The document discusses several cases of acute nephritic syndrome. It describes the typical presentation of nephritic syndrome including hematuria, proteinuria, hypertension, and renal dysfunction. It also discusses ways to classify glomerular diseases based on clinical syndrome, biochemical abnormalities, or histopathology. Several cases are presented and discussed in terms of etiology, diagnosis, and management based on lab results, serology, immune workup, and kidney biopsy findings where applicable. Conditions discussed include post-streptococcal glomerulonephritis, membranoproliferative glomerulonephritis, lupus nephritis, IgA nephropathy, rapidly progressive glomerulonephritis, and

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