Glomerulonephritis

• presents with haematuria or proteinuria (protein >3.5g/day + hypoalbuminaemia + oedema = nephrotic syndrome)

• IgA Nephropathy
  • most common GN, deposition of IgA in glomerulus
  • classically haematuria starting with in 1-2 days of URTI
  • associated with HSP

• Post strep glomerulonephritis
  • classically 1-2 weeks post strep infection
  • haematuria, oliguria, odema, HTN

• Minimal Change Disease
  • most cases in children, 20% adults with nephrotic syndrome
  • assoc atopy in children and possible underlying Hodgkins in adults
  • does not progress to ESRF

• Focal Segmental Glomerulonephritis
  • haematuria
  • CRF with in 10 years, delayed with steroid treatment

• Membranous nephropathy
  • nephrotic syndrome in older adults
  • idiopthic, SLE, hep B, malignancy, gold, penicillamine

• Mesangiocapillary Glomerulonephritis
• -nephrotic or nephritic syndrome in children and young adults

• Crescentic Glomerulonephritis
  • ANCA-positive vasculitis of kidney (idiopathic form)
  • progresses to ESRF with in weeks to months with out treatment

• Goodpasture’s Syndrome
  • autoantibodies against alpha3 chain of type IV collagen (structural component of glomerular and alveolar basement membrane)
  • may also present with haemoptysis from pulmonary haemorrhage
  • rapidly progressive renal failure
  • prednisolone, cyclophosphamide, plasma exchange to remove antibodies generally effective if started before renal disease is advanced
  • relapse rare

• Systemic Diseases
  • Systemic Lupus Erythematous
    • lupus nephritis
  • Primary Systemic Vasculitis
    • necrotising inflammation of blood vessels
    • Wegener’s Granulomatosis
    • Microscopic Polyangiitis
    • Churg-Strauss Syndrome
  • Haemolytic Uraemic Syndrome
    • thrombotic microangiopathy, widespread interglomerular thrombi
    • overlap with thrombotic thrombocytopaenic purpure
    • in children commonly related to GI E coli infection
  • Systemic sclerosis
    • obstructive vasculopathy “scleroderma kidney”
    • usually have systemic features of scleroderma
    • ACE inhibitors improve renal outcomes
• Sarcoidosis
  • granulomatous inflammation of numerous organs including lung and kidney
  • granulomatous tubulointerstitial nephritis
• Cryoglobulinemia
  • immunoglobuline precipitate in cold
  • purpuric rash, arthraligia, peripheral neuropathy
  • many cases assoc with Hep C

• Myeloma and Monoclonal Dysproteinaemias
  • light chain cast nephropathy, light chain depositions
  • plasma exchangemay be helpful

• Amyloidosis
  • insoluble protein deposits in kidney (amyloid AL and AA)leading to nephrotic syndrome
  • commonly liver, spleen heart and nervous system involvement depending on type of amyloid

• Investigations
  • -Urine dipstick
  • -BP 
  • -ECG
  • -Urine M/C/S, spot protein, 24 hour urine protein
  • -FBE, UEC, blood glucose, coagulation screen, LFT, CRP, ESR, CMP
  • -Imaging, USS and CT (beware contrast)
  • -ANA, ANCA, anti GBM, complement levels (C3, C4), cryoglobulins
  • -throat swab, antistreptolysin
  • -serum immunoglobulin titres, paraprotein electrophoresis, uriniary Bence Jones protein
  • -CK
  • -Hep B/C, HIV (if risk factors or dialysis rpeparation)

• Management
  • -treat underlying cause
  • -most will require hospitalisation and nephrology input
  • -most GN treated with prednisolone +/- cyclophosphamide

Nephrotic syndrome 

• Clinical
  • High protein – 3/4+ on dipstick, Urine PCR > 200
  • Frothy appearance urine
  • Hypoalbuminemia < 25g/L
  • Significant oedema
  • Swelling around ankles and eyes

• Associated diseases
  • In children most commonly idiopathic
  • Minimal change disease
  • Focal segmental glomerulosclerosis
  • Membranous glomerulonephritis
  • SLE
  • Henoch Schoenlein Purpura

• Assessment
  • Intravascular volume depletion
    • Dizziness
    • Hypoperfusion
    • Tachycardia
    • reduced urine output
    • hypotension
  • Severe oedema
    • Discomfort
    • Genital
    • skin breakdown
    • pleural effusion
    • ascites
  • Infection – increased risk – cellulitis, SBP
  • Thrombosis – increased risk
  • Systemic symptoms – fever, rash, joint pains

• Treatment
  • Usually need admission/specialty care
  • Prednisolone
  • Albumin and frusemide as needed

• Follow up – daily checking urine protein dipstick – prompt treatment of relapses

Nephritic syndrome

• Clinical
  • Haematuria ++
  • Protein +
  • Hypertension
  • Low urine volume <300mL/day
  • Mild oedema – often periorbitial

• Causes
  • Post streptococcal glomerulonephritis – most common cause for children
  • IgA nephropathy – after URTI
  • Rapidly progressive glomerulonephritis
  • Henoch Schonlein purpura