Today we discussed glomerulonephritis
GN is suggested by hematuria, proteinuria, HTN, edema. The hallmark is RBC casts on urinalysis
First division of GN is primary vs. secondary.
Secondary is suggested by associated symptoms and signs: fever, arthritis, rash
bloodwork for secondary causes includes ANA, complements, dsDNA, ANCA, HBV, HCV, HIV, SPEP, cryoglobulins, rheumatoid factor
Primary GN is divided into proliferative and non-proliferative.
Non-proliferative means no extra cells in glomerulus; presents as nephrotic end of spectrum.
These are generally less aggressive diseases:
1) Minimal change 2) Membranous 3) FSGS
Minimal change- mainly children, but seen in adults too. Rapid onset and offset of nephrotic syndrome. Tx is prednisone
Membranous- Most common primary GN in white males. Gradual onset of nephrotic syndrome. Associated with solid tumors in males over 60. Treatment is controversial.
FSGS- second most common primary GN ~40% respond to high dose prednisone
Proliferative GN- Means increased cells in glomerulus. Prominent RBC casts, hematuria, 'nephritic' presentation. Generally requires more aggressive immunosuppressive treatment
IgA nephropathy:
usually asymptomatic. Sometimes presents as post-URTI hematuria (within 1-5d). Rarely, rapidly progressive. 20% will progress; becomes relatively common reason for ESRD. Treatment is controversial; steroids, fish oil, ACE, ARB
Post-infectious (AKA post-streptococcal). Follows infection by 10-21d. Tx is supportive; usually self-limited. Possible in adults, but less common than children
Crescentic:
may be called "rapidly progressive GN" (although other types of GN can progress rapidly)
Divided by immunofluorescence findings:
1) pauci-immune (means ANCA +ve Wegener's, Churg-Strauss, others).
2) immune complex (vasculitis, endocarditis, SLE)
3) linear (Goodpasture's or anti-GBM)
Tx here is aggressive, intensive immunotherapy. PLEX for anti-GBM.
Post-infectious complications of streptococcal infection
Acute rheumatic fever
Glomerulonephritis
Reactive arthritis
Erythema nodosum
Links:
Click here for a review article on IgA nephropathy from the Toronto Nephrology Rounds series
Click here for a NEJM clinical pathological conference addressing a practical approach to renal failure
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