Glomerulonephritis

GLOMERULONEPHRITIS

Glomerulonephritis (GN) is inflammation of the glomeruli, these are structures in the kidneys that are made up of tiny blood vessels. These knots of vessels help filter blood and remove excess fluids. If the glomeruli are damaged, the patient's kidneys will stop working properly, and they can go into kidney failure.

Other times called nephritis, GN is a serious illness that can be life-threatening and requires immediate treatment. GN can be both acute, or sudden, and chronic, or long-term. The condition used to be known and called Bright's disease.

TYPES OF GLOMERULONEPHRITIS

Basically, there are two types of glomerulonephritis

• Acute and

The acute form develops suddenly. A person may get it after an infection in the throat or on the skin. Sometimes, one may get better on their own. Other times, the kidneys may stop working unless the right treatment is initiated quickly. The early symptoms of the acute disease are:

• Urinating less than normal
• Blood in the urine (or brown urine)
• Puffiness of the face in the morning

The patient may be short of breath and cough because of extra fluid in the lungs. He/she may also have high blood pressure. It would be best for anyone that has one or all of these symptoms, to see their doctor immediately.

The chronic form may develop silently, even without symptoms over several years. It often leads to complete kidney failure. Early signs and symptoms of the chronic form may include:

• Swelling of the ankles or face
• Very bubbly or foamy urine
• Blood or protein in the urine (hematuria, proteinuria)
• High blood pressure
• Frequent nighttime urination

Symptoms of kidney failure include:

• Difficulty sleeping
• Nighttime muscle cramps
• Lack of appetite
• Nausea and vomiting
• Tiredness
• Dry and itchy skin

CAUSES

Many conditions can cause glomerulonephritis. Sometimes the disease runs in families and sometimes too the cause is unknown.

Conditions that can lead to inflammation of the kidneys' glomeruli include:

• Infections

Post-streptococcal glomerulonephritis - Glomerulonephritis may develop a week or two after a person recovers from a strep throat infection or, rarely, a skin infection (impetigo). To fight the infection, the body produces extra antibodies that can eventually settle in the glomeruli, causing inflammation.

Children are more likely than adults to develop post-streptococcal glomerulonephritis, and they're also more likely to make quicker recoveries.

• Bacterial endocarditis

Occasionally, bacteria can spread through a person's bloodstream and lodge in the heart, this will cause an infection of one or more of the heart valves. Individuals are at greater risk of this condition if they have heart defects, such as damaged or artificial heart valve. Though the connection between the two is yet to be made clear, bacterial endocarditis is associated with glomerular disease.

• Viral infections

Viral infections, such as the human immunodeficiency virus (HIV), hepatitis B and hepatitis C, can trigger glomerulonephritis.

• Immune diseases

Lupus : Lupus, a chronic inflammatory disease, can affect many parts of a person's body, (e.g. the joints, skin, kidneys, blood cells, heart and lungs).

Goodpasture's syndrome : this is a rare immunological lung disorder that looks in several ways like pneumonia, Goodpasture's syndrome causes bleeding in the lungs as well as glomerulonephritis.

IgA nephropathy - Also known as Berger's disease, is a kidney disease that occurs when an antibody called immunoglobulin A (IgA) builds up in the kidneys. This results in local inflammation that, over time, can hamper the kidneys' ability to filter waste from the blood.

• Vasculitis

Vasculitis is simply, inflammation of the blood vessels.

Polyarthritis - This form of vasculitis affects small and medium blood vessels in many parts of the body, such as the heart, kidneys and intestines.

Granulomatosis with polyangiitis : Yet another form of vasculitis, formerly known as Wegener's Granulomatosis, it affects small and medium blood vessels in the lungs, upper airways and kidneys.

Conditions likely to cause scarring of the glomeruli

• High blood pressure - Hypertension can damage a person's kidneys and impair their ability to function as normal. Glomerulonephritis can also lead to high blood pressure because it reduces kidney function and does influence how the kidneys handle sodium.
• Diabetic kidney disease (diabetic nephropathy) - Anyone with diabetes is susceptible to this condition which usually takes years to develop. However, good control of blood sugar levels and blood pressure might prevent or slow kidney damage.
• Focal segmental glomerulosclerosis - Described by the dotted scarring of some of the glomeruli, this condition could be the cause of another disease or occurs for no known reason. In some cases, chronic glomerulonephritis has been found to run in families. Alport syndrome, an inherited form of this condition might impair hearing or vision. Glomerulonephritis is also associated with certain cancers, such as multiple myeloma, lung cancer and chronic lymphocytic leukemia

Causes of acute glomerulonephritis

The acute disease may be caused by infections such as strep throat, lupus, Goodpasture's syndrome, Wegener's disease, and polyarteritis nodosa. Early diagnosis and prompt treatment are important to prevent kidney failure.

Causes of chronic glomerulonephritis

Sometimes, the disease is inherited, as it runs in the family. This type typically shows up among young men who may also have hearing loss and/or vision loss. However, in many cases, the cause is not known. It also happens that a person will have one acute attack of the disease and develop the chronic form many years after that.

SYMPTOMS

The kidneys play three major roles in regulating the body.

They:

• Produce hormones that control other body functions, such as blood pressure, maintenance of bone, and production of red blood cell
• Filter urine to remove waste from the body, in the process they keep toxins from building up in the bloodstream
• Regulate the minerals or electrolytes (e.g. sodium, calcium, and potassium) and the levels of fluids in the body.

Due the huge role the kidneys play in the maintenance of the body's health, the symptoms of glomerulonephritis and kidney failure can be quite diverse.

Symptoms of glomerulonephritis include:

• Increased urination
• Extreme foaming of urine
• Blood in the urine

Chronic kidney (renal) failure may develop. Symptoms occur as a direct result of the kidneys' inability to eliminate waste and excess fluid from the body. When kidney failure is severe or near end stage, the symptoms of glomerulonephritis will depend on whether the infection is the acute or chronic form and the cause. Symptoms will include:

• Fatigue - A term used to describe an overall feeling of tiredness or lack of energy.
• Confusion - A symptom that makes one feel as if he/she can't think clearly.
• Decreased urination - Decreased urine output means that less urine is produced than normal. Most adults make at least 500 mL of urine in 24 hours
• Headache - Headache is defined as pain arising from the head or upper neck of the body.
• High blood pressure - A common condition in which the long-term force of the blood against the artery walls is high enough that it may eventually cause health problems, such as heart disease.
• Nose bleeding - A nosebleed is simply bleeding from the blood vessels in the nose.
• Itchy skin - An irritating and uncontrollable sensation that makes one want to scratch to relieve the feeling.
• Loss of appetite - Loss of appetite means one doesn't have the same desire to eat as he/she used to.
• Muscle twitch or cramps - A sudden, involuntary movement in one or more muscles. People may also call it a charley horse or a muscle cramp or twitch.
• Nausea and vomiting - Vomiting is an uncontrollable reflex that expels the contents of the stomach through the mouth. Nausea is a term that describes the feeling that one might vomit, but isn't actually vomiting.
• Puffy eyes, hands, and feet (called edema) - Edema is swelling caused by excess fluid trapped in the body's tissues
• Shortness of breath - an uncomfortable condition that makes it difficult to fully get air into the lungs.
• Thirst - Thirst is the feeling of needing to drink something.
• Weight loss - Weight loss is a decrease in body weight resulting from either voluntary or involuntary circumstances.
• Pink or cola-colored urine from red blood cells in the urine (hematuria) - Gross hematuria produces pink, red or cola-colored urine due to the presence of red blood cells.
• Foamy urine due to excess protein (proteinuria) - Proteinuria is increased levels of protein in the urine.

The symptoms can become more severe if the inflammation is left untreated and kidney damage gets worse. Seizures and coma are a possibility in the later stages.

Glomerulonephritis is a serious condition. If it is left untreated, glomerulonephritis can lead to the following:

• Congestive heart failure,
• High blood pressure
• Chronic kidney failure,
• End-stage renal disease,
• Pulmonary edema, and
• An increased risk of other infections, especially urinary tract and kidney infections.

COMPLICATIONS

Glomerulonephritis can damage a person's kidneys so that they lose their ability to filter. Subsequently, dangerous levels of fluid, electrolytes and waste will build up in the body.

Possible complications of glomerulonephritis include:

• Acute kidney failure - The filtering function of the nephron is lost which can result in rapid accumulation of waste products. One might need emergency dialysis in such an instance.
• High blood pressure - Damage to kidneys will ultimately result in the buildup of wastes in the bloodstream. This build up can raise blood pressure.
• Nephrotic syndrome - Too much protein in the urine simply means too little protein in the blood. Nephrotic syndrome is usually associated with high blood cholesterol and the swelling (edema) of the eyelids, feet and abdomen.
• Chronic kidney disease - The kidneys gradually lose their filtering ability. Kidney function deteriorates to less than 10 percent of its normal capacity. This will result in end-stage kidney disease, which will requires dialysis or a kidney transplant to sustain life.

WHEN TO SEE A DOCTOR

People must see their doctor if they notice blood in their urine. This does not always indicate glomerulonephritis, but the cause should be investigated.

If the doctor suspects glomerulonephritis, they'll usually arrange:

• A blood test to measure creatinine level
• A urine test to check for blood or protein in the urine

If glomerulonephritis is confirmed, further blood tests may be needed to help find out the cause.

If the kidney problem needs to be investigated further, the following may be recommended:

• An ultrasound scan : To check the size of the kidneys, to make sure there are no blockages, and to look for any other problems
• A biopsy : A small sample of kidney tissue is removed, with local anaesthetic to numb the area; an ultrasound machine will locate the kidneys and a small needle is used to take a sample

RISK FACTORS

The following may increase a person's risk:

• A history of cancer - One may be at greater risk for some cancers if they have a personal or family history of cancer
• Blood or lymphatic system disorders - The primary function of the lymphatic system is to transport lymph, a fluid containing infection-fighting white blood cells, throughout the body.
• Exposure to hydrocarbon solvents - Some hydrocarbons can cause other effects, including coma, seizures, irregular heart rhythms or damage to the kidneys or liver.
• Infections such as strep infections, viruses, heart infections, or abscesses

Many conditions can cause or increase the risk for glomerulonephritis, including:

• Blood vessel diseases - This ranges from diseases of the arteries, veins and lymph vessels to blood disorders that affect circulation
• Goodpasture syndrome - A rare disorder in which a person's body mistakenly makes antibodies that attack the lungs and kidneys.
• Membranoproliferative GN - Membranoproliferative Glomerulonephritis (MPGN) is a specific type of glomerular disease that occurs when the body's immune system functions abnormally.
• Henoch-Schonlein purpura - A disorder that causes the small blood vessels in the skin, joints, intestines, and kidneys to become inflamed and bleed.
• Lupus nephritis - With lupus, the body's immune system targets its own body tissues. Lupus nephritis happens when lupus involves the kidneys
• Amyloidosis - Amyloidosis is when an abnormal protein called amyloid builds up in the tissues and organs. Amyloidosis is a serious health problem that can lead to life-threatening organ failure.
• Anti-glomerular basement membrane - Anti:glomerular basement membrane (anti-GBM) disease is a rare small vessel vasculitis that affects the capillary beds of the kidneys and lungs.
• Focal segmental glomerulosclerosis - A disease in which scar tissue develops on the parts of the kidneys that filter waste from the blood (glomeruli).
• Heavy use of pain relievers, especially NSAIDs - Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are widely used to relieve pain, reduce inflammation, and bring down a high temperature.
• IgA nephropathy - A kidney disease that occurs when an antibody called immunoglobulin A (IgA) builds up in the kidneys.

DIAGNOSING GN

Since Blood and protein in urine are important markers for the disease, the first step in diagnosing this condition is a urinalysis test. A routine physical exam for an entirely different condition can also lead to the discovery of GN.

More urine testing may be necessary to check for important signs of kidney health, including:

• Urine osmolality - Urine osmolality is used to measure the number of dissolved particles per unit of water in the urine.
• Urine specific gravity - The urine specific gravity test is easier and more convenient, and is usually part of a routine urinalysis.
• Creatinine clearance - Doctors use creatinine and creatinine clearance tests to check how well kidneys work.
• Total protein in the urine - A protein in urine test measures how much protein is in the urine.
• Urine concentration - More concentrated urine means that there are more solutes and less water in the sample.
• Urine red blood cells - A high count of red blood cells in the urine can indicate infection, trauma, tumors, or kidney stones

Blood tests may show:

• High creatinine levels - Elevated creatinine level signifies impaired kidney function or kidney disease
• Anemia - which is a low level of red blood cells
• Abnormal albumin levels - Lower albumin level, may indicate malnutrition. It can also mean liver disease or an inflammatory disease.
• Abnormal blood urea nitrogen - Generally, a high blood urea nitrogen level means the kidneys aren't working well.

To learn more about the condition, a person may also have imaging tests such as:

• Intravenous pyelogram - Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast material to evaluate the patient's kidneys, ureters and bladder and help diagnose blood in the urine or pain in the side or lower back
• Chest X-ray - The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray produces images of the heart, lungs, airways, blood vessels and the bones of the spine and chest.
• CT scan - A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside the body. CT scan images provide more-detailed information than plain X-rays do.
• Kidney ultrasound - Ultrasound can detect cysts, tumors, abscesses, obstructions, fluid collection, and infection within or around the kidneys.

TREATMENTS

Focus will be on treating the causative disorder.

• For rapidly progressive glomerulonephritis, focus will be suppression of the immune system
• For chronic glomerulonephritis, focus will be an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) and reducing dietary sodium

Acute glomerulonephritis

No specific treatment is available in most cases of acute glomerulonephritis. The disorder causing glomerulonephritis is treated if and when possible. A diet that is low in protein and sodium may be necessary until kidney function recovers. Diuretics may also be prescribed to help the kidneys excrete excess sodium and water. High blood pressure will have to be treated.

When a bacterial infection is suspected as the cause of acute glomerulonephritis, antibiotics are usually ineffective because the nephritis begins 1 to 6 weeks after the infection, and so by then, would have been resolved. However, if a bacterial infection is still present when acute glomerulonephritis is discovered, antibiotic therapy would begin.

Some autoimmune disorders that cause glomerulonephritis are treated with corticosteroids, drugs that suppress the immune system.

Rapidly progressive glomerulonephritis

For rapidly progressive glomerulonephritis, drugs to suppress the immune system are promptly employed. High doses of corticosteroids are usually given intravenously for about a week, followed by a period of time during which the drugs are taken orally. Cyclophosphamide, an immunosuppressant, may also be recommended. In addition, plasma exchange is sometimes used to remove antibodies from the blood. The sooner the treatment occurs, the less likely the kidney failure and the need for dialysis. Sometimes Kidney transplantation is considered for people who develop chronic kidney disease with kidney failure. Unfortunately however, rapidly progressive glomerulonephritis may recur in the transplanted kidney.

Chronic glomerulonephritis

Either an ACE inhibitor or an ARB will often slow the progression of chronic glomerulonephritis and reduces blood pressure and the excretion of protein in the urine. Reducing blood pressure and sodium intake are highly recommended as beneficial. Restricting the amount of protein in the diet is modestly helpful in reducing the rate of kidney deterioration. End-stage kidney failure can be treated with dialysis or a kidney transplant.

Dietary changes

In mild cases, a doctor or dietitian will offer relevant advice about appropriate diet. The patient may be advised to reduce their intake of:

• Salt
• Potassium , and
• Fluids

This should help control blood pressure and ensure the amount of fluid in the body is regulated. Regular reviews to ensure the blood contains the right levels of potassium, sodium chloride and other salts will be recommended.

Quit smoking

Smoking may make kidney disease caused by glomerulonephritis worse. It may also increase the risk of complications like heart disease and stroke, which are quite common in people with glomerulonephritis.

Immunosuppressants

Severe cases of glomerulonephritis, caused by problems with the immune system, are sometimes treated with types of medicine known as Immunosuppressants which are medicines that suppress the immune system. One problem that emerges is that whereas suppressing the immune system can be effective in that sense, it also increases the risk of other infections and can cause other side effects.

Therefore if a patient is offered treatment with immunosuppressant medicines, the effort will be adjusted to the needed level to treat the condition and will be carefully monitored.

Steroids - The patient may be put on a course of medicines containing steroids such as prednisolone. Such steroids are used to reduce swelling and suppress the immune system.

Usually once the kidneys begin to recover, the dose of steroids will be lowered.

Cyclophosphamide - Cyclophosphamide is an immunosuppressant used in very high doses to treat certain cancers. It is also an established treatment (though in much lower doses), for glomerulonephritis.

Other medicines

If the condition is thought to be linked to a viral infection, it may be treated with antiviral medication.

In some cases, individual symptoms can be treated (e.g. a swelling caused by a build-up of fluid may be treated with a type of medicine called a diuretic).

Treating high blood pressure

Glomerulonephritis often results in high blood pressure, which can cause further kidney damage and other health problems. The patient's blood pressure will be carefully monitored by the doctor.

One may need to take medicines that lower blood pressure and at the same time, help reduce the amount of protein that leaks into the urine, examples are:

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARB)

Sometimes these medicines are commonly prescribed, even if the patient's blood pressure is not particularly high, because they can help protect the kidneys.

Treating high cholesterol

High cholesterol levels are common among people with glomerulonephritis.

A doctor may recommend statins to reduce cholesterol and help protect the patient against complications such as heart and vascular disease.

Exchange of Plasma

Plasma is a fluid that forms part of the blood. It contains proteins that can inflame kidneys.

Plasma exchange involves removing some of the plasma from the blood. During the procedure, the patient will be connected to a machine that gradually removes some of the blood. The plasma is separated from the blood cells and removed. A substitute plasma is then added to the blood before putting it back into the body.

Plasma exchange may be employed in circumstances when the condition is severe.

TREATING CHRONIC KIDNEY DISEASE OR KIDNEY FAILURE

In severe cases that cannot be improved with other treatments, one may require:

• Kidney dialysis : Treatment in which a machine takes over part of the kidney's job and removes waste products from the body
• A kidney transplant : Where a healthy kidney from a donor is surgically implanted to replace the patient's own kidney

LIFESTYLE AND HOME REMEDIES

If the patient has kidney disease, the doctor might recommend certain lifestyle changes:

• Quit smoking
• Restrict salt intake to prevent or minimize fluid retention, swelling and hypertension
• Consume less protein and potassium to slow the buildup of wastes in the blood
• Maintain a healthy weight
• Control blood sugar level if there is diabetes

PREVENTION

Here are some steps that might be beneficial:

• Control blood sugar to help prevent diabetic nephropathy.
• Seek prompt treatment of a strep infection with a sore throat or impetigo.
• Practice safe-sex and avoid intravenous drugs so as to prevent infections that can lead to glomerulonephritis.
• Control blood pressure, this lessens the likelihood of damage to the kidneys from hypertension.

These steps help to prevent the viral and other infections that could lead to GN