Glomerular diseases

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 RxDialysis 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
• 6.
  Primary glomerular diseases Minimalchange disease Idiopathic membranous nephropathy Primary FSGS IgA nephropathy Mesangio Capillary Nephropathy Acute Post Streptococcal GN Anti Glomerular Basement membrane disease
• 7.
  Secondary glomerular Diabetic nephropathy Lupusnephritis ANCA- Associated vasculitis Hepatitis B and C related nephropathy Amyloidosis Cryoglobulinemia Alports Syndrome
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  Secondary FSGS dueto Nephron Loss Secondary to non glomerular diseases like VUR Obesity related Others – Post Nephrectomy : Solitary Kidney FSGS
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  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
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  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
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  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
• 12.
  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
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  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.
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  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.
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  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.
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  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.
• 17.
  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.
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  A systematic approachwill help to diagnose glomerular diseases and to preserve the renal function. Thank you.