GLOMERULO GLOMERULO NEPHRITISNEPHRITIS

Dr. Muhammad Hussain BalochDr. Muhammad Hussain BalochAssistant Professor/ Head of Nephrology Assistant Professor/ Head of Nephrology

Department RMC & Allied HospitalsDepartment RMC & Allied HospitalsRawalpindiRawalpindi

GLOMERULO NEPHRITISGLOMERULO NEPHRITIS

Implies an immune pathogenesisImplies an immune pathogenesis All glomerular diseases not caused by GN All glomerular diseases not caused by GN

D.D D.D DN, Amyloidosis, HTN & Hereditary DN, Amyloidosis, HTN & Hereditary nephropathies (Alport’s synd.)nephropathies (Alport’s synd.)

11OO clinical manifestations restricted to clinical manifestations restricted to kidneykidney

Part of multi system disease (SLE or Part of multi system disease (SLE or vasculitis)vasculitis)

GLOMERULUSGLOMERULUS

GLOMERULUSGLOMERULUS

Tuft of capillaries attached to Tuft of capillaries attached to

mesangum enclosed in mesangum enclosed in

Bowmann’s capsule Bowmann’s capsule

Filtration Barrier Filtration Barrier Barrier is negatively chargeBarrier is negatively charge

CLASSIFICATIONCLASSIFICATION Based on HistopathologyBased on Histopathology Not IDEAL – One etiology may produce a variety of histologic patterns Not IDEAL – One etiology may produce a variety of histologic patterns

OROR Various etiologies may produce similar patternVarious etiologies may produce similar pattern

L.M focal or diffuse - segmental or globalL.M focal or diffuse - segmental or global I.F or immunoperoxidase microscopy I.F or immunoperoxidase microscopy E.M E.M morphology of basement membrane morphology of basement membrane

MCDMCD FSGSFSGS Membranous NephropathyMembranous Nephropathy MPGNMPGN Masangial proliferative GNMasangial proliferative GN Post infectious GNPost infectious GN Crescentic G.NCrescentic G.N

ETIOLOGYETIOLOGY IdiopathicIdiopathic Hereditary Hereditary INFECTIONS: Staph, Strept, E.Coli Leptospirosis, T.Pallidum, Coxiella, bmcella, INFECTIONS: Staph, Strept, E.Coli Leptospirosis, T.Pallidum, Coxiella, bmcella,

listeria monocytogenes listeria monocytogenes Schistosoma, Trichinella, SpiralisSchistosoma, Trichinella, Spiralis Hepatitis A,B,C, HIV, CMV, MUMPS, Influnsa, EBV and EchoHepatitis A,B,C, HIV, CMV, MUMPS, Influnsa, EBV and Echo Histoplasma, candida Histoplasma, candida Plasmodum, Toxaplasma, trypanosomaPlasmodum, Toxaplasma, trypanosoma Multisystem disease Multisystem disease D.MD.M HTNHTN Amyloidosis Amyloidosis Vasculitis - ANCA Vasculitis Vasculitis - ANCA Vasculitis SLESLE MalignanciesMalignancies

CLINICAL PRESENTATIONCLINICAL PRESENTATION

1.1. ASYMPTOMATIC PROTEINURIAASYMPTOMATIC PROTEINURIA Proteinuria 150mg – 3 gram / dayProteinuria 150mg – 3 gram / day Hematuria > 2 RBCs/HPFHematuria > 2 RBCs/HPF FSGS Mesangial proliferative GN (IgA)FSGS Mesangial proliferative GN (IgA)

2.2. NEPHROTIC SYNDNEPHROTIC SYND Proteinuria > 3.5g/day or > 40mg/hour/m2Proteinuria > 3.5g/day or > 40mg/hour/m2 Hypoalbuminemia <3.5 g/dLHypoalbuminemia <3.5 g/dL Edema Edema HyperclolesterolemiaHyperclolesterolemia LipiduriaLipiduria

MCDMCD Membranous GN Membranous GN MEMBRANOUS GNMEMBRANOUS GN FSGS, Mesangioproliferative GNFSGS, Mesangioproliferative GN MPGN – I, MPGN IIMPGN – I, MPGN II Diabetic glomerulosclerosis Diabetic glomerulosclerosis AmyloidosisAmyloidosis LCDDLCDD

3.Asymptomatic Microscopic Hematuria3.Asymptomatic Microscopic Hematuria

T.B.M NephropathyT.B.M Nephropathy 1gA Nephropathy1gA Nephropathy Alport’s Synd.Alport’s Synd.

4.RECURRENT GROSS HEMATURIA 4.RECURRENT GROSS HEMATURIA

TBM NephropathyTBM Nephropathy IgA NephropathyIgA Nephropathy Alport’s synd.Alport’s synd.

5.ACUTE NEPHRITIC SYND5.ACUTE NEPHRITIC SYND OliguriaOliguria HematuriaHematuria RBC castsRBC casts Proteinuria usually <3g/dayProteinuria usually <3g/day Edema Edema HTN HTN Acute diffuse Proliferative GN (Post staph and Acute diffuse Proliferative GN (Post staph and

post strept)post strept)6.FOCAL OR DIFFUSE PROLIFERRATIVE GN 6.FOCAL OR DIFFUSE PROLIFERRATIVE GN

1GA AND LUPUS NEPHRITIS 1GA AND LUPUS NEPHRITIS

7. RPGN7. RPGN Renal Failure over day /weeksRenal Failure over day /weeks Proteinuria usually < 3g/day Proteinuria usually < 3g/day Hematuria RBC castsHematuria RBC casts BP often normalBP often normal

CRESCENTIC GNCRESCENTIC GN Anti GBM disease and syndromeAnti GBM disease and syndrome

MPAMPA W.GW.G Goodpasture’s Goodpasture’s disease disease S.L.ES.L.E

CSSCSS HSPHSP HUSHUS BEHCEST’S DIS. BEHCEST’S DIS. Essential Mixed cryoglobaulinemia Essential Mixed cryoglobaulinemia Rheumatoid vasculitis Rheumatoid vasculitis Penicillamine therapy Penicillamine therapy

Immue complex GNImmue complex GN ANCA GNANCA GN

8.CHRONIC GN8.CHRONIC GN Hypertension Hypertension Renal Insufficiency Renal Insufficiency Proteinuria > 3gramProteinuria > 3gram Small shrunken Kidneys Small shrunken Kidneys

DIAGNOSIS DIAGNOSIS

HISTORY HISTORY Symptoms – few & LateSymptoms – few & Late UrineUrine DM. HTN, Amyloid, SLE, VasculitisDM. HTN, Amyloid, SLE, Vasculitis Family History – ALPORT’s HUSFamily History – ALPORT’s HUS NSAID use HeroinNSAID use Heroin InfectionsInfections Malignancies Malignancies G.I – Membranous Hodgkin this G.I – Membranous Hodgkin this

–MCD Non Hodgkin MPGN–MCD Non Hodgkin MPGN

PHYSICAL EXAMPHYSICAL EXAM Edema Edema LABLAB UrineUrine Serological testsSerological tests

Anti dS DNA antibodiesAnti dS DNA antibodies CryogloblinsCryogloblins RA FactorRA Factor Anti GBM antibodiesAnti GBM antibodies ANCAANCA A.S.O titresA.S.O titres Urine electrophoresis Urine electrophoresis Serum complements levelSerum complements level

IMAGING IMAGING USGUSG RENAL BIOPSY RENAL BIOPSY

TREATMENTTREATMENT

B.P Control B.P Control Na+ restriction Na+ restriction Target 125/75 mm of HgTarget 125/75 mm of Hg ACEIS & ARBsACEIS & ARBs

Proteinuria Proteinuria NSAIDS ?NSAIDS ? Protein restriction 0.8 – 1 g/day, Protein restriction 0.8 – 1 g/day, Nephrectomy Nephrectomy

HyperlipidemiaHyperlipidemia Avoid nephrotoxic agents:Avoid nephrotoxic agents:

NSAIDSNSAIDS RadiocontrastRadiocontrast Aminoglycosides Aminoglycosides

Treat edema Treat edema

Hypercoagulability heparin 5000 units s/c x Hypercoagulability heparin 5000 units s/c x BDBD Management of infection Management of infection S.B.PS.B.P

SPECIFIC THERAPIESSPECIFIC THERAPIES