Glomerular diseases
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Glomerular Diseases. Dr. Atapour. Differential diagnosis and evaluation of glomerular disease. CLINICAL PATTERNS OF GLOMERULAR DISEASE . Nephrotic Nephritic. Nephrotic pattern . The nephrotic proteinuria that is usually above 3.5 g/day Lipiduria Edema Hyperlipidemia

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Glomerular Diseases

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Glomerular diseases

GlomerularDiseases

Dr. Atapour


Glomerular diseases

Differential diagnosis and evaluation of glomerular disease


Clinical patterns of glomerular disease

CLINICAL PATTERNS OF GLOMERULAR DISEASE 

  • Nephrotic

  • Nephritic


Nephrotic pattern

Nephrotic pattern 

  • The nephroticproteinuria that is usually above 3.5 g/day

  • Lipiduria

  • Edema

  • Hyperlipidemia

  • Some patients also have microscopic hematuria

  • Red cell casts


Glomerular diseases

  • Asymptomatic proteinuria

  • Full-blown nephrotic syndrome


The bland sediment

The bland sediment

  • Absence of immune complex deposition in most of these disorders:

    • Minimal change disease

    • Focal segmental glomerulosclerosis

    • Diabetic nephropathy

    • Amyloidosis.


Glomerular diseases

  • Lack of inflammation

  • The serum creatinine concentration


Acute kidney injury in the nephrotic syndrome

Acute kidney injury in the nephrotic syndrome

  • Concurrent acute tubular necrosis

  • Usually in minimal change disease


Nephritic pattern

Nephritic pattern

  • Presence of red cells

  • White blood cells

  • Red cell

    • Dysmorphic appearance

    • Acanthocytes

  • Mixed cellular casts

  • Variable degrees of proteinuria


Glomerular diseases

dysmorphic RBCs muddy brown casts

tubular cell casts oval fat body


Glomerular diseases

RBC cast Hyaline cast


Pathologic classification

Pathologic classification 

  • Light microscopy 

  • Focal

  • Diffuse

    • This terminology is most often used in lupus nephritis

    • ANCA-positive vasculitis.


Limitations of this classification

Limitations of this classification 

  • Same pathology and multiple causes

  • Nonspecific nature of the histologic patterns


Glomerular diseases

MPGN

Can be a systemic immune complex disease

  • To infective endocarditis

  • Systemic lupus erythematosus

  • Hepatitis C virus complement


Membranous nephropathy

Membranous nephropathy

  • Systemic lupus erythematosus

  • Chronic hepatitis B virus infection

  • Underlying malignancy

  • Drugs


Focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis

  • Primary condition

  • Secondary change induced by intraglomerular hypertension or healing of previous glomerular injury.


Nephrotic syndrome without a nephritic sediment

Nephrotic syndrome without a nephritic sediment

  • Mild hematuria

  • No red cell casts


Depend on age

Depend on age

What do you think?


Less than 15 years

Less than 15 years :

  • Minimal change disease

  • Focal segmental glomerulosclerosis

  • Mesangial proliferative glomerulonephritis


15 to 40 years

15 to 40 years :

  • Minimal change disease

  • Membranous nephropathy

  • Focal segmental glomerulosclerosis

  • Diabetic nephropathy

  • Preeclampsia

  • Postinfectiousglomerulonephritis


Greater than 40 years

Greater than 40 years:

  • Focal segmental glomerulosclerosis

  • Membranous nephropathy

  • Diabetic nephropathy

  • Minimal change disease

  • IgA nephropathy

  • Primary amyloidosis

  • Benign nephrosclerosis

  • Postinfectiousglomerulonephritis


Mild glomerulonephritis

Mild glomerulonephritis

  • Mild glomerulonephritis is defined as a nephritic sediment and:

    • Normal or near normal estimated GFR

    • Do not have the nephrotic syndrome


Less than 15 years1

Less than 15 years

  • Mild postinfectiousglomerulonephritis

  • IgA nephropathy

  • Thin basement membrane disease

  • Hereditary nephritis

  • Henoch-Schönleinpurpura

  • Mesangial proliferative glomerulonephritis


15 to 40 years1

15 to 40 years

  • IgA nephropathy

  • Thin basement membrane disease

  • Lupus nephritis, hereditary nephritis

  • Mesangial proliferative glomerulonephritis


Greater than 40 years1

Greater than 40 years

  • IgA nephropathy


Moderate to severe glomerulonephritis

Moderate to severe glomerulonephritis

  • Moderate to severe glomerulonephritis is defined as a nephritic sediment

    • Reduced estimated GFR

    • Nephrotic syndrome ±


Less than 15 years2

Less than 15 years

  • Postinfectiousglomerulonephritis

  • Membranoproliferativeglomerulonephritis


15 to 40 years2

15 to 40 years

  • Postinfectiousglomerulonephritis

  • lupus nephritis

  • RPGN (crescenticglomerulonephritis)

  • IgA nephropathy

  • Fibrillaryglomerulonephritis

  • Membranoproliferativeglomerulonephritis


Greater than 40 years2

Greater than 40 years :

  • Rapidly progressive glomerulonephritis

  • Vasculitis

  • IgA nephropathy

  • Fibrillaryglomerulonephritis

  • Postinfectiousglomerulonephritis


Effect of race

Effect of race


In black patients

In black patients :

  • Focal segmental glomerulosclerosis (57 percent)

  • Membranous nephropathy (24 percent)

  • Minimal change disease (14 percent)

  • Membranoproliferativeglomerulonephritis, IgA nephropathy, and immunotactoid nephropathy were each present in 1 to 2 percent.


In white patients

In white patients:

  • Membranous nephropathy (36 percent),

  • Focal segmental glomerulosclerosis (23 percent)

  • Minimal change disease (20 percent)

  • IgA nephropathy (8 percent)

  • Membranoproliferativeglomerulonephritis (6%)

  • Immunotactoidglomerulopathy (6 percent).


Positive family history

Positive family history 

  • Thin basement membrane nephropathy

  • Hereditary nephritis (Alport syndrome)

  • Focal segmental glomerulosclerosis are examples:


Laboratory testing in patients with suspected glomerular disease

LABORATORY TESTING IN PATIENTS WITH SUSPECTED GLOMERULAR DISEASE

  • serum creatinine

  • serum albumin

  • complete blood count

  • Estimation of protein excretion in patients with proteinuria

  • serologic testing for disorders that cause glomerular disease

  • measurement of serum complement levels


Membranous nephropathy1

membranous nephropathy

  • The value of hepatitis B virus

  • Hepatitis C virus (HCV) infection

  • Congenital and secondary syphilis

  • HIV infection (FSGS)


Glomerular diseases

  • Chronic bacterial

    • Endocarditis

    • Shunt nephritis

    • Abscesses

  • Fungal

  • Parasitic infections can cause


Summary and recommendations

SUMMARY AND RECOMMENDATIONS

  • There are many causes of glomerular disease,

  • the characteristics of the urine sediment,

  • The degree of proteinuria

  • Patient’s age often


Glomerular diseases

  • Two different urinary patterns are seen:

    • Nephrotic

    • Nephritic.


Glomerular diseases

  • The nephrotic pattern

    = proteinuria > 3.5 g/day

  • Lipiduria


The nephritic

The nephritic

  • Red cells

  • White blood cells

  • Red cell or mixed cellular casts

  • Acanthocytes

  • Some patients have the concurrent presence of two glomerular diseases,


Approaching a patient

Approaching a patient

  • Urinalysis

  • Estimated glomerular filtration rate

  • Patient age help to identify

  • Race

  • Family history

  • Renal biopsy


Standard laboratory testing

Standard laboratory testing

  • Serum creatinine

  • Serum albumin

  • Protein excretion in patients with proteinuria

  • Serologic testing for disorders that cause glomerular disease


Glomerular diseases

  • Serologic tests

    • Lupus

    • Amyloidosis

    • Hepatitis B (HBV)

    • Hepatitis C (HCV)

    • HIV infection

    • ANA

    • Anti-dsDNA

    • C3

    • C4


Glomerular diseases

  • Primary amyloidosis and light chain deposition disease

    • Serum and urine immunofixation

    • Serum free light chain ratio analysis


Glomerulonephritis

Glomerulonephritis

Nephritic urine

RBCs, RBC casts

Low – mod proteinuria

Nephrotic urine

No casts, few RBCs

Heavy proteinuria

  • Diabetes

  • Amyloid

  • Membranous Nephropathy

  • FSGS

  • Minimal Change Disease

  • Sometimes MPGN

C3, C4

Low

Normal

  • Postinfectious

  • Lupus nephritis

  • MPGN (often Hep C)

ANCA (+)

ANCA (-)

  • Vasculitis

  • Wegener’s

  • MPA

  • Churg-Strauss

  • IgA nepropathy

  • Anti-GBM/Goodpasture’s

progress fast progress slow


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