APPROACH TO NEPHRITIC SYNDROME

1. APPROACH TO NEPHRITIC SYNDROME
ANIRUDDHA RUDRA
PDT
NEPHROLOGY
NRSMCH

4. Acute Nephritic Syndrome
Acute nephritic syndromes classically present with the following:
• Hematuria
• Subnephrotic proteinuria (1- 2 g/24 h )
• Hypertension
• Fluid retention
• Red blood cell casts
• Pyuria
• Rise in serum creatinine
• Reduction in GFR

7. Primary Vs Secondary glomerular disease
• Primary
– The cause of which is not known or has not been found yet
• Secondary
– Cause-obvious at the time of diagnosis.
[ Like, systemic features of vasculitis along with renal
involvement ]

9. SITE OF GLOMERULAR INJURY

10. CLASSIFICATION
No perfect classification for glomerular diseases
• Three ways to approach it:
A. Clinical syndrome: Like nephrotic syndrome has edema but not HT
B. Biochemical: NS has hypoalbuminemia and nephrotic range
proteinuria
C. Histopathological

11. CAUSES ACCORDING TO AGE
CHILDREN AND
ADOLESCENTS
• PSGN
• MPGN
• Crescentic GN
• IgA nephropathy
• Lupus Nephritis
• Henoch-Schönlein purpura
ADULTS
• IgA Nephropathy
• Rapidly progressive glomerulonephritis
SLE or lupus nephritis
ANCA associated
• Membranoproliferative GN
• Hepatitis B or C
• Infective endocarditis
• Abdominal abscesses
• Viral diseases such as mononucleosis,
measles, mumps

12. CASE 1
•43 yr/ female / no h/o DM HTN
•She had h/o fever with sore throat 2 weeks ago
•Presented with 5 days h/o progressive facial puffiness, orthopnea and PND
•A day before admission she developed sudden gross hematuria.
•PE- Afebrile, BP 140/92 and generalized edema.
• Cr 1.5 mg, serum albumin-3.2gm
•Urine r/e m/e : protein 2+ RBC 80- 100 WBC 5-7
•USG KUB: NAD
•Immune work up: C3 – low , C4- N, ANA HEP2-NEG
•Serology: NR
Diagnosis???

13. COMPLEMENT IN RENAL DISEASES

16. PSGN

17. CASE 2
• 30y/F/ Non diabetic/non hypertensive
• Presented with generalized body swelling/frothy urine/oliguria for 10
days
• BP- 150/94
• Urine R/E M/E : protein 4+ blood-3+ RBC casts+
• 24 hours urinary protein- 5 gm, sr. albumin- 2.1 gm
• Creatinine- 1.6 mg
• USG KUB –B/L size- N, B/L mild cortical echo raised, CMD- maintained
• Syndromic diagnosis:
Nephritic syndrome with Nephrotic range proteinuria

18. CASE 2
• Immune work up: C3 low/ C4 N / ANA –NEG
• Serology: NR
DIAGNOSIS ?
• Kidney biopsy: DONE

19. CASE 2
KIDNEY BIOPSY- Membranoprolifeartive GN TYPE I

20. MPGN I

21. MPGN

22. CASE 3
• 35/F, married since 10 yrs, no issues
• No H/O DM, HTN
• Taking NSAIDS for low back ache
• Presented with generalized body swelling
• Denied any other systemic features
• Symptoms dated to increased intake of NSAIDS for back ache
• O/E: bipedal oedema, BP- 160/ 100
• Syndromic diagnosis (clinical):
Drug induced Acute interstitial Nephritis

23. CASE 3
• Urine R/E M/E C/S: protein- 3+ blood- 3 + C/S- no growth
• albumin -3.6 gm, creatinine 1.4 mg
• USG KUB: RK- 10.2 LK- 10.7 [ B/L increased cortical echo,CMD B/L –
maintnd]
• Syndromic diagnosis:
Nephritic Syndrome

24. CASE 3
Primary or Secondary??
• No history s/o of secondary glomerular disease:
– fever, cough, hemoptysis, rash, photosensitivity, joint pain and
swelling, alopecia
• No signs s/o secondary GN on systemic exam

25. CASE 3
On further evaluation:
Serology: NR
Immune work up:
- C3 LOW / C4 LOW
- ANA HEP2: 1: 320 SPECKLED
- ANTI DS DNA: POSITIVE
Renal Biopsy: Done

26. CASE 3

27. CASE 3
LUPUS NEPHRITIS- CLASS IV

28. CASE 4
• 16 / male
• Painless hematuria on and off since 6 m, associated with URI
• PE- WNL
• BP- 130/80
• Cr- 0.8, serum albumin- 3.7
• USG KUB – WNL
• Urine R/E M/E: Proteins- 2 + blood 4 +
• Immune work up: WNL
• Serology: NR
• Diagnosis: ?
• RENAL BIOPSY: Done

29. CASE 4: RENAL BIOPSY

30. CASE 4
IgA NEPHROPATHY

31. CASE 5
• 66 yr/ male/ no h/o DM, HTN/non smoker
• He had h/o fever cough for 10 days, hemoptysis for 2 days 4 days ago
• Generalized body swelling with oliguria for last 3 days
• PE: Pallor +, bipedal edema, BP-150/90, Chest- b/l coarse crepts
• Cr- 2.9[ prior cr -1.3, 10 days ago]
• Urine RE ME: Blood 3+, protein 2+
• 24 hr ur pr-2.6 gm , serum albumin-3.4
• Cxray PA: infiltrate b/l lower zone
• USG KUB: B/L KIDNEY SIZE –N, ECHO – RAISED, CMD- MAINTAINED
DIAGNOSIS??

32. CASE 5
• C3/C4—WNL
• ANA HEP 2– NEG
• ANCA–
ANTI PR3 – 125
ANTI MPO-- 11

35. RPGN
Rapidly Progressive Glomerulonephritis (RPGN) Refers to a clinical
syndrome characterized by
• Rapid loss of renal function [≥ 50% decline in GFR within 3 months]
• Oliguria or anuria
• Features of glomerulonephritis
dysmorphic RBCS in urine
glomerular proteinuria.
• CRESCENTIC GN
- RPGN – morphologically - extensive crescent formation.[usually
involving ≥ 50% of glomeruli]
- The severity of the disease - Degree of crescent formation.

42. ANCA VASCULITIS

43. CASE 6
• A 48 year old female/Non diabetic/ HTN for 4 yrs/ P 1+1
• History of DVT 4 yrs ago and PE 2 years ago.
• She presented with bipedal edema for 1 month
• PE: BP 150/92, Bi-pedal edema, prominent P2, livedo
reticularis of the legs
• Cr -1.8, urinalysis- 3+ protein Blood -2+
• 24 hr urinary protein - 1.9 g,
• ANA+ 1:160, anti ds DNA-negative, C3/C4- WNL;
• Hb-10gm, wbc 6200, platelets- 100,000.

44. APLA DIAGNOSTIC CRITERIA