Glomerulonephritis

Definition

Glomerulonephritis is a group of diseases that cause inflammation of the tiny filtering units in the kidneys known as glomeruli. This inflammation impairs the kidneys’ ability to filter waste and excess fluids from the blood.

Pathophysiology

• Immune System Attack:- In glomerulonephritis, the immune system mistakenly targets the glomeruli, leading to inflammation and damage. This can happen due to infections, autoimmune diseases, or other triggers that cause the immune system to overreact.

• Glomerular Damage:- The inflammation in the glomeruli causes the capillaries within them to thicken and become scarred, reducing their ability to filter blood efficiently. This results in the leakage of proteins and blood into the urine.

• Decreased Filtration Rate:- The overall kidney function declines as more glomeruli are damaged. This leads to a reduction in the glomerular filtration rate (GFR), the rate at which the kidneys filter waste from the blood.

Causes

• Infections:-

  • Streptococcal Infections:- Certain strains of the streptococcus bacteria, particularly those that cause throat and skin infections, can trigger post-streptococcal glomerulonephritis.

    • Rationale:- The body’s immune response to the infection mistakenly attacks the glomeruli.

  • Viral Infections:- Hepatitis B, hepatitis C, and HIV can also lead to glomerulonephritis by causing immune-mediated damage to the kidneys.

    • Rationale:- Viral infections can alter the immune system’s response, leading to glomerular inflammation.

• Autoimmune Diseases:-

  • Systemic Lupus Erythematosus (SLE):- is a disease where the immune system attacks the body’s own tissues, including the kidneys. It often shows up as a red, butterfly-shaped rash on the nose and cheeks, which looks like a wolf’s snout.

    • Rationale:- In SLE, immune complexes are deposited in the glomeruli, causing inflammation.

  • Goodpasture Syndrome:- A rare autoimmune disease that affects the lungs and kidneys, leading to glomerulonephritis.

    • Rationale:- The immune system produces antibodies against the glomerular basement membrane, leading to damage.

• Vasculitis:-

  • Wegener’s Granulomatosis:- A form of vasculitis that causes inflammation of the blood vessels, including those in the kidneys.

    • Rationale:- The inflammation restricts blood flow to the glomeruli, leading to damage.

• IgA Nephropathy:-

  • Berger’s Disease:- A condition where deposits of the protein IgA build up in the glomeruli, causing inflammation.

    • Rationale:- The IgA deposits trigger an immune response, leading to glomerular damage.

Symptoms

• Hematuria (Blood in Urine):-

  • Visible Hematuria:- Urine that appears pink, red, or cola-colored due to the presence of blood.

    • Rationale:- Damaged glomeruli allow red blood cells to leak into the urine.

  • Microscopic Hematuria:- Blood in the urine that is not visible to the naked eye but can be detected under a microscope.

    • Rationale:- Even minor glomerular damage can cause red blood cells to pass into the urine.

• Proteinuria (Excess Protein in Urine):-

  • Foamy Urine:- The presence of excess protein in the urine can cause it to appear foamy or bubbly.

    • Rationale:- Protein leakage into the urine occurs when the glomeruli’s filtering ability is compromised.

  • Edema:- Swelling in the face, hands, feet, and abdomen due to the retention of fluid and sodium.

    • Rationale:- Protein loss in the urine leads to low blood protein levels, reducing oncotic pressure and causing fluid to leak into tissues.

• Hypertension (High Blood Pressure):-

  • Elevated Blood Pressure:- Increased blood pressure due to the retention of sodium and fluid by the damaged kidneys.

    • Rationale:- Impaired kidney function leads to fluid and sodium retention, raising blood pressure.

• Oliguria (Reduced Urine Output):-

  • Decreased Urine Production:- A significant reduction in the amount of urine produced.

    • Rationale:- Damage to the glomeruli reduces their ability to filter blood, resulting in decreased urine output.(urine output less then 400ml/day or less then 30ml/hours)

• Fatigue:-

  • General Weakness:- Persistent tiredness and lack of energy due to the buildup of waste products in the blood.

    • Rationale:- Reduced kidney function leads to the accumulation of toxins, causing fatigue.

• Flank Pain:-

  • Pain in the Lower Back:- Discomfort or pain in the lower back or side, typically on one side.

    • Rationale:- Inflammation and swelling of the kidneys can cause pain in the surrounding areas.

Diagnostic Tests

• Antistreptolysin O (ASO) Titer:-

  • Test:- This blood test detects antibodies against streptococcal bacteria. It is often elevated in post-streptococcal glomerulonephritis.

    • Details:- A rising ASO titer suggests a recent streptococcal infection, which can trigger glomerulonephritis.

    • Normal Value:- <200 IU/mL in adults

• Urinalysis:-

  • Proteinuria:- This test checks for the presence of protein in the urine. In glomerulonephritis, the damaged glomeruli allow proteins to leak into the urine.

    • Details:- A dipstick test or a 24-hour urine collection can measure protein levels. Persistent proteinuria is a hallmark of glomerular damage.

    • Normal Value:- Less than 150 mg/day in a 24-hour collection or a negative/trace result on a dipstick.

  • Hematuria:- This test detects blood in the urine, which is a common sign of glomerular inflammation.

    • Details:- Microscopic hematuria (blood detected only under a microscope) or gross hematuria (visible blood in urine) can occur.

    • Normal Value:- 0-4 red blood cells per high power field (HPF) or Nill.

  • Increased Urine Specific Gravity:- This measures the concentration of solutes in the urine, which may be elevated in glomerulonephritis due to proteinuria and reduced kidney function.

    • Details:- Specific gravity reflects the kidney’s ability to concentrate urine. In glomerulonephritis, this value may increase as the kidneys struggle to filter waste efficiently.

    • Normal Value:- 1.005 – 1.030

• Blood Tests:-

  • Serum Creatinine and Blood Urea Nitrogen (BUN):- These tests measure waste products in the blood, which are typically filtered out by the kidneys. Elevated levels indicate impaired kidney function.

    • Details:- Serum creatinine and BUN levels rise when the kidneys are unable to efficiently filter and excrete waste, a common consequence of glomerular damage.

    • Normal Creatinine Value:- 0.6 – 1.2 mg/dL

    • Normal BUN Value:- 7 – 20 mg/dL

  • C-Reactive Protein (CRP):- CRP is a marker of inflammation in the body. Elevated CRP levels indicate active inflammation, which is common in glomerulonephritis.

    • Details:- CRP levels increase in response to inflammation, making it a useful indicator of the severity of the disease.

    • Normal Value:- <10 mg/L

  • Glomerular Filtration Rate (GFR):- GFR measures how well the kidneys are filtering blood. A reduced GFR indicates a decline in kidney function.

    • Details:- GFR is calculated based on serum creatinine levels, age, sex, and body size. It is a key indicator of kidney function.

    • Normal Value:- 90 – 120 mL/min/1.73 m²

  • Serum Albumin:- This test measures the level of albumin, a type of protein, in the blood. Low levels may indicate Nephrotic syndrome, a condition that can accompany glomerulonephritis.

    • Details:- In glomerulonephritis, protein loss through urine can lead to hypoalbuminemia (low blood albumin levels), contributing to edema.

    • Normal Value:- 3.5 – 5.0 g/dL

• Renal Ultrasound:-

  • Test:- A non-invasive imaging test that uses sound waves to visualize the kidneys. It can detect changes in kidney size, shape, and structure.

    • Details:- Renal ultrasound may reveal swollen or shrunken kidneys, cysts, or other abnormalities. It helps assess the extent of kidney damage.

    • Findings:- Kidneys may appear swollen in the early stages or show scarring and shrinkage in chronic cases.

• Kidney Biopsy:-

  • Test:- Involves taking a small sample of kidney tissue for examination under a microscope. This is the definitive test for diagnosing glomerulonephritis.

    • Details:- A kidney biopsy can identify the specific type of glomerulonephritis and the extent of damage, guiding treatment decisions. The procedure involves using a needle to extract a small tissue sample from the kidney, usually under ultrasound or CT guidance.

    • Findings:- The biopsy may show inflammation, scarring, or deposits of immune complexes in the glomeruli.

Management

Non-Pharmacological Management

• Dietary Modifications:-

  • Low-Sodium Diet:- Limiting sodium intake to reduce fluid retention and manage hypertension.

    • Rationale:- Sodium reduction helps control blood pressure and reduces the risk of edema.

  • Protein Restriction:- Reducing protein intake to prevent further kidney damage.

    • Rationale:- Lowering protein intake decreases the workload on the kidneys (Azotemia).

• Fluid Restriction:- Limiting fluid intake to prevent fluid overload and manage edema.

  • Rationale:- Reducing fluid intake helps control swelling and prevents complications like pulmonary edema.

• Potassium and Phosphate Restriction:- Monitoring and possibly reducing potassium and phosphate intake depending on kidney function.

  • Rationale:- Damaged kidneys may struggle to maintain normal potassium and phosphate levels, leading to dangerous imbalances and complications.

• Lifestyle Modifications:-

  • Smoking Cessation:- Quitting smoking improves overall kidney health and reduces the risk of cardiovascular complications.

    • Rationale:- Smoking exacerbates kidney damage and increases the risk of heart disease.

  • Weight Management:- Maintaining a healthy weight through diet and exercise to reduce the strain on the kidneys.

    • Rationale:- Obesity is a risk factor for kidney disease, and weight management can slow disease progression.

Pharmacological Management

• Antihypertensive Medications:-

  • ACE Inhibitors (e.g., Enalapril):- Lower blood pressure and reduce proteinuria by dilating blood vessels and decreasing the workload on the heart.

    • Rationale:- By lowering blood pressure, ACE inhibitors protect the kidneys from further damage.

  • Angiotensin II Receptor Blockers (ARBs) (e.g., Losartan):- Similar to ACE inhibitors, ARBs help control blood pressure and reduce proteinuria.

    • Rationale:- ARBs provide an alternative for patients who cannot tolerate ACE inhibitors.

  • Diuretics (e.g., Furosemide):- Help reduce fluid retention and lower blood pressure by promoting the excretion of excess fluid.

    • Rationale:- Diuretics relieve edema and help manage hypertension, reducing the strain on the kidneys.

• Immunosuppressive Therapy:-

  • Corticosteroids (e.g., Prednisone):- Reduce inflammation in the glomeruli by suppressing the immune system’s activity.

    • Rationale:- Corticosteroids help control immune-mediated damage in glomerulonephritis.

  • Cytotoxic Agents (e.g., Cyclophosphamide):- Used in severe cases to further suppress the immune system and reduce glomerular inflammation.

    • Rationale:- Cytotoxic agents are effective in controlling aggressive forms of glomerulonephritis but require careful monitoring for side effects.

  • Plasma Exchange (Plasmapheresis):- Removes harmful antibodies and immune complexes from the blood, particularly in rapidly progressive glomerulonephritis.

    • Rationale:- Plasma exchange helps reduce the immune response that causes glomerular damage.

• Antibiotics:-

  • Penicillin or Erythromycin:- Used to treat underlying streptococcal infections in post-streptococcal glomerulonephritis.

    • Rationale:- Treating the infection helps prevent further immune-mediated kidney damage.

• Anticoagulants:-

  • Heparin or Warfarin:- Prescribed to prevent blood clots in patients with severe proteinuria, which increases the risk of thrombosis.

    • Rationale:- Anticoagulants reduce the risk of clot formation, a common complication in nephrotic syndrome associated with glomerulonephritis.

Surgical Management

• Kidney Transplantation:- Considered in cases of end-stage renal disease (ESRD) due to irreversible glomerular damage.

  • Rationale:- A kidney transplant can restore kidney function in patients with severe glomerulonephritis who have not responded to other treatments.

• Dialysis:-

  • Hemodialysis:– Used to filter waste products and excess fluid from the blood when the kidneys are no longer able to do so.

    • Rationale:- Hemodialysis replaces the lost filtration function of the kidneys in patients with severe kidney failure.

  • Peritoneal Dialysis:– An alternative to hemodialysis, where the lining of the abdomen (peritoneum) is used to filter blood inside the body.

    • Rationale:- Peritoneal dialysis offers a home-based option for patients with severe glomerulonephritis.

Nursing Care

• Monitoring and Assessment:-

  • Vital Signs Monitoring:- Regular monitoring of blood pressure, heart rate, and temperature to detect early signs of complications.

    • Rationale:- Early detection of changes in vital signs can help prevent or manage complications such as hypertensive crisis.

  • Fluid Balance Monitoring:- Accurate recording of input and output to manage fluid overload and prevent edema.

    • Rationale:- Maintaining fluid balance is crucial to preventing complications like pulmonary edema.

  • Daily Weights:- Regular monitoring of body weight at the same time in minimal clothes.

    • Rationale:- Weight gain may indicate worsening fluid retention and require adjustment of treatment.

  • Edema Assessment:- Regular checks for swelling in the face, hands, feet, and abdomen.

    • Rationale:- Monitoring edema helps assess the effectiveness of diuretics and fluid restriction.

  • Urinalysis Monitoring:- Frequent testing of urine for protein, blood, and other abnormalities.

    • Rationale:- Urinalysis helps track the progression of glomerulonephritis and the effectiveness of treatment.

• Patient Education:-

  • Medication Adherence:- Educating patients on the importance of taking prescribed medications as directed.

    • Rationale:- Proper medication adherence is essential to controlling blood pressure and reducing kidney damage.

  • Dietary Education:- Teaching patients about dietary restrictions, including high-calorie, low-sodium, low-potassium, low-protein, and fluid restrictions.

    • Rationale:- Adhering to dietary guidelines helps manage symptoms and prevent complications.

  • Self-Monitoring:- Instructing patients on how to monitor their blood pressure, weight, and urine output at home.

    • Rationale:- Self-monitoring empowers patients to manage their condition and recognize early signs of complications.

  • Signs of Complications:- Educating patients about the signs and symptoms of potential complications, such as worsening edema, shortness of breath, or severe hypertension.

    • Rationale:- Early recognition of complications allows for prompt intervention and reduces the risk of severe outcomes.

• Psychosocial Support:-

  • Counseling and Support Groups:- Providing access to counseling services and support groups for patients coping with chronic kidney disease.

  • Family Education:- Involving family members in the care plan and educating them about the condition and how they can support the patient.

Complications

• Chronic Kidney Disease (CKD):- Progression to chronic kidney disease due to ongoing glomerular damage.

  • Rationale:- Persistent inflammation and scarring of the glomeruli can lead to irreversible kidney damage.

• End-Stage Renal Disease (ESRD):- The final stage of chronic kidney disease, where the kidneys can no longer function on their own.

  • Rationale:- Severe glomerular damage leads to complete loss of kidney function, requiring dialysis or transplantation.

• Hypertensive Crisis:- A sudden and severe increase in blood pressure that can lead to stroke, heart attack, or other life-threatening conditions.

  • Rationale:- Uncontrolled hypertension due to kidney dysfunction can escalate to a hypertensive crisis.

• Pulmonary Edema:- Accumulation of fluid in the lungs, causing difficulty breathing and reduced oxygen levels.

  • Rationale:- Fluid retention and decreased kidney function can lead to fluid overload, resulting in pulmonary edema.

• Thromboembolism:- Formation of blood clots in the veins or arteries, which can travel to the lungs, heart, or brain, causing serious complications.

  • Rationale:- Severe proteinuria increases the risk of blood clots, which can lead to life-threatening events like pulmonary embolism or stroke.

• Electrolyte Imbalances:- Disruptions in sodium, potassium, calcium, and phosphate levels due to impaired kidney function.

  • Rationale:- The kidneys play a crucial role in maintaining electrolyte balance, and damage can lead to dangerous imbalances.

• Infections:- Increased risk of infections due to the loss of protective proteins in the urine and weakened immune response.

  • Rationale:- Protein loss and immune dysfunction make patients more susceptible to infections, which can worsen kidney function.