Fortnightly Review: Glomerulonephritis: diagnosis and treatment

doi:10.1136/bmj.309.6968.1557

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P D Mason, senior lecturer in renal medicinea,
C D Pusey, reader in renal medicinea

^a Renal Unit, Department of Medicine, Hammersmith Hospital, London W12 0NN

Correspondence to: Dr Mason.

Box 1—Manifestations of glomerular disease

* Asymptomatic proteinuria

* Asymptomatic haematuria

* The nephrotic syndrome

* The nephritic syndrome

* Acute/rapidly progressive renal failure

* End stage chronic renal failure

* Hypertension

Summary points

Summary points
Glomerulonephritis presents in many different ways and an accurate diagnosis cannot be made clinically
Dipstix testing of urine is a sensitive way of detecting occult glomerulonephritis once infection has been excluded
Early referral of patients for assessment and renal biopsy is essential to detect treatable conditions
Early treatment is more likely to result in preservation of or improvement in renal function
Patients with glomerular disease of whatever type and severity require long term follow up while urinary abnormalities persist
Assiduous blood pressure control (aiming for < 145/90 mm Hg) is vital to minimise the rate of progression of renal failure
Consider antithrombotic and anti-infection prophylaxis in patients with severe and refractory nephrotic syndrome
Specific treatment may be indicated depending on the disease

There is a spectrum of disease, from such asymptomatic urinary abnormalities to the nephritic and nephrotic syndromes and indeed some patients have features of both. The nephritic syndrome is the abrupt onset of haematuria (often with red blood cell casts), proteinuria (usually moderate), reduced renal function, and salt and water retention causing oedema and hypertension. The nephrotic syndrome is heavy proteinuria (> 3.5 g/24 h) associated with hypoproteinaemia, distinct oedema, and often hypercholesterolaemia. Although the history, examination, urine analysis, and blood investigations (box 2) may suggest a likely cause, definitive diagnosis requires a renal biopsy. Underlying glomerulonephritis is also considered to be the cause of end stage renal failure in about a quarter of patients accepted on to dialysis programmes. As the progression of glomerulonephritis may be insidious some patients present in chronic renal failure with small smooth kidneys. By this time renal biopsy is more hazardous and less …