Glomerulonephritis

Brian S. Pavey, DO, MS

Presentation

• Sudden onset– Hematuria– Hypertension– Edema– Acute kidney injury

Broad Differential Diagnosis• Asymptomatic microscopic or gross hematuria

– Thin basement membrane nephropathy– IgA nephropathy– Mesangioproliferative nephropathy– Alport’s syndrome

• Acute Nephritis– Acute proliferative glomerulonephritis– Post-infectious glomerulonephritis

• Focal or diffuse proliferative glomerulonephritis– IgA nephropathy– Lupus nephritis

• Type I MPGN• Type II MPGN• Fibrillary glomerulonephritis• Rapidly Progressive glomerulonephritis• Pulmonary-renal vasculitic syndrome

– Goodpasture (Anti-GBM) syndrome– Immune complex vasculitis– Lupus– Wegener’s granulomatosis

• ANCA Vasculitis– Microscopic Polyangiitis– Wegener’s granulomatosis– Churg-Strauss syndrome

Approaching Acute Nephritis

• Urinalysis– Hematuria– Proteinuria

• Urine microscopy– Dysmorphic RBCs, RBC casts, acanthocytes

• Assess 24-hour proteinuria (prot/creat ratio)• Acute phase reactants– ESR, CRP,

• Renal Ultrasound

Nephritic Workup• CBC• CMP, Phosphorus• ESR/CRP• Complement C3 and C4• UA with microscopic evaluation• Quantify proteinuria• Streptozyme (anti-streptolysin O)• Blood culture• ANA• Anti-DS DNA• Hepatitis B & C serologies• ANCA’s• Anti-GBM• UPEP with immunofixation• SPEP with immunofixation• Serum free light chains• Renal ultrasound• ? Chest Xray or CT chest• ? Echocardiogram

What is the Diagnosis?

Henoch-Schonlein Purpura• Tetrad of HSP– Palpable purpura without thrombocytopenia and

coagulopathy– Arthritis/arthralgia– Abdominal pain– Renal disease (of 52 patients in a case series)

• Microscopic hematuria in 37 patients (11 percent)• Gross hematuria in 12 patients (5 percent)• Of the 49 patients with hematuria, 28 had proteinuria• Nephrotic syndrome in 2 patients• Isolated proteinuria in 2 patients

• Cause unknown, possible autoimmune• Supportive care, typically self-limiting

What is the Diagnosis?

Cryoglobulinemia

• Commonly associated with Hepatitis C infection, can other causes

• Can develop into rapidly progressive GN or chronic progressive GN

• Treatment aimed at underlying disorder

What is the diagnosis?

Thrombotic Thrombocytopenic Purpura

• Pentad– Microangiopathic hemolytic anemia– Thrombocytopenia, often with purpura but not

usually severe bleeding– Acute Kidney Injury– Altered mental status– Fever is rare

• Treatment– Plasma exchange– Immune suppression

What is the Diagnosis?

Systemic Lupus Erythematosis

• Types of Lupus-related kidney damage– Class 1: minimal mesangial lupus nephritis– Class 2: mesangial proliferative lupus nephritis– Class 3: focal lupus nephritis– Class 4: diffuse lupus nephritis– Class 5: membranous lupus nephritis– Class 6: advances sclerosing lupus nephritis

What is the Diagnosis?

Infective Endocarditis

• Four potential causes of kidney damage– Post-infectious immune complex-mediated GN– Drug induced interstitial nephritis– Aminoglycoside induced ATN– Thromboembolic