Diffuse Proliferative Glomerulonephritis

00:01 Now, we're going to our next glomerulonephritis, and this one is an interesting one.

00:06 This is called DPGN.

00:08 The reason I called this interesting is for two main reasons.

00:10 Number one, it’s a fact that really, in terms of your presentation, it will be nephritic, nephrotic, nephritic, nephrotic.

00:18 And by that I mean, oh, well, there might be hematuria and RBC casts that are involved in hypertension.

00:23 But there might be actual protein loss of being greater than 3.5 grams of protein.

00:28 There might be lipid that is then risen. Interesting.

00:31 So I just gave you the symptoms in this patient that has components of both nephritic and nephrotic.

00:37 DPGN will do that.

00:39 Also, the second important point, is that this is the prototype.

00:43 This is the most common subtype of SLE induced kidney damage.

00:48 Now, the other types can have a nephrotic presentation but what you're keeping in mind is if your patient has SLE and comes back to be positive for anti-double stranded DNA, the most likely type of kidney damage or glomerulonephritis that you're finding in this patient is going to be DPGN.

01:06 Now, what you have to memorize is DPGN, will be sub-endothelial.

01:13 Earlier with P, PSGN, it was sub-epithelial.

01:19 With DPGN, it’s sub-endothelial. Are we clear? Now, I don’t care how you do it, you memorize that.

01:28 This immune-complex that’s being deposited, where are you? On the side of the blood and the capillary lumen or are you on the side of your urine and your podocyte? Sub-endothelial, will be underneath your endothelial cell in the capillary lumen between the endothelial cell and the basement membrane.

01:46 With that said, if you find such a deposition, on electron microscopy, what are you going to find in immunofluorescence? You tell me the description. Very good. It's a granular.

01:56 Next, if you find this to be SLE induced then, what is this called? A DNA, anti-DNA immunocomplexes or in other words, Anti-double stranded DNA.

02:07 You're also going to find activation of your complement pathway but any immune-complex will do that.

02:13 Now, what you do find, and the description is called wire looping of the capillaries corresponding to sub-endothelial immune-complex.

02:21 There’s going to be neutrophil infiltration with hyaline thrombi in the capillary lumen.

02:26 There’s enough information here for you to properly diagnose your patient with DPGN.

02:30 Look for SLE and look for anti-double stranded DNA, and the fact that you have sub-endothelial deposits giving you a granular pattern.

02:38 Next, kidneys are major target organ in SLE for DPGN.

02:44 Your serum ANA test usually has a rim pattern which then corresponds with, please take a look, anti-double stranded DNA.

02:54 How many kidneys do you have? Two. Double stranded.

02:57 If it’s SLE in antihistone, it’s drug induced SLE, isn't it? And by drug-induced, you might be thinking about, well, procainamide.

03:07 You might be thinking about hydralazine, isoniazid, and for different reasons, maybe phenytoin.

03:14 Evolves into chronic renal failure in most cases.

03:18 And ends up being a common cause of death in a patient with SLE is actually chronic renal failure.

03:26 An important point.

03:28 Please make sure that you're quite familiar with the SLE induced DPGN issue resulting to chronic renal failure with the various tests that we just walked through.