Diffuse Proliferative Glomerulonephritis Clinical Presentation

Updated: Mar 03, 2018
  • Author: Moro O Salifu, MD, MPH, FACP; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Presentation

History

Focus the history on the causes of diffuse proliferative glomerulonephritis (DPGN) and the associated clinical manifestations. While a minority (<15%) of patients may be asymptomatic and are diagnosed on the basis of routine laboratory test findings, most patients manifest signs and symptoms of the primary disease as well as those relating to renal injury. Nonspecific manifestations (eg, nausea, vomiting, fatigue, weight loss) may indicate uremia or the primary disease process. 

Suspect DPGN in patients with systemic lupus erythematosus (SLE), infectious disease processes, a recent streptococcal throat infection, or in patients with sinopulmonary disease who have recent onset of the following:

  • HArtension

  • Microscopic or gross hematuria

  • Nonnephrotic or nephrotic range proteinuria or an increase in proteinuria from baseline

  • Serum creatinine of more than 0.4 mg/dL above the reference range or the baseline

  • Oligoanuria and symptoms of uremia in severe cases of rapidly progressive glomerulonephritis (RPGN) with crescent formation

Also suspect DPGN in a patient with other systemic diseases who has recent onset of the same findings listed above. 

Features in the history may provide clues to an undiagnosed primary disease process. The following suggest SLE  as the primary disease:

  • Rash
  • Photosensitivity
  • Oral ulcers
  • Arthralgias, arthritis
  • Serositis
  • A renal, neurologic, hematologic, or immunologic disorder

A history of cough, dyspnea, hemoptysis, and renal disease suggests Goodpasture syndrome, but other pulmonary-renal syndromes must be ruled out, including the following:

  • SLE pneumonitis
  • Granulomatosis with polyangiitis (GPA; formerly Wegener granulomatosis)
  • Cryoglobulinemia
  • Renal vein thrombosis with pulmonary embolism
  • Legionella infection
  • Congestive heart failure

GPA presents as follows:

  • Sinopulmonary disease (ie, paranasal sinus pain and drainage with purulent or bloody nasal discharge and occasional nasal mucosal ulceration/perforation, leading to saddle nose deformity)
  • Serous otitis media (ie, blockage of the eustachian tube)
  • Cough, dyspnea, and hemoptysis

Patients with IgA nephropathy (ie, Berger disease) may present with the classic findings of flank pain and gross hematuria following upper respiratory infections. Others may simply have indolent microhematuria found incidentally. Much less commonly, patients present with acute glomerulonephritis, renal failure, and nephrotic syndrome.

Next:

Physical Examination

If azotemia is present, exclude prerenal and postrenal causes. Hypertension and fever (present in infectious and noninfectious glomerulonephritis) are nonspecific findings that suggest DPGN. 

Findings pertaining to SLE include the often acute onset of conjunctivitis, episcleritis, photosensitivity, oral ulcers, malar rash (eg, erythema of the nose and malar eminences in a butterfly distribution), discoid lupus, pleural or pericardial friction rub, psychosis, seizures, nonerosive arthritis, or arthralgia

Findings relating to pauci-immune disease (eg, anti-GBM disease, Wegener granulomatosis) and Goodpasture syndrome include the following:

  • Sinusitis, otitis, saddle nose deformity, hemoptysis

  • Lung consolidation, which suggests pulmonary hemorrhage

Findings relating to IgA nephropathy (usually postinfectious) and other infectious glomerulonephritis include the following:

  • Pharyngitis

  • Gastroenteritis

  • Impetigo, which is the most common cause of poststreptococcal glomerulonephritis worldwide

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