1. Institute of Health Science
Department of Nursing
Postgraduate Program of Adult Health Nursing
Chronic Glomerulonephritis Seminar Presentation
Set By: Rebira Workineh (AHN Student)
Rebira W. (AHN student)
2/13/2024
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2. Objectives
Rebira W. (AHN student)
At the end of this session, the participants will be able to:
Define chronic glomerulonephritis
Identify the development of chronic glomerulonephritis
Explain etiologies of chronic glomerulonephritis
Understand how to diagnose chronic glomerulonephritis
Describe the differential diagnosis of chronic glomerulonephritis
Identify possible management for patients with chronic glomerulonephritis
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4. Introduction to CGN
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Nearly all forms of AGN have a tendency to progress to chronic glomerulonephritis.
CGN is characterized by irreversible & progressive glomerular & tubulointerstitial
fibrosis, leading to a reduction in the GFR & retention of uremic toxins.
If disease progression is not halted with therapy, it results in CKD, ESRD, & CVD.
CGN is the 3rd leading cause of CKD, & accounts for about 10% of all patients on
dialysis.
(Kawasaki Y et al, 2011)
5. Introduction to CGN Cont’d…
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Definition
CGN 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.
6. The National Kidney Foundation
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NKF defines CKD on the basis of either of the following criteria
o Evidence of kidney damage based on abnormal urinalysis results or
structural abnormalities observed on ultrasound images
o A GFR of < 60 mL/min for 3 months or longer
According to this criteria, the NKF developed guidelines that classify the progression
of renal disease into five stages
This classification includes treatment strategies for each progressive level as follow
7. The NKF Cont’d…
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Stage 1
This stage is characterized by kidney damage with a normal GFR - ≥ 90 mL/min
The action plan consists of diagnosis and treatment, treatment of comorbid conditions, slowing of the
progressing of kidney disease, and reduction of CVD risks
Stage 2
This stage is characterized by kidney damage with a mild decrease in the GFR- 60-90 mL/min
The action plan is estimation of the progression of kidney disease
8. The NKF Cont’d…
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Stage 3
This stage is characterized by a moderately decreased GFR- 30-59 mL/min
The action plan consists of evaluation and treatment of complications
Stage 4
This stage is characterized by a severe decrease in the GFR - 15-29 mL/min
The action plan is preparation for renal replacement therapy
Stage 5
This stage is characterized by kidney failure
The action plan is kidney replacement if the patient is uremic
9. Epidemiology
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student)
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In the United States, CGN is the 3rd leading cause of ESRD
It accounts for 10% of patients on dialysis
In Japan and some Asian countries, CGN has accounted for as many as 40% of
patients on dialysis
However, subsequent data suggest that in Japan, the rate of CGN in patients on
dialysis is 28%.
The cause of this decline rate is not known
(Nakai S et al, 2004)
11. Etiology
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The progression from AGN to CGN is variable, based on the cause of the condition
Complete recovery of renal function occurs in patients with poststreptococcal
glomerulonephritis
Other glomerulonephritis, such as IgA nephropathy, often has a relatively benign
course
Many do not progress to ESRD
Progression patterns may be summarized as follows
12. Etiology Cont’d…
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Rapidly progressive glomerulonephritis or crescentic glomerulonephritis
About 90% of patients progress to ESRD within weeks or months
Focal segmental glomerulosclerosis
About 80% of patients progress to ESRD in 10 years
This form may be related to HIV infection
Membranous nephropathy
About 20-30% of patients with membranous nephropathy progress to CRF &
ESRD in 10 years
13. Etiology Cont’d…
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Membranoproliferative glomerulonephritis
About 40% of patients with membranoproliferative glomerulonephritis progress to
CRF & ESRD in 10 years
IgA nephropathy
About 10% of patients with IgA nephropathy progress to CRF & ESRD in 10
years
Poststreptococcal glomerulonephritis
About 1-2% of patients with poststreptococcal glomerulonephritis progress to CKD
& ESRD
14. Etiology Cont’d…
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Lupus nephritis
About 20% of patients with lupus nephritis progress to CRF& ESRD in 10 years
The presence of antineutrophil cytoplasmic antibody is also an independent risk
factor for poor renal outcome.
(Wang Y et al, 2016)
15. Pathophysiology
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Reduction in nephron mass from the initial injury reduces the GFR
This reduction leads to hypertrophy and hyperfiltration of the remaining nephrons
and to the initiation of intraglomerular hypertension
These changes occur in order to increase the GFR of the remaining nephrons, thus
minimizing the functional consequences of nephron loss
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The changes, however, are ultimately detrimental because they lead to
glomerulosclerosis & further nephron loss
16. Pathophysiology Cont’d…
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In early renal disease, decline in the GFR leads to slight increases in serum
creatinine levels
Azotemia (i.e., a rise in blood urea nitrogen & serum creatinine levels) is
apparent when the GFR decreases to < 60-70 mL/min
Reduction in the GFR also results in the following
17. Pathophysiology Cont’d…
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Decreased production of erythropoietin, thus resulting in anemia
Decreased production of vitamin D, resulting in hypocalcemia, secondary
hyperparathyroidism, hyperphosphatemia, & renal osteodystrophy
Reduction in acid, potassium, salt, and water excretion, resulting in acidosis,
hyperkalemia, hypertension, & edema
Platelet dysfunction, leading to increased bleeding tendencies
18. Clinical Manifestations
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Symptoms
Weakness and fatigue
Loss of energy, appetite, and weight
Pruritus
Early morning nausea and vomiting
Change in taste sensation
Reversal in sleep pattern
Peripheral neuropathy
Seizures
Tremors
19. Clinical Cont’d…
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Signs
Hypertension
Jugular venous distention
Pulmonary rales
Pericardial friction rubs in pericarditis
Tenderness in the epigastric region or blood in the stool
Decreased sensation and asterixis
20. Investigations
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Clinical findings
History collection
Physical examination
Urinalysis
The presence of dysmorphic RBCs, albumin, or RBC casts suggest
glomerulonephritis as the cause of kidney failure
(Edgar V Lerma et al, 2022)
21. Investigations Cont’d…
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Urinary protein excretion
Estimated by calculating the protein to creatinine ratio on spot morning urine
sample
Complete blood count
Anemia is a significant finding in patients with some decline in the GFR
Is the result of marked impairment of erythropoietin production & alterations
in iron absorption that accompany CKD from ferroprotein and FGF23
22. Investigations Cont’d…
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Serum chemistry
Serum creatinine & BUN levels are elevated
Impaired excretion of potassium, free water, & 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
23. Investigations Cont’d…
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Renal biopsy
Kidney biopsy is usually unnecessary
Imaging Studies
Ultrasound: Presence of both kidneys, size & exclude structural lesions that
may be responsible for azotemia
25. Management- Diet & Activity
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student)
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Diet
Protein restriction (0.4 to 0.6 mg/kg/day)
Slow the decline in GFR and reduce hyperphosphatemia (serum phosphate > 5.5
mg/dl) in patient with serum creatinine levels > 4 mg/dl
Should follow low potassium diets (2000-3000 mg/dl)
Activity
Patient should increase their activity level as tolerated
This may aid in blood pressure control
26. Pharmacologic Therapy
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BP Management
Angiotensin converting enzyme inhibitors are the first treatment of choice
Angiotensin II receptor blockers are used to retard the progression of CKD in
patient with diabetic and nondiabetic nephropathy
Combination of ACEIs and ARBs- to achieve better pressure control & preservation
of kidney function
27. Pharmacologic…
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Diuretics
Are used to treat edema & hypertension
Increase urine excretion by inhibiting sodium and chloride transporters
Loop and thiazide are among classes of diuretics
Examples: Furosemide (Lasix), bumetanide, torsemide, ethacrynic acid &
hydrochlorothiazide, metolazone
Others: Beta blockers, calcium channel blockers, alpha1 antagonists, direct
vasodilators, etc.
28. Pharmacologic…
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Fibrosis inhibition
Progressive fibrosis is the hallmark of chronic glomerulonephritis
Inhibitors of fibrosis is intended to slow the progression
Pirfenidone is the best candidate, inhibits transforming growth factor & collagen
synthesis
Others: Mineralocorticoid antagonists, nonsteroidal mineralocorticoid antagonists
(better, b/c the former induce hyperkalemia)
(DeFronzo RA et al ,2022)
29. Pharmacologic…
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Sodium bicarbonate
Reduce tubulointerstitial injury & endothelin production
Slow progressive kidney damage
In one study on patients with advanced kidney failure, the administration of sodium
bicarbonate preserved GFR decline
Even in patients with relatively preserved GFR in stage 2 CKD, the administration of
sodium bicarbonate was shown to preserve kidney function over 5 years
(I de Brito-Ashurst et al, 2009 & Mahajan A et al, 2010)
30. Renal Replacement Therapy
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These options of renal replacement therapy are used when GFR falls below 20-25
ml/min
Renal transplantation must explored when GFR falls below 20 ml/min
Hemodialysis
Peritoneal dialysis
Renal transplantation
31. Nursing Management
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Nursing diagnosis
Acute pain R/T inflammation of renal cortex AEB facial expressions & verbalization of patient
Goals
To reduce pain
Intervention
Assess pain characteristics
Provide comfort devices, quite environment and calm activities
Administer the analgesic according to physician order
32. Nursing Management Cont’d…
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Nursing diagnosis
Excess fluid volume R/T accumulation of fluid in the body AEB edema & weight gain.
Goal
To maintain the fluid volume
Intervention
To change the position frequently
To elevate the edematous extremities
To administer the diuretics to promote the diuresis
To administer the albumin helps in shifting the fluid from the ISC to IVC
33. Nursing Management Cont’d…
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Nursing diagnosis
Ineffective breathing pattern R/T accumulation of fluid in the peritoneal cavity AEB
respiration rate, dyspnea.
Goal
To improve the breathing pattern
Intervention
Instruct the patient to perform the deep breathing exercise
To provide the semi-fowler position
Encourage the rest between the activities to avoid the overexertion
34. Prevention
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One should seek medical assistance as soon as possible if they have impetigo or a
sore throat due to a strep infection.
Follow safe-sex guidelines and abstain from intravenous drug use to prevent
infections like HIV & hepatitis, which can cause some types of glomerulonephritis.
Control high blood pressure to reduce the risk of kidney damage from
hypertension.
In order to help avoid diabetic nephropathy, control blood sugar.
36. References
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Kawasaki Y, (2011). Mechanism of onset and exacerbation of chronic
glomerulonephritis and its treatment.
Nakai S, et al, (2006). An overview of regular dialysis treatment in Japan (as of 31
December 2004).
de Brito-Ashurst I, et al, (2009). Bicarbonate supplementation slows progression of
CKD and improves nutritional status.
Mahajan A, et al, (2010). Daily oral sodium bicarbonate preserves glomerular
filtration rate by slowing its decline in early hypertensive nephropathy.
DeFronzo RA, et al, (2022). Modifying chronic kidney disease progression with the
mineralocorticoid receptor antagonist finer none in patients with type II diabetes.
