MR 7/27/09 J. Chen

 Background  Pathophysiology  Histologic Findings  Clinical  History  Physical  Lab  Differential Diagnosis  Treatment  Follow Up

 Glomerulonephritis-various renal diseases in which inflammation of the glomerulus, manifested by proliferation of cellular elements, is secondary to an immunologic mechanism  Most associated with postinfectious state  4-12yr with peak 5-6years  Male:Female 1.7-2:1  Prognosis is good

 Winter and Spring-respiratory infection  Latency period 10 days for pharyngitis  Summer and Fall-associated with pyoderma  Latent period difficult to determine

 Not fully understood  Immune Complexes localize on glomerular capillary wall and activate the complement system (Zymogen and GAPDH)  Activation of complement cascade generates C5a and platelet derived inflammatory mediators  Various cytokines initiate an inflammatory response manifested by cellular proliferation and edema of glomerular tuft

Ab-Ag complexes Classical pathway C3 convertase Microbial surfaces (polysaccharides) Alternative pathway C3 convertase C3 C3b C3a (C4 + C2) (C4bC2a) Membrane attack complex Recruitment of PMNs Opsonization, phagocytosis Anaphylaxis, Chemotaxis

 Measurable reduction in volume of glomerular filtrate  Decreased capacity to excrete salt and water leading to expansion of extracellular fluid volume  Responsible for edema and in part for hypertension, anemia, circulatory congestion, encephalopathy

 Light Microscopy-Glomerular tufts enlarged and swollen

 Electron-dense deposits (humps) in the subepithelial space

 History: latent period 7-21 days btw streptococcal infection and glomerulonephritis characteristics  Edema most frequent manifesting symptom  85%  Abrupt onset  Periorbital area, may be generalized  Gross hematuria 30-50%  Smoky, cola, rust, tea colored  +/- oliguria  Various degree of malaise, lethargy, anorexia, fever, abdominal pain, headache

 Hypertensive encephalopathy-HA, vomitting, depressed sensorium, confusion, visual disturbances, aphasia, memory loss, convulsions, coma  Possible dyspnea, orthopnea, cough  Pallor

 Edema  Systolic and Diastolic HTN to varying degree (Inc ECF, cytokines with pressor effects)  Pallor  Pulmonary rales  Bradycardia/tachycardia  Depressed sensorium

 Urine-output reduced, concentrated, acidic  Hematuria  Proteinuria  Glucosuria  RBC Casts-60-85%  Hyaline and/or cellular casts

 Renal:  Elevation of BUN/Cr usually modest  Electrolytes usually normal (hyperK and met acid with significant renal impairment)

 Streptococcal infection:  Culture from Pharynx and skin may be positive  Strep ab titers more meaningful Measured at 2-3 wk intervals-Rise more significant

 Hemolytic Complement  C3 decreased in 90%  C4 normal  C5 decreased  Complement levels return to normal 6-8 weeks after onset

 Mild Anemia-parallels the degree of ECF expansion  WBC-Nl  Plts-Nl

 Renal US-nl to slightly enlarged kidneys  CXR-Central venous congestion  Occasionally enlarged cardiac shadow

Hypocomplementemia  PIGN Bacteria (GAS, S. viridans, pneumococcus, S. aureus, S. epi, atypical mycobacterium, meningococcus, Brucella, Leptospirosis, Propionibacterium) Viruses (VZV, EBV, CMV, rubeola) Parasites (Toxo, Trich, Riskettsia)  Membranoproliferative GN  SLE  Cryoglobulinemia  Bacterial Endocarditis  Shunt nephritis Normal complement HUS IgA Nephropathy HSP Alport’s / TBMD Nephrotic Syndrome

Myoglobin Hemaglobin Bile Urate Crystals Beets Blackberry Food dye Drugs Exercise PIGN IGAN Benign Familial Glomerul onephritis MPGN HSP SLE Alport Pyelonephri tis Hypercalciu ria Nephrolithi asis Trauma Sickle Cell NSAIDS Renal V. Thrombos is Cystitis Meatal Stenosis Urethritis Bladder tumor Menstrual contamin ation Diaper rash

 Nephrotic Syndromes  Acquired Glomerular Disease  MPGN  SLE  IGAN  SBE  DM  HTN  HUS  Genetic Disorders  Nail-patella syndrome  Alport syndrome  Fabry Disease  Glycogen storage disease  CF  Hurler  Gaucher Disease  Wilson Disease  SC  Leukemia  Lymphoma  Infectious  PSGN  HIV nephropathy  HEP B and C  Malaria  Syphilis  Pyelonephritis  Drugs/toxins

 Treatment mainly supportive  Hospitalization indicated if:significant HTN, Oliguria, Generalized Edema, High Cr or K  Antibiotics do not influence course of disease-however, administered to ensure eradication of disease

 Fluid Restriction  Salt Restriction  Loop Diuretics  Antihypertensives  Limited activity  Dialysis if necessary

 Prognosis usually excellent  0.5% mortality due to pulmonary edema or pneumonia  <1% progress to CKD stage 5  Follow-up  Must ensure that HTN controlled, Edema resolved, hematuria/ proteinuria resolved, Cr normalized  Gross hematuria resolves within 2 weeks  Complement low for 6-8 weeks  Proteinuria remains upto 6 months  Hematuria remains upto 2 years