Glomerulonephrites

Aetiology

Symptoms and findings

• Haematuria, often red cell casts in urine ("nephritic sediment"), proteinuria
• Often elevated plasma creatinine levels
• Oedema, hypertension
• Depending on the aetiology, often additionally general symptoms (in patients with systemic disease often mild fever, fatigue, rash, respiratory, joint or gastrointestinal tract symptoms)
• In rapidly progressive glomerulonephritis, renal function deteriorates progressively within a few days or weeks.
• Laboratory tests may help to confirm the diagnosis.
  • Positive ANCA antibodies in patients with vasculitis
  • Hypocomplementaemia and positive DNA antibodies in patients with SLE
  • Positive basement membrane antibodies in patients with basement membrane nephritis
• A renal biopsy should be taken urgently to confirm the diagnosis.

Treatment and prognosis

• Treatment according to aetiology, and supportive treatment: treatment of hypertension and renal failure Treatment of Chronic Renal Failure
• For postinfectious glomerulonephritis treatment of the infection and supportive treatment
  • For prolonged cases sometimes glucocorticoids
  • The prognosis is good in children; in adults, the disease may become chronic.
• For vasculitis, SLE nephritis and basement membrane nephritis, immunosuppressive treatment (glucocorticoid, cyclophosphamide, azathioprine, mycophenolate, rituximab)
• Treatment for rapidly progressive glomerulonephritis should be started urgently.
  • Initially often a massive dose of glucocorticoids i.v.
  • For basement membrane nephritis and vasculitis plasma exchange
• For rapidly progressive glomerulonephritis sufficiently aggressive immunosuppressive treatment started early enough will improve the prognosis decisively.

Aetiology

• Focal segmental glomerulosclerosis (FSGS)
  • The most common form of glomerulonephritis causing nephrotic syndrome in adults
  • May be primary or secondary to, for example, obesity or loss of nephrons.
• Minimal change glomerulonephritis (MCN)
  • The most common form of glomerulonephritis causing nephrosis in children but may also occur in adults
  • Adults sometimes have this as a paraneoplastic phenomenon.
• Membranous glomerulonephritis (MGN)
  • A common cause of nephrosis in adults
  • May be either idiopathic or associated with other diseases (SLE) or malignancies, for instance.
  • Antibodies to phospholipase-A2-receptor can often be detected in the idiopathic disease.
• Membranoproliferative glomerulonephritis (MPGN)
  • There may be various underlying disorders such as infections (viral hepatitis, endocarditis, shunt nephritis), SLE, acquired or congenital disorders of the complement system or malignancies (solid tumours or haematological malignancies).
• IgA nephropathy Iga Nephropathy may sometimes present with a clinical picture of nephrosis.
• Renal biopsy will confirm the diagnosis.

Symptoms and findings

• Oedema, weight gain
• Proteinuria > 3 g/day, plasma albumin < 30 g/l, often additionally haematuria
• Sometimes elevated plasma creatinine levels and hypertension
• Severe nephrosis may be associated with acute renal failure.
• Hyperlipidaemia, increased risk of venous thrombosis

Treatment and prognosis

• Medication for proteinuria and hypertension: ACE inhibitor, ATR blocker
• Symptomatic treatment of oedema: salt restriction, diuretics
• Treatment of hyperlipidaemia; thrombosis prophylaxis should be considered
• Immunomodulatory treatment depending on the aetiology
  • Minimal change glomerulonephritis and focal segmental glomerulosclerosis should primarily be treated with high-dose glucocorticoids, alternatively ciclosporin and cyclophosphamide.
  • For idiopathic membranous glomerulonephritis, immunosuppressants if nephrosis persists or GFR starts to decline (glucocorticoid, ciclosporin, cyclophosphamide, mycophenolate mofetil, rituximab) Immunosuppressive Treatment for Idiopathic Membranous Nephropathy
  • In IgA mesangial glomerulonephritis, glucocorticoid therapy should be considered if proteinuria of > 1 g/day continues despite antiproteinuric treatment or the GFR starts to decline.
  • Treatment of membranoproliferative glomerulonephritis depends on the aetiology
• The long-term prognosis of minimal change glomerulonephritis is good. In other forms of glomerulonephritis, the prognosis depends on how well proteinuria can be controlled.
• If nephrotic symptoms (oedema, fluid overload) are pronounced and plasma creatinine is clearly elevated or increasing, urgent referral - possibly even as an emergency case - is indicated. Otherwise, normal referral is sufficient.

Aetiology

• May be primary or associated with systemic diseases.
• IgA mesangial glomerulonephritis Iga Nephropathy is the most common type of primary glomerulonephritis causing haematuria and proteinuria.
• Membranous glomerulonephritis, membranoproliferative glomerulonephritis and secondary focal segmental glomerulosclerosis may also present with haematuria and proteinuria.

Symptoms and findings

• Often an asymptomatic, incidental finding
• Haematuria and/or proteinuria < 3 g/day
  • Patients with IgA mesangial glomerulonephritis often have periods of macrohaematuria in association with infections.
  • Plasma creatinine levels often elevated
  • Hypertension

Treatment and prognosis

• Treatment of hypertension. If urinary protein levels are > 0.5 g/day, an ACE inhibitor or ATR blocker should be given.
• Treatment of renal failure Treatment of Chronic Renal Failure.
• Treatment depending on aetiology
  • For vasculitis or SLE usually immunomodulatory treatment. For IgA mesangial glomerulonephritis, glucocorticoid therapy should be considered if the daily urinary protein levels do not fall to below 1 g/day or if the GFR has decreased or is starting to decrease.
• If in membranous glomerulonephritis or focal segmental glomerulosclerosis proteinuria stays below 2 to 3 g/day, the long-term prognosis is quite good and no immunomodulatory treatment is needed.