Glomerular disease

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This page contains general information about Glomerular disease. For more information on specific types, please visit the pages on nephritic syndrome, nephrotic syndrome, Fabry's disease, amyloidosis, pulmonary-renal syndromes (vasculitis), thin basement membrane disease, Alport's Syndrome, anti-GBM Disease, hypertensive nephrosclerosis, and subacute bacterial endocarditis.

Glomerular disease
Acute Glomerulonephritis: Micro H&E high mag; an excellent example of acute exudative glomerulonephritis.
Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Glomerular disease Main page

Glomerular disease patient information

Overview

Classification

1- Poststreptococcal Glomerulonephritis
2- Renal disease due to Subacute Bacterial Endocarditis, or cardiac shunt
3- Lupus nephritis
4- Goodpasture syndrome
5- IgA nephropathy
6- Granulomatosis with Polyangiitis (Wegener's)
7- Microscopic Polyangiitis
8- Churg-Strauss Syndrome
9- Membranoproliferative Glomerulonephritis
10- Henoch-Schönlein purpura
11- Cryoglobulinemia
12- Minimal change disease
13- Focal segmental glomerulosclerosis
14- Membranous glomerulonephritis
15- Diabetic Nephropathy
16- Glomerular deposition disease
17- Alport's Syndrome
18- Thin Basement Membrane Disease
19- Nail-Patella Syndrome
20- Hypertensive nephrosclerosis
21- Cholesterol Emboli
22- Sickle Cell Disease
23- Thrombotic Microangiopathies
24- Antiphospholipid Antibody Syndrome

Pathophysiology

Differential Diagnosis

Diagnosis

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2], Syed Hassan A. Kazmi BSc, MD [3]

Overview

Glomerular disease is a condition that affects the glomerulus. It consists of different diseases with different clinical courses and treatment options. Glomerular disease can be isolated hematuria, isolated proteinuria; acute or chronic glomerulonephritis, and nephrotic or nephritic features of glomerulonephritis. The end stage of all of these diseases will be glomerulosclerosi swhich is characterized by fibrosis of the glomerulus, and end-stage renal disease.

Classification

Glomerular dieseases can be classified into several clinical and pathological syndromes as below:

Syndrome Disease
Acute nephritic syndromes
Nephrotic syndrome
Glomerular Deposition Diseases
Pulmonary-Renal Syndromes:
Basement Membrane Syndromes
Glomerular-Vascular Syndromes
Infectious Disease–Associated Syndromes

Also, glomerular diseases can be classified based on their clinical and urinary pattern in to below types:

Mild nephritc:

This category include mild nephritic sediment that is associated with less than half involvement of glomeruli.

Severe nephritic:

More severe clinical features such as edema, heavy proteinuria, hypertension, and/or renal failure may occur.

Nephrotic:

This syndrome is associated with heavy proteinuria and lipiduria.

Glomerular diseases also may classified by their presentation as below:

Glomerular hematuria:

1- Isolated hematuria

2- Glomerulonephritis (nephritic syndrome)

Proteinuria:

1-Isolated non-nephrotic proteinuria 

2- Nephrotic syndrome

Rapidly progressive glomerulonephritis

Glomerulonephritis

Glomerulonephritis which is inflammation of the glomeruli can be classified based on pathogenic type into three subtypes:

  • Anti-GBM disease: Linear deposit
    1. Goodpasture syndrome (renal and lung involvement)
    2. Renal involvement alone
    3. Lung involvement alone

Glomerulonephritis (nephritic syndrome) also may be classified based on disease course into acute or chronic nephritic syndrome; primary vs secondary causes; or systemic vs renal limited disease. For more information about nephritic syndrome classifications click here.

Differential Diagnosis

Glomerulonephritis may be proliferative or non-proliferative and may be associated with nephrotic or nephritic features. The various types of glomerulonephritides should be differentiated from each other based on associations, presence of pitting edema, hemeturia, hypertension, hemoptysis, oliguria, peri-orbital edema, hyperlipidemia, type of antibodies, light and electron microscopic features. The following table differentiates between various types of glomerulonephritides:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]

Glomerular diseases Sub-entity History and Symtoms Laboratory Findings Pathology
Hyperlipidemia and hypercholesterolemia Auto-antibodies,

Complements

Light microscope Electron microscope Immunoflourescence pattern
History Systemic symptoms Hemeturia Proteinuria Hypertension Pitting edema Oliguria Nephrotic features Nephritic features
Acute Nephritic Syndromes Poststreptococcal Glomerulonephritis +/- + +/- +/- +/- +/- +/- +/-
  • Anti-DNA antibodies
  • Anti-C1q antibodies
  • Antineutrophil cytoplasmic antibodies (ANCA)
Hypercellular and inflamed glomeruli Immune complex GN, granular deposit
Renal disease due to Subacute Bacterial Endocarditis, or cardiac shunt (Atrioventricular)
  • History of infective endocarditis mostly due to S. aureus
  • Cardiac shunt
+/- + +/- +/- +/- +/- +/- +/-
  • Crescentic GN is the most common pathological features
  • Mesangial deposits,
  • Subendothelial deposits
  • Subepithelial "humps," in minority of cases
  •  Pauci-immune GN
Lupus Nephritis
  • History of SLE features
+/- + +/- +/- +/- +/- +/- +/-
  • Anti-C1q antibodies
  • Anti-dsDNA
Differs based on the disease classification Differs based on the disease classification Differs based on the disease classification, mostly immune complex GN, granular deposit
Antiglomerular Basement Membrane Disease (Goodpasture's syndrome)
  • Young adults
+ + + + + + - - Immune complex GN, Linear deposit
IgA Nephropathy + +/- + +/- + - + - Immune complex deposition
  • Crescent formation
Immune complex GN, granular deposite
ANCA Small-Vessel Vasculitis Granulomatosis with Polyangiitis (Wegener's)
  • Middle age male
+ + + +/- + - + - ANCA
  • Necrotizing and crescentic glomerulonephritis
 Pauci-immune GN
Microscopic Polyangiitis +/- + + + + + + - -  Pauci-immune GN
Churg-Strauss Syndrome +/- + + + + + + - Hypercellular and inflamed glomeruli (Crescent formation)-

(pauci-immune)

-  Pauci-immune GN
Membranoproliferative Glomerulonephritis + + + +/- + + - -
  • Immune complex deposition
Immune complex GN, granular deposite
Henoch-Schönlein purpura  + + + +/- + + - -
  • Diffuse mesangial IgA deposits often associated with mesangial hypercellularity
Immune complex GN, granular deposite
Cryoglobulinemia Patients having cryoglobulinemia may have positive history of: Pulmonary symptoms:
  • Cough

Cutaneous symptoms:

Gastrointestinal symptoms:

  • Abdominal pain

General symptoms:

+/- + +/- + +/- +/- +/- +/- +/-
Nephrotic Syndrome Minimal Change Disease - + - + +/- + - +
  • Normal
-
Focal Segmental Glomerulosclerosis - + - + +/- + - + -
Membranous Glomerulonephritis - + - + +/- + - + Immune complex deposition Immune complex GN, granular deposite
Diabetic Nephropathy For more information on diabetes click here. - + - + +/- + - +
  • Diffuse mesangial matrix expansion (nodular glomerulosclerosis)
  • Increased mesangial hypercellularity
  • Prominent glomerular basement membranes
  • Thick basement membrane without any deposit
  • Nodular glomerulosclerosis
-
 Glomerular Deposition Diseases  Light Chain Deposition Disease[25]
  • Occurs in the setting of high tumor burden
- - + - + +/- + - + -
  • Light-chain deposits
  • Granular deposits on electron microscopy
  • Detection of light chain deposits using anti–light chain antibody
Renal Amyloidosis[26][27][28][29] - + - + +/- + - + -
  • Diffuse glomerular deposition of amorphous hyaline material (nodular pattern), in mesangium (weakly staining with periodic acid-Schiff (PAS)
  • Nodular deposit
  • AA amyloidosis type: negative for immunoglobulins and complement
  • AL amyloidosis type: Positive for lambda or kappa light chains
Fibrillary-Immunotactoid Glomerulopathy[30] - +/- + +/- +/- +/- + +/- +/- -
  • Diffuse sclerosing glomerulonephritis
  • Diffuse proliferative glomerulonephritis
  • Membranoproliferative glomerulonephritis
  • Mesangioproliferative/sclerosing disease
  • Membranous glomerulonephritis
  • Large fibrillar deposits in the mesangium randomly
  • Glomerular capillary walls different from amloidosis
  • No staining with Congo red or thioflavine-T or with antibodies to a specific type
  • Positive for immunoglobulin G (IgG), C3
  • Kappa and lambda (ie, polyclonal) light chains
Fabry's Disease[31][32][33] - + - + +/- + - + -
  • Vacuolization of visceral glomerular epithelial cells (podocytes) and distal tubular epithelial cells
  • Glycolipid accumulation
  • Myeloid or zebra bodies: Gb3 deposition within enlarged secondary lysosomes as lamellated membrane structures
  • Inclusions, composed of concentric layers (onion skin appearance)
-
Basement Membrane Syndrome Alport's Syndrome[34][35][36][37][38][39]
  • Positive family history
Auditary:

Occular problems:

  • Refractory Error
  • Arcus
  • Glaucoma
  • Vogt’s White Limbal Girdle
  • Band Keratopathy
  • Lenticonus
  • Spherophakia
  • Cataracts
  • Lens Coloboma
  • Anterior Lenticonus
  • Flecked Retinopathy of the Macula or Periphery
- + - + +/- + - + -
  • Early stage: unremarkable
Thin Basement Membrane Disease
  • Positive family history
- - + -/+ - -/+ - -/+ - - - Diffuse thinning of the glomerular basement membranes (GBM) -
Nail-Patella Syndrome[40][41]
  • Positive family history
  • Poorly developed fingernails, toenails, and patellae (kneecaps).
  • Elbow deformities
  • Abnormally shaped pelvis bone (hip bone)
  • Knee may be small, deformed or absent
+ + - - - - - - -
  • Mostly unremarkable changes
  • Secondary FSGS
  • Late stages:
    • Global glomerulosclerosis,
    • Tubulointerstitial fibrosis
  • Glomerular basement membranes (GBMs): Focal or diffuse irregular thickening with electron-lucent areas (moth-eaten appearance) containing type III collagen bundles.
  • Similar collagen fibrils can be seen in mesangial matrix.
  • Podocytes: Segmental effacement of foot processes.
  • Nonspecific IgM and C3 deposition may be seen in sclerotic glomeruli.
 Glomerular-Vascular Syndromes  Hypertensive Nephrosclerosis[42] Chronic hypertension +/- +/- + +/- +/- +/- - +/- -
  • Interstitial fibrosis and atrophy
  • Medial thickening and intimal fibrosis of medium-sized and larger vessels
  • Arteriolar thickening, and hyalinosis
  • Chronic stages:
    • Global sclerosis
    • Focal segmental sclerosis
Cholesterol Emboli[43]
  • Depends on the organ involved
+/- +/- + +/- +/- +/- - +/- -
  • Atheroemboli are seen in interlobular and arcuate arteries, as lance-shaped clefts, due to dissolution of cholesterol crystals
  • Acute lesions:
    • Atheroemboli are surrounded by red blood cells, fibrin, and leukocytes, with multinucleated giant cell reactions
  • Chronic lesions:
    • Cholesterol clefts are surrounded by intimal fibrosis
    • Vessel recanalization of chronic lesions can occur.
  • Global and segmental sclerosis of glomeruli may be present.
  • Extensive foot process effacement can be seen
  • Not specific changes
Sickle Cell Disease
  • Positive family history
+/- +/- +/- - - - - - -
  • Glomerular hypertrophy
  • Hemosiderin deposits
  • Focal areas of hemorrhage or necrosis
  • Chronic stage: interstitial inflammation, edema, fibrosis, tubular atrophy, and papillary infarcts
  • Glomerular enlargement and focal segmental glomerulosclerosis (FSGS)
Thrombotic Microangiopathies[44] Click for more information on Thrombotic Microangiopathies. + +/- + +/- +/- +/- - - -
  • Acute stage:
    • Inravasculr fibrin thrombi
  • Chronic stage:
    • Endocapillary hypercellularity.
    • Intimal proliferation of arterioles
  • Swollen glomerular endothelial cells with loss of fenestrations
  • Chronic stage: interposed cells with new GBM matrix material deposition.
  • Thrombi stain positive for fibrinogen
Antiphospholipid Antibody Syndrome [45][46][47]
  • Fatigue
  • Fever
  • Weight loss
+ +/- + +/- +/- +/- - - -
  • Acute stage:
    • Inravasculr fibrin thrombi
  • Chronic stage:
    • Endocapillary hypercellularity.
    • Intimal proliferation of arterioles
  • Swollen glomerular endothelial cells with loss of fenestrations
  • Chronic stage: interposed cells with new GBM matrix material deposition.
  • Thrombi stain positive for fibrinogen

Some infectious diseases such as HIV, HBV, HCV, syphilis, leprosy, malaria, and schistosomiasis may cause glomerular diseases.

Images

Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology


Microscopic Pathology

Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology


Glomerulonephritis Videos

Rapidly progressive glomerulonephritis

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Chronic glomerulonephritis

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Images:

References

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