Glomerulonephritis (GN): Causes, Symptoms, Diagnosis, Treatment and Complications

What is Glomerulonephritis (GN)?

Glomerulonephritis refers to a group of kidney disorders characterized by damage to the glomeruli, the small filtering units of the kidney, typically caused by immune system activity. This condition can lead to kidney dysfunction, allowing protein (proteinuria)and sometimes blood (hematuria)to enter the urine.

Glomerulonephritis occurs when the glomeruli become inflamed and scarred, which can impair their ability to filter waste and excess fluids from the blood. If left untreated, this damage may progress to kidney failure. There are two primary types of glomerular disease: glomerulonephritis and glomerulosclerosis, the latter involving scarring and hardening of blood vessels in the kidneys.

The nephron, which is the fundamental structural and functional unit of the kidney, consists of a renal corpuscle (glomerulus enclosed by Bowman’s capsule) and a renal tubule. Each human kidney contains approximately one million nephrons. The glomerular filtration barrier is composed of a fenestrated endothelium, a glomerular basement membrane (GBM), and podocytes, which are specialized epithelial cells. In glomerulonephritis, the immune system attacks components of the glomeruli, leading to injury in the GBM, mesangium, or capillary endothelium. This damage results in hematuria, proteinuria, and azotemia, indicating impaired kidney function.
If the kidneys lose their ability to properly filter blood, complications such as fluid retention, high blood pressure,and kidney failuremay arise.

Causes of Glomerulonephritis

Glomerulonephritis occurs when the glomeruli, the filtering units of the kidney, become damaged, leading to proteinuria(protein loss in urine), hematuria (blood in urine),and potential kidney failure. The condition may arise due to immune system dysfunction, infections, toxins, or medications. In many cases, the exact cause remains unknown.
The immune system, which typically fights infections, can mistakenly attack the glomeruli, causing inflammation and scarring. In some cases, the immune system dysfunction may have no clear trigger, while in others, infections or other factors may initiate the immune response.

Certain infections can trigger immune-related kidney damage, leading to glomerulonephritis:

• Post-Streptococcal Glomerulonephritis: A bacterial infection, often caused by streptococcal bacteria, may lead to glomerulonephritis one to three weeks after an upper respiratory or skin infection.
• Viral Infections: HIV, hepatitis B, and hepatitis C have been associated with glomerular inflammation.
• Bacterial Infections: Infections caused by strep or staph bacteria, which often affect the throat and skin, can trigger immune system reactions leading to kidney damage.
• Exposure to certain toxins and drugs can contribute to glomerular damage, including:
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
• Certain medications, including antibiotics and immune-modulating drugs

Types of Glomerulonephritis

Glomerulonephritis is classified based on its onset, underlying causes, and microscopic changes in kidney tissue. It can be categorized into acute and chronic forms, as well as primary or secondary glomerulonephritis.

Primary Glomerulonephritis:Develops independently without any underlying disease or condition.

Secondary Glomerulonephritis:Occurs as a complication of another illness, such as systemic lupus erythematosus (SLE) or polyarteritis nodosa.

Acute Glomerulonephritis

Acute glomerulonephritis occurs suddenly, often following infections such as strep throat. It can also result from autoimmune conditions like lupus, Wegener's disease, and Goodpasture's syndrome. Without prompt treatment, it can lead to kidney failure.

Chronic Glomerulonephritis

Chronic glomerulonephritis progresses slowly over years, often without noticeable symptoms in its early stages. Over time, it can cause irreversible kidney damage and lead to chronic kidney disease (CKD).

Classifications of Glomerulonephritis

A kidney biopsy can further classify glomerulonephritis based on microscopic changes in kidney tissue (kidney biopsy). The classifications are as follows;

Focal and Segmental Glomerulosclerosis (FSGS):This is the scarring or sclerosed of only some part of the glomeruli (focal) and partial damage to individual glomerulus (segmental)

IgA Glomerulonephritis:Caused by IgA antibody deposits (one of the antibodies produced by the immune system to fight infection), leading to inflammation and scarring.

IgM Glomerulonephritis:Damage occurs due to IgM antibody deposits in the glomeruli.

Membranoproliferative Glomerulonephritis:In this type, both the glomerular membrane and the mesangium is affected, leading to structural damage.

Membranous Glomerulonephritis:This involves solely damage to the glomerular membrane, whiles the mesangium is not affected

Minimal Change Nephropathy:Kidney tissue appears essentially normal under a microscope when sample of affected kidney is taken, but symptoms of glomerulonephritis persist. This is a common type in children.

Signs and Symptoms of Glomerulonephritis

Glomerulonephritis (GN) presents with various signs and symptoms depending on whether it is acute or chronic. In some cases, the condition can progress silently, with kidney damage occurring before noticeable symptoms appear.

Symptoms of Acute Glomerulonephritis (Acute GN)

Acute glomerulonephritis develops suddenly, often after an infection or immune system trigger. Symptoms may include:

• Facial puffiness, especially in the morning
• Blood in the urine (hematuria), making it appear dark, rust-colored, or brown
• Foamy or bubbly urine due to excess protein (proteinuria)
• Decreased urination or urinating less frequently
• Swelling (edema) in the face, eyes, ankles, feet, legs, or abdomen
• Cough and shortness of breath due to fluid buildup in the lungs
• High blood pressure
• Fatigue and general ill feeling
• Abdominal pain, joint pain, or muscle aches
• Nausea, vomiting, and fever
• Blood in vomit or stools
• Excessive urination or frequent nighttime urination
• Nosebleeds

Symptoms of Chronic Glomerulonephritis (Chronic GN)

Chronic glomerulonephritis can develop slowly over time, sometimes without noticeable symptoms in its early stages. When symptoms do appear, they often include:

• Protein in the urine (albuminuria/proteinuria)
• Blood in the urine (hematuria)
• High blood pressure
• Swelling (edema) in the ankles, face, or hands
• Frequent nighttime urination
• Foamy or bubbly urine, indicating protein loss
• Abdominal pain
• Frequent nosebleeds
• Fatigue, loss of appetite, and weight loss
• Rash or jaundice (yellowing of the skin and eyes)
• Peeing less often or more frequently than usual

Diagnostic Test & Investigations

Diagnosing glomerulonephritis involves a range of investigations to assess kidney function and identify possible underlying causes. Various tests help detect abnormalities in the urine and blood, as well as structural changes in the kidneys if glomerulonephritis is suspected. These may include:

• Dipstick test
• 24-hour urine collection Blood Tests
• Creatinine test
• Estimated glomerular filtration rate (eGFR)
• Full blood count (FBC)
• Serum electrolytes
• Chest X-ray
• Ultrasound scan of the kidneys
• Immunoglobulin levels
• C-reactive protein (CRP)
• Electrophoresis
• Imaging Tests such as CT Scan
• Streptococcal infection tests – A throat swab, skin swab, or blood test may be used to confirm recent infection with streptococcal bacteria, a known trigger for glomerulonephritis.
• Autoimmune disease tests – Blood tests can help diagnose conditions such as systemic lupus erythematosus (SLE), which can cause glomerulonephritis.
• Urea and electrolyte levels – Elevated urea levels indicate kidney dysfunction, while electrolytes such as sodium and potassium may be imbalanced due to kidney damage.
• Blood protein and albumin levels – Low levels suggest protein loss through urine, which is a sign of nephrotic syndrome.
• Renal function tests – Blood urea nitrogen (BUN) and creatinine levels are typically elevated in individuals with kidney dysfunction. Glomerular filtration rate (GFR) may also be low.
• Liver function tests – These may help identify the underlying cause of glomerulonephritis.

Kidney Biopsy

A kidney biopsy is often performed to confirm the diagnosis and determine the specific type of glomerulonephritis. In this procedure, a small sample of kidney tissue is obtained using a needle under ultrasound guidance. The tissue sample is examined under a microscope to assess structural changes, inflammation, and potential causes of glomerular damage.

Treatment of Glomerulonephritis

Treatment for glomerulonephritis depends on the underlying cause of the condition, as well as the type and severity of symptoms. Managing high blood pressure is often a critical part of treatment to protect kidney function and prevent further complications.

Several types of medications may be prescribed to treat glomerulonephritis and its associated symptoms

Blood Pressure Medications:Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are commonly used to manage high blood pressure and protect kidney function. Examples include:

• Captopril
• Lisinopril (Zestril)
• Perindopril (Aceon)
• Losartan (Cozaar)
• Irbesartan (Avapro)
• Valsartan (Diovan)

Corticosteroids:These medications help reduce inflammation that leads to kidney damage and scarring.

Immunosuppressive Drugs:In cases where glomerulonephritis is caused by an autoimmune reaction, immunosuppressive drugs may be used to slow disease progression and reduce kidney inflammation.

Diuretics (Water Pills):These medications help remove excess fluid from the body by increasing urine production, which can relieve swelling (edema).

Plasmapheresis:In cases where glomerulonephritis is caused by immune system problems, plasmapheresis may be used to remove harmful antibodies from the blood. During this procedure, the plasma (the fluid part of blood that contains antibodies) is removed and replaced with intravenous fluids or donated plasma free of antibodies. This process helps reduce inflammation and damage to the kidney tissues.

In a more advance cases, patients with severe or chronic glomerulonephritis that leads to kidney failure, more intensive treatment options may be necessary:

Dialysis:If the kidneys can no longer effectively remove waste and excess fluids from the body, dialysis may be required to filters the blood to remove waste, excess fluids, and toxins.

Kidney Transplant:In cases where kidney function is severely impaired and irreversible, a kidney transplant may be considered.

Dietary and Lifestyle Modifications

Certain dietary restrictions can help manage glomerulonephritis and protect kidney function:

• Reduced Sodium Intake - Limiting sodium can help control blood pressure and reduce fluid retention.
• Protein Restriction - Lowering protein intake may help reduce strain on the kidneys, especially in cases of chronic glomerulonephritis.
• Fluid Management - Monitoring and controlling fluid intake can help prevent excessive fluid buildup and swelling.
• Potassium Regulation - Patients may need to limit potassium intake to prevent imbalances that can occur with kidney dysfunction.
• Calcium and Vitamin D Supplements - These may be recommended to support bone health in patients with chronic kidney disease.

Nursing Management of Glomerulonephritis

The subsequent measures are essential for effectively caring for patients with Glomerulonephritis

• Check vital signs, blood pressure or otherwise Strict intake and output
• Monitor for signs and symptoms of fluid overload
• Daily weight checks
• Urine test for albumin, protein and blood stain / Side effects of drugs
• Monitor for level of consciousness
• Ensure compete bed rest in acute phase until edema subside and BP record normal
• Put patient in recumbent position with two or three pillows

• Give mouth care and treat dry mouth with petroleum jelly or Vaseline
• Give daily warm bath & Treat pressure areas / Ensure patient's skin is dried well after bath
• Change bed linen when necessary

• Restrict sodium intake
• Restrict fluid intake to 400 - 500mls (in excess of urinary output over 24 hours)
• Regulate potassium and chlorine intake
• Give high carbohydrate diet
• Provide protein in the form of essential proteins or adjust protein intake to meet the level of proteinuria.
• Care for the hands and feet.

• Reassure patient
• Allow patient and family to ask question and express their feelings
• Carry out your duties in well composed and confident manner
• Allow or encourage relatives to visit patient
• Be ready to give simple well explanatory answers to patient's questions
• Introduce patient to the other patients with similar conditions but have recovered.
• Explain procedures and laboratory investigations on patient to him/her

Preventions

Preventing glomerulonephritis involves addressing its underlying causes and reducing risk factors that contribute to kidney damage. If you have kidney disease certain lifestyle changes maybe recommended:

• Quit smoking
• Maintain a healthy weight
• Regulate salt intake in your diet.
• Eating a balanced diet and unprocessed food
• Managing high blood pressure
• Regular exercise and medication
• Controlling blood sugar (diabetes)
• Prevent infections by practicing good hygiene and safe sex
• Consume less protein and potassium to slow the buildup of wastes in your blood