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Glomerulonephritis, Acute: Differential Diagnoses & Workup
Updated: Oct 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Other Problems to Be Considered
Bacterial, viral, and fungal etiologies
Chronic glomerulonephritis
Acute interstitial nephritis
Membranoproliferative glomerulonephritis
Rapidly progressive glomerulonephritis
Idiopathic hematuria
Irradiation of Wilms tumor
Hemolytic-uremic syndrome
IgA nephropathy
The following 4 renal syndromes commonly mimic the early stage of acute glomerulonephritis:
Anaphylactoid purpura with nephritis
Chronic glomerulonephritis with an acute exacerbation
Idiopathic hematuria
Familial nephritis
Workup
Laboratory Studies
- Complete blood cell count
- A decrease in hematocrit may demonstrate a dilutional anemia.
- In the setting of an infectious etiology, pleocytosis may be evident.
- Electrolytes, including BUN and creatinine (to estimate the glomerular filtration rate [GFR]): The BUN and creatinine levels will exhibit a degree of renal compromise.
- Urinalysis
- Urine is dark.
- Specific gravity is greater than 1020 osm.
- Proteinuria is observed.
- RBCs and red cell casts are present.
- Although not indicated in the ED setting, a 24-hour urine protein excretion and creatinine clearance may be helpful to document the degree of renal dysfunction and proteinuria.
- Streptozyme test: This test includes many streptococcal antigens that are sensitive for screening but are not quantitative.
- Antistreptolysin O (ASO)
- This quantitative titer is increased in 60-80% of patients.
- Increase begins in 1-3 weeks, peaks in 3-5 weeks, and returns to normal in 6 months.
- Antistreptolysin O titer is unrelated to severity, duration, or prognosis of renal disease.
- Erythrocyte sedimentation ratio (ESR) usually is increased.
- Urine or plasma creatinine level greater than 40; decreased renin level is noted.
- Cultures of throat and skin lesions to rule out Streptococcus species may be obtained.
- Blood cultures
- Indicated in patients with fever, immunosuppression, intravenous drug use history, indwelling shunts, or catheters.
- Blood culture may indicate hypertriglyceridemia, decreased glomerular filtration rate, or anemia.
Imaging Studies
- Radiography
- Chest radiography is needed in patients with a cough, with or without hemoptysis (ie, Wegener granulomatosis, Goodpasture syndrome, pulmonary congestion).
- Abdominal radiographic imaging (ie, computed tomography) is needed if visceral abscesses are suspected; also look for chest abscesses.
- Echocardiography in patients with a new cardiac murmur or a positive blood culture to rule out endocarditis or a pericardial effusion.
- Bedside renal ultrasonography may be appropriate to evaluate kidney size as well as to determine the extent of fibrosis. A kidney size of less than 9 cm is suggestive of extensive scarring and a low likelihood of reversibility.
- CT scan of the head without contrast may be necessary in any patient with malignant hypertension or altered mental status.
Other Tests
- Serology and complement levels
- Various etiologies largely are differentiated by serum complement levels.
- Results are not readily available to the emergency physician but may be useful to the consultant.
- Antinuclear antibody: This test is useful for patients with acute glomerular nephritis and symptoms of underlying systemic illness, such as systemic lupus erythematosus and polyarteritis nodosa.
- Serum complement (C3, C4)
- Differentiation of low and normal serum complement levels may allow the ED physician to narrow the differential diagnosis.
- Low serum complement levels suggest the following systemic diseases: cryoglobulinemia, systemic lupus erythematosus, bacterial endocarditis, and shunt nephritis.
- Under the same conditions, renal diseases characteristic of membranoproliferative or poststreptococcal glomerulonephritis also may be considered.
- Normal serum complement levels suggest a visceral abscess, polyarteritis nodosa, Goodpasture syndrome, or Henoch-Schönlein purpura. In addition, normal complement levels suggest renal diseases such as immune complex disease, idiopathic rapidly progressive glomerulonephritis, and IgG or IgA nephropathy.
- Others include anti-DNA antibodies, triglyceride levels, hepatitis B and C serologies, antineutrophil cytoplasmic antibodies (ANCA), c-ANCA (ie, if Wegener granulomatosis is suspected).
Procedures
- Renal biopsy
- Acute glomerulonephritis usually has a self-limited course with a good prognosis.
- Renal biopsy is required for definitive diagnosis, particularly in primary renal diseases.
- Candidates for biopsy are patients with an individual or family history of renal disease and patients with an atypical presentation, including massive proteinuria, nephrotic syndrome, or a rapid rise in creatinine level without resolution.
- Renal biopsy is not indicated as an ED procedure.
More on Glomerulonephritis, Acute |
| Overview: Glomerulonephritis, Acute |
 Differential Diagnoses & Workup: Glomerulonephritis, Acute |
| Treatment & Medication: Glomerulonephritis, Acute |
| Follow-up: Glomerulonephritis, Acute |
| References |
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References
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Further Reading
Keywords
acute glomerular nephritis, acute hemorrhagic glomerulonephritis, acute glomerulonephritis, acute nephritis, poststreptococcal nephritis, acute poststreptococcal glomerulonephritis, nephritic syndrome, acute nephritic syndrome, nephritis syndrome, acute nephritis syndrome, kidney disease, renal disease, hematuria, oliguria, anuria, proteinuria
hypertension, malignant hypertension, edema, impaired renal function, puffiness of the eyelids, facial edema, postinfectious acute nephritis, pharyngitis, postpharyngitis, postdermal infection, Berger disease, Wegener granulomatosis, Henoch-Schönlein purpura, systemic lupus erythematosus, arthralgias, hemoptysis
Goodpasture syndrome, idiopathic progressive glomerulonephritis, hypersensitivity vasculitis, cryoglobulinemia, hypertensive encephalopathy, hypocomplementemia, scarlet fever, impetigo, upper respiratory infection, visceral abscesses, endocarditis, infected grafts, infected shunts, pneumonia, cytomegalovirus, coxsackievirus, Epstein-Barr virus, hepatitis B, rubella, rickettsial scrub typhus, mumps, polyarteritis nodosa, membranoproliferative glomerulonephritis, immunoglobulin G-immunoglobulin Anephropathy, IgG-IgA nephropathy
