glomerulonephritis

1. Chronic Glomerulonephritis
by: Dr Shruti

2. Chronic Glomerulonephritis
Chronic glomerulonephritis is a kidney disorder
caused by slow, cumulative damage and scarring,
usually by inflammation, of the tiny blood filters in the
kidneys. These filters, known as glomeruli, remove
waste products from the blood. Inflammation
typically results in one or both of
the nephrotic or nephritic syndromes.

3. Chronic Glomerulonephritis
Nearly all forms of acute glomerulonephritis have a
tendency to progress to chronic glomerulonephritis.
The condition is characterized by irreversible and
progressive glomerular and tubulointerstitial fibrosis,
ultimately leading to a reduction in the glomerular
filtration rate (GFR) and retention of uremic toxins.

4. NKF Guidelines
The National Kidney Foundation (NKF) defines CKD
on the basis of:
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Evidence of kidney damage based on abnormal
urinalysis results (proteinuria or hematuria) or
structural abnormalities observed on ultrasound
images
A GFR of less than 60 mL/min for 3 or more months

5. NKF Guidelines
Classification of the renal disease progression:
 Stage 1 – This stage is characterized by kidney
damage with a normal GFR (≥ 90 mL/min)
Diagnosis + treatment + slowing of the progress of
the disease + reduction of cardiovascular disease
risks

6. NKF Guidelines
Stage 2 – This stage is characterized
by kidney damage with a mild
decrease in the GFR (60-90 mL/min)
Estimation of the progression of
kidney disease

7. NKF Guidelines
Stage 3 – This stage is characterized
by a moderately decreased GFR (to
30-59 mL/min)
Evaluation + treatment of
complications

8. NKF Guidelines
Stage 4 – This stage is characterized
by a severe decrease in the GFR (to
15-29 mL/min) Preparation for renal
replacement therapy

9. NKF Guidelines
Stage 5 – This stage is characterized
by kidney failure
Kidney replacement if the patient is
uremic

10. If not treated
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Chronic Kidney Disease (CKD)
End-Stage Renal Disease (ESRD)
Cardiovascular Disease
Renal Failure
Death

11. Cause
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The specific cause of most cases of chronic
glomerulonephritis is unknown.
Viral infections, such as hepatitis B or C and
acquired immunodeficiency syndrome (AIDS), may
lead to chronic glomerulonephritis. Autoimmune
disorders, such as systemic lupus erythematosus,
or other causes of vasculitis (inflammation of small
blood vessels) may cause chronic
glomerulonephritis.
Acute glomerulonephritis may, after a symptom-
less period of many years, reappear as chronic
glomerulonephritis.

12. Pathophysiology
The majority of the glomeruli are affected.
Depending on the stage of the disease, they may
present different degrees of hyalinization. The
hyaline is an amorphous material, pink,
homogenous, resulted from combination of plasma
proteins, increased mesangial matrix and collagen.
Totally hyalinised glomeruli are atrophic (smaller),
lacking capillaries, hence these glomeruli are non
functional.

13. Pathophysiology
Few glomeruli may still present changes which
permit to discern the etiology of chronic
glomerulonephritis. Obstruction of blood flow will
produce secondary tubular atrophy, interstitial
fibrosis and thickening of the arterial wall by hyaline
deposits. In the interstitium is present an abundant
inflammatory infiltrate (mostly with lymphocytes).

14. Pathophysiology

15. Symptoms
Specific symptoms include:
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Blood in the urine (dark, rust-colored, or brown urine)
Foamy urine
Facial puffiness in the morning
Swelling of the legs or ankles or other parts of the body,
due to fluid accumulation (edema)
Shortness of breath during exertion due to anemia
Chronic kidney failure symptoms that gradually develop
may include the following:
Decreased alertness
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Drowsiness, somnolence, lethargy
Confusion, delirium
Coma

16. Symptoms
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Decreased sensation in the hands, feet, or other
areas
Decreased urine output
Easy bruising or bleeding
Fatigue
Frequent hiccups
General ill feeling (malaise)
Generalized itching
Headache
Increased skin pigmentation -- skin may appear
yellow or brown

17. Symptoms
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Muscle cramps
Muscle twitching
Nausea and vomiting
Need to urinate at night
Seizures
Unintentional weight loss
Additional symptoms that may be associated with this
disease:
Blood in the vomit or stools
Excessive urination
High blood pressure
Nosebleed

18. Physical examination
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Hypertension
Jugular venous distention (if severe volume overload
is present)
Pulmonary rales (if pulmonary edema is present)
Pericardial friction rub in pericarditis
Tenderness in the epigastric region or blood in the
stool (possible indicators of uremic gastritis or
enteropathy)
Decreased sensation and asterixis (indicators of
advanced uremia)

19. Laboratory tests and examination
Because symptoms develop gradually, the
disorder may be discovered when there is an
abnormal urinalysis during a routine physical
or during an examination for another,
unrelated disorder. It may be discovered as a
cause of high blood pressure that is difficult to
control.
Laboratory tests may reveal anemia or show
signs of reduced kidney functioning,
including azotemia. Later, signs of chronic
kidney failure may be apparent,
including edema .

20. Laboratory tests and examination
Tests that may be done include:
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Chest x-ray
Kidney or abdominal CT scan
Kidney or abdominal ultrasound
IVP
Urinalysis
A kidney biopsy may show one of the forms of
chronic glomerulonephritis or scarring of the
glomeruli.

21. Laboratory tests and examination
 Urinalysis:
The presence of dysmorphic red blood
cells (RBCs), albumin, or RBC casts
suggests glomerulonephritis as the cause
of renal failure. Waxy or broad casts are
observed in all forms of chronic kidney
disease (CKD), including chronic
glomerulonephritis. Low urine-specific
gravity indicates loss of tubular
concentrating ability, an early finding in
persons with CKD.

22. Laboratory tests and examination
 Urinary protein excretion:
Urinary protein excretion can be estimated by
calculating the protein-to-creatinine ratio on a spot
morning urine sample. The ratio of urinary protein
concentration (in mg/dL) to urinary creatinine (in
mg/dL) reflects 24-hour protein excretion in grams.
The estimated creatinine clearance rate is used to
assess and monitor the glomerular filtration rate
(GFR). The are two formulas available for calculation
of the GFR. One is Cockcroft-Gault formula and the
other is Modification of Diet in Renal Disease
(MDRD) Study formula.

23. Laboratory tests and examination
 CBC:
Anemia is a significant finding in patients with some
decline in the GFR. Physicians must be aware that
anemia can occur even in patients with serum
creatinine levels lower than 2 mg/dL. Even severe
anemia can occur at low serum creatinine levels.
Anemia is the result of marked impairment of
erythropoietin production.

24. Laboratory tests and examination
 Serum chemistry:
Serum creatinine and urea nitrogen levels are
elevated. Impaired excretion of potassium, free
water, and acid results in hyperkalemia,
hyponatremia, and low serum bicarbonate levels,
respectively. Impaired vitamin D-3 production results
in hypocalcemia, hyperphosphatemia, and high
levels of parathyroid hormone. Low
serum albumin levels may be present if uremia
interferes with nutrition or if the patient is nephrotic.

25. Treatment
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Antihypertensive drugs may be prescribed to reduce high
blood pressure.
Diuretics may be prescribed to reduce excess fluid retention
and increase urine production.
Corticosteroids, immunosuppressives, or other medications
may be used to treat some of the causes of chronic
glomerulonephritis.
Dietary restrictions like low-protein, low-salt and iron or vitamin
supplements.
Steroid medication or immunosuppressive drugs may be
prescribed for some patients.
In severe cases where kidney failure occurs, dialysis may be
necessary. Dialysis performs the functions of the kidney by
removing waste products and excess fluid from the blood
when the kidney cannot (Renal Failure, Chronic).
A kidney transplant is an alternative to dialysis in cases of
kidney failure.