Glomerulonephritis, Emergency Medicine

Basics

Description

Syndrome characterized by:
- Hematuria
- Proteinuria
- Red blood cell casts
- Hypertension
- Renal insufficiency
Common pathway of multiple diseases resulting in intraglomerular inflammation and cellular proliferation
Contributing factors:
- Genetics
- Infectious
- Rheumatologic
- Leading to antibody deposition:
  - Antibody attaches to glomerular antigen (native or implanted).
  - Circulating antigen-antibody complex deposited
- Causing an influx and activation of inflammatory mediators:
  - Leukocytes, complement, cytokines
  - Cell-mediated immune mechanisms
Results in glomerular dysfunction
Persistent inflammation that can lead to scarring and permanent damage.

Etiology

Postinfectious:
- Poststreptococcal glomerulonephritis (PSGN):
  - Occurs 7-21 days after Streptococcal pharyngitis or skin infection
  - Highest prevalence in ages 2-14 and the elderly
  - Male predominance
  - Ranges from asymptomatic hematuria to oliguric renal failure
- Can follow other bacterial, fungal, viral, or parasitic infections
IgA nephropathy (Berger disease):
- Most common in men in the 3rd and 4th decades of life
- Possibly related to increased production of IgA after infection usually a URI
- Henoch-Sch ¶nlein purpura (HSP) has IgA nephropathy but affects a younger age and has systemic symptoms
Rapidly progressive glomerulonephritis (RPGN):
- Can destroy renal function in days
- Crescentic deposits in glomeruli destroy function.
- Pauci-immune (small vessel vasculitides):
  - Often antineutrophil cytoplasmic antibody (ANCA)-positive
  - Can involve other areas (i.e., lungs, skin)
  - Wegener granulomatosis
  - Microscopic polyangiitis
  - Churg-Strauss syndrome
- Immune complex deposits:
  - Postinfectious
  - Endocarditis associated
  - Systemic disease (i.e., systemic lupus erythematosus [SLE], HSP)
- Anti-glomerular basement membrane (GBM) deposits:
  - Older patients of age >60
  - Goodpasture disease with pulmonary involvement
Membranoproliferative glomerulonephritis (MPGN):
- Complement deposits in basement membrane
- Hepatitis C
- Non-Hodgkin lymphoma
- Occult infection

Diagnosis

Signs and Symptoms

Cardinal signs:
- Hematuria
- Proteinuria
Edema:
- Owing to renal salt and water retention
- Periorbital
- Ascites
- Pleural effusion
HTN
Oliguria
Azotemia
CHF
Renal failure
Nonspecific manifestations:
- Fatigue
- Weight loss
- Abdominal pain
- Nausea/vomiting
Autoimmune disorders:
- Arthralgias
- Arthritis
- Rash
- Fever
Goodpasture syndrome:
- Hemoptysis
Wegner granulomatosis:
- Purulent rhinorrhea/sinus pain
- Arthritis/arthralgias
- Hemoptysis
HSP:
- Abdominal pain
- Purpura
- Arthritis

Pauci-immune RPGN is common in this population (hematuria, proteinuria, and elevated CR).
Urgent diagnosis and biopsy are indicated as this may progress to ESRD.
Consult nephrology to discuss steroids, cyclophosphamide, and plasma exchange.

Essential Workup

Urinalysis for:

Hematuria, proteinuria, and RBC casts

Diagnosis Tests & Interpretation

Lab

Electrolytes, BUN, Creatinine, GFR:
- Renal function
- Hyperkalemia
Albumin, total protein:
- Varying degrees of hypoalbuminemia depending on clinical process
CBC:
- Anemia secondary to chronic renal disease, neoplasm, Goodpasture, and Wegener
- With or without elevated WBC in infections
PT, PTT:
- Coagulation factors consumed in certain types of GN
Labs to be considered for consultants:
- Cultures-throat, skin, blood
- 24-hr urine collection-protein, urine electrolytes
- Streptozyme or antistreptolysin O titer
- Complement levels (C1, C3, C4, CH50)-reduced in PSGN, MPGN, SLE
- ANA, rheumatoid factor-connective tissue diseases
- ESR and CRP inflammatory markers
- Anti-GBM-Goodpasture
- c-ANCA-Wegener; p-ANCA-pauci-immune
- Anti-DNA antibodies (SLE)
- Hepatitis B and C serologies
- HIV

Imaging

Renal ultrasound (if GFR is decreased):
- Kidney size predictor of potential reversibility of disease, alternative diagnosis (i.e., neoplasm, stone)
Chest radiograph (CXR): Heart size, pulmonary edema, or hemorrhage

Diagnostic Procedures/Surgery

Renal biopsy: Discern primary glomerulopathies vs. other causes
Cystoscopy: If concern for bladder neoplasm

Differential Diagnosis

Hematologic:
- Sickle cell disease
- Coagulopathy
Renal:
- Infectious
- Malformation
- Neoplasm
- Ischemic
- Trauma
- Vasculitis
Postrenal:
- Mechanical (i.e., stones, reflux, obstruction, catheterization)
- Inflammatory (i.e., cystitis, prostatitis, epididymitis, endometriosis, periurethritis)
- Neoplasm
Factitious:
- Food
- Drugs
- Pigmenturia (i.e., myoglobin, porphyria, hemoglobin)
- Vaginal bleeding

Treatment

Pre-Hospital

Supportive
ABCs and fluid restriction in stable patients with significant edema.

Initial Stabilization/Therapy

ABCs: Airway, breathing, circulation

Ed Treatment/Procedures

Treatment mainly supportive care:
- BP control: <125/75 mm Hg
  - Loop diuretics
  - ACE inhibitor for maintenance
  - Treat hypertensive emergencies
- Dialysis:
  - Fluid overload
  - Hyperkalemia
  - Uremia
PSGN:
- Supportive care
- Usually resolves spontaneously
- No benefit to antibiotics
IgA nephropathy:
- Supportive care
- Immunosuppressives if inflammation on biopsy
- Variable course, most recover but may relapse
RPGN:
- Can irreversibly destroy renal function in days
- Emergently consult nephrologist to discuss starting potentially toxic therapies.
- Immunosuppressives and high-dose steroids:
  - Methylprednisolone and prednisone
  - Cyclophosphamide
  - Rituximab
  - Plasmapheresis for anti-GBM antibody
MPGN:
- Treat underlying disease if known.
- Emergently consult nephrologist to discuss starting potentially toxic therapies.
- May include plasma exchange, cyclophosphamide, and/or steroids

Medication

Benazepril: 5-40 mg PO daily (or any other ACE inhibitor)
Cyclophosphamide: Dose in conjunction with nephrology
Diazoxide: 1-3 mg/kg IV, max. 150 mg, repeat q15min
Furosemide: 20-80 mg IV; max. 2 mg/kg/d
Methylprednisolone: 30 mg/kg IV on alternative days for 3 doses, followed by oral prednisone (dose in conjunction with nephrology)
Nitroprusside: 0.3-10 Î¼g/kg/min IV
Prednisone: 0.5-2 mg/kg/d

Follow-Up

Disposition

Admission Criteria

Unstable vital signs
Oliguria, anuria
Uremia
Acute renal failure
Electrolyte abnormality
Hypertensive emergency
CHF
Infectious cause of GN

Discharge Criteria
Healthy patients with no comorbid illness who present with mild hematuria and proteinuria with:

Stable vital signs
No signs of infection
Otherwise normal lab work
Close follow-up recommended

Followup Recommendations

All patients with glomerulonephritis should follow-up with nephrology

Pearls and Pitfalls

Discussion with nephrology if management with immunosuppressives is sought.
The finding of proteinuria or hematuria should always prompt follow-up to ensure that the patient is not progressing to GN.

Additional Reading

Balogun RA, Abdel-Rahman EM. Therapeutic plasma exchange and renal related vasculitis: Therapeutic apheresis academy 2010. J Clin Apher. 2011;26:291-296.
Beck LH Jr, Salant DJ. Glomerular and tubulointerstitial diseases. Prim Care. 2008;35(2):265-296, vi.
Glassock RJ. Glomerular disease in the elderly.Clin Geriatr Med. 2009;25(3);413-422.
Glomerular disease. In: Longo D, Fauci A, Kasper D, et al., eds. Harrisons Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2011.
Walters GD, Willis NS, Craig JC. Interventions for renal vasculitis in adults. A systematic review. BMC Nephrol. 2010;11:12.

Codes

ICD9

580.0 Acute glomerulonephritis with lesion of proliferative glomerulonephritis
583.4 Nephritis and nephropathy, not specified as acute or chronic, with lesion of rapidly progressive glomerulonephritis
583.9 Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney
583.2 Nephritis and nephropathy, not specified as acute or chronic, with lesion of membranoproliferative glomerulonephritis

ICD10

N00.9 Acute nephritic syndrome with unsp morphologic changes
N01.9 Rapidly progr nephritic syndrome w unsp morphologic changes
N05.9 Unsp nephritic syndrome with unspecified morphologic changes
N05.5 Unsp nephritic syndrome w diffuse mesangiocap glomrlneph

SNOMED

36171008 Glomerulonephritis (disorder)
68544003 Acute post-streptococcal glomerulonephritis (disorder)
236392004 Rapidly progressive glomerulonephritis (disorder)
80321008 Mesangiocapillary glomerulonephritis (disorder)

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