eMedicine Specialties > Nephrology > Glomerular Diseases
Glomerulonephritis, Chronic: Differential Diagnoses & Workup
Updated: Oct 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Other Problems to Be Considered
Mesangial glomerulonephritis
Workup
Laboratory Studies
- Urinalysis
- The presence of dysmorphic RBCs, albumin, or RBC casts suggests glomerulonephritis as the cause of renal failure.
- Waxy or broad casts are observed in all forms of CKD, including chronic glomerulonephritis.
- Low urine-specific gravity indicates loss of tubular concentrating ability, an early finding in persons with CDK.
- Urinary protein excretion
- This can be estimated by calculating the protein-to-creatinine ratio on a spot morning urine sample. The ratio of urinary protein concentration (in mg/dL) to urinary creatinine (in mg/dL) reflects 24-hour protein excretion in grams. For instance, if the spot urine protein value is 300 mg/dL and the creatinine value is 150 mg/dL, then the ratio is 300 divided by 150, which equals 2. Thus, in this example, the 24-hour urine protein excretion is 2 g.
- The estimated creatinine clearance rate is used to assess and monitor the GFR. The 2 formulas available to calculate the value are the Cockroft-Gault formula, which estimates creatinine clearance, and the Modification of Diet in Renal Disease Study (MDRD) formula, which is used to calculate the GFR. The Cockroft-Gault formula is simple to use but overestimates the GFR by 10-15% because creatinine is both filtered and secreted. The MDRD formula is much more complex but is available as a PDA through the National Kidney Foundation or can be calculated online through the Hypertension, Dialysis, and Clinical Nephrology Web site.
- The estimated creatinine clearance rate is also used to monitor response to therapy and to initiate an early transition to renal replacement therapy (eg, dialysis access placement, transplantation evaluation). The degree of proteinuria, especially albuminuria, helps predict renal prognosis in patients with chronic glomerulonephritis. Patients with greater than 1 g/d have an increased risk of progression to ESRD.
In a study of 38 patients with chronic glomerulonephritis, Hayakawa et al examined the relationship between plasma adiponectin, leptin, and proteinuria levels; glomerular filtration rate; and metabolic risk factors.2 They found that plasma adiponectin levels were much higher in patients with heavy proteinuria (38.8 +/- 27.8 μ g/mL) than they were in patients who had mild (13.3 +/- 5.1 μ g/mL, P <0.001) or moderate proteinuria (18.1 +/- 8.0 μ g/mL, P <0.01). Serum leptin levels, however, did not differ according to the degree of proteinuria.
- CBC count
- Anemia is a significant finding in patients with some decline in the GFR.
- Physicians must be aware that anemia can occur even in patients with serum creatinine levels of less than 2 mg/dL. Even severe anemia can occur at low serum creatinine levels. Anemia is the result of marked impairment of erythropoietin production.
- Serum chemistry
- Serum creatinine and urea nitrogen levels are elevated.
- Impaired excretion of potassium, free water, and acid results in hyperkalemia, hyponatremia, and low serum bicarbonate levels, respectively.
- Impaired vitamin D-3 production results in hypocalcemia, hyperphosphatemia, and high levels of parathyroid hormone.
- Low serum albumin levels may be present if uremia interferes with nutrition or if the patient is nephrotic.
Imaging Studies
- Renal ultrasonogram
- Obtain a renal ultrasonogram to determine renal size, to assess for the presence of both kidneys, and to exclude structural lesions that may be responsible for azotemia.
- Small kidneys often indicate an irreversible process.
Procedures
- Kidney biopsy
- If the kidney is small, kidney biopsy is usually unnecessary; no specific pattern of disease can be discerned at this point.
- A kidney biopsy may be considered in the minority of patients who exhibit an acute exacerbation of their chronic disease. This may be particularly pertinent to patients with preserved kidney size and in those with lupus nephritis.
Histologic Findings
In early stages, the glomeruli may still show some evidence of the primary disease.
In advanced stages, the glomeruli are hyalinized and obsolescent. The tubules are disrupted and atrophic, and marked interstitial fibrosis and arterial and arteriolar sclerosis occur.More on Glomerulonephritis, Chronic |
| Overview: Glomerulonephritis, Chronic |
 Differential Diagnoses & Workup: Glomerulonephritis, Chronic |
| Treatment & Medication: Glomerulonephritis, Chronic |
| Follow-up: Glomerulonephritis, Chronic |
| References |
| Further Reading |
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References
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Further Reading
Clinical guidelines:
ACR Appropriateness Criteria® renal failure. American College of Radiology - Medical Specialty Society. 1995 (revised 2008). 10 pages. NGC:007019
Clinical trials:
Efficacy and Safety Study of Abatacept to Treat Lupus Nephritis
Etanercept for the Treatment of Lupus Nephritis
Retinoids for Minimal Change Disease and Focal Segmental Glomerulosclerosis
Keywords
glomerulonephritis, chronic glomerulonephritis, IgA nephropathy, membranous nephropathy, membranoproliferative glomerulonephritis, poststreptococcal glomerulonephritis, glomerulonephritis treatment, crescentic glomerulonephritis, glomerulosclerosis, rapidly progressive glomerulonephritis, RPGN, focal segmental glomerulosclerosis, FSGS, glomerular fibrosis, tubulointerstitial fibrosis, lupus nephritis, azotemia, uremia
