Nephritic syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Yazan Daaboul, Serge Korjian, Dildar Hussain, MBBS [3], Mehrian Jafarizade, M.D [4]

Synonyms and keywords: Acute nephritis syndrome; Acute glomerulunephritis

Overview

Nephritic syndrome is defined as the inflammation of the renal glomeruli. It is characterized by the presence of glomerular microscopic or gross hematuria with active sedimentation of dysmorphic red blood cells in the urine. Due to renal involvement, the syndrome includes a reduced glomerular filtration rate (GFR), oliguria, azotemia, high blood pressure, and edema. Unlike nephrotic syndrome, proteinuria in nephritic syndrome is not very significant, although frequently present nonetheless. Nephrotic and nephritic syndromes can both still occur concomitantly.

Historical Perspective

The symptoms of glomerulonephritis were first described by Richard Bright in 1827 when he discovered that several patients died with generalized edema were found to have renal disease. It was not until 1914 that Volhard and Fahr classified renal diseases in Die Brightsche Nierenkrankheit to 3 main categories: nephroses, nephritis, and arteriosclerotic disease. Acute post-streptococcal glomerulonephritis is thus considered the earliest nephritic syndrome to be described. In 1908, C.F. Wahrer described an epidemic of hemorrhagic nephritis preceded by scarlet fever in 35 patients. Epidemics of nephritis continued in 1915 among British troops during World War I. Clinical and pathological findings from both epidemics were similar. Hemolytic streptococci were isolated from cultures of the oropharynx in many patients.

Classification

The acute nephritic syndrome can be classified according to the etiology of the underlying disease (renal vs. non-renal etiology). Similarly, acute nephritis may be classified as idiopathic vs. secondary to other conditions. Finally, diseases may be classified according to the proliferative vs. non-proliferative changes seen on pathology.

Renal vs. Non Renal

Renal Diseases

• Acute post-streptococcal glomerulonephritis
• Membranoproliferative glomerulonephritis - Type 1 and 2
• IgA nephropathy
• Idiopathic rapidly progressive glomerulonephritis
  • Anti-GBM disease
  • Pauci-immune disease
  • Immune-deposit disease

Systemic Diseases

• Systemic lupus erythematosus
• Cryoglobulinemia
• Subacute bacterial endocarditis
• "Shunt" nephritis
• Polyarteritis nodosa
• Wegener granulomatosis
• Hypersensitivity vasculitis
• Henoch-Schonlein purpura
• Goodpasture's syndrome
• Visceral abscesses

Primary vs. Secondary

Classification of Glomerular Diseases

Type of Disorder	Proliferative Changes	No Proliferative Changes
Primary Renal Disorder	IgA nephropathy IgM nephropathy Other mesangioproliferative glomerulonephritides Crescentic glomerulonephritis With immune deposits Pauci-immune Membranoproliferative glomerulonephritis	Focal segmental glomerulosclerosis Membranous glomerulopathy Minimal-change disease Thin basement membrane disease
Secondary Disorder	Lupus nephritis Post-infectious glomerulonephritis Glomerulonephritis related to hepatitis B or C Systemic vasculitides Wegener's granulomatosis Polyarteritis nodosa Henoch-Schonlein purpura Idiopathic	Diabetic nephropathy Amyloidosis Light-chain nephropathy Human immunodeficiency virus nephropathy Alport's syndrome Drug-induced glomerulopathies

^{Adapted from Hricik DE, Chung-Park M, Sedor JR. Glomerulonephritis. N Engl J Med. 1998;339(13):888-99}

Renal vs. Non Renal

Renal Diseases

• Acute post-streptococcal glomerulonephritis
• Membranoproliferative glomerulonephritis - Type 1 and 2
• IgA nephropathy
• Idiopathic rapidly progressive glomerulonephritis
  • Anti-GBM disease
  • Pauci-immune disease
  • Immune-deposit disease

Systemic Diseases

• Systemic lupus erythematosus
• Cryoglobulinemia
• Subacute bacterial endocarditis
• "Shunt" nephritis
• Polyarteritis nodosa
• Wegener granulomatosis
• Hypersensitivity vasculitis
• Henoch-Schonlein purpura
• Goodpasture's syndrome
• Visceral abscesses

Primary vs. Secondary

Classification of Glomerular Diseases

Type of Disorder	Proliferative Changes	No Proliferative Changes
Primary Renal Disorder	IgA nephropathy IgM nephropathy Other mesangioproliferative glomerulonephritides Crescentic glomerulonephritis With immune deposits Pauci-immune Membranoproliferative glomerulonephritis	Focal segmental glomerulosclerosis Membranous glomerulopathy Minimal-change disease Thin basement membrane disease
Secondary Disorder	Lupus nephritis Post-infectious glomerulonephritis Glomerulonephritis related to hepatitis B or C Systemic vasculitides Wegener's granulomatosis Polyarteritis nodosa Henoch-Schonlein purpura Idiopathic	Diabetic nephropathy Amyloidosis Light-chain nephropathy Human immunodeficiency virus nephropathy Alport's syndrome Drug-induced glomerulopathies

^{Adapted from Hricik DE, Chung-Park M, Sedor JR. Glomerulonephritis. N Engl J Med. 1998;339(13):888-99}

Pathophysiology

Role of Antibodies

Immunological mechanisms mediated by antibodies are required in the pathogenesis of glomerulonephritis. Antibodies are thought to bind either intrinsic glomerular components or specific compounds with unique physiochemical features that are present surrounding the glomerulus. Type IV collagen is an intrinsic glomerular component involved in Goodpasture's syndrome; whereas histone-DNA complexes in systemic lupus erythematosus are not intrinsic compounds to the glomerulus. However, presence of antibodies alone is not sufficient for glomerular inflammation. Complexes formed by the antibody-antigen complexes must in fact be able to evade clearance by the reticuloendothelial system to effectively deposit at the glomerulus.

Role of Neutrophils

When complement pathway is activated, complement-derived neutrophil chemotactic factors facilitate the infiltration of neutrophils. Neutrophils undergo respiratory burst to release toxic oxygen metabolites that are nephritogenic. Hydrogen peroxide interacts with myeloperoxidase enzyme derived form the neutrophils leading to a direct injury to the glomerular basement membrane. Damage to the capillary wall and proteinuria have also been shown to be induced by elastase and cathepsin G, both of which are serine proteases derived from neutrophils.

Role of Platelets

Platelets play a role in the neutrophil-mediated injury as well. It is believed that platelets exacerbate the injury caused by neutrophils in a mechanism that is yet to be understood.

Role of Macrophages

Macrophages are involved in glomerular injury through the release of oxidants and proteases. These compounds help in the synthesis of tissue factor that leads to deposition of fibrin material on the glomerulus. Subsequently, cytokines and growth factors, such as IL-1 and TGF-B, are released and cause the abnormal production of extracellular matrix.

Role of T Cells

T cells are important for inducing glomerular hypercellularity. T cells are present in both proliferative and non-proliferative glomerular diseases. Pro-inflammatory pathways are activated following initial injury to induce further synthesis of cytokines, complement activation, influx of circulating leukocytes, release of proteolytic enzymes, and activation of coagulation pathway. These changes make the glomerular cell itself, in addition to the infiltrating glomerular cells, an active component of destruction and subsequent restoration.

Matrix Remodeling

Matrix remodeling is in part involved in the activation and proliferation of glomerular cells. The resident and the infiltrating cells will both receive unique signals following matrix remodeling that are involved in the activation of pro-inflammatory pathways in these cells. Autocrine activation of platelet-derived growth factors (PDGF) B-chain and B-receptors is believed to cause the proliferation of mesangial cells during glomerular injury. Growth factors ultimately cause the increase in proteinase synthesis and matrix expansion.

Adaptive Mechanisms

Due to ongoing injury, adaptive changes take place in order to help in the resolution of glomerulonephritis. Hyperfiltration, intraglomerular hypertension, and irregular intravascular stress and shear are all processes that may on one hand worsen the renal injury, but are also crucial for the remainder of the functioning glomerulus.

Resolution of Disease

Apoptosis, defined as programmed cell death, plays a significant role in defining the resolution of disease and in the renal scarring following glomerulonephritis.

Causes

• Causes of nephritic syndrome may vary by age. Causes of nephritic syndrome include post-infectious glomerulonephritis, IgA nephropathy (Berger disease), thin basement membrane disease, and rapidly progressive glomerulonephritis.
• Age plays an important role in identifying the cause of nephritic syndrome. Nonetheless, age should not be the only factor in defining the etiology of nephritic syndrome.

Common Causes of Nephritic Syndrome by Age

Age (Years)	Cause of Nephritic Syndrome
< 15	Post-infectious glomerulonephritis IgA nephropathy (Berger disease) Thin basement membrane disease Alport's syndrome (hereditary nephritis) Henoch-Schonlein purpura Lupus nephritis
15-40	IgA nephropathy (Berger disease) Thin basement membrane disease Lupus nephritis Alport's syndrome (hereditary nephritis) Rapidly progressive glomerulonephritis Post-infectious glomerulonephritis
> 40	IgA nephropathy (Berger disease) Rapidly progressive glomerulonephritis Vasculitis Post-infectious glomerulonephritis

^{Adapted from Rose BD. Pathophysiology of renal diseases, ed. 2. New York, McGraw-Hill, 1987,p. 167}

• There are a number of different causes of nephritic syndrome such as:

Primary renal diseases	Secondary renal diseases	Multi-system disease	Allergy
Immunoglobulin A nephropathy (Berger disease) Membranoproliferative glomerulonephritis Idiopathic rapidly progressive crescenteric glomerulonephritis	Subacute bacterial endocarditis Infected ventriculoperitoneal shunt Glomerulonephritis with visceral abscess Glomerulonephritis with bacterial, viral or parasitic infections	Systemic lupus erythematosus (SLE) Wegener’s granulomatosis Goodpasture’s syndrome Microscopic polyarteritis Mixed cryoglobulinaemia Henoch-Schonlein purpura Haemolytic uraemic syndrome	Acute allergic tubulointerstitial nephritis

Differential Diagnosis

The clinical differentiation between nephritic and nephrotic syndromes is crucial to establish the proper differential diagnosis and determine the appropriate management. In addition, the clinical history and prognosis of nephritic syndrome is different from that of nephrotic syndrome.

• The following table summarizes the key differences between nephrotic syndrome and nephritic syndrome:

Distinguishing Nephritic Syndrome from Nephrotic Syndrome

Clinical Feature	Nephritic Syndrome	Nephrotic Syndrome
Hematuria	Yes	Yes / No
Proteinuria	< 3.5 g/24 hrs	> 3.5 g/24hrs
Red Cell Casts	Yes	No
Hypoalbuminemia	Yes / No	Yes
Hypertension	Yes	Yes / No
Progression	Insidious	Abrupt

Nephritic syndrome should be differentiate from other causes of glomerular disease. The various types of glomerular diseases may be differentiated from each other based on associations, presence of pitting edema, hemeturia, hypertension, hemoptysis, oliguria, peri-orbital edema, hyperlipidemia, type of antibodies, light and electron microscopic features. The following table differentiates between various types of glumerular diseases:

Glomerular diseases	Disease		History and Symtoms									Laboratory Findings		Pathology
			History	Systemic symptoms	Hemeturia	Proteinuria	Hypertension	Pitting edema	Oliguria	Nephrotic features	Nephritic features	Hyperlipidemia and hypercholesterolemia	Auto-antibodies, Complements	Light microscope	Electron microscope	Immunoflourescence pattern
Acute Nephritic Syndromes	Poststreptococcal Glomerulonephritis		Streptococcal skin infections Streptococcal pharyngitis 2-3 weeks after infection	Fever Fatigue Skin rash	+/-	+	+/-	+/-	+/-	+/-	+/-	+/-	Anti-dsDNA antibodies Anti-C1q antibodies Antineutrophil cytoplasmic antibodies (ANCA)	Hypercellular and inflamed glomeruli	Sub-epithelial immune complex deposits Obliteration of epithelial cell foot processes	Immune complex GN Granular deposit
	Renal disease due to Subacute Bacterial Endocarditis, or cardiac shunt (Atrioventricular)		History of infective endocarditis mostly due to S. aureus Cardiac shunt	Fever Fatigue Weight loss	+/-	+	+/-	+/-	+/-	+/-	+/-	+/-	ANCA (myeloperoxidase) positive in 1/3 Activation of the alternative complement pathway (Decreased C3, C4) Positive RF Positive anti-GBM autoantibodies	Crescentic GN is the most common pathological features Diffuse membranoproliferative glomerulonephritis features Focal proliferative GN Mesangial proliferative GN	Mesangial deposits, Subendothelial deposits Subepithelial "humps," in minority of cases	Pauci-immune GN
	Lupus Nephritis		History of SLE features	Lupus criteria: Malar rash Arthritis Arthralgia Anemia Easy bruising	+/-	+	+/-	+/-	+/-	+/-	+/-	+/-	Anti-C1q antibodies Anti-dsDNA	Differs based on the disease classification	Differs based on the disease classification	Differs based on the disease classification, mostly immune complex GN Granular deposit
	Antiglomerular Basement Membrane Disease (Goodpasture's syndrome)		Young adults	Dry cough Hemoptysis Malaise  Fever and chills Arthralgia  Fatigue Lethargy Pallor Anorexia Easy bruising	+	+	+	+	+	+	-	-	ANCA (myeloperoxidase) Positive anti-GBM autoantibodies	Hypercellular and inflamed glomeruli (Crescent formation)	Diffuse thickening of the glomerular basement membrane with absence of sub-epithelial and sub-endothelial deposits	Immune complex GN Linear deposit
	IgA Nephropathy		Young children History of mucosal infections (e.g. gastroenteritis) and upper respiratory tract infection 2-3 days after infection (synpharyngitic)	Low grade fever Flank pain	+	+/-	+	+/-	+	-	+	-	Immune complex deposition	Crescent formation	Mesangial proliferation	Immune complex GN, granular deposite
	Disease		History	Systemic symptoms	Hemeturia	Proteinuria	Hypertension	Pitting edema	Oliguria	Nephrotic features	Nephritic features	Hyperlipidemia and hypercholesterolemia	Auto-antibodies, Complements	Light microscope	Electron microscope	Immunoflourescence pattern
	ANCA Small-Vessel Vasculitis	Granulomatosis with Polyangiitis (Wegener's)	Middle age male	Constitutional symptoms Dyspnea Purpura Arthralgias Neurologic dysfunction Sinusitis Otitis media Epistaxis.	+	+	+	+/-	+	-	+	-	ANCA	Necrotizing and crescentic glomerulonephritis	Subendothelial edema Microthrombosis Degranulation of neutrophils	Pauci-immune GN
		Microscopic Polyangiitis	+/-	Constitutional symptoms Dyspnea Purpura Arthralgias Neurologic dysfunction	+	+	+	+	+	+		-	P-ANCA	Hypercellular and inflamed glomeruli (Crescent formation)	Hypercellular and inflamed glomeruli (Crescent formation)	Pauci-immune GN
		Churg-Strauss Syndrome	+/-	Asthma Sinusitis Myalgia  Arthralgia Purpura Arrythmias Peripheral neuropathy	+	+	+	+	+	+		-	C-ANCA	Hypercellular and inflamed glomeruli (Crescent formation)	Hypercellular and inflamed glomeruli (Crescent formation)	Pauci-immune GN
	Membranoproliferative Glomerulonephritis		Idiopathic Hepatitis B and C (Type 1) C3 nepritic factor (Type2)	Hematuria Oliguria Periorbital edema Hypertension	+	+	+	+/-	+	+	-	-	-	Thick glomerular basement membrane (Tram-track appearance)	Mesangial proliferation Leukocyte infiltration	Immune complex GN Granular deposite
	Henoch-Schönlein purpura		Most common in young male, following upper respiratory infections	Skin manifestations- Palpable purpura on buttocks Gastrointestinal manifestations- Abdominal pain Melena Bloody diarrhea Hematemesis Joints manifestations- Arthralgia	+	+	+	+/-	+	+	-	-	-	Diffuse mesangial IgA deposits often associated with mesangial hypercellularity	Diffuse mesangial IgA deposits often associated with mesangial hypercellularity	Immune complex GN, granular deposite
	Disease		History	Systemic symptoms	Hemeturia	Proteinuria	Hypertension	Pitting edema	Oliguria	Nephrotic features	Nephritic features	Hyperlipidemia and hypercholesterolemia	Auto-antibodies, Complements	Light microscope	Electron microscope	Immunoflourescence pattern
	Cryoglobulinemia		Patients having cryoglobulinemia may have positive history of: Hepatitis C infection Hepatitis B infection Leg ulcers Recurrent thrombosis	Pulmonary symptoms: Difficulty breathing Cough Cutaneous symptoms: Purpura  Skin ulcer Gastrointestinal symptoms: Abdominal pain General symptoms: Fever Arthralgia, Myalgia Fatigue Blurring/loss of vision Diplopia Confusion	+/-	+	+/-	+	+/-	+/-	+/-	+/-	+/-	Membranoproliferative glomerulonephritis	Mesangial and subendothelial deposits	Prominent IgM and C3
Nephrotic Syndrome	Minimal Change Disease		Young children Recent infection and immunization Atopy Hodgkin lymphoma Thrombosis (due to urinary loss of antithrombin-III)		-	+	-	+	+/-	+	-	+		Normal	Fusion of podocytes	-
	Focal Segmental Glomerulosclerosis		Idiopathic HIV Heroine use Sickle cell disease Interferon Severe obesity Mixed cryoglobulinemia (Hepatitis C)		-	+	-	+	+/-	+	-	+		Focal (some glomeruli) and segmental (only part of glomerulus)	Effacement of podocytes	-
	Membranous Glomerulonephritis		Idiopathic Hepatitis B and C Solid tumors Systemic lupus erythematosus Drugs (NSAIDS, pencilamine, gold, captopril)		-	+	-	+	+/-	+	-	+	Immune complex deposition	Thick glomerular basement membrane	Sub-epithelial immune complex depositis with 'spike and dome' appearance	Immune complex GN, granular deposite
	Diabetic Nephropathy		For more information on diabetes click here.		-	+	-	+	+/-	+	-	+		Diffuse mesangial matrix expansion (nodular glomerulosclerosis) Increased mesangial hypercellularity Prominent glomerular basement membranes Thick basement membrane without any deposit	Nodular glomerulosclerosis	-
	Disease		History	Systemic symptoms	Hemeturia	Proteinuria	Hypertension	Pitting edema	Oliguria	Nephrotic features	Nephritic features	Hyperlipidemia and hypercholesterolemia	Auto-antibodies, Complements	Light microscope	Electron microscope	Immunoflourescence pattern
	Glomerular Deposition Diseases	Light Chain Deposition Disease	Occurs in the setting of high tumor burden	-	-	+	-	+	+/-	+	-	+	-	Light-chain deposits	Granular deposits on electron microscopy	Detection of light chain deposits using anti–light chain antibody
		Renal Amyloidosis	For the secondary causes of amloidosis: Tuberculosis Familial Mediterranean fever Rheumatoid arthritis Multiple myeloma	Dyspnea Lethargy Weight loss Bleeding tendency	-	+	-	+	+/-	+	-	+	-	Diffuse glomerular deposition of amorphous hyaline material (nodular pattern), in mesangium (weakly staining with periodic acid-Schiff (PAS)	Nodular deposit	AA amyloidosis type: negative for immunoglobulins and complement AL amyloidosis type: Positive for lambda or kappa light chains
		Fibrillary-Immunotactoid Glomerulopathy	Malignancy Monoclonal gammopathy Autoimmune disease	-	+/-	+	+/-	+/-	+/-	+	+/-	+/-	-	Diffuse sclerosing glomerulonephritis Diffuse proliferative glomerulonephritis Membranoproliferative glomerulonephritis Mesangioproliferative/sclerosing disease Membranous glomerulonephritis	Large fibrillar deposits in the mesangium randomly Glomerular capillary walls different from amloidosis No staining with Congo red or thioflavine-T or with antibodies to a specific type	Positive for immunoglobulin G (IgG), C3 Kappa and lambda (ie, polyclonal) light chains
		Fabry's Disease	Family history suggestive of the disorder	Anhidrosis or decreased sweating Fatigue Angiokeratomas Burning pain of the extremities Corneal opacities. Dysphagia Abdominal pain Steatorrhea Delayed puberty Raynaud's phenomenon Hearing loss Telangiectasis Ataxia	-	+	-	+	+/-	+	-	+	-	Vacuolization of visceral glomerular epithelial cells (podocytes) and distal tubular epithelial cells Glycolipid accumulation	Myeloid or zebra bodies: Gb3 deposition within enlarged secondary lysosomes as lamellated membrane structures Inclusions, composed of concentric layers (onion skin appearance)	-
Basement Membrane Syndrome	Alport's Syndrome		Positive family history	Auditary: Early Tinnitus Vertigo High-frequency progressive bilateral hearing loss Occular problems: Refractory Error Arcus Glaucoma Band Keratopathy Lenticonus Spherophakia Cataracts	-	+	-	+	+/-	+	-	+	-	Early stage: unremarkable Late stages: glomerulosclerosis, interstitial fibrosis, and interstitial foam cells (due to prolonged proteinuria).	Within glomerular basement membrane (GBM): longitudinal splitting of the lamina densa	Absence of staining of the alpha-3, alpha-4, and alpha-5 (IV) chains in the glomerular basement membrane Minimal binding to a glomerulus in indirect immunofluorescence microscopy with anti-glomerular basement membrane antibodies
	Disease		History	Systemic symptoms	Hemeturia	Proteinuria	Hypertension	Pitting edema	Oliguria	Nephrotic features	Nephritic features	Hyperlipidemia and hypercholesterolemia	Auto-antibodies, Complements	Light microscope	Electron microscope	Immunoflourescence pattern
	Thin Basement Membrane Disease		Positive family history Gross hematuria following upper respiratory tract infection	-	-	+	-/+	-	-/+	-	-/+	-	-	-	Diffuse thinning of the glomerular basement membranes (GBM)	-
	Nail-Patella Syndrome		Positive family history	Poorly developed fingernails, toe nails, and patellae (kneecaps). Elbow deformities Abnormally shaped pelvis bone (hip bone) Knee may be small, deformed or absent	+	+	-	-	-	-	-	-	-	Mostly unremarkable changes Secondary FSGS Late stages: Global glomerulosclerosis, Tubulointerstitial fibrosis	Glomerular basement membranes (GBMs): Focal or diffuse irregular thickening with electron-lucent areas (moth-eaten appearance) containing type III collagen bundles. Similar collagen fibrils can be seen in mesangial matrix. Podocytes: Segmental effacement of foot processes.	Immunofluorescence studies are typically negative. Nonspecific IgM and C3 deposition may be seen in sclerotic glomeruli.
Glomerular-Vascular Syndromes	Hypertensive Nephrosclerosis		Chronic hypertension	Hypertensive retinal changes. High jugular venous pressure Rales from pulmonary edema on auscultation .Signs of left ventricular hypertrophy Left ventricular heave Shifting of apex towards the left S3 and gallop rhythm Loud S2 Ascites Paralysis from stroke secondary to hypertension Inferior limb edema	+/-	+/-	+	+/-	+/-	+/-	-	+/-	-	Interstitial fibrosis and atrophy Medial thickening and intimal fibrosis of medium-sized and larger vessels Arteriolar thickening, and hyalinosis Chronic stages: Global sclerosis Focal segmental sclerosis
	Cholesterol Emboli		Atherosclerotic cardiovascular disease Anticoagulation therapy Cardiopulmonary resuscitation Hypertension Aortic aneurysm Hypercholesterolemia Smoking history Male sex Age over 55 years Vascular procedures Invasive angiography Aortic aneurysm rupture or surgery Vascular surgery	Depends on the organ involved	+/-	+/-	+	+/-	+/-	+/-	-	+/-	-	Atheroemboli are seen in interlobular and arcuate arteries, as lance-shaped clefts, due to dissolution of cholesterol crystals Acute lesions: Atheroemboli are surrounded by red blood cells, fibrin, and leukocytes, with multinucleated giant cell reactions Chronic lesions: Cholesterol clefts are surrounded by intimal fibrosis Vessel recanalization of chronic lesions can occur. Global and segmental sclerosis of glomeruli may be present.	Extensive foot process effacement can be seen	Not specific changes
	Disease		History	Systemic symptoms	Hemeturia	Proteinuria	Hypertension	Pitting edema	Oliguria	Nephrotic features	Nephritic features	Hyperlipidemia and hypercholesterolemia	Auto-antibodies, Complements	Light microscope	Electron microscope	Immunoflourescence pattern
	Sickle Cell Disease		Positive family history	Pain and/or bone pain Dactylitis Blurry vision Persistent and painful erection Numbness Tingling Motor skill loss Speech deficits Gait disturbance Leg ulceration Jaundice	+/-	+/-	+/-	-	-	-	-	-	-	Glomerular hypertrophy Hemosiderin deposits Focal areas of hemorrhage or necrosis Chronic stage: interstitial inflammation, edema, fibrosis, tubular atrophy, and papillary infarcts Glomerular enlargement and focal segmental glomerulosclerosis (FSGS)
	Thrombotic Microangiopathies		Click for more information on Thrombotic Microangiopathies.		+	+/-	+	+/-	+/-	+/-	-	-	-	Acute stage: Inravasculr fibrin thrombi Chronic stage: Endocapillary hypercellularity. Intimal proliferation of arterioles	Swollen glomerular endothelial cells with loss of fenestrations Chronic stage: interposed cells with new GBM matrix material deposition.	Thrombi stain positive for fibrinogen
	Antiphospholipid Antibody Syndrome		Thrombosis Miscarriage  History of nephropathy History of hematologic abnormalities Nonthrombotic neurologic symptoms, such as migraine headaches Pulmonary hypertension	Fatigue Fever Weight loss Venous thrombosis Arterial thrombosis Thrombocytopenia Recurrent fetal loss	+	+/-	+	+/-	+/-	+/-	-	-	-	Acute stage: Inravasculr fibrin thrombi Chronic stage: Endocapillary hypercellularity. Intimal proliferation of arterioles	Swollen glomerular endothelial cells with loss of fenestrations Chronic stage: interposed cells with new GBM matrix material deposition.	Thrombi stain positive for fibrinogen

Some infectious diseases such as HIV, HBV, HCV, syphilis, leprosy, malaria, and schistosomiasis may cause glomerular diseases.

Epidemiology and Demographics

Approximately 25% of patients with acute glomerulonephritis present with nephritic syndrome. Acute glomerulonephritis accounts for 10-15% of glomerular diseases in the USA. The reported incidence of glomerulonephritis in adults varies between 0.2 to 2.5/100,000 annually with a male to female ratio reaching 2 to 1. The most common cause of glomerulonephritis worldwide is IgA nephropathy (Berger disease). Approximately 25-30% of patients eventually develop end-stage renal disease (ESRD). The yearly variation of incidence of glomerulonephritis is not validated. While some studies report a decrease in the incidence due to improved healthcare and socioeconomic status, others report an increase in the reported incidence due to increased number of biopsies. Additionally, the true incidence is difficult to predict because the disease might present subclinically.

Natural History, Complications, and Prognosis

Prognosis, complications, and outcome depend on the underlying etiology. Generally, nephritic syndrome is characterized by an abrupt onset. The course of the disease varies greatly.

History and Symptoms

Symptoms of nephritic syndrome include change in the urine color, decreased urine output, nocturia, and fatigue. In patients with secondary etiologies of glomerular diseases, the clinical presentation might be consistent with the etiology of the disease. Patients must always be inquired about recent illnesses, symptoms of vasculitides or other organ involvement, and constitutional symptoms. Symptoms of nephritic syndrome include change in the urine color, decreased urine output, nocturia, and fatigue. In patients with secondary etiologies of glomerular diseases, the clinical presentation might be consistent with the etiology of the disease. Patients must always be inquired about recent illnesses, symptoms of vasculitides or other organ involvement, and constitutional symptoms.

Symptoms

• Red urine (or dark urine)
• Headache and blurred vision due to high blood pressure
• Oliguria, defined as low urine output <400 mL/day
• Nocturia
• Edema may or may not be present
• Fatigue and lethargy

Physical Examination

The physical examination of patients with nephritic syndrome due to a primary glomerular disease is usually not very remarkable. Nonetheless, a few signs on physical exam might still be present such as high blood pressure in a minority of patients and signs of fluid overload (peripheral or periorbital edema, pulmonary edema, ascites, and jugular venous distention). A full physical examination is required when patients present with nephritic syndrome in search for causes of secondary glomerular pathology.

Laboratory Findings

Laboratory work-up must be directed to first identify the exact diagnosis of nephritic syndrome by ruling out common etiologies, and to monitor disease progression and renal function. Work-up might be different from one individual to another based on the patient's presentation and medical history and physical examination findings.

Initial Work-Up

Blood Work-up

• Complete blood count (CBC)

• Serum electrolytes

• Serum creatinine

• Blood urea nitrogen (BUN)

• Erythrocyte sedimentation rate (ESR) and C-reactive protein

Findings associated with glomerulonephritis include anemia, leukocytosis, and electrolyte disturbances such as hyperkalemia. Creatinine and BUN are required to monitor renal function, calculate eGFR, and possible renal deterioration.

Inflammatory markers, such as CRP and ESR, may or may not be elevated in acute glomerulonephritis. They may be helpful in the diagnosis of systemic illnesses, such as malignancies or vasculitides.

Urinalysis

A urinalysis is always recommended in acute glomerulonephritis, looking for:

• Hematuria

• Proteinuria

• RBC casts

• Urine culture

Further Work-Up

A more extensive work-up may be necessary for patients who present with symptoms of signs consistent with secondary glomerulonephritis. Work-up includes, but is not limited to:

• Complement levels

• Blood culture

• Streptozyme test (ASO titer)
• Streptococcal antigens, such as nephritis-associated protease (NAPR), DNase, streptolysin O, streptokinase, and hyaluronidase
• ANA profile
• c-ANCA and p-ANCA
• HBV, HCV, and HIV serologies
• Serum C3 and C4 complement levels
• Anti-glomerular basement membrane (GBM) autoantibodies
• Anti-dsDNA antibodies
• Serum free light chains and serum immunofixation

Renal Biopsy

A renal biopsy may be helpful to differentiate etiologies of renal disease, monitor disease progression, and estimate prognosis. Not all cases of nephritic syndrome require renal biopsy. The procedure itself is invasive and may be associated with its own risks. As such, renal biopsy is only indicated if benefit will outweigh the risks. Renal biopsies for patients with initial presentation of nephritic syndrome may be affected greatly by age, progression of symptoms, clinical suspicion, and response to empirical therapy.

Echocardiography or Ultrasound

Renal ultrasound is useful to estimate the kidney size and echogenicity. Decreased renal size (eg. less than 8 cm) is consistent with irreversible renal injury. Echocardiography is indicated when a cardiac murmur is noted on physical examination or when there is a high suspicion of bacterial endocarditis causing renal involvement and nephritic syndrome.

Medical Therapy

Management and therapy vary greatly according to the diagnosis of nephritic syndrome. While most causes of nephritic syndrome are self-resolving and do not require medical intervention, such as post-infectious streptococcal glomerulonephritis, other etiologies require high doses of steroids and immunotherapy, such as rapidly progressing glomerulonephritis. In secondary etiologies of nephritic syndrome, management of the underlying disease is the mainstay of the management.