2. Clinical presentation and classification of
glomerular diseases
Glomerular diseases present with varying combinations of the following :
◦ Proteinuria
◦ Hematuria
◦ Pyuria
◦ Reduced Glomerular filtration rate
◦ Reduced excretion of sodium
Based on various combinations glomerular diseases are divided into major clinical syndromes such as
◦ Nephrotic syndrome : Proteinuria
◦ Acute Nephritic syndrome : Present with all above conditions
◦ Rapidly progressive Glomerulonephritis : Present with all above if not RxDialysis dependence
◦ Chronic Glomerulonephritis : any of the above lasting for more than 3 months usually combination
3. Category A : Clinical presentation
Pure Nephrotic illness ( Classically the minimal Change disease)
Nephritic illness of mild severity ( Post Streptococcal Acute Glomerulonephritis)
Nephritic illness of moderate severity( RPGN/Crescentic Glomerulonephritis )
Nephritic- Nephrotic Illness ( MembranoProliferative Glomerulonephritis)
Category B : Glomerular Disease associated With renal dysfunction such as
Acute Kidney Injury (AKI)
Rapidly Progressive Renal Dysfunction
Chronic Kidney disease
Category C : Miscellaneous
5. Based on time of onset of disease :
Acute Glomerulo Nephritis : presents from Few Hours to weeks
Rapidly Glomerulo Nephritis : When onset is over few weeks
Chronic Glomerulo Nephritis : Few months
it should not be confused with ARF/CKD
9. Secondary FSGS due to Nephron Loss
Secondary to non glomerular diseases like VUR
Obesity related
Others – Post Nephrectomy : Solitary Kidney FSGS
11. Approach to Diagnosis
Step wise Approach
Step 1 : when to suspect
Step 2 : how to categorize the various glomerular disease
Step 3 : characterize the etiology – through various investigations as appropriate
Step 4 : complete the diagnostic arc
Step 5 : treatment and follow up
12. Step 1 : Suspect glomerular diseases
-By history /Clinical Examination and Urinary Abnormalities.
Proteinuria and Hematuria are not exclusive in Glomerular diseases and can also be seen in
Tubular diseases . Hence a Syndromic approach is required
Glomerular Proteinuria : disruption of Glomerular filtration barrier either hereditary/ acquired
either renal limited or associated with systemic illness can lead to proteinuria and in particular
ALBUMINURIA ( Albumin being the abundant protein ) protein other wise normal is excluded.
Though proteinuria is the hallmark of glomerular proteinuria it may also be seen in Tubular
diseases ( less than 1gm/day)
Proteinuria may also be noted when there is over flow
13. albuminuria
Urinary dipstick of 2+ or more ( approx. : 100mg/dl ) indicates albuminuria
How ever false evidences may be seen in cases like
Highly concentrated urine
Alkaline urine
Immediately following exercise
During sepsis
To rule out it 20% sulfa salicylic acid is used and if no turbidity is there then it is false positive
14. Glomerular Hematuria
Disruption to glomerular membrane results in hematuria
It is characterized by presence of dysmorphic red cells or acanthocytes in urine
Greater than 5% urine red cells are characteristic of hematuria
Presence of red cell casts is indicative of Down stream damage to tubules formation of
Tamm-horsfall protein.
It can be either isolated as in case of in basement membrane disease or with glomerular
proteinuria when a presentation of nephritic syndrome is suspected.
There fore a good urine examination can help in recognize a indeed a glomerular disease.
15. Step 2 : categorizing glomerular
syndrome
Step 3 : Characterizing the glomerular disease by the following :
Clinical diagnosis : Nephrotic/ Nephritic /Rapidly progressive/ Isolated urinary abnormalities.
Physiological diagnosis: help us to assess renal function
Anatomical diagnosis: help us to rule out other non glomerular pathology.
Pathological diagnosis: renal biopsy help us to find out histological types of proliferative
glomerulonephritis, Crescentic glomerulonephritis, minimal change disease, membranous nephropathy,
proliferative glomerulonephritis.
Etiological diagnosis: primary focal segmental glomerulonephritis and secondary due to diabetes, SLE,
Hepatitis B and C.
Laboratory diagnosis: identification of protein levels, renal parameters, ANA, complement levels, Blood
glucose levels.
16. Step:3- therapeutic approach
Management of edema: Restrict fluid, Restrict sodium and initiate Diuretics.
Diet modifications: Restricted salt intake, Fluid restriction, low fat diet.
Manage Hypertension: Diuretics and calcium channel blockers.
◦ ACE inhibitors and ARB’s can be managed and help to reduce proteinuria. But to be avoided in acute
renal failure and hyperkalemia
◦ Manage glycemic status.
◦ Manage lipid abnormalities
◦ Hemodialysis to be initiated, if uremia is worsening.
◦ Prevent and treat complications: if pulmonary edema persists-diuretics
◦ Venous thrombosis- heparin and oral anticoagulants
◦ Seizures- antiepileptics.
◦ Infections- culture specific antibiotics.
17. Immunosuppression:
◦ Acute glomerular nephritis-no role unless biopsy showed crescents greater than 50%.
◦ Minimal change disease- corticosteroids, if not cyclophosphamide.
Immunomodulation:
◦ Levamisole is used in steroid dependent and frequent relapses of Nephrotic syndrome.
Rapidly progressive glomerulonephritis:
◦ Cyclophosphamide and plasmapharesis is added with corticosteroids.
18. Other treatment:
◦ Identify the acute factors and treat to stabilize the renal parameters.
◦ Manage diabetes and hypertension.
◦ Restrict protein intake.
◦ Correct fluid status by restricting fluid and salt intake.
◦ Correct anemia- identify iron deficiency and use of erythropoietin if iron stores are adequate.
◦ Calcium-Phosphorous balance to be maintained.
◦ Vitamin D deficiency and hyperparathyroidism to be identified.
◦ Hemodialysis and peritoneal dialysis.
◦ Renal transplantation.
19. A systematic approach will help to diagnose glomerular diseases and to preserve the renal
function.
Thank you.
