of glomeruli ,typically diffuse sub -endothelial immune deposits. CLASS V : MEMBRANOUS LUPUS NEPHRITIS Histological features. Thickening of capillary walls. Global/segmental sub-epithelial immune deposits. CLASS VI : ADVANCED SCLEROSIS LUPUS NEPHRITIS. Histological features. Irreversible advanced disease. >>>90 % glomerulosclerosis. PATHOPHYSIOLOGY OF SLE Multiple influences are thought to underlie the pathogenesis of SLE like 1.Genetic factors. 2.Epigenetic modifications. 3.Environmental triggers. 4.Hormonal influences. 5.Aberrant immune mechanismslike Adaptive immune dysfunction. Innate immune dysfunction. LABORATORY DIAGNOSIS. Laboratory tests to evaluate renal function in SLE are 1.Blood urea nitrogen (BUN ) testing. 2.Serum creatinine assessment. 3.Urine analysis - to check for protein,RBC casts, and cellular casts. 4.Spot urine test for creatinine and protein concentration. Laboratory tests to evaluate SLE disease activity are 1.Antibodies to double stranded DNA (ds DNA) 2.Complement(C3,C4,and CH50.). 3.ESR. 4.C-reactive protein.(CRP). RENAL BIOPSY is considered in any patient with SLE who has clinical or laboratory evidence of active nephritis ,especially upon the first episode of nephritis . MANAGEMENT. THE PRINCIPAL GOAL OF THERAPY IN LUPUS NEPHRITIS IS TO NORMALISE RENAL FUNCTION OR,ATLEAST ,TO PREVENT THE PROGRESSIVE LOSS OF RENAL FUNCTION. Key points of American college of Rheumatology guidelines for managing lupus nephritis are as follows 1.Patients with clinical evidence of active, previously untreated lupus nephritis should have a RENAL BIOPSY to classify the disease according to ISN/RPS criteria. 2.All patients with lupus nephritis should receive background therapy with HYDROXYCHLOROQUINE ,unless contra indicated. 3.GLUCOCORTICOIDS along with CYCLOPHOSPHAMIDE intra venously (OR ) MYCOPHENOLATE MOFETIL orally should be administered to Patients with CLASS III/IV disese. Patients with class I/II nephritis do not require immunosuppressant therapy. 4.ACE INHIBITORS/ANGIOTENSIN RECEPTOR BLOCKERS should be administered if proteinuria exceeds 0.5 gm/day. 5.B.P should be maintained below 130/80 mm Hg. Patients with CLASS V. lupus nephritis are generally treated with prednisone for 1-3months ,followed by tapering for 1-2 years , if a response occurs. INVESTIGATIONAL THERAPIES FOR SLE NEPHRITIS. 1.Rituximab 2.Other anti-CD20 monoclonal antibodies like Ocrelizumab. Ofatumumab. Epratuzumab. TRU-015. 3.Belimumab. 4.Atacicept. 5.Abetimus. 6.Anti-cytokine therapies. Patients with end stage renal disease require DIALYSIS and are good candidates for RENAL TRANSPLANTATION.Hemodialysis is preferred to peritoneal dialysis. MY DOUBT: WONT THAT TRANSPLANTED KIDNEY BE AFFECTED BY SLE?????

What Is Kidney Failure? Your kidneys are pair of organs located toward your lower back. One kidney is on each side of your spine. They filter your blood and remove toxins from your body. Your kidneys send toxins to your bladder. Your body later removes toxins during urination. Kidney failure occurs when your kidneys lose the ability to filter waste from your blood sufficiently. Many factors can interfere with your kidney health and function, such as: toxic exposure to environmental pollutants certain acute and chronic diseases severe dehydration kidney trauma Your body becomes overloaded with toxins if your kidneys can’t do their regular job. This can lead to kidney failure and even be life-threatening if it’s left untreated. What Causes Kidney Failure? People who are most at risk for kidney failure usually suffer from one or more of the following causes: Loss of Blood Flow to the Kidneys A sudden loss of blood flow to your kidneys can prompt kidney failure. Some diseases and conditions that cause loss of blood flow to the kidneys include: a heart attack heart disease scarring of the liver or liver failure dehydration a severe burn an allergic reaction a severe infection, such as sepsis Blood pressure and anti-inflammatory medications can also limit blood flow. Urine Elimination Problems When your body can’t eliminate urine, toxins build up and overload the kidneys. Some cancers can block the urine passageways. These include prostate (most common type in men), colon, cervical, and bladder cancers. Other conditions can interfere with urination and possibly lead to kidney failure, including: kidney stones an enlarged prostate blood clots within your urinary tract damage to the nerves that control your bladder Other Causes Some diseases and conditions may lead to kidney failure, including: a blood clot in or around your kidneys infection an overload of toxins from heavy metals drugs and alcohol vasculitis, which is an inflammation of blood vessels lupus, which is an autoimmune disease that can cause inflammation of many body organs glomerulonephritis, which is an inflammation of the small blood vessels of the kidneys hemolytic uremic syndrome, which involves the breakdown red blood cells following a bacterial infection, usually of the intestines multiple myeloma, which is a cancer of the plasma cells in your bone marrow scleroderma, which is an autoimmune disease that affects your skin thrombotic thrombocytopenic purpura, which is a disorder that causes blood clots in small vessels chemotherapy drugs, which are medications that treat cancer and some autoimmune diseases dyes used in some imaging tests certain antibiotics

30yrs old male patient in our nephro ward jj hospital, patient had b/l pedal edema, low back pain radiating to foots, systolic bp always below 100mmhg Investigation creatine- borderline high ANA- positive dsDNA- positive C3 ,C4- decreased 24hrs urine protein- 1 GM usg- normal kidney sizes URM- had UTI but now resolved Renal biopsy done - sample send for LM, IF, EM reports awaited we start tab Prednisone and tab MMF we are suspecting as case of glomerulonephritis, what further treatment will require ??, because his edema is not resolved..

60 year old female patient, blood sugar fasting 155 mg/dl pp 186 mg/dl HbA1c is 6.8...what does this report of microalbumin creatinine ratio denotes please give your valuable openion

Hepatitis *Hepatitis* refers to an inflammatory condition of the liver. It’s commonly caused by a viral infection, but there are other possible causes of hepatitis. These include autoimmune hepatitis and hepatitis that occurs as a secondary result of medications, drugs, toxins, and alcohol. Autoimmune hepatitis is a disease that occurs when your body makes antibodies against your liver tissue.  Timeline 8th Century:  Infectious Nature of HBV suggested 17th-19th Centuries:  Outbreaks of epidemics of jaundice in military and civilian populations during wars 1883:  Lurman reports outbreaks of serum hepatitis follwing vaccination of dockers 1908: McDonald postulates that the infectious jaundice is caused by a virus 1939-1945: WWII-A series of outbreaks after vaccination for measles and yellow fever 1947: MacCallum classifies viral hepatitis into two types- Viral hepatitis A—> Infectious hepatitisViral hepatitis B—> Serum hepatitis 1965: Blumberg discovers Australia antigen (HBsAg) in aborigines and shows presence of antigen at high frequency in patients with leukemia and children with Down’s syndrome 1970: Dane discovers the Dane particle (complete HBV particle) 1972: Discovers HBeAg 1973: Feinstone and Purcell identifies HAV 1977: Rizzetto describes delta antigen HDV 1983: Recovery of HEV 1988: Chiron group (Choo, Kuo, Houghton) closes and identifies HCV. 1995: Abbot group reports GB Virus-C (GBV-C) and Genelabs group reports in 1996 hepatitis G virus (HGV)—GBV-C=HGV 1996: Chang’s group at NTUH reports in JAMA the successful prevention of HBV infection by nation-wide vaccination on newborn babies launched in 1984 in Taiwan. 1997: Chang’s group at NTUH reports in NEJM a decrease in annual incidence rate of hepatocellular carcinoma in children ascribed to nation-wide vaccination against HBV on newborn babies launched in 1984 in Taiwan. Epidemiology Globally, viral It was the seventh leading cause of death in 2013, up from the 10th leading cause in 1990. Worldwide, HAV is responsible for an estimated 1.4 million infections annually.  About 2 billion people in the world have evidence of past or current HBV infection, with 240 million chronic carriers of HBsAg. HBV, along with the associated infection by the hepatitis D virus, is one of the most common pathogens afflicting humans. HBV leads to 650,000 deaths annually as a result of viral hepatitis–induced liver disease. The worldwide annual incidence of acute HCV infection is not easily estimated, because patients are often asymptomatic. An estimated 71 million people are chronically infected with HCV worldwide.  About 55-85% of these people infected progress to chronic HCV infection, with a 15-30% risk of developing liver cirrhosis within two decades.  China, the United States, and Russia have the largest populations of anti-HCV positive injection drug users (IDUs). It is estimated that 6.4 million IDUs worldwide are positive for antibody to hepatitis B core antigen (HBcAg) (anti-HBc), and 1.2 million are HBsAg-positive. Types and causes Viral infections of the liver that are classified as hepatitis include hepatitis A, B, C, D, and E. A different virus is responsible for each type of virally transmitted hepatitis. Hepatitis A is always an acute, short-term disease, while hepatitis B, C, and D are most likely to become ongoing and chronic. Hepatitis E is usually acute but can be particularly dangerous in pregnant women. Hepatitis A Hepatitis A is caused by an infection with the hepatitis A virus (HAV). This type of hepatitis is most commonly transmitted by consuming food or water contaminated by feces from a person infected with hepatitis A. Hepatitis B Hepatitis B is transmitted through contact with infectious body fluids, such as blood, vaginal secretions, or semen, containing the hepatitis B virus (HBV). Injection drug use, having sex with an infected partner, or sharing razors with an infected person increase your risk of getting hepatitis B. It’s estimated by the CDC that 1.2 million people in the United States and 350 million people worldwide live with this chronic disease. Hepatitis C Hepatitis C comes from the hepatitis C virus (HCV). Hepatitis C is transmitted through direct contact with infected body fluids, typically through injection drug use and sexual contact. HCV is among the most common bloodborne viral infections in the United States. Approximately 2.7 to 3.9 million Americans are currently living with a chronic form of this infection. Hepatitis D Also called delta hepatitis, hepatitis D is a serious liver disease caused by the hepatitis D virus (HDV). HDV is contracted through direct contact with infected blood. Hepatitis D is a rare form of hepatitis that only occurs in conjunction with hepatitis B infection. The hepatitis D virus can’t multiply without the presence of hepatitis B. It’s very uncommon in the United States. Hepatitis E Hepatitis E is a waterborne disease caused by the hepatitis E virus (HEV). Hepatitis E is mainly found in areas with poor sanitation and typically results from ingesting fecal matter that contaminates the water supply. This disease is uncommon in the United States. However, cases of hepatitis E have been reported in the Middle East, Asia, Central America, and Africa, according to the CDC. Autoimmune Hepatitis Autoimmune hepatitis is a rare form of chronic hepatitis. Like other autoimmune disorders, its exact cause is unknown. Autoimmune hepatitis may develop on its own or it may be associated with other autoimmune disorders, such as systemic lupus erythematosus. In autoimmune disorders, a misdirected immune system attacks the body’s own cells and organs (in this case the liver). Symptoms When symptoms occur, they can include: Jaundice (a yellowing of the skin and eyes)Abdominal painLoss of appetiteNausea and vomitingDiarrheaFeverClay-colored bowel movementsPainful joints  Yellowing of skin and eye  Complications of hepatitis Chronic hepatitis B or C can often lead to more serious health problems. Because the virus affects the liver, people with chronic hepatitis B or C are at risk for: Chronic liver diseaseCirrhosisLiver cancer When your liver stops functioning normally, liver failure can occur. Complications of liver failure include: Bleeding disordersA buildup of fluid in your abdomen, known as ascitesIncreased blood pressure in portal veins that enter your liver, known as portal hypertensionKidney failureHepatic encephalopathy , which can involve fatigue, memory loss, and diminished mental abilities due to the buildup of toxins, like ammonia, that affect brain functionHepatocellular carcinoma, which is a form of liver cancerDeath People with chronic hepatitis B and C are encouraged to avoid alcohol because it can accelerate liver disease and failure. Certain supplements and medications can also affect liver function. If you have chronic hepatitis B or C, check with your doctor before taking any new medications. Diagnosis and test History and physical exam To diagnose hepatitis, first your doctor will take your history to determine any risk factors you may have for infectious or noninfectious hepatitis. During a physical examination, your doctor may press down gently on your abdomen to see if there’s pain or tenderness. Your doctor may also feel to see if your liver is enlarged. If your skin or eyes are yellow, your doctor will note this during the exam. Liver function tests Liver function tests use blood samples to determine how efficiently your liver works. Abnormal results of these tests may be the first indication that there is a problem, especially if you don’t show any signs on a physical exam of liver disease. High liver enzyme levels may indicate that your liver is stressed, damaged, or not functioning properly. Other blood tests If your liver function tests are abnormal, your doctor will likely order other blood tests to detect the source of the problem. These tests can check for the viruses that cause hepatitis. They can also be used to check for antibodies that are common in conditions like autoimmune hepatitis. Ultrasound An abdominal ultrasound uses ultrasound waves to create an image of the organs within your abdomen. This test allows your doctor to take a close at your liver and nearby organs. It can reveal: Fluid in your abdomenLiver damage or enlargementLiver tumoursAbnormalities of your gallbladder Sometimes the pancreas shows up on ultrasound images as well. This can be a useful test in determining the cause of your abnormal liver function. Liver biopsy A liver biopsy is an invasive procedure that involves your doctor taking a sample of tissue from your liver. It can be done through your skin with a needle and doesn’t require surgery. Typically, an ultrasound is used to guide your doctor when taking the biopsy sample. This test allows your doctor to determine how infection or inflammation has affected your liver. It can also be used to sample any areas in your liver that appear abnormal. Treatment and medications Treatment options are determined by which type of hepatitis you have and whether the infection is acute or chronic. Hepatitis A Hepatitis A usually doesn’t require treatment because it’s a short-term illness. Bed rest may be recommended if symptoms cause a great deal of discomfort. If you experience vomiting or diarrhea , follow your doctor’s orders for hydration and nutrition. The hepatitis A vaccine is available to prevent this infection. Most children begin vaccination between ages 12 and 18 months. It’s a series of two vaccines. Vaccination for hepatitis A is also available for adults and can be combined with the hepatitis B vaccine. Hepatitis B Acute hepatitis B doesn’t require specific treatment. Chronic hepatitis B is treated with antiviral medications. This form of treatment can be costly because it must be continued for several months or years. Treatment for chronic hepatitis B also requires regular medical evaluations and monitoring to determine if the virus is responding to treatment. Hepatitis B can be prevented with vaccination. The CDC recommends hepatitis B vaccinations for all newborns. The series of three vaccines is typically completed over the first six months of childhood. The vaccine is also recommended for all healthcare and medical personnel. Hepatitis C Antiviral medications are used to treat both acute and chronic forms of hepatitis C. People who develop chronic hepatitis C are typically treated with a combination of antiviral drug therapies. They may also need further testing to determine the best form of treatment. People who develop cirrhosis (scarring of the liver) or liver disease as a result of chronic hepatitis C may be candidates for a liver transplant . Currently, there is no vaccination for hepatitis C. Hepatitis D No antiviral medications exist for the treatment of hepatitis D at this time. According to a 2013 study , a drug called alpha interferon can be used to treat hepatitis D, but it only shows improvement in about 25 to 30 percent of people. Hepatitis D can be prevented by getting the vaccination for hepatitis B, as infection with hepatitis B is necessary for hepatitis D to develop. Hepatitis E Currently, no specific medical therapies are available to treat hepatitis E. Because the infection is often acute, it typically resolves on its own. People with this type of infection are often advised to get adequate rest, drink plenty of fluids, get enough nutrients, and avoid alcohol. However, pregnant women who develop this infection require close monitoring and care. Autoimmune hepatitis Corticosteroids, like prednisone or budesonide, are extremely important in the early treatment of autoimmune hepatitis. They’re effective in about 80 percent of people with this condition.Azothioprine ( Imuran ), a drug that suppresses the immune system, is often included in treatment. It can be used with or without steroids.Other immune suppressing drugs like mycophenolate (CellCept), tacrolimus (Prograf) and cyclosporine (Neoral) can also be used as alternatives to azathioprine for treatment. Prevention There are many steps you can take to reduce the risk of viral hepatitis: Consider getting vaccinated against hepatitis A and B if you weren’t vaccinated as a child. This is the number one way to prevent these illnesses.Wash your hands with soap and water after using the bathroom or changing a baby’s diaper and before handling food.When traveling in developing countries, avoid unpeeled or raw foods. Drink only bottled, boiled or chemically treated water.Practice safe sex. Hepatitis B is about 50–100 times more transmissible during sex than HIV. Condoms and other barrier methods greatly reduce the risk.Never share syringes, shaving razors, toothbrushes or tattooing or piercing supplies.Wear gloves when performing first aid.Disinfect blood spills (including dried ones) with diluted bleach and wear gloves during clean-up.Follow all occupational safety precautions in your workplace.If you are pregnant, seek early and regular prenatal care. To reduce the risk of non-viral hepatitis, avoid excessive alcohol consumption and consult with a healthcare professional about medications and supplements.