Nephritic Syndrome

Introduction

Nephritic syndrome is a clinical picture produced by an active inflammatory process in the kidney that can be caused by a number of underlying diseases. It differs from nephrotic syndrome in that there is a proliferative lesion in the glomerulus. This means that the endothelial cells or mesangial cells are affected, reducing the integrity of the glomerular basement membrane and allowing red blood cells to enter the urine. There is often also a defect to podocytes which causes proteinuria, as in nephrotic syndrome. It is an actute presentation as acute kidney injury is one of the features.

Presentation

The features of nephritic syndrome are:

  • Haematuria (microscopic or macroscopic)
  • Oliguria (reduced urine output 80-400ml/day)
  • Oedema/fluid retention
  • Hypertension
  • Active urine sediment (red cell casts, red blood cells, granular casts)

History

This helps to distinguish various causes of inflammation in the glomerulus:

  • Recent infections (esp upper resp/pharyngitis) - glomerulonephritis such as IgA nephropathy, rapidly progressive GN
  • Haemoptysis - anti-glomerular basement membrane/Goodpasture's disease
  • Purpuric rash - Henloch-Schonlein Purpura
  • Past medical history - Lupus nephritis, vasculitis (GPA/Churg-Strauss)

Vital signs

  • Blood pressure - raised
  • Others may be normal

Examination findings

  • Peripheral oedema
  • Pulmonary oedema
  • Ascites

Bedside tests

Urinalysis

  • Haematuria
  • Proteinuria

Laboratory investigations

  • U+E - determine extent of AKI, check for electrolyte imbalances
  • FBC
  • CRP - monitor degree of inflammation
  • LFT - hypoalbuminaemia may be present
  • Serology for ANA, ANCA, anti-dsDNA, anti-GBM
  • Other immunological tests: serum autoantibodies, complement, protein electrophoresis
  • Urinary protein: creatinine ratio
  • Urine microscopy: look for RBCs, red cell casts, granular casts

Special tests

If glomerulonephritis is suspected, renal biopsy under ultrasound guidance may be required to confirm the diagnosis

Management

  1. Refer to nephrology
  2. Regularly monitor and control BP under 130/80
  3. ACEi/ARB
  4. Other measures to manage acute kidney injury

Further management depends on the cause; see other pages, especially [[wiki: glomerulonephritis | glomerulonephritis ]]

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