The Kidney in Sistemic Disease

1. Zehra Eren M.D. NephrologyDepartment TheKidney in SistemicDisease

2. LEARNING OBJECTIVES TheKidney in: • Congestiveheartfailure • Liverdisease • DiabetesMellitus • SystemicVasculitis • İnfections • SystemicLupusErythematosus • Dysproteinemiasandamyloidosis • HemolyticUremicSyndrom /ThromboticThrombocyticPurpura • Canceranditstreatment

3. RenalFunctionIn CongestiveHeartFailure

4. HeartFailure • Definition -complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability to supply blood to adequatly meet the metabolic needs of bodily tissues -it is characterized by specific symptoms, such as dyspnea and fatigue, and signs, such as fluid retention

5. Cardiorenalsyndrome • interactionsbetween heart disease and kidney disease • the interaction is bidirectional as acute or chronic dysfunction of the heart or kidneys can induce acute or chronic dysfunction in the other organ

6. Classificationof Cardiorenalsyndrome • Type 1 (acute) — Acute HF results in acutekidneyinjury (AKI, previouslycalledacuterenalfailure) • Type 2 — Chroniccardiacdysfunction (eg, chronic HF) causesprogressivechronickidneydisease (CKD, previouslycalledchronicrenalfailure) • Type 3 — Abruptandprimaryworsening of kidneyfunctiondue, forexample, torenalischemiaorglomerulonephritiscausesacutecardiacdysfunction, whichmay be manifestedby HF • Type 4 — Primary CKD contributestocardiacdysfunction, whichmay be manifestedbycoronarydisease, HF, orarrhythmia • Type 5 (secondary) — Acuteorchronicsystemicdisorders (eg, sepsisordiabetesmellitus) thatcausebothcardiacandrenaldysfunction.

11. Renal Function In Liver Disease

12. AcuteRI • Hepatorenalsyndrom • CronicRI • Post transplantation

13. Hepatorenalsyndrom • Definition development of acute kidneyinjury in a patient who usually has advanced liver disease due to cirrhosis, severe alcoholic hepatitis, or (less often) metastatic tumor, but can occur in a substantial proportion of patients with fulminant hepatic failure from any cause

18. DIABETIC NEPHROPATHY (DN)

19. DIABETIC NEPHROPATHY • Definition progressive decline in glomerular filtrationrate (GFR) in context of long-standingdiabetes, usually accompanied by nephroticrangeproteinuria and other end-organ complications,such as retinopathy

21. DN PATHOLOGY • Diabetic kidneys generally increased in size • Light microscopy -mesangial expansion -glomerular basement membrane thickening -glomerular sclerosis

22. DN PATHOLOGY Kimmelstein-Wilson nodules

23. DN Pathogenesis • glomerularhyperfiltration • hyperglycemiaandtheincreasedproduction of advancedglycationendproducts • increasedplasmaproreninactivity • hypoxia-inflammation • activationof cytokines

24. Risk factorsforprogression • family history of diabetes • black race • higher systemic blood pressures • evidence of hyperfiltration early in course of disease • poor glycemic control • smoking • obesityand older age No one factor is predictive in the individual patient

27. RenalInvolvement in SystemicVasculitis

29. Types of vesselsin the Chapel Hill Consensus Conferencenomenclature system Largevessels:aorta anditsmajorbranchesandtheanalogousveins Mediumvessels: main visceralarteriesandveinsandtheirinitialbranches Small vessels: intraparenchymalarteries, arterioles, capillaries, venules, andveins

30. 2012 Revised International Chapel Hill Consensus Conference Nomenclature ofVasculitides

31. Renal angiogram in polyarteritis nodosa

32. Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides(CHCC2012)

33. Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

34. Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

35. Definitions for vasculitides adopted by the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides (CHCC2012)

37. Infection-RelatedGlomerulonephritis

40. LupusNephritis

41. LupusNephritis • An abnormal urinalysis (hematuria and/or proteinuria) with or without an elevated plasma creatinine concentration is observed in up to 75 percent of patients with systemic lupus erythematosus • The most frequently observed abnormality is proteinuria

42. Classification revised by the International Society of Nephrology (ISN) and the Renal Pathology Society (RPS) • Class I – Minimal mesangiallupusnephritis • Class II – Mesangialproliferativelupusnephritis • Class III – Focallupusnephritis (activeandchronic; proliferativeandsclerosing) • Class IV – Diffuselupusnephritis (activeandchronic; proliferativeandsclerosing; segmentaland global) • Class V – Membranouslupusnephritis • Class VI – Advanced sclerosislupusnephritis

43. Renal Amyloidosis and Glomerular Diseases with Monoclonal Immunoglobulin Deposition

47. Noninfiltrated purpuric macule

49. Renalİnvolvementn in Hemolytic- Uremic Syndrome (HUS) / Thrombotic- ThrombocytopenicPurpura (TTP)

50. Clinic presentation of HUS/TTP • Microangiopathic hemolytic anemia • Thrombocytopenic purpura • Acute renal failure • Fever • Neurologic dysfunction