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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