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<publicationStmt><distributor>BASE and Oxford Text Archive</distributor>


<availability><p>The British Academic Spoken English (BASE) corpus was developed at the

Universities of Warwick and Reading, under the directorship of Hilary Nesi

(Centre for English Language Teacher Education, Warwick) and Paul Thompson

(Department of Applied Linguistics, Reading), with funding from BALEAP,

EURALEX, the British Academy and the Arts and Humanities Research Board. The

original recordings are held at the Universities of Warwick and Reading, and

at the Oxford Text Archive and may be consulted by bona fide researchers

upon written application to any of the holding bodies.

The BASE corpus is freely available to researchers who agree to the

following conditions:</p>

<p>1. The recordings and transcriptions should not be modified in any


<p>2. The recordings and transcriptions should be used for research purposes

only; they should not be reproduced in teaching materials</p>

<p>3. The recordings and transcriptions should not be reproduced in full for

a wider audience/readership, although researchers are free to quote short

passages of text (up to 200 running words from any given speech event)</p>

<p>4. The corpus developers should be informed of all presentations or

publications arising from analysis of the corpus</p><p>

Researchers should acknowledge their use of the corpus using the following

form of words:

The recordings and transcriptions used in this study come from the British

Academic Spoken English (BASE) corpus, which was developed at the

Universities of Warwick and Reading under the directorship of Hilary Nesi

(Warwick) and Paul Thompson (Reading). Corpus development was assisted by

funding from the Universities of Warwick and Reading, BALEAP, EURALEX, the

British Academy and the Arts and Humanities Research Board. </p></availability>




<recording dur="00:50:40" n="8224">


<respStmt><name>BASE team</name>



<langUsage><language id="en">English</language>

<language id="fr">French</language>



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<item n="speechevent">Lecture</item>

<item n="acaddept">Medicine</item>

<item n="acaddiv">ls</item>

<item n="partlevel">UG2/PG</item>

<item n="module">Urinary System</item>




<u who="nm0572"> <kinesic desc="writes on board" iterated="y" dur="10"/> right okay settle down everybody <pause dur="0.7"/> # <pause dur="0.7"/> i think i'm meant to be talking to you about glomerular pathology <pause dur="0.5"/> # i'm not a pathologist <pause dur="0.5"/> # <pause dur="0.6"/> a pathologist perhaps should be giving <pause dur="0.4"/> this talk perhaps they shouldn't <pause dur="0.9"/> # <pause dur="0.3"/> i don't think we could get a pathologist to do it so i was asked to do it <pause dur="1.4"/> so # <pause dur="0.6"/> like all good # <pause dur="0.3"/> lecturers i'm not going to teach you what i said i'm going to teach you <pause dur="0.5"/> and i'm going to talk to you a bit <pause dur="0.3"/> about glomerular disease <pause dur="0.2"/> <kinesic desc="writes on board" iterated="y" dur="2"/> and bring in a bit of pathology <pause dur="0.3"/> <trunc>i</trunc> if i can <pause dur="0.5"/> i remember being taught this as a medical student <pause dur="0.4"/> # <pause dur="0.3"/> and # we had a lecture a very dry lecture pathologist who went through <pause dur="0.3"/> all thirty forty <pause dur="0.2"/> slides which we didn't understand which had pink blobs on it <pause dur="0.4"/> and # i don't

remember anything of the lecture or even the go home message that i thought well i'm not going to do the same <pause dur="0.5"/> if you want your pink blobs <pause dur="0.2"/> if you like your pink blobs <pause dur="0.3"/> then it's all in the books there are there are <pause dur="0.2"/> books of glomerular pathology <pause dur="0.2"/> # <pause dur="0.4"/> i would however recommend <kinesic desc="holds up book" iterated="n"/> this book Textbook of Renal Disease by Whitworth and Lawrence <pause dur="0.3"/> this is a second edition but i think # there are further editions <pause dur="0.4"/> and <pause dur="0.4"/> as well as having the pink blobs which are not pink <pause dur="0.4"/> # <pause dur="0.2"/> they actually have some much better diagrams <pause dur="0.3"/> <kinesic desc="holds up book" iterated="n"/> i'm sure you can't see that from the back but <pause dur="0.2"/> # <kinesic desc="indicates point in book" iterated="n"/> this is an electron microscopy <pause dur="0.3"/> # of a glomerulus <pause dur="0.3"/> <kinesic desc="indicates point in book" iterated="n"/> this is light microscopy that's <kinesic desc="indicates point on book" iterated="n"/> amino fluorescence <pause dur="0.4"/> and i <trunc>f</trunc> personally find that the <pause dur="0.2"/> electron micrographs are easier to understand <pause dur="0.4"/> # and this is book is full of electron

micrographs <pause dur="0.3"/> of various renal diseases <pause dur="0.3"/> including diabetes <pause dur="1.3"/> okay <pause dur="0.4"/> so if i'm not going to talk about what i said i'm going to talk about what am i going to talk about <pause dur="0.4"/> # <pause dur="0.2"/> i'm going to talk about <pause dur="0.3"/> nephrotic syndrome <pause dur="0.7"/> # chronic glomerulonephritis and <pause dur="0.2"/> glomerular disease in general <pause dur="0.3"/> you have got a handout <kinesic desc="holds up handout" iterated="n"/> i'm sorry <pause dur="0.3"/> # <pause dur="0.4"/> there's been a <pause dur="0.3"/> photocopier cock-up <pause dur="0.3"/> and i've only got about ten down here so you can <pause dur="0.3"/> they they are coming you will have them at the end and maybe it's a good idea that you <pause dur="0.4"/> pay a bit of attention <pause dur="0.6"/> okay <pause dur="0.4"/> so <pause dur="0.3"/> who said <pause dur="0.8"/> i've got Bright's disease and he's got mine <pause dur="2.4"/> anybody heard that one <pause dur="3.9"/> i've got Bright's disease <pause dur="0.2"/> and he's got mine <pause dur="7.2"/> oh dear <pause dur="0.3"/> it's going to be a long long session this morning <pause dur="2.6"/> anybody <pause dur="0.2"/> calculated guess <pause dur="0.3"/> American comedian <pause dur="0.2"/> nineteen-thirties </u><pause dur="1.4"/> <u who="sm0573" trans="pause"> # </u><pause dur="0.9"/> <u who="nm0572" trans="pause"> who would say it </u><pause dur="1.4"/> <u who="sm0574" trans="pause"> Marx </u><pause dur="0.3"/> <u who="sm0575" trans="pause"> Marx </u><pause dur="0.3"/> <u who="sm0576" trans="pause"> Marx </u><u who="sm0577" trans="latching"> Marx </u><u who="nm0572" trans="latching"> Marx Groucho Marx okay <vocal desc="laugh" iterated="n" n="ss"/> i've got Bright's

disease and he's got mine <pause dur="0.3"/> so there's a bit of a joke in there it's obviously not a very funny joke <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> it's obviously a # a joke that's only appreciated by kidney doctors <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="0.4"/> and # <pause dur="0.2"/> so i'm going to have to explain this joke to you <pause dur="0.6"/> # <pause dur="0.2"/> any joke that needs explaining is not funny actually is it <pause dur="0.8"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # <pause dur="0.5"/> okay <pause dur="0.2"/> <shift feature="voice" new="laugh"/> Bright <shift feature="voice" new="normal"/><pause dur="0.4"/> who was who was Bright Richard Bright <vocal desc="laughter" iterated="y" n="ss" dur="1"/><pause dur="0.5"/> shush come on anybody <pause dur="0.9"/> who was Richard Bright has anybody heard of <pause dur="0.4"/> Bright's disease <pause dur="2.4"/> still lurking in your textbooks actually if you look for it <pause dur="2.2"/> well Richard Bright was the or <trunc>s</trunc> <pause dur="0.3"/> is said to be the father of <pause dur="0.2"/> British and world pathology <pause dur="0.4"/> published his thesis <pause dur="0.5"/> eighteen-twenty-seven you still read it <pause dur="0.3"/> top floor of the Wellcome bulding in the Euston Road what <pause dur="0.3"/> the library in Guy's if you go and read the actual words or actual

Richard Bright <pause dur="0.3"/> he's # <pause dur="0.2"/> said to be our <pause dur="0.2"/> our forefather <pause dur="0.3"/> and and <pause dur="0.4"/> nephrology started to exist as a specialty <pause dur="0.3"/> # <pause dur="1.1"/> they say when when when Bright wrote his thesis <pause dur="0.3"/> i actually think it probably only started about twenty or thirty years ago when we started dialysing in the U-K <pause dur="0.4"/> # <pause dur="0.4"/> but # <pause dur="0.3"/> the story as they say goes back to to eighteen-twenty-seven <pause dur="0.4"/> so Richard Bright was a nephrologist perhaps the world's first nephrologist at Guy's Hospital <pause dur="0.3"/> and Guy's <pause dur="0.2"/> still considers it the world centre it isn't <pause dur="0.5"/> but they they still <pause dur="0.2"/> # consider themselves the you know the centre of that's why everything in in the U-K and <pause dur="0.2"/> just 'cause we invented it we think we're we're the best at it and have <pause dur="0.3"/> have # rights over it <pause dur="0.7"/> # <pause dur="1.2"/> and # <pause dur="0.4"/> nobody actually nobody knows what Bright's disease is <pause dur="0.4"/> # <pause dur="0.5"/> and <pause dur="0.4"/> some people think it's nephrotic syndrome some people think it's glomerulonephritis <pause dur="0.3"/> # <pause dur="0.7"/> it's <pause dur="0.4"/> better not not to define it 'cause obviously Bright didn't define it <pause dur="0.3"/> i take it to be <pause dur="0.2"/> # <pause dur="0.3"/> synonymous with nephrotic

<kinesic desc="writes on board" iterated="y" dur="2"/> syndrome <pause dur="0.7"/> # <pause dur="0.4"/> which is <pause dur="0.3"/> the thing i'm going to talk about at the <trunc>i</trunc> in the first stage of this talk <pause dur="0.4"/> # i'm going to later on move on to <pause dur="0.2"/> glomerulonephritis <pause dur="0.4"/> and and which is one of the causes of nephrotic syndrome <pause dur="0.5"/> okay <pause dur="0.4"/> so lady here <pause dur="0.3"/><kinesic desc="indicates member of audience" iterated="n"/> have a have a bash at at defining <trunc>nec</trunc> nephrotic syndrome <pause dur="2.4"/> # have you heard of nephrotic syndrome </u><u who="sf0578" trans="overlap"> yep </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> okay <pause dur="0.7"/> anybody else lady behind in the blue with the glasses <pause dur="0.5"/> have a go at defining nephrotic syndrome actually there there is a set definition <pause dur="0.6"/> for this one </u><pause dur="1.3"/> <u who="sf0579" trans="pause"> # <pause dur="0.9"/> i don't know </u><pause dur="0.6"/> <u who="nm0572" trans="pause"> okay anybody else anyone want to have a go at it <pause dur="1.0"/> come on <pause dur="0.5"/> doesn't matter if you're wrong <pause dur="1.9"/> ladies at the front <pause dur="0.2"/> nephrotic syndrome have you heard of it </u><u who="sf0580" trans="overlap">

i can read it out of here </u><u who="nm0572" trans="latching"> go on read it out <vocal desc="laughter" iterated="y" n="ss" dur="1"/> </u><pause dur="1.2"/> <u who="sf0580" trans="pause"> it's defined as proteinuria </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> yes </u><u who="sf0580" trans="overlap"> sufficient to cause <trunc>hypoalbin</trunc> <pause dur="0.3"/> <trunc>albiniu</trunc> bleurgh <vocal desc="laughter" iterated="y" n="ss" dur="1"/> <unclear>i can't say that</unclear> </u><u who="nm0572" trans="overlap"> yeah yeah yeah right </u><u who="sf0580" trans="overlap"> intense peripheral oedema </u><pause dur="0.4"/> <u who="nm0572" trans="pause"> very good okay <pause dur="0.5"/> so <pause dur="0.2"/> # <pause dur="0.2"/> there are three features to the definition of nephrotic syndrome <pause dur="1.2"/> # <pause dur="0.6"/><kinesic desc="writes on board" iterated="y" dur="5"/> hypo<pause dur="1.4"/><trunc>al</trunc> <pause dur="0.3"/> i can't say it neither <pause dur="0.4"/> hypoalbuminaemia <pause dur="0.2"/> that's low albumin in the blood <pause dur="0.8"/> # <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="10"/> proteinuria of greater than what <pause dur="2.0"/> does it say there </u><u who="sf0580" trans="overlap"> no it doesn't say </u><u who="sm0581" trans="latching"> three grams over twenty-four hours </u><pause dur="0.9"/> <u who="nm0572" trans="pause">

it's it's actually <trunc>ver</trunc> <trunc>i</trunc> every book's different it's <pause dur="0.2"/> most of the world </u><u who="sf0580" trans="overlap"> <gap reason="inaudible" extent="1 sec"/> five grams </u><u who="nm0572" trans="overlap"> takes it to be three-point-five <pause dur="0.3"/> the U-K we used to take it to be five perhaps this is an American definition <pause dur="0.8"/><kinesic desc="writes on board" iterated="y" dur="4"/> # <pause dur="0.8"/> and peripheral oedema <pause dur="0.9"/> and these are the three features of of nephrotic syndrome <pause dur="1.7"/> okay <pause dur="0.2"/> we can't get away with that # type definition with <trunc>abou</trunc> without a few buts <pause dur="0.4"/> clearly nephrotic syndrome <pause dur="0.4"/> is an arbitrary definition you don't go from nought to three-point-five <pause dur="0.3"/> you go through other numbers <pause dur="0.6"/> # <pause dur="0.3"/> and <pause dur="0.4"/> there is such a concept as mild proteinuria moderate proteinuria <pause dur="0.4"/> more severe <trunc>protein</trunc> <pause dur="0.2"/> and what you could say <pause dur="0.4"/> is that nephrotic syndrome is <pause dur="0.3"/> if you like severe proteinuria <pause dur="1.4"/> # <pause dur="0.4"/> having said that <pause dur="0.7"/> how <trunc>mu</trunc> <pause dur="0.4"/> in terms of the amount of protein that you eat <pause dur="0.6"/> # how much <pause dur="0.3"/> do you think three-point-five is <pause dur="0.3"/> what proportion of the protein that you eat <pause dur="3.7"/> how much protein do we eat a day <pause dur="2.0"/> any nutritionists in the room ex-dieticians <pause dur="1.7"/> anorexics <pause dur="2.0"/><vocal desc="laughter" iterated="y" n="ss" dur="2"/>

medical students don't <trunc>ge</trunc> get anorexia <pause dur="1.6"/> don't mention that <pause dur="1.7"/> how much protein do we eat a day <pause dur="2.0"/> eighty grams roughly i mean it depends on whether you eat ten steaks a day or <pause dur="0.4"/> two chickpeas or whatever <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> but you know that's a a a an average in in a Western diet <pause dur="0.7"/> and <pause dur="0.2"/> if <pause dur="0.2"/> you are losing <pause dur="0.2"/> three-point-five grams a day <pause dur="1.5"/> and that leads to the spiel we tell the patients <vocal desc="laughter" iterated="y" n="ss" dur="1"/> which is what <pause dur="0.5"/> what spiel do we give the patient lady lady here <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> if i was <pause dur="0.2"/> if if if you if you're trying to explain <pause dur="0.9"/> nephrotic syndrome to a patient <pause dur="1.8"/> # <pause dur="1.7"/> what would you tell them <pause dur="1.1"/> how would you <pause dur="1.0"/> put that little triad together <pause dur="2.4"/> come on have a go what <pause dur="0.9"/> so you've got no protein in the blood <pause dur="0.5"/> lots of protein in the urine <pause dur="0.3"/> peripheral oedema <pause dur="1.9"/> you're the doc i want to know why have i

got this <pause dur="3.2"/> lady next to her </u><pause dur="1.4"/> <u who="sf0582" trans="pause"> it's not in layman's terms <vocal desc="laughter" iterated="y" dur="1"/></u><u who="nm0572" trans="overlap"> well have a go in non-layman's terms how how how would you explain in non-layman's terms </u><u who="sf0582" trans="latching"> # <pause dur="0.2"/> if you're losing <pause dur="0.4"/> protein <pause dur="0.5"/> <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.5"/> <u who="nm0572" trans="pause"> yeah and that is therefore leads to </u><pause dur="0.5"/> <u who="sf0582" trans="pause"> # <pause dur="1.5"/> it's hard to keep <pause dur="0.8"/> fluid <pause dur="1.0"/> in <gap reason="inaudible" extent="1 sec"/></u><pause dur="0.5"/> <u who="nm0572" trans="pause"> yeah very good <pause dur="1.0"/> i mean i think what i would say to a patient is <pause dur="0.3"/> you're losing protein in your urine here i can see it on my dipstick <pause dur="0.6"/> and therefore you don't normally lose protein in your urine and therefore that's why you've got low levels in the blood <pause dur="0.2"/> here <pause dur="1.1"/> and for various complicated reasons that i can't explain to you today because it's all too complicated <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # and it's probably <pause dur="0.7"/> # <gap reason="inaudible" extent="2 secs"/><vocal desc="laughter" iterated="y" n="ss" dur="3"/> all the water back into the cells isn't it <pause dur="0.5"/>

you can try explaining that to <pause dur="0.2"/> to Joe Public <pause dur="0.4"/> but what i would say to a patient <pause dur="0.7"/> with # <pause dur="1.1"/> hypoalbuminaemia and the line is <kinesic desc="writes on board" iterated="y" dur="4"/> usually taken at less than thirty grams per litres <pause dur="0.2"/> normal is thirty-five to fifty <pause dur="0.8"/> # <pause dur="0.7"/> losing protein in the urine <pause dur="0.2"/> leads to low protein levels in the <trunc>bu</trunc> blood which in <pause dur="0.4"/> in a <pause dur="0.2"/> long and convoluted # <pause dur="0.7"/> # a way that's too complicated to explain to you here today oh i've got a patient to see in another five minutes <pause dur="0.4"/> # <pause dur="0.6"/> leads to peripheral oedema <pause dur="1.8"/> but <pause dur="1.0"/> there <pause dur="1.0"/> there's a big but there <pause dur="0.2"/> you're eating eighty grams a day <pause dur="1.7"/> and you're getting low levels of protein in the blood <pause dur="0.7"/> with small amounts of proteinuria and therefore what's wrong with the theory <pause dur="2.5"/> what's wrong with the spiel <pause dur="0.2"/> our colleagues come out with </u><pause dur="2.6"/> <u who="sm0583" trans="pause"> where's the rest of it gone </u><pause dur="0.5"/> <u who="nm0572" trans="pause"> very good <pause dur="0.2"/> okay <pause dur="0.4"/> so # <pause dur="0.2"/> it's not enough is it <pause dur="0.5"/> # <pause dur="0.2"/> you know you're only losing small amounts of

protein in the urine <pause dur="0.6"/> and you're eating lots <pause dur="0.3"/> of protein <pause dur="0.6"/> so where's the rest of it gone <pause dur="0.4"/> exactly <pause dur="0.5"/> and # the the the answer is that nephrotic syndrome is probably not <pause dur="0.2"/> a renal disease <pause dur="0.3"/><vocal desc="clears throat" iterated="n"/><pause dur="0.4"/> # <pause dur="0.4"/> and i'm going to expand on that in a minute <pause dur="0.4"/> # but that's <pause dur="0.2"/> you know if you <pause dur="0.3"/> forget everything else i say about nephrotic syndrome it probably isn't just a renal disease <pause dur="0.3"/> it's probably a problem of <pause dur="0.2"/> protein metabolism in a variety of organs <pause dur="0.4"/> including the liver and why must the liver be involved </u><pause dur="0.8"/> <u who="sm0583" trans="pause"> it makes albumin </u><pause dur="0.5"/> <u who="nm0572" trans="pause"> it makes albumin okay so <pause dur="0.5"/> if you've got low albumin levels in the blood and you're not excreting it <pause dur="0.5"/> there's probably a problem with synthesis <pause dur="0.4"/> and and most proteins including albumin are made in the liver <pause dur="1.4"/> so there's probably liver trouble in nephrotic syndrome <pause dur="0.3"/> but we'll call it nephrotic syndrome for the moment <pause dur="0.9"/> # <pause dur="0.8"/> okay <pause dur="0.3"/> so <pause dur="0.5"/> can anybody tell me <pause dur="0.2"/> some # causes of nephrotic

syndrome <pause dur="4.9"/> causes <pause dur="1.1"/> most important cause <pause dur="0.5"/> clue in the previous lecture <kinesic desc="writes on board" iterated="y" dur="2"/></u><pause dur="0.6"/> <u who="ss" trans="pause"> diabetes </u><pause dur="0.5"/> <u who="nm0572" trans="pause"> diabetes okay <pause dur="1.1"/> so diabetes by far and away the commonest cause of nephrotic syndrome if you think about it what nephrotic syndrome is it's stage four of the Mogensen classification <pause dur="0.2"/> we talked about in the first lecture <pause dur="0.9"/> # <pause dur="0.4"/> so <pause dur="0.8"/> but diabetes is not the only thing that can affect the glomerulus <pause dur="0.7"/> and the glomerular basement membrane <pause dur="0.5"/> and <pause dur="0.2"/> loads of other systemic diseases such as what <pause dur="0.3"/> # could affect the glomerulus </u><pause dur="1.0"/> <u who="sm0584" trans="pause"> S-L-E </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> S-L-E very good lupus any others <pause dur="0.4"/> <trunc>re</trunc> read your list </u><pause dur="0.5"/> <u who="sm0584" trans="pause"> <unclear>okay</unclear> the tumour amyloid <pause dur="0.6"/> H-S-P </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> yeah <pause dur="0.5"/> Henoch-Schoenlein purpura </u><pause dur="0.5"/> <u who="sm0584" trans="pause"> # drugs including <pause dur="1.3"/> penicillamine </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> gold </u><u who="sm0584" trans="latching"> gold </u><pause dur="0.6"/> <u who="nm0572" trans="pause"> <gap reason="inaudible" extent="2 secs"/></u><u who="sm0584" trans="latching"> and congenital nephrotic syndrome </u><u who="nm0572" trans="latching">

yeah <pause dur="0.2"/> i mean the the <pause dur="0.4"/> generally speaking if you have to learn something in the form of a list <pause dur="0.2"/> don't bother <pause dur="0.6"/> you won't forget it you won't remember it <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="0.4"/> and # <pause dur="1.0"/> rather than learn lists <pause dur="0.3"/> it's sometimes better to use <pause dur="0.3"/> # what we call the have you heard of the surgical sieve <pause dur="0.5"/> anybody <pause dur="1.2"/> introduce any surgeons giving a lecture and talk about the surgical sieve <pause dur="1.8"/> no <pause dur="0.2"/> okay <pause dur="0.4"/> you've had lectures from surgeons <pause dur="0.3"/> presume it <unclear><trunc>bu</trunc></unclear> <pause dur="0.5"/> surgeons are very simple people <pause dur="0.4"/> # <pause dur="0.2"/> don't repeat that <pause dur="0.5"/> and # they have to have ways of remembering things <pause dur="1.1"/> right where did i leave my Bentley <pause dur="0.3"/><vocal desc="laughter" iterated="y" n="ss" dur="5"/> and <pause dur="0.9"/> # <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="5"/> no no enough of that <pause dur="1.4"/> # i'll give you my surgical sieve you're welcome to use it or <pause dur="0.2"/> better to invent your own one <pause dur="0.7"/> and really a surgical sieve is a way of remembering the causes of anything and it it can be applied to <pause dur="0.4"/> # epilepsy <pause dur="0.9"/> <unclear>pyrexia</unclear> of unknown

origin <pause dur="0.3"/> this whatever <pause dur="0.4"/> # <pause dur="0.5"/> <kinesic desc="writes on board" iterated="y" dur="11"/> degenerative <pause dur="0.6"/> effective inflammatory metabolic <pause dur="0.2"/> including all the failures endocrine diabetes and other and other <pause dur="0.2"/> neoplastic <pause dur="0.5"/> benign malignant primary secondary iatrogenic drugs <pause dur="0.4"/> # <pause dur="0.3"/> either # # prescribed drugs or <pause dur="0.2"/> # recreational drugs trauma <pause dur="0.7"/> haematological <pause dur="0.4"/> and that's just one surgical sieve my it's my surgical sieve <unclear>DIANITH</unclear> invent your own <pause dur="0.4"/> # use mine if you want to <pause dur="0.3"/> and <pause dur="0.4"/> # so if somebody says to you what are the causes of nephrotic syndrome you don't want to have to look it up in a book you <pause dur="0.2"/> just try to work it out from first principles degenerative including <pause dur="0.2"/> amyloid you know <pause dur="0.2"/> infective including <pause dur="0.2"/> T-B malaria and metabolic including all the failures endrocrine diabetes neoplastic <pause dur="0.4"/> cancers such as <pause dur="0.3"/> # lymphoma and other things <pause dur="0.4"/> # iatrogenic drugs yes <pause dur="0.4"/> # trauma not really haematological back to lymphoma <pause dur="0.4"/>

# <pause dur="1.1"/> don't learn don't learn a list don't buy the stupid American books of lists absolute rubbish <pause dur="0.4"/> # you won't remember them <pause dur="0.3"/> and they'll just irritate you and you'll have a panic and don't know the <pause dur="0.2"/> twenty-eighth <pause dur="0.2"/> cause of clubbing <pause dur="0.4"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> don't buy books of lists <pause dur="0.5"/> # <pause dur="1.9"/> okay <pause dur="0.3"/> so <pause dur="0.4"/> # <pause dur="0.9"/> pathophysiology of nephrotic syndrome much mo re interesting than the list <pause dur="0.5"/> # <pause dur="0.3"/> what <pause dur="0.2"/> causes it well we've rubbished the <pause dur="0.5"/> the patient explanation <pause dur="0.6"/> protein in the urine <pause dur="0.3"/> low <trunc>plote</trunc> protein levels in the blood <pause dur="0.4"/> # peripheral oedema <pause dur="0.5"/> can we get at it in in a bit more detail the more articulate patient <pause dur="1.1"/> well we can a bit # <pause dur="0.3"/> without <pause dur="0.2"/> clearly <pause dur="0.2"/> there's got to be something wrong <pause dur="0.3"/> with the glomerulus <pause dur="0.5"/> if you develop nephrotic syndrome <pause dur="1.0"/> # <pause dur="0.4"/> and <pause dur="0.9"/> the glomerulus <pause dur="1.8"/> a million glomeruli per kidney <pause dur="0.3"/> # <pause dur="1.2"/> don't think of it like that don't think of it <kinesic desc="writes on board" iterated="y" dur="3"/> the <pause dur="0.2"/>

don't think of a kidney like that with a million glomeruli in <pause dur="0.5"/> it's a bad <pause dur="0.2"/> visual concept <pause dur="0.5"/> # <pause dur="1.6"/> it's much better to think of a kidney <pause dur="0.7"/> like this <pause dur="0.6"/> <kinesic desc="writes on board" iterated="y" dur="12"/> which is a tube <pause dur="1.1"/> # <pause dur="0.5"/> and <pause dur="2.3"/> with something in the middle <pause dur="1.8"/> # which we call the glomerular basement membrane <pause dur="0.8"/> and that's really what a kidney is <pause dur="0.7"/> so what comes in at <kinesic desc="indicates point on board" iterated="n"/> this end </u><pause dur="1.2"/> <u who="ss" trans="pause"> blood </u><pause dur="0.5"/> <u who="nm0572" trans="pause"> blood <pause dur="0.4"/> and what comes out <kinesic desc="indicates point on board" iterated="n"/> that end </u><pause dur="0.6"/> <u who="ss" trans="pause"> urine </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> urine <pause dur="0.9"/> and what do we call <pause dur="0.3"/> wee-wee when it's in <kinesic desc="indicates point on board" iterated="n"/> here </u><pause dur="0.2"/> <u who="ss" trans="pause"> filtrate </u><u who="nm0572" trans="overlap"> glomerular filtrate <pause dur="0.4"/> that's what a kidney is <pause dur="1.2"/> it's a thing that converts stuff into other stuff <pause dur="0.2"/> but <kinesic desc="indicates point on board" iterated="n"/> that stuff is really the same as <kinesic desc="indicates point on board" iterated="n"/> that stuff <pause dur="0.3"/> but i've got a few things <pause dur="0.4"/> # added and taken

away <kinesic desc="writes on board" iterated="y" dur="1"/> at various points <pause dur="0.5"/> proximal convoluted tubule et cetera <pause dur="0.3"/> it's still stuff <pause dur="1.2"/> and some of it goes back again <pause dur="0.8"/> and # <pause dur="0.6"/> a medical student # said to me the other day that my # tube analogy was completely wrong <pause dur="0.5"/> and # that was it was much more complicated how could i possibly <pause dur="0.3"/> # <pause dur="0.2"/> call the kidney just a tube this wonderful organ that i love so much <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # and <trunc>i</trunc> and # <pause dur="0.6"/> he was right to an extent but the only thing i've really missed out it's really <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="2"/> there's another bit there really isn't there <pause dur="0.7"/> you know <pause dur="0.3"/> # you have <pause dur="0.2"/> an afferent an efferent arteriole and a tube and some of it does go back i mean he was right <pause dur="0.7"/> he was <pause dur="0.3"/> # <pause dur="0.2"/> # <trunc>d</trunc> wouldn't let me get away with my <pause dur="0.3"/> # my tube analogy <pause dur="0.3"/> but # <pause dur="0.3"/> i i still think my <pause dur="0.2"/> it's easier to think of it as a tube <pause dur="1.1"/> okay <pause dur="0.3"/> and so normally what happens is that you have big <kinesic desc="writes on board" iterated="y" dur="7"/> things in the blood like cells <pause dur="0.8"/> and

other things like proteins some of which are big <pause dur="0.5"/> and some of which are small like albumin <pause dur="1.2"/> but they're bigger than a certain critical pore size <pause dur="1.0"/> and they come <kinesic desc="indicates point on board" iterated="n"/> piling down here <pause dur="0.3"/> and meet the sieve <pause dur="0.8"/> and <pause dur="0.2"/> generally speaking they don't get through <kinesic desc="writes on board" iterated="y" dur="2"/> and what does get through <pause dur="2.5"/> so proteins and cells don't get through but what does get through </u><u who="sm0585" trans="latching"> ions </u><pause dur="0.3"/> <u who="ss" trans="pause"> ions </u><u who="nm0572" trans="overlap"> ions such as </u><pause dur="0.4"/> <u who="ss" trans="pause"> sodium </u><u who="nm0572" trans="overlap"> sodium <kinesic desc="writes on board" iterated="y" dur="6"/> potassium phosphate and all the rest of it <pause dur="0.6"/> most of which are then reabsorbed <pause dur="0.4"/> some of which are then secreted at various points <pause dur="0.4"/> sodium is almost completely reabsorbed ninety-eight per cent of it <pause dur="0.7"/> # <pause dur="1.0"/> at various stages in the <pause dur="0.3"/> # <pause dur="0.3"/> proximal and distal convoluted tubule <pause dur="0.7"/> # and the cells just <kinesic desc="writes on board" iterated="y" dur="2"/> go back again down the medical student's bit <pause dur="0.5"/> # and and just go round again <pause dur="1.0"/>

but in glomerular disease <pause dur="0.3"/> there's trouble with the sieve <pause dur="1.5"/> # <pause dur="0.2"/> if we just <pause dur="1.2"/> look at the sieve in a bit more detail and look at the cross section of my tube <pause dur="1.6"/> it's not really just # a a single tube <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="9"/> it's a tube with <pause dur="0.4"/> like all tubes in the body it doesn't matter whether they're a blood vessel <pause dur="0.5"/> # <pause dur="0.6"/> a # <pause dur="0.4"/> a bit of the nephron <pause dur="0.3"/> most tubes in the body have three layers <pause dur="0.4"/> they have an endothelium <pause dur="0.4"/> a basement membrane and an epithelium and the kidney's no different <pause dur="0.7"/> and <pause dur="0.4"/> the tube <pause dur="0.3"/> is the same <pause dur="0.8"/> # so we've now we've sorry <pause dur="0.2"/> just to <pause dur="0.5"/> <kinesic desc="writes on board" iterated="y" dur="2"/> realign you <pause dur="0.3"/> when we're talking about <pause dur="0.2"/> the sieve <pause dur="0.6"/> and and what what the sieve looks like <pause dur="1.5"/> and now as we look at this <kinesic desc="writes on board" iterated="y" dur="1"/> in cross section <pause dur="1.9"/> # <pause dur="1.3"/> <kinesic desc="writes on board" iterated="y" dur="5"/> what you have is something like that <pause dur="0.8"/> with stuff going through here <pause dur="0.9"/> urine glomerular filtrate blood so

blood <pause dur="0.3"/> glomerular filtrate and urine <pause dur="0.4"/> and it's got to get through the wall <pause dur="1.1"/> and so it has to go through <pause dur="1.0"/><kinesic desc="writes on board" iterated="y" dur="3"/> the <pause dur="0.3"/> endothelium the basement membrane and the epithelium <pause dur="1.1"/> and this will be true whether it's a blood vessel or whether it's a tubule in a kidney or most tubes in the body <pause dur="0.4"/> it's got to get through there <pause dur="0.8"/> and normally what happens is it doesn't get through it <kinesic desc="writes on board" iterated="y" dur="1"/> and it all comes back again all the cells and the proteins <pause dur="0.6"/> but in glomerular disease and diabetes it's it's it's the classic cause of glomerular disease <pause dur="0.4"/><kinesic desc="writes on board" iterated="y" dur="1"/> you get <shift feature="voice" new="mimicking northern English accent"/>trouble at t'mill <shift feature="voice" new="normal"/> <pause dur="0.8"/> and something happens <pause dur="0.3"/> probably <pause dur="0.2"/> to the basement membrane <pause dur="1.1"/> but in other glomerular diseases other bits of it go wrong <pause dur="0.7"/> such as <kinesic desc="writes on board" iterated="y" dur="5"/> in minimal change nephropathy the podocytes get defaced or knocked off <pause dur="0.6"/> either way something happens <pause dur="0.3"/> to the wall <pause dur="0.3"/> of the glomerulus <pause dur="1.4"/> and i think it's better not to think of

the glomerulus as a glomerulus just think of it as part of the tube <pause dur="0.6"/> # <pause dur="0.3"/> because <pause dur="0.3"/> you know <pause dur="0.9"/> you can say oh well you know <kinesic desc="writes on board" iterated="y" dur="4"/> there's the thingy there's the thingy <pause dur="0.2"/> Bowman's capsule thingy thingy thingy these are all quite different <pause dur="0.6"/> they're not really it's the same tube <pause dur="0.6"/> <kinesic desc="writes on board" iterated="y" dur="1"/> and you just need to go <vocal desc="stretch noise" iterated="n"/><kinesic desc="demonstrates tube lengthening" iterated="n"/><pause dur="0.2"/> and lengthen it out <pause dur="0.7"/> and # you can start to understand how the kidney works <pause dur="0.5"/> the glomerulus is just part of the tube it's just <pause dur="0.2"/> the glomerulus is a scrunched up capillary that's what a glomerulus is <pause dur="3.2"/> don't worry that this hasn't occurred to you before and i know you're thinking that's probably a load of <gap reason="name" extent="1 word"/> rubbish <pause dur="0.3"/> # <pause dur="0.2"/> it <trunc>i</trunc> <pause dur="0.8"/> it is a pretty good analogy <pause dur="0.3"/> or a pretty good <pause dur="0.2"/> visual concept of of what a kidney is <pause dur="0.4"/> # <pause dur="0.3"/> even if it is simplistic <pause dur="1.4"/> and when you start looking at glomerular pathology <pause dur="0.2"/> i think one of the problems in the way it's taught <pause dur="0.3"/>

is that they they they don't start from these very simple <unclear>concepts</unclear> they just start from <pause dur="0.4"/> pictures of pink things with blobs in <pause dur="0.6"/> and and and you you can't imagine <pause dur="0.3"/> what it is or where it is or or how it's doing the damage <pause dur="0.6"/> so going back to nephrotic syndrome <pause dur="0.4"/> if you've got <pause dur="0.3"/> a problem with <kinesic desc="writes on board" iterated="y" dur="9"/> leaky glomeruli <pause dur="1.5"/> you're going to either have a problem with the <pause dur="1.1"/> endothelium <pause dur="0.3"/> the basement membrane or the epithelium <pause dur="0.9"/> so what can go wrong <pause dur="0.3"/> in <pause dur="0.3"/> the <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="2"/> glomerular basement membrane <pause dur="1.0"/> that would let <pause dur="0.2"/> bad things through <pause dur="4.7"/> gentleman in the blue there <kinesic desc="indicates member of audience" iterated="n"/></u><pause dur="1.2"/> <u who="sm0586" trans="pause"> # </u><u who="nm0572" trans="overlap"> what could go wrong </u><pause dur="0.8"/> <u who="sm0586" trans="pause"> some of the <pause dur="0.3"/> transport proteins might be broken or some of the pores might be larger than <gap reason="inaudible due to overlap" extent="1 sec"/> </u><u who="nm0572" trans="overlap"> very good so <pause dur="0.3"/> that's the so-called pore theory <pause dur="1.3"/> # so you get holes appearing <pause dur="0.7"/> # what else <trunc>c</trunc> conceptually could go wrong </u><pause dur="2.1"/> <u who="sm0587" trans="pause">

defects in collagen synthesis </u><pause dur="0.4"/> <u who="nm0572" trans="pause"> yeah <pause dur="0.4"/> leading to what </u><pause dur="0.6"/> <u who="sm0587" trans="pause"> # <pause dur="0.2"/> 'cause it's collagen <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.3"/> <u who="nm0572" trans="pause"> yeah </u><u who="sm0587" trans="latching"> and goes in <pause dur="0.4"/> # <pause dur="0.4"/> pores </u><pause dur="1.2"/> <u who="nm0572" trans="pause"> well we have pores we have holes in the pores <pause dur="1.4"/> do you you you're getting there <pause dur="0.5"/> you <pause dur="0.3"/> defects in collagen synthesis could lead to <pause dur="0.2"/> problems with permeability <pause dur="0.4"/> so <pause dur="0.2"/> if you like the function <pause dur="0.9"/><kinesic desc="writes on board" iterated="y" dur="1"/> of the sieve <pause dur="0.6"/> # <pause dur="0.4"/> and that the so-called permeability theory <pause dur="0.6"/> # <pause dur="0.4"/> there is # a final theory <pause dur="0.5"/> # <pause dur="0.5"/> which # relates to charge <pause dur="0.4"/> # <pause dur="0.2"/> and i don't really understand but <pause dur="0.3"/> # <pause dur="0.3"/> there is <pause dur="0.2"/> a charge <kinesic desc="writes on board" iterated="y" dur="1"/> gradient apparently <trunc>a</trunc> <trunc>a</trunc> across the glomerulus <pause dur="0.6"/> and # sorry i have to look this up 'cause i always forget <pause dur="0.6"/> # <pause dur="3.4"/> yeah most proteins are very negatively charged <pause dur="0.9"/> and they therefore <pause dur="0.4"/> repel each other and <pause dur="0.4"/> also the glomerular basement membrane is <pause dur="0.4"/> is <trunc>appa</trunc> <trunc>apparent</trunc> i don't know how the hell they do this <pause dur="0.5"/> but # <pause dur="0.3"/> negatively charged <pause dur="0.2"/> and there is a natural <kinesic desc="writes on board" iterated="y" dur="1"/>

repulsion to going through it <pause dur="0.4"/> and apparently changes in charge could possibly explain why <pause dur="0.3"/> why <pause dur="0.3"/> # pores develop so there is a link in the charge theory to the pore theory <pause dur="0.5"/> # <pause dur="0.2"/> but the bottom line is that we don't know <pause dur="1.0"/> and # diabetes <pause dur="0.2"/> is a is a classic example of a disease a glomerular disease <pause dur="0.3"/> where we we don't know which of these theories is correct but somehow <pause dur="0.4"/> the the high blood sugar or more likely the blood pressure <pause dur="0.4"/> # affects the glomerular basement membrane and starts to let things through <pause dur="0.9"/> there is a trendy theory at the moment that the <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="3"/> proteins that are allowed through <pause dur="0.6"/> are not just a marker <pause dur="0.3"/> of glomerular disease <pause dur="0.2"/> and proteinuria is the hallmark whenever you see significant proteinuria <pause dur="0.3"/> greater than say two grams per twenty-four hours <pause dur="0.2"/> up to one-fifty milligrams is normal per twenty-four hours <pause dur="0.7"/> so you eat about eighty a day <pause dur="0.2"/> and you <pause dur="0.2"/> # excrete about one-fifty so normally <pause dur="0.2"/>

some protein but not much does go through the glomerulus about a hundred-and-fifty milligrams a day <pause dur="0.7"/> # <pause dur="1.1"/> and <pause dur="0.3"/> # <pause dur="1.1"/> in diabetes and other glomerular diseases <pause dur="0.5"/> it's considered that the proteinuria which is by this stage in the <pause dur="0.2"/> # the later stages of the nephron the proximal convoluted distal convoluted tubule et cetera <pause dur="0.3"/> # is itself toxic <pause dur="0.3"/> and somehow <pause dur="0.2"/> <kinesic desc="writes on board" iterated="y" dur="1"/> again then makes the problem worse <pause dur="0.8"/> # and and one of the groups in <gap reason="name" extent="1 word"/> <gap reason="name" extent="1 word"/> <pause dur="0.2"/> # is got # several research groups <pause dur="0.3"/> we don't do too much research in <gap reason="name" extent="1 word"/> but <gap reason="name" extent="1 word"/> has a big <pause dur="0.3"/> # research area in in nephrology <pause dur="0.3"/> and and they're looking into this theory of whether the proteinuria in itself is is is toxic <pause dur="0.3"/> and makes the problem worse <pause dur="0.3"/> what's interesting is now electron micrographs have been done <pause dur="0.3"/> and <kinesic desc="indicates point on board" iterated="n"/> these holes are are <pause dur="0.2"/> which have to be there there has to be a pore <pause dur="0.2"/> 'cause sometimes

you may physiologically want to open them up and send things through or not send things <pause dur="0.4"/> send <trunc>s</trunc> things through <pause dur="0.4"/> but <pause dur="0.2"/> # <pause dur="0.2"/> it may be <pause dur="0.9"/> # <pause dur="0.3"/> that # <pause dur="0.8"/> # the proteinuria is <pause dur="0.3"/> part of the problem of course the the treatment is is is not identified but that <pause dur="0.3"/> that is one of the current theories <pause dur="0.8"/> okay <pause dur="0.5"/> so <pause dur="0.2"/> they're some of the theories about why we get proteinuria the hallmark of glomerular disease <pause dur="1.5"/> # <pause dur="0.2"/> how can how do we prove proteinuria <pause dur="1.7"/> how do we <pause dur="0.3"/> how do we <pause dur="0.2"/> find out whether somebody has proteinuria </u><pause dur="0.7"/> <u who="ss" trans="pause"> dipstick </u><u who="nm0572" trans="overlap"> dipstick okay <pause dur="0.4"/> how do you do a <trunc>dipst</trunc> has <trunc>any</trunc> who's done a dipstick <pause dur="0.2"/> anybody <pause dur="0.7"/> a few people <pause dur="0.8"/> has <trunc>any</trunc> <pause dur="0.2"/> put your hand up if you've not done a dipstick <pause dur="1.6"/> good all right so you've all done a dipstick <pause dur="0.4"/> okay <pause dur="0.3"/> so very simple you get some wee-wee you put the <trunc>dip</trunc> dipstick in take it out look at it <pause dur="0.8"/> and and what does it tell you about <pause dur="0.7"/> about <pause dur="0.2"/> protein <pause dur="0.5"/> what what what's

the scoring system </u><pause dur="1.5"/> <u who="sf0588" trans="pause"> <vocal desc="laugh" iterated="n"/><pause dur="1.1"/> # just whether it's there or whether it's not <pause dur="0.3"/> of a certain amount </u><u who="nm0572" trans="overlap"> no that's a <pause dur="0.4"/> yeah there is a scoring system usually </u><pause dur="0.7"/> <u who="sf0589" trans="pause"> is it just pluses </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> pluses <pause dur="0.2"/> yes pluses <pause dur="0.5"/> # <pause dur="0.2"/> one of the problems is that all the dipstick kits are different they all use different assays and have different levels <pause dur="0.3"/> of proteinuria that leads to <trunc>p</trunc> <pause dur="0.2"/> to pluses and this is one of so you can't compare one hospital to another one ward to another <pause dur="0.6"/> but most of them work on some system <pause dur="0.3"/> of colouring <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="13"/> trouble if you if <trunc>chu</trunc> if you're colour-blind you can't do it <pause dur="0.3"/> where you either get <pause dur="0.2"/> no colour <pause dur="0.5"/> or a trace <pause dur="0.3"/> one plus <pause dur="0.2"/> two pluses or three pluses <pause dur="0.6"/> but rather irritatingly some dipsticks also four pluses <pause dur="0.6"/> # <pause dur="1.0"/> and <pause dur="0.3"/> that's <pause dur="0.3"/> one of the simplest ways of measuring proteinuria <pause dur="0.3"/> # <pause dur="0.2"/> it's a very simple test <pause dur="0.4"/> it's # a test beloved of G-Ps a test beloved of nephrologists <pause dur="0.3"/>

i'll talk a bit in a minute about <pause dur="0.3"/> # why we like it so much and and the problems with it <pause dur="0.4"/> what what do you think is the the the the good <pause dur="0.3"/> side of a a urinary dipstick <pause dur="0.5"/> gentleman <kinesic desc="indicates member of audience" iterated="n"/> in the green top there <pause dur="0.6"/> <trunc>wh</trunc> why why do we like urinary dipsticks </u><pause dur="0.5"/> <u who="sm0590" trans="pause"> it's quick and easy </u><pause dur="0.3"/> <u who="nm0572" trans="pause"> quick and easy cheap <pause dur="0.2"/> painless no risk <pause dur="0.4"/> reliable <pause dur="0.6"/> okay lady next to her <pause dur="0.3"/> you had a headband on last time you thought you'd hide by not wearing a headband <pause dur="0.3"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> # <pause dur="0.2"/> <trunc>wh</trunc> why # why what's wrong what's <pause dur="0.2"/> wrong with urinary dipsticks </u><pause dur="1.2"/> <u who="sf0591" trans="pause"> it's not always accurate </u><pause dur="0.4"/> <u who="nm0572" trans="pause"> they're not <trunc>al</trunc> yeah let's expand on that you're right <pause dur="1.1"/> what way are they not accurate <pause dur="3.2"/> there's some handouts coming round now by the way sorry the answer to this question is <gap reason="inaudible" extent="1 sec"/><pause dur="1.8"/> anybody

else why why are they not accurate </u><pause dur="0.3"/> <u who="sm0592" trans="pause"> it's up to the person who reads it </u><pause dur="0.6"/> <u who="nm0572" trans="pause"> yeah i mean there there is <pause dur="0.2"/> problems with the colour vision you know how do i know <pause dur="0.3"/> that you see the same <trunc>bl</trunc> <pause dur="0.2"/> blue as everybody <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> you know <pause dur="0.2"/> # <pause dur="0.5"/> # # how do we know what we see is the same <pause dur="0.9"/> and also it's pretty crude often you're not sure whether it's two pluses or one plus <pause dur="0.2"/> it may make a lot of difference okay <pause dur="0.3"/> and what have you're right what other <trunc>al</trunc> <pause dur="0.4"/> that's a very important <pause dur="0.7"/> answer <pause dur="0.2"/> what other ways is a urinary dipstick </u><pause dur="0.3"/> <u who="sm0593" trans="pause"> it's only a snapshot <pause dur="0.3"/> <gap reason="inaudible" extent="1 sec"/></u><u who="nm0572" trans="overlap"> it's only a snapshot so we're getting well problem of linear bias again <pause dur="0.3"/> you know and <shift feature="voice" new="laugh"/>it<shift feature="voice" new="normal"/> you know it may come and go <pause dur="0.3"/><kinesic desc="writes on board" iterated="y" dur="1"/> particularly if it's low level <pause dur="0.7"/> <trunc>any</trunc> anything else <pause dur="1.1"/> other problems </u><pause dur="0.4"/> <u who="sm0594" trans="pause"> <gap reason="inaudible due to overlap" extent="2 secs"/> </u><u who="sf0595" trans="overlap"> it's not a natural number it's just a </u><pause dur="0.4"/> <u who="nm0572" trans="pause"> yeah it's a it's not a natural number <pause dur="0.2"/> it's just # some vague number of pluses <pause dur="0.9"/> what what

are some more technical problems with a urinary dipstick then </u><pause dur="1.4"/> <u who="sm0596" trans="pause"> does it only measure in like macro <pause dur="0.7"/> # </u><u who="nm0572" trans="overlap"> yeah you're getting there <pause dur="0.3"/> yeah </u><pause dur="0.6"/> <u who="sm0596" trans="pause"> <gap reason="inaudible" extent="1 sec"/></u><u who="nm0572" trans="overlap"> it mainly measures what </u><pause dur="0.3"/> <u who="sm0596" trans="pause"> its albumin </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> albumin <pause dur="0.6"/> that's the trouble <pause dur="0.4"/> it mainly measures albumin <pause dur="0.3"/> and albumin is one of many proteins and it may not be the protein <pause dur="0.4"/> that is going through <pause dur="0.4"/> the glomerulus which should not be going through <pause dur="0.2"/> may be globulins may be other proteins <pause dur="0.5"/> it may be Bence-Jones protein what condition causes Bence-Jones proteinuria </u><pause dur="0.5"/> <u who="sm0597" trans="pause"> myeloma </u><pause dur="0.3"/> <u who="nm0572" trans="pause"> myeloma <pause dur="0.6"/> okay so a urinary dipstick would miss myeloma <pause dur="0.3"/> very important cause of significant proteinuria <pause dur="1.2"/> so if you forget everything i say in this talk just remember that fact <pause dur="0.5"/> that a urinary dipstick measures albumin and albumin alone <pause dur="0.3"/> there are technical problems with it <pause dur="0.4"/>

and it's not completely reliable it will miss certain diseases <pause dur="0.9"/> # <pause dur="0.5"/> another problem with it which is identified on your <pause dur="0.2"/> # handout <pause dur="0.3"/> # <pause dur="0.2"/> is that <pause dur="0.4"/> there's no standard setting you know <kinesic desc="writes on board" iterated="y" dur="23"/> i've told you there's nought <pause dur="0.3"/> there's a trace <pause dur="0.2"/> there's a plus there's two pluses <pause dur="0.3"/> nobody has ever set a standard you know <pause dur="0.2"/> either that <pause dur="0.2"/> is equivalent to X <pause dur="0.2"/> numbers or milligrams per twenty-four hours <pause dur="0.3"/> remember <pause dur="0.2"/> the normal range is up to one-fifty milligrams per twenty-four hours <unclear>or</unclear> <pause dur="0.4"/> if you pass one-and-a-half litres a day that's about <pause dur="0.3"/> a hundred milligrams <unclear>or</unclear> <pause dur="0.2"/> or nought-point-one grams per litre <pause dur="1.0"/> that's another way of expressing it <pause dur="0.2"/> actually in <gap reason="name" extent="1 word"/> we get <pause dur="0.3"/> a concentration most <pause dur="0.3"/> # <pause dur="0.2"/> countries in the world <pause dur="0.3"/> and <trunc>le</trunc> and <shift feature="voice" new="laugh"/>cities<shift feature="voice" new="normal"/> in in the U-K <pause dur="0.2"/> we actually get a twenty-four excretion but we have a concentration <pause dur="0.5"/> # <pause dur="0.3"/> and that's another problem with this <pause dur="0.2"/> with a dipstick it measures concentration <pause dur="0.6"/> so if you if you're a little old lady who drinks <pause dur="0.5"/> three cups of

tea a day you only drink four-hundred mls a day your urine will be concentrated <pause dur="0.3"/> so that will immediately shift all your <kinesic desc="writes on board" iterated="y" dur="1"/> values down a bit <pause dur="1.2"/> so depending on how much you drink it affects the sensitivity of the test <pause dur="1.7"/> that's why you can't say 'cause it measures the concentration <pause dur="0.3"/> that that is equivalent to X <pause dur="0.4"/> amount of proteinuria for twenty-four hours and that's equivalent to Y <pause dur="1.0"/> but roughly speaking <pause dur="0.4"/> # <pause dur="0.5"/> what we would normally say is a trace <pause dur="0.3"/> you don't necessarily have to investigate but <pause dur="0.2"/> one plus <pause dur="0.3"/> or more of proteinuria you should investigate <pause dur="0.5"/> and <pause dur="0.5"/> <kinesic desc="writes on board" iterated="y" dur="7"/> some people say <pause dur="1.3"/> that you start to get one plus when you have greater than three-hundred milligrams per twenty-four hours <pause dur="1.3"/> in other words <pause dur="0.2"/> there are levels of proteinuria which are biologically significant in the difference between <kinesic desc="indicates point on board" iterated="n"/> these two numbers <pause dur="0.3"/> which are missed by a urinary dipstick <pause dur="0.7"/> so in other words <pause dur="0.2"/> you get false positives <pause dur="0.4"/> and you get false negatives <pause dur="0.7"/> # with

urinary dipsticks <pause dur="0.8"/> false positives <pause dur="0.3"/> because there are non-renal diseases such as pyrexia <pause dur="0.2"/> such as pregnancy such as heart failure <pause dur="0.2"/> various <trunc>hydy</trunc> hyperdynamic <pause dur="0.3"/> states <pause dur="0.3"/> which will give you a trace of proteinuria so <kinesic desc="indicates point on board" iterated="n"/> that's a false positive <pause dur="0.5"/> # <pause dur="0.4"/> a false negative <pause dur="0.3"/> is when you miss <pause dur="0.2"/> important <pause dur="0.4"/> biological levels of proteinuria which a dipstick said was a trace <pause dur="0.3"/> and was normal <pause dur="0.5"/> and if the patient happened to drink a bit less it would <trunc>the</trunc> then have become positive <pause dur="1.0"/> but nonetheless <pause dur="0.5"/> it's not a bad screening test <pause dur="0.3"/> # <pause dur="0.7"/> and <pause dur="0.6"/> i hope you don't take those words away from you <pause dur="0.2"/> those of you who are going to be G-Ps <pause dur="0.4"/> and # <pause dur="0.3"/> think for the rest of your lives <pause dur="0.3"/> as many G-Ps do when your patient is apparently well has normal blood pressure a normal creatinine and a normal dipstick they don't have <pause dur="0.3"/> renal disease <pause dur="0.2"/> they could easily have polycystic kidney disease <pause dur="0.4"/> there are lots of renal diseases that don't give you <pause dur="0.3"/> normal blood pressure normal <pause dur="0.3"/> # dipstick <pause dur="0.3"/> normal creatinine <pause dur="0.3"/> and that

they are significant <pause dur="0.6"/> and so certanly it was <pause dur="0.3"/> taught to me as a medical student that a <pause dur="0.2"/> a urinary dipstick combined with normal blood pressure normal renal function <pause dur="0.3"/> excludes significant renal disease that is not true <pause dur="0.3"/> it excludes most <pause dur="0.5"/> significant renal disease it doesn't exclude cancer in a kidney <pause dur="0.6"/> it doesn't exclude polycystic kidney disease <pause dur="0.3"/> it doesn't exclude many tubular interstitial diseases <pause dur="0.9"/> okay <pause dur="0.3"/> so <pause dur="0.2"/> we've knocked or i've knocked <pause dur="0.2"/> # the urinary dipstick test <pause dur="0.3"/> # what do we do instead <pause dur="0.3"/> ah <pause dur="0.4"/> we've got a much better test twenty-four hour urine <kinesic desc="writes on board" iterated="y" dur="4"/> that's a nice test <pause dur="0.4"/> because it gives you <pause dur="0.2"/> a nice number <pause dur="0.3"/> and it's reliable <pause dur="0.7"/> # <pause dur="0.2"/> how do we how do we </u><pause dur="0.6"/> <u who="sf0598" trans="pause"> can i just say the handout <pause dur="0.3"/> # # the second page is the same as the last handout <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0572" trans="overlap"> is it </u><u who="sf0598" trans="latching"> this page </u><pause dur="0.3"/> <u who="nm0572" trans="pause"> oh that's a cock-up <pause dur="0.3"/> can i have a look </u><pause dur="0.7"/> <u who="sf0599" trans="pause"> <gap reason="inaudible" extent="2 secs"/> </u><u who="nm0572" trans="latching"> <event desc="looks at handout" iterated="n"/>

yes <pause dur="0.9"/> right thank you for spotting that <pause dur="0.9"/> okay <pause dur="0.3"/> sorry about that team <pause dur="0.8"/> # <pause dur="1.1"/> great <pause dur="3.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # what i suggest you do is don't read the back of that <pause dur="0.7"/> okay <pause dur="0.6"/> # 'cause it's it's all about diabetes <pause dur="2.3"/> is that right yeah <pause dur="0.3"/> it's all about diabetes <pause dur="0.7"/> and </u><pause dur="0.7"/> <u who="nf0600" trans="pause"> i can the <pause dur="0.3"/> the photocopier is broken which is why we're late but i'll put one in the pigeonholes as soon as i can photocopy them </u><pause dur="1.0"/> <u who="nm0572" trans="pause"> right <pause dur="0.2"/> okay </u><pause dur="0.2"/> <u who="nf0600" trans="pause"> that's the best i can do </u><u who="nm0572" trans="overlap"> sorry about that <pause dur="0.4"/> # <pause dur="0.4"/> cock-up <pause dur="0.4"/><vocal desc="laughter" iterated="y" n="ss" dur="2"/> Dr <gap reason="name" extent="1 word"/> <pause dur="0.5"/> Dr <gap reason="name" extent="1 word"/> to blame <pause dur="1.1"/> and # we will # <pause dur="0.4"/> try to <pause dur="0.5"/> # address that for you <pause dur="0.3"/> okay <pause dur="0.3"/> well it may be quite good 'cause you might you might listen a bit more to what i'm saying <pause dur="0.5"/> so # <pause dur="0.6"/> what's the problem <pause dur="0.7"/> how do we do a twenty-four hour protein <pause dur="0.6"/> <trunc>le</trunc> <pause dur="1.1"/> you're on the case </u><pause dur="0.7"/> <u who="sf0598" trans="pause"> you collect <pause dur="0.2"/> every <pause dur="0.3"/> # <pause dur="0.7"/> urine that the patient does in a bottle and collect it </u><u who="nm0572" trans="latching"> mm </u><u who="sf0598" trans="latching"> put it in the fridge for twenty-four hours and send it to the lab </u><pause dur="0.8"/> <u who="nm0572" trans="pause">

how many times have you been to the loo today </u><pause dur="1.1"/> <u who="sf0601" trans="pause"> <vocal desc="laugh" iterated="n"/> <shift feature="voice" new="laugh"/>once<shift feature="voice" new="normal"/> </u><pause dur="0.2"/> <u who="nm0572" trans="pause"> sure</u><pause dur="1.4"/> <u who="sf0602" trans="pause"> sure <vocal desc="laughter" iterated="y" n="ss" dur="3"/></u><pause dur="1.2"/> <u who="nm0572" trans="pause"> sure <kinesic desc="nods head" iterated="n" n="sf0602"/><pause dur="3.5"/> how many once <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> sure <pause dur="2.0"/><kinesic desc="nods head" iterated="n" n="sf0606"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> i've been at least two i can't possibly <gap reason="inaudible" extent="1 sec"/> at least two <vocal desc="laughter" iterated="y" n="ss" dur="1"/> but i can't remember can't remember having been to the loo this morning <pause dur="0.6"/> # <pause dur="0.2"/> and <pause dur="0.3"/> it's # <pause dur="0.4"/> people can't remember <pause dur="0.6"/> and people <pause dur="0.2"/> don't remember <pause dur="0.3"/> to do it <pause dur="0.7"/> # when do you start <pause dur="1.1"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> you know if you're going to say to a patient here's a bottle go away and fill up a twenty-four hour urine go on start <pause dur="0.3"/> fill it up <pause dur="0.9"/> now they won't they don't know what to do <pause dur="0.3"/> and if you do a twenty-four hour urine you have to explain it very clearly <pause dur="0.4"/> you have to explain to them that <pause dur="0.7"/> you want them to start at a certain time and usually it's best to say when you get up <pause dur="0.7"/> and put every <pause dur="1.1"/> urine <pause dur="0.3"/> that you pass through the day into that bottle <pause dur="1.0"/> and then stop <pause dur="0.4"/> when you get up the following morning but then what if you get up

in the night <pause dur="0.6"/> you know which day is that in <pause dur="0.8"/> so it actually becomes quite hard to ask them to do a a very simple thing like a twenty-four hour urine <pause dur="0.5"/> and <pause dur="0.2"/> what i normally say is <pause dur="1.1"/> write down <pause dur="0.4"/> the time which you got up <pause dur="1.9"/> and then <pause dur="0.3"/> put in every urine <pause dur="0.2"/> for the following twenty-four hours and and you really have to explain in incredible detail <pause dur="0.4"/> # <pause dur="0.2"/> and the problem is one urine sample <pause dur="0.3"/> <trunc>l</trunc> <pause dur="0.4"/> in there that should be in there or should or or is missed <pause dur="0.4"/> messes up the whole thing <pause dur="0.4"/> if you've taken out perhaps a quarter <pause dur="0.2"/> of the day's urine output <pause dur="0.6"/> so it's intrinsically unreliable i know you're told it's all <trunc>br</trunc> it's brilliant to do a twenty-four hour urine <pause dur="0.4"/> but # <pause dur="0.3"/> the other problem <trunc>i</trunc> in women <pause dur="0.5"/> # is that <pause dur="0.2"/> women for the for the boys <unclear>being</unclear> in the room who don't know this <pause dur="0.3"/> # sometimes do wee-wees and poo-poos <pause dur="0.4"/> at the same time or <vocal desc="laughter" iterated="y" n="ss" dur="2"/> vaguely the same time <pause dur="0.5"/> so you can't always not exactly the same time <vocal desc="laughter" iterated="y" n="ss" dur="2"/> you know # <pause dur="0.5"/>

# <pause dur="1.4"/><vocal desc="laughter" iterated="y" n="ss" dur="2"/> and # this <gap reason="inaudible" extent="1 sec"/><vocal desc="laughter" iterated="y" n="ss" dur="2"/> <pause dur="0.8"/> you know <pause dur="1.1"/> isn't it ladies <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="3"/> you know to control these things <pause dur="0.4"/> and you know how how do you <pause dur="0.3"/><kinesic desc="makes stance" iterated="n"/> <vocal desc="laughter" iterated="y" n="ss" dur="6"/> you know <pause dur="1.4"/> you know <pause dur="1.5"/><kinesic desc="makes stance" iterated="n"/> how do you do it <pause dur="0.6"/> <trunc>y</trunc> <trunc>y</trunc> <trunc>y</trunc> you know <gap reason="inaudible" extent="1 sec"/> in a pot do it in there <trunc>w</trunc> what <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> how do i sit on that thing you know <pause dur="0.3"/><kinesic desc="makes stance" iterated="n"/> and it's very difficult <vocal desc="laughter" iterated="y" n="ss" dur="2"/> and they're they're given these # <pause dur="0.5"/> # pots to wee into and then you tip that and oh ah <pause dur="0.3"/> all down his shoes <pause dur="1.0"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/><gap reason="inaudible" extent="1 sec"/> <pause dur="0.5"/> i've got it on my fingers <vocal desc="laughter" iterated="y" n="ss" dur="1"/> horrible <pause dur="0.4"/> you know that's quite difficult to do a twenty-four hour urine and # so # the bottom line is i rarely organize them <pause dur="0.3"/> or if i do organize them <pause dur="0.3"/> # i explain very clearly to the patient exactly what i want them to do <pause dur="0.3"/> 'cause it affects clinical decision making <pause dur="0.2"/> and a <trunc>s</trunc> and a

small difference between say <pause dur="0.2"/> two grams per twenty-four hour proteinuria <pause dur="0.2"/> one gram or three grams could decide whether we do a renal biopsy or not <pause dur="0.8"/> so it's got to be accurate <pause dur="0.7"/> and ladies if you <unclear>order with</unclear> ladies it's <pause dur="0.4"/> you've got to give them the equipment <pause dur="0.2"/> you know <pause dur="0.2"/> you give them one of the what happens <pause dur="0.2"/> they go down the the doctor says <shift feature="voice" new="mumble"/><gap reason="inaudible" extent="1 sec"/> twenty-four hour urine <gap reason="inaudible" extent="1 sec"/> go away <shift feature="voice" new="normal"/> <pause dur="0.5"/> and # what <pause dur="0.8"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> and # they take the form away <pause dur="0.3"/> and then they show it to someone and they go <pause dur="0.2"/> oh i don't like this and they go oh go and show it to somebody else <pause dur="0.4"/> and then they <trunc>sh</trunc> they show it to somebody in the lab and they give you a a <trunc>p</trunc> a pot with a narrow top <pause dur="0.9"/> i mean <trunc>th</trunc> how do you do that <pause dur="0.4"/> i mean how do you <pause dur="0.4"/> you know it's very difficult <pause dur="0.4"/> to pee into a narrow neck you know

'cause they don't give you the other bit of equipment which you need <pause dur="0.3"/> which is a sort of tray thing to pee into to pour it into the pot <pause dur="0.7"/> sorry to get so sort of basic on the <pause dur="1.8"/> actually i quite like talking about that <pause dur="0.4"/><vocal desc="laughter" iterated="y" n="ss" dur="3"/> # <pause dur="0.7"/> and # <pause dur="1.2"/> it's very difficult to do a twenty-four urine but nonetheless it is it is the gold standard test if you can do it accurately and it won't miss <pause dur="0.4"/> # myeloma <pause dur="0.2"/> because <pause dur="0.2"/> # it does measure other things other than albumin <pause dur="1.2"/> okay <pause dur="0.7"/> now in the in the last # ten or fifteen minutes <pause dur="0.3"/> # <pause dur="0.3"/> i'm going to talk about glomerulonephritis <pause dur="0.8"/> <event desc="noise from audience" iterated="y" n="ss" dur="6"/><kinesic desc="writes on board" iterated="y" dur="10"/> # <pause dur="0.3"/> now as we've said there are many causes of <pause dur="0.2"/> nephrotic syndrome <pause dur="0.4"/> shush <pause dur="0.5"/> and there are many causes <pause dur="0.4"/> of <trunc>nep</trunc> <pause dur="0.2"/> of glomerular disease including diabetes <pause dur="0.6"/> the thing that gets a nephrologist excited is glomerulonephritis <pause dur="0.6"/> this is it <pause dur="0.2"/> for us we love this thing glomerulonephritis it's a long word <pause dur="0.5"/> nobody else understands it only we

know we're not going to tell you <pause dur="1.2"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> we're just not going to tell you <pause dur="0.5"/> 'cause it's a secret <pause dur="0.4"/> and it's why <pause dur="0.2"/> people think kidney doctors are clever 'cause we can come up with long names like <pause dur="0.2"/> <shift feature="voice" new="mimicking an other's voice"/> type three mesangiocapillary glomerulonephritis an obvious case <pause dur="0.4"/> can't believe you missed it <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> God <pause dur="1.1"/> so obvious <shift feature="voice" new="normal"/><pause dur="0.4"/> # <pause dur="0.5"/> crescentric glomerulonephritis rapidly progressive glomerulonephritis <pause dur="0.4"/> that <pause dur="0.2"/> for us <pause dur="0.3"/> is nearly sex <pause dur="1.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> nearly <pause dur="0.7"/> crescentic glomerulonephritis <pause dur="0.3"/><vocal desc="laughter" iterated="y" n="ss" dur="2"/> oh <pause dur="0.7"/> my <pause dur="0.4"/> God <pause dur="0.4"/> do we get excited about it we ring each other up <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="6"/> we <pause dur="0.3"/> tell each other about it we relive it <pause dur="1.8"/> it's great isn't it <pause dur="0.4"/> and # <pause dur="0.8"/> it # <pause dur="0.3"/> i only tell you these things because you'll read about them in books you'll read five different books they've got six different classifications it's all too complicated <pause dur="1.2"/> are we stopping there for

handouts <gap reason="inaudible" extent="1 sec"/> </u><u who="nf0600" trans="overlap"> no i haven't haven't got the page </u><u who="nm0572" trans="overlap"> # <pause dur="0.6"/> we we <pause dur="0.8"/> we # <pause dur="1.1"/> forgot what i'm saying now mid-flow <pause dur="0.8"/> <vocal desc="laughter" iterated="y" n="ss" dur="3"/> talking <pause dur="0.3"/> oh i <trunc>wa</trunc> i was <pause dur="0.4"/> talking about rude things i was glad you were out of the room <pause dur="0.4"/> # <pause dur="1.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> the # <pause dur="0.8"/> the the we get very excited about these things crescentic glomerulonephritis <pause dur="0.3"/> # <pause dur="0.6"/> all the books are different <pause dur="0.3"/> all the classifications are different bottom line don't have to know about it <pause dur="0.7"/> okay <pause dur="0.4"/> so what i'm about to tell you in the next ten minutes <trunc>i</trunc> is purely out of interest <pause dur="0.7"/> # <pause dur="0.4"/> now <pause dur="1.1"/> on the handout which you will get <pause dur="0.6"/><vocal desc="laugh" iterated="n"/> there lists <pause dur="0.2"/> # <kinesic desc="writes on board" iterated="y" dur="1"/> seven different groups of types of glomerulonephritis <pause dur="0.3"/> and they can be largely divided into <kinesic desc="writes on board" iterated="y" dur="8"/> two groups one of three and one of four <pause dur="0.5"/> the first group <pause dur="0.3"/> the so-called non-proliferative

glomerulonephritides <pause dur="0.5"/> which are usually heavily proteinuric minimal change glomerulonephritis <pause dur="0.7"/> membranous glomerulonephritis <pause dur="0.4"/> and the dreaded F-S-G-S focal and segmental glomerulosclerosis <pause dur="1.8"/> and <pause dur="0.3"/><kinesic desc="writes on board" iterated="y" dur="2"/> these three diseases <pause dur="0.6"/> # <pause dur="0.3"/> are <pause dur="0.7"/> non-proliferative proliferative means there's an increase in cell numbers there's no increase in cell number <pause dur="0.2"/> if you do a renal biopsy in these diseases <pause dur="0.4"/> pictures of them in <kinesic desc="holds up book" iterated="n"/> this book and lots of other books if you want to see them <pause dur="0.7"/> i'm only really going to talk about one in much detail today and that's the good one <kinesic desc="indicates point on board" iterated="n"/><pause dur="0.2"/> if you're going to have glomerulonephritis <pause dur="0.5"/> have minimal change <pause dur="0.9"/> why do you think it's called minimal change glomerulonephritis </u><u who="sm0603" trans="pause"> there's not much change </u><pause dur="0.3"/> <u who="nm0572" trans="pause"> yeah there's not there's no change <pause dur="0.3"/> no change <pause dur="0.4"/> unlike microscopy <pause dur="1.0"/> # <pause dur="0.3"/> it normally presents in children sometimes in adults as <pause dur="0.2"/> <kinesic desc="writes on board" iterated="y" dur="2"/> severe nephrotic syndrome in fact most of these present as nephrotic syndrome usually but not always <pause dur="0.4"/> in

kidney medicine anything can present as anything <pause dur="1.4"/> and this <pause dur="0.6"/> usually affects children children <pause dur="0.9"/> difficult to do biopsies on them 'cause you have to hold them down and parents don't like it tie them up <pause dur="0.3"/> parents don't like it <pause dur="0.2"/> difficult can't anaesthetize them to do a biopsy <pause dur="0.4"/> parents don't like it <pause dur="0.2"/> so so we guess in children <pause dur="0.3"/> but i actually think it's wrong that we guess <pause dur="0.3"/> because i think we make we make # a lot of misdiagnoses in children because we don't biopsy them <pause dur="0.2"/> if i had my way i'd give them <pause dur="0.2"/> quick <pause dur="0.3"/> quick general anaesthetic <pause dur="0.2"/> biopsy much much more scientific <pause dur="0.6"/> # <pause dur="0.7"/> and # <pause dur="1.4"/> though i didn't have too much problem with that bloke in Liverpool who used to take organs home with him so i wouldn't <vocal desc="laughter" iterated="y" n="ss" dur="1"/> wouldn't trust my judgement <pause dur="0.5"/> # <pause dur="0.5"/> and # <pause dur="0.8"/> the # it's still not illegal actually what he did was not illegal just a slight aside i know it's terrible inappropriate wrong everything like that but it wasn't it wasn't and isn't illegal <pause dur="0.6"/> # you don't you didn't and don't have to ask permission from

patients to take <pause dur="0.3"/> bits of organs out of them <pause dur="0.4"/> # the law's going to change soon and it will all be illegal and then <pause dur="1.1"/> pathology will cease to exist <pause dur="0.3"/> # <pause dur="0.2"/> anyway so minimal change if you if you do a biopsy light microscopy is normal <pause dur="0.7"/> electron microscopy is abnormal and shows thinning of the basement <trunc>mem</trunc> facement of the podocytes that's the key phrase <pause dur="0.4"/> so do you remember <pause dur="0.2"/><kinesic desc="writes on board" iterated="y" dur="6"/> the three layered <pause dur="0.4"/> # <pause dur="0.2"/> glomerulus <pause dur="0.3"/> it's the <pause dur="0.3"/> epithelium in which there are podocytes they get effaced they in other words they get flattened <pause dur="0.3"/> that's the key pathological finding <pause dur="0.6"/> # <pause dur="0.7"/> immunofluorescence normal <pause dur="0.5"/> # <pause dur="0.8"/> self-limiting disease <pause dur="0.2"/> probably will get better anyway in some children <pause dur="0.3"/> # we don't biopsy we presume it's that if they <trunc>nephre</trunc> if they present with nephrotic syndrome there's no other obvious cause <pause dur="0.3"/> short course of steroids usually goes away <pause dur="0.9"/> # prednisolone <pause dur="0.5"/> # <pause dur="0.5"/> in adults it can be a more severe disease and some people say

it's a spectrum of disease that # # which include F-S-G-S <pause dur="0.5"/> and <pause dur="0.3"/> in adults can sometimes require more than steroids we have to use other drugs which are cyclophosphamide <pause dur="0.4"/> chlorambucil a variety of other drugs <pause dur="0.8"/> sometimes cyclosporin <pause dur="0.5"/> # <pause dur="0.3"/> it's quite interesting sometimes in kidney medicine we use drugs that we that that we know are the cause of renal disease but <pause dur="0.2"/> in certain situations that they are of benefit <pause dur="0.9"/> and cyclosporin is a classic example <pause dur="0.3"/> nephrotoxic drug <pause dur="0.3"/> but it's been found <pause dur="0.2"/> to be particularly useful in <pause dur="0.2"/> steroid-resistant <pause dur="0.4"/> # minimal change in adults <pause dur="1.1"/><kinesic desc="writes on board" iterated="y" dur="4"/> that's got a good prognosis <pause dur="0.3"/> that's medium <pause dur="0.3"/> # and that's terrible <pause dur="0.6"/> and # it's part of the reason F-S-G-S is terrible is it <pause dur="0.2"/> recurs after a kidney transplant <pause dur="1.1"/> so don't have <trunc>s</trunc> F-S-G-S <pause dur="0.4"/> when i was at an S-R in London Senior Registrar i <pause dur="0.2"/> looked after a young lady who had had <trunc>s</trunc> got seven kidneys inside her <pause dur="0.3"/> and she was only in her early twenties <pause dur="0.3"/> she had five transplants all of which had failed

because of recurrent F-S-G-S <pause dur="0.8"/> and i asked her one day whether she wanted another transplant and she said oh you might as well i mean i've got # i i've got seven might as well have eight <pause dur="0.7"/> # <pause dur="0.8"/> and # <pause dur="0.2"/> <kinesic desc="writes on board" iterated="y" dur="2"/> anyway <pause dur="0.4"/> so the other <pause dur="0.2"/> # glomerulonephritides the other four <pause dur="0.8"/> # <pause dur="0.3"/> there's the <pause dur="0.2"/> so-called <pause dur="0.4"/> proliferative in other words there's an increase in cell number <pause dur="0.6"/> glomerulonephritides <pause dur="0.5"/> and are usually less proteinuric <pause dur="0.8"/> but still have some proteinuria <pause dur="0.5"/> # and they are <kinesic desc="writes on board" iterated="y" dur="7"/> I-G-A nephropathy which is probably the commonest of the glomerulonephritides <pause dur="1.7"/> # mesangiocapillary glomerulonephritis which irritatingly has the same <pause dur="0.4"/> # eponym as minimal change mesangiocapillary <pause dur="0.3"/> in the States called membranoproliferative in other countries lobular it's got a variety of other names <pause dur="0.3"/> it's why in all the books it's got different names 'cause it has got different names <pause dur="0.9"/>

<kinesic desc="writes on board" iterated="y" dur="2"/> post-infectious which we hardly see any more <pause dur="1.5"/> related to streptococci usually self-limiting disease <pause dur="0.3"/> though interestingly it it in books of old <pause dur="0.4"/> # <pause dur="0.3"/> it # if you read if you go into the Wellcome Library on the Euston Road read some of the old nephrology books <pause dur="0.4"/> # i think the the original Bright's disease which were described were probably <pause dur="0.3"/> post-infectious post-strep <pause dur="0.3"/> <distinct lang="fr">à la</distinct> rheumatic fever <pause dur="0.2"/> <distinct lang="fr">à la</distinct> other <pause dur="0.4"/> autoimmune complications of infectious diseases <pause dur="0.3"/> but i think in in i've been in nephrology fourteen years i've only ever seen one person <pause dur="0.3"/> with post-infectious G-N <pause dur="0.3"/> and finally <kinesic desc="writes on board" iterated="y" dur="4"/> the thing that we love <pause dur="0.3"/> <sic corr="crescentic">crescentric</sic> <pause dur="0.3"/> or some people call it rapidly progressive glomerulonephritis <pause dur="1.1"/><kinesic desc="indicates point on board" iterated="n"/><kinesic desc="writes on board" iterated="y" dur="1"/> that usually presents as intermittent macroscopic haematuria in young men <kinesic desc="indicates point on board" iterated="n"/><kinesic desc="writes on board" iterated="y" dur="1"/> that as anything <pause dur="0.2"/> that as acute renal failure or nephritic syndrome <pause dur="0.4"/><kinesic desc="indicates point on board" iterated="n"/><kinesic desc="writes on board" iterated="y" dur="1"/> that <pause dur="0.3"/> as <pause dur="0.3"/> as you can imagine with a

name like rapidly progressive glomerulonephritis acute renal failure usually <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="2"/> # <pause dur="0.2"/> associated often with either <pause dur="0.2"/> upper airway <pause dur="0.2"/> haemorrhage <pause dur="0.2"/> or lower airway haemorrhage or upper airway haemorrhage <pause dur="0.3"/> epistaxis <pause dur="0.2"/> bleeding out of your ears <pause dur="0.3"/> anything upper airway <pause dur="0.3"/> and we call those sort of diseases Wegener's granulomatosis <pause dur="0.4"/> lower airway <pause dur="0.5"/> pulmonary haemorrhage <pause dur="0.3"/> of which there are many causes lupus <pause dur="0.9"/> <unclear>polyarthritis</unclear> <gap reason="inaudible" extent="1 sec"/> so a variety of other causes <pause dur="0.4"/> i don't want to go through these in any great detail you don't need to know about them in any great detail <pause dur="0.2"/> what you deed need to know is that they exist and if you think you've got one you go and get the cavalry which is <pause dur="0.4"/> somebody like us <pause dur="1.2"/> # <pause dur="1.0"/> briefly the thing that we we jump up and down about the thing that we <pause dur="0.3"/> # <pause dur="0.3"/> like so much <pause dur="0.3"/> <sic corr="crescentic">crescentric</sic> <pause dur="0.2"/> <kinesic desc="writes on board" iterated="y" dur="3"/> glomerulonephritis <pause dur="0.7"/> i'll <pause dur="0.2"/> talk about for a couple of minutes <pause dur="0.4"/> # <pause dur="0.2"/> so if you do a

<kinesic desc="writes on board" iterated="y" dur="11"/> renal biopsy <pause dur="0.2"/> there's lots of bits in the middle the mesangium in the middle looks a bit like that <pause dur="0.3"/> and in a <sic corr="crescentic">crescentric</sic> glomerulonephritis you have a crescent <pause dur="0.6"/> of abnormal <trunc>tissu</trunc> tissue <pause dur="0.4"/> hence it's called <sic corr="crescentic">crescentric</sic> <pause dur="0.6"/> # <pause dur="1.0"/> and <pause dur="0.3"/> the reason we like it so much is because it's a paradigm <pause dur="0.4"/> in other words <pause dur="0.3"/> it's a disease <pause dur="0.3"/> which helps you understand other diseases <pause dur="0.4"/> and the classic cause of <sic corr="crescentic">crescentric</sic> glomerulonephritis of which there are many causes <pause dur="0.4"/> is a disease <kinesic desc="writes on board" iterated="y" dur="4"/> called Goodpastures disease <pause dur="0.5"/> does anybody know why Goodpasture's disease <pause dur="0.4"/> being a cause of <sic corr="crescentic">crescentric</sic> G-N <pause dur="0.3"/> is a paradigm for other diseases <pause dur="1.6"/> do you know what i mean by a paradigm it it it's a disease that helps you <pause dur="1.2"/> understand normal physiology <pause dur="0.3"/> and other diseases <pause dur="2.9"/> can anybody give me a sentence on <pause dur="0.2"/> Goodpasture's disease </u><pause dur="0.3"/> <u who="sm0604" trans="pause"> autoimmunity to the basement membrane </u><u who="nm0572" trans="latching"> yeah very good so it's a disease <pause dur="0.2"/> which there is <pause dur="0.2"/> an autoimmune reaction <pause dur="0.4"/> to the basement

membrane <pause dur="0.4"/> both in the kidney <pause dur="0.6"/> and in the lung <pause dur="0.9"/> the same antibody is directed towards the glomerular basement membrane in the kidney and the lung <pause dur="1.2"/> and <pause dur="0.2"/> you can actually prove this you can measure the level of this antibody in the blood <pause dur="0.4"/> when you have somebody and they usually present with a combination of acute renal failure and pulmonary haemorrhage <pause dur="1.0"/> usually on a Friday afternoon <vocal desc="laughter" iterated="y" n="ss" dur="1"/> for some strange reason <pause dur="0.5"/> and # <pause dur="0.4"/> actually i think the only reason things occur <pause dur="0.3"/> on a Friday afternoon why do you think things are referred to specialist units on a Friday afternoon <pause dur="0.5"/> do diseases really happen <pause dur="0.6"/> more commonly on a Friday afternoon </u><u who="ss" trans="overlap"> <gap reason="inaudible" extent="2 secs"/> </u><u who="nm0572" trans="overlap"> speak up </u><pause dur="0.4"/> <u who="sf0605" trans="pause"> G-Ps don't want to get called out on the weekends <vocal desc="laughter" iterated="y" n="ss" dur="2"/></u><u who="nm0572" trans="overlap"> very good yeah i'm a cynic ah i know <pause dur="0.9"/> # yeah G-Ps don't want to get called out at weekends <pause dur="0.2"/> also some hospital doctors <pause dur="0.4"/> # <pause dur="0.4"/> sit on their arses all week go to the mess <pause dur="0.4"/> # sit around pontificate <pause dur="0.2"/> now

bloody hell Thursday <unclear>all the oh</unclear> bad blood tests <pause dur="0.5"/> i'd better tell somebody oh i'll do it tomorrow Friday comes <pause dur="0.4"/> tell everybody's <vocal desc="squawk" iterated="n"/> <pause dur="0.3"/> # send them to the renal unit or the cardiac unit just get them out of there get them out of Nuneaton <pause dur="0.3"/> get them out of your small hospital <pause dur="0.3"/> and get them to the teaching centre <pause dur="0.2"/> so it's actually <pause dur="0.5"/> <trunc>ho</trunc> teaching hospital doctors always moan about Friday afternoons there are <pause dur="0.2"/> there are reasons why things happen on a Friday i think it's people <pause dur="0.5"/> # clearing the rubbish out <pause dur="0.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> before you go go all go off for the weekend <pause dur="1.3"/> # <pause dur="0.4"/> and # <pause dur="0.6"/> so the reason it's a paradigm is you can measure and prove the autoantibodies in the blood you can also do <pause dur="0.2"/> biopsies of both the lung and the kidney and use immunofluorescent techniques <pause dur="0.4"/> and <pause dur="0.2"/> show up these autoantibodies <pause dur="0.3"/> # to glomerular basement membrane and they're very pretty <pause dur="0.9"/> the other reason why it's a paradigm <pause dur="0.3"/> # is you've got a disease <pause dur="0.4"/> autoimmunity <pause dur="0.5"/> antibody in the

right place in the blood in the kidney in the lung <pause dur="0.3"/> and you suppress the immune system with a combination of methylprednisolone <pause dur="0.2"/> cyclophosphamide and plasma exchange <pause dur="0.5"/> and they get better <pause dur="1.0"/> magic <pause dur="0.4"/> all the antibody goes away <pause dur="0.3"/> you can repeat the biopsy at the end but it's gone the levels go down in the blood the patient gets better <pause dur="0.6"/> # <pause dur="0.5"/> obviously it's not as simple as that we don't really understand <pause dur="0.4"/> the cause of <pause dur="0.9"/> Goodpasture's disease or how the causes <pause dur="0.7"/> does the damage and whether these autoantibodies are <pause dur="0.2"/> are truly pathological <pause dur="0.2"/> or are they innocent bystanders are they drawn in by some other cytokines or something like that <pause dur="0.4"/> but either way they're there <pause dur="0.7"/> # <pause dur="0.3"/> and they go away <pause dur="0.2"/> if you immunosuppress the patient <pause dur="1.5"/> okay <pause dur="0.2"/> so that's a brief run-through of glomerulonephritis <pause dur="0.3"/> from a a a a

non # pathological perspective if you're interested <pause dur="0.3"/> the books are out there the web sites are out there <pause dur="0.5"/><event desc="noise from audience" iterated="y" dur="3"/> # <pause dur="0.4"/> i don't suggest don't rustle your papers yet hold on wait for it <pause dur="0.6"/> # <pause dur="1.4"/> i suggest you know <pause dur="0.4"/> a reasonable amount of minimal change nephropathy partly when you do paediatrics <pause dur="0.4"/> # they'll be talking a lot about minimal change nephropathy <pause dur="0.4"/> # i suggest you do some reading <pause dur="0.3"/> # <pause dur="0.2"/> on the other forms of glomerulonephritis not particularly for your exams <pause dur="0.3"/> but but just <pause dur="0.3"/> # for your own interest and also to make you aware of how different all the books are <pause dur="0.2"/> in terms of glomerulonephritis <pause dur="0.4"/> and i would do some reading about <sic corr="crescentic">crescentric</sic> G-N 'cause <pause dur="0.2"/> there are a lot of things you can learn <pause dur="0.3"/> about the working of the <pause dur="0.2"/> immune system and autoimmunity <pause dur="0.2"/> if you understand <sic corr="crescentic">crescentric</sic> G-N <pause dur="0.9"/> okay that's it any questions on <pause dur="0.8"/> nephrotic syndrome glomerular disease <pause dur="0.2"/> glomerulonephritis <pause dur="2.0"/> or anything