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Glomerular diseases
This document discusses the classification and approach to diagnosing glomerular diseases. Glomerular diseases present with various combinations of proteinuria, hematuria, pyuria, reduced glomerular filtration rate, and reduced sodium excretion. They are classified into syndromes like nephrotic syndrome, acute nephritic syndrome, and chronic glomerulonephritis. The diagnosis involves categorizing the clinical presentation, characterizing the etiology through investigations, and completing the diagnostic workup which may involve renal biopsy. Treatment depends on the specific glomerular disease and syndrome but generally includes managing symptoms like edema, diet modifications, treating hypertension, and using immunosuppression or immunomodulation if indicated.
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Glomerular diseases
- 1. Approach to Glomerular diseases. DR.YUGANDHAR TUMMALA
- 2. Clinical presentation andclassification of glomerular diseases Glomerular diseases present with varying combinations of the following : ◦ Proteinuria ◦ Hematuria ◦ Pyuria ◦ Reduced Glomerular filtration rate ◦ Reduced excretion of sodium Based on various combinations glomerular diseases are divided into major clinical syndromes such as ◦ Nephrotic syndrome : Proteinuria ◦ Acute Nephritic syndrome : Present with all above conditions ◦ Rapidly progressive Glomerulonephritis : Present with all above if not RxDialysis dependence ◦ Chronic Glomerulonephritis : any of the above lasting for more than 3 months usually combination
- 3. Category A :Clinical presentation Pure Nephrotic illness ( Classically the minimal Change disease) Nephritic illness of mild severity ( Post Streptococcal Acute Glomerulonephritis) Nephritic illness of moderate severity( RPGN/Crescentic Glomerulonephritis ) Nephritic- Nephrotic Illness ( MembranoProliferative Glomerulonephritis) Category B : Glomerular Disease associated With renal dysfunction such as Acute Kidney Injury (AKI) Rapidly Progressive Renal Dysfunction Chronic Kidney disease Category C : Miscellaneous
- 4. Non Renal symptomsof Glomerular diseases Pulmonary symptoms : Pulmonary Edema/pulmonary Hemorrhage Neurological Symptoms : Seizures Cardiac Symptoms : Pericarditis , CCF Gastro intestinal Symptoms : Vomiting from Uremia Rheumatological Symptoms : Arthralgia , Arthritis Pyrexia of Origin : Collagen vascular diseases , Vasculitis , Endocarditis Urological symptoms : hematuria Surgical symptoms : acute abdominal pain of HSP Endocrine problems : growth failure , Infertility
- 5. Based on timeof onset of disease : Acute Glomerulo Nephritis : presents from Few Hours to weeks Rapidly Glomerulo Nephritis : When onset is over few weeks Chronic Glomerulo Nephritis : Few months it should not be confused with ARF/CKD
- 7. Primary glomerular diseases Minimalchange disease Idiopathic membranous nephropathy Primary FSGS IgA nephropathy Mesangio Capillary Nephropathy Acute Post Streptococcal GN Anti Glomerular Basement membrane disease
- 8. Secondary glomerular Diabetic nephropathy Lupusnephritis ANCA- Associated vasculitis Hepatitis B and C related nephropathy Amyloidosis Cryoglobulinemia Alports Syndrome
- 9. Secondary FSGS dueto Nephron Loss Secondary to non glomerular diseases like VUR Obesity related Others – Post Nephrectomy : Solitary Kidney FSGS
- 10. Etiology Infections : Bacterial/Prototozoal /viral/ Helminthic Hereditary : Alports syndrome / Fabrys disease Multi System : Auto Immune/ vasculitis (SLE/HSP/Cryoglobulinemia) Systemic Diseases : DM/ amyloidosis Drugs : NSAIDS/ Allopurinol /gold/Penicillamine /ACE inhibitors Toxins : vaccines / bee stings Neoplasia : Multiple myeloma / Ca.Breast
- 11. Approach to Diagnosis Stepwise Approach Step 1 : when to suspect Step 2 : how to categorize the various glomerular disease Step 3 : characterize the etiology – through various investigations as appropriate Step 4 : complete the diagnostic arc Step 5 : treatment and follow up
- 12. Step 1 :Suspect glomerular diseases -By history /Clinical Examination and Urinary Abnormalities. Proteinuria and Hematuria are not exclusive in Glomerular diseases and can also be seen in Tubular diseases . Hence a Syndromic approach is required Glomerular Proteinuria : disruption of Glomerular filtration barrier either hereditary/ acquired either renal limited or associated with systemic illness can lead to proteinuria and in particular ALBUMINURIA ( Albumin being the abundant protein ) protein other wise normal is excluded. Though proteinuria is the hallmark of glomerular proteinuria it may also be seen in Tubular diseases ( less than 1gm/day) Proteinuria may also be noted when there is over flow
- 13. albuminuria Urinary dipstick of2+ or more ( approx. : 100mg/dl ) indicates albuminuria How ever false evidences may be seen in cases like Highly concentrated urine Alkaline urine Immediately following exercise During sepsis To rule out it 20% sulfa salicylic acid is used and if no turbidity is there then it is false positive
- 14. Glomerular Hematuria Disruption toglomerular membrane results in hematuria It is characterized by presence of dysmorphic red cells or acanthocytes in urine Greater than 5% urine red cells are characteristic of hematuria Presence of red cell casts is indicative of Down stream damage to tubules formation of Tamm-horsfall protein. It can be either isolated as in case of in basement membrane disease or with glomerular proteinuria when a presentation of nephritic syndrome is suspected. There fore a good urine examination can help in recognize a indeed a glomerular disease.
- 15. Step 2 :categorizing glomerular syndrome Step 3 : Characterizing the glomerular disease by the following : Clinical diagnosis : Nephrotic/ Nephritic /Rapidly progressive/ Isolated urinary abnormalities. Physiological diagnosis: help us to assess renal function Anatomical diagnosis: help us to rule out other non glomerular pathology. Pathological diagnosis: renal biopsy help us to find out histological types of proliferative glomerulonephritis, Crescentic glomerulonephritis, minimal change disease, membranous nephropathy, proliferative glomerulonephritis. Etiological diagnosis: primary focal segmental glomerulonephritis and secondary due to diabetes, SLE, Hepatitis B and C. Laboratory diagnosis: identification of protein levels, renal parameters, ANA, complement levels, Blood glucose levels.
- 16. Step:3- therapeutic approach Managementof edema: Restrict fluid, Restrict sodium and initiate Diuretics. Diet modifications: Restricted salt intake, Fluid restriction, low fat diet. Manage Hypertension: Diuretics and calcium channel blockers. ◦ ACE inhibitors and ARB’s can be managed and help to reduce proteinuria. But to be avoided in acute renal failure and hyperkalemia ◦ Manage glycemic status. ◦ Manage lipid abnormalities ◦ Hemodialysis to be initiated, if uremia is worsening. ◦ Prevent and treat complications: if pulmonary edema persists-diuretics ◦ Venous thrombosis- heparin and oral anticoagulants ◦ Seizures- antiepileptics. ◦ Infections- culture specific antibiotics.
- 17. Immunosuppression: ◦ Acute glomerularnephritis-no role unless biopsy showed crescents greater than 50%. ◦ Minimal change disease- corticosteroids, if not cyclophosphamide. Immunomodulation: ◦ Levamisole is used in steroid dependent and frequent relapses of Nephrotic syndrome. Rapidly progressive glomerulonephritis: ◦ Cyclophosphamide and plasmapharesis is added with corticosteroids.
- 18. Other treatment: ◦ Identifythe acute factors and treat to stabilize the renal parameters. ◦ Manage diabetes and hypertension. ◦ Restrict protein intake. ◦ Correct fluid status by restricting fluid and salt intake. ◦ Correct anemia- identify iron deficiency and use of erythropoietin if iron stores are adequate. ◦ Calcium-Phosphorous balance to be maintained. ◦ Vitamin D deficiency and hyperparathyroidism to be identified. ◦ Hemodialysis and peritoneal dialysis. ◦ Renal transplantation.
- 19. A systematic approachwill help to diagnose glomerular diseases and to preserve the renal function. Thank you.