Rapidly progressive glomerulonephritis diagnostic study of choice: Difference between revisions

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__NOTOC__
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{{Rapidly progressive glomerulonephritis}}
{{Rapidly progressive glomerulonephritis}}
{{CMG}}; {{APM}} {{AE}} {{KW}}, {{ADS}}, {{AEL}}  
{{CMG}}; {{APM}} {{AE}} {{KW}}, {{ADS}},  
 
{{AEL}}, {{N.F}}  


==Overview==
==Overview==
Rapid diagnosis of rapidly progressive glomerulonephritis is very crucial to save kidneys function  
Rapid diagnosis of rapidly progressive glomerulonephritis is very crucial to save kidneys function. It includes blood workup and renal [[biopsy]].Renal [[biopsy]] will provide the definitive diagnosis about the extent of involvement. Sometimes the result can be delayed ,in such cases the emperative therapy should be started to prevent [[end stage renal disease]].


=== Diagnostic study of choice: ===
== Diagnostic study of choice ==


==== Renal biopsy: ====
==== Renal biopsy: ====
* Renal biopsy will provide the most accurate reslt.  
* [[Renal biopsy]] will provide the most accurate reslt.  
* Renal biopsy will give accurate information about the extent of the disease and therapy can be planned accordingly.
* [[Renal biopsy]] will give accurate information about the extent of the disease and therapy can be planned accordingly.
'''results of Renal biopsy:'''
 
* Light microscopy reveals
* Findings include:<ref name="pmid12631105">{{cite journal |vauthors=Jennette JC |title=Rapidly progressive crescentic glomerulonephritis |journal=Kidney Int. |volume=63 |issue=3 |pages=1164–77 |date=March 2003 |pmid=12631105 |doi=10.1046/j.1523-1755.2003.00843.x |url=}}</ref>
** Diffuse inflammation in glomeruli with rupture and damage to glomerular basement membrane.
** Diffuse [[inflammation]] in [[glomeruli]] with rupture and damage to [[glomerular]] basement membrane.
** Crescents are present in the Bowmans space.
** [[Crescents]] are present in the [[Bowmans space]].
** Renal vessels can show transmural vasculitis, with necrosis and lymphocyte infiltrates.
** Renal vessels can show [[transmural]] [[vasculitis]], with [[necrosis]] and [[lymphocyte]] infiltrates.
** Tubular necrosis may also be present.
** [[Tubular]] necrosis may also be present.
** Interstitial granulomas in the glomeruli indicate Wegener’s granulomatosis
** [[Interstitial granulomas]] in the [[glomeruli]] indicate [[Wegener’s granulomatosis]].
**
[[File:192px-Crescentic glomerulonephritis (1).jpg|200px|center|thumb| Microscopic findings of RPGN Source:By Nephron - Own work<ref>https://commons.wikimedia.org/w/index.php?curid=17591464 </ref>]]
Diabetic nephropathy and fibrillary glomerulonephritis can be easily distinguished from anti-GBM disease on both clinical and histopathologic grounds. Circulating anti-GBM antibodies are absent in both disorders, and crescents are not seen in diabetic nephropathy. The history of diabetes, the finding of diabetic glomerulosclerosis on light microscopy, and, in fibrillary glomerulonephritis, the presence of the characteristic fibrils on electron microscopy are also helpful.
 
=====Immunoflourescence=====
*In type I RPGN- diffuse and linear deposition of [[Immunoglobulin G|IgG]] along the [[GBM]].
*In ttype II RPGN- diffuse and irregular deposition of IgG and C3 in the [[Mesangial cell|mesangial]] matrix.
*In type III RPGN- no finding.
*'''Electron microscopy'''
*In type I and type III, no electron dense deposits are seen.
**In type II RPGN, [[subepithelial]] electron dense deposits indiacting the presence of [[Immune complex|immune complexes]] are seen.  


Serologic studies
===== Serologic studies =====
*[[ Complete blood cell count]] (CBC) with[[ differential]],
*[[ Complete blood cell count]] (CBC) with[[ differential]],
**[[ Anemia]] can be seen in patienst with [[renal failure]] or gastrointestinal tract bleeding.
**[[ Anemia]] can be seen in patienst with [[renal failure]] or gastrointestinal tract bleeding.
** [[Eosinophilia]] of 13% or greater suggest [[Churg-Strauss disease]].
** [[Eosinophilia]] greater than 13% suggest [[Churg-Strauss disease]].
* [[Serum electrolytes]]
* [[Serum electrolytes]]
* BUN([[blood urea nitrogen)]]
* BUN([[blood urea nitrogen)]]
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* Microscopic [[hematuria]]
* Microscopic [[hematuria]]
*[[ Red cell casts]] indicates [[glomerular]] [[inflammation]]
*[[ Red cell casts]] indicates [[glomerular]] [[inflammation]]
* Erythrocyte sedimentation, elevated with active disease.
* [[Erythrocyte sedimentation]], elevated with active disease.
* C-reactive protein: levels are elevated and correspond with disease activity.
* [[C-reactive protein]]: levels are elevated and correspond with disease activity.
*[[ Antinuclear antibody]] (ANA).High ANA titer is present in systemic lupus erythematosus.
*[[ Antinuclear antibody]] (ANA).High ANA titer is present in [[systemic lupus erythematosus]].
* ANCA with ELISA subtyping: More than 80% of patients with microscopic polyangiitis are ANCA-positive, and most of these demonstrate pANCA with MPO specificity. Of patients with granulomatosis with polyangiitis, 90% are ANCA-positive and most have cANCA with PR3 specificity, especially in pulmonary involvement. However, ANCA type and specificity is not pathognomonic for each of these clinical syndromes because some patients with granulomatosis with polyangiitisare pANCA-positive and some patients with microscopic polyangiitis are cANCA-positive. Simon and colleagues investigated the presence of anti-pentraxin 3 (PTX3)- autoantibodies (aAbs) in the sera of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) patients and found that anti-PTX3 aAbs were present in nearly 40% of patients studied including in patients without detectable MPO and PR3 ANCA.
* Urine and serum protein electrophoresis,helpful in light-chain disease or multiple myeloma..
 
Biopsy
 
Determination of [[antineutrophil cytoplasmic antibody|ANCA]]s can aid in the diagnosis, but positivity is not conclusive and negative ANCAs are not sufficient to reject the diagnosis. Cytoplasmic staining ANCAs that react with the enzyme [[proteinase 3]] (cANCA) in [[neutrophil granulocyte|neutrophils]] (a type of [[white blood cell]]) are associated with Granulomatosis with polyangiitis. If the patient has [[chronic renal failure|renal failure]] or cutaneous vasculitis, these are the most logical organs to obtain a [[biopsy]] from. Rarely, [[thoracoscopy|thoracoscopic]] lung biopsy is required.
 
==Diagnostic Criteria==
A diagnosis of Granulomatosis with polyangiitis can be made when three out of the six criteria are established. They are:<ref name="pmid27596099">{{cite journal| author=Noone D, Hebert D, Licht C| title=Pathogenesis and treatment of ANCA-associated vasculitis-a role for complement. | journal=Pediatr Nephrol | year= 2016 | volume=  | issue=  | pages=  | pmid=27596099 | doi=10.1007/s00467-016-3475-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27596099  }}</ref>
# a histopathology that shows granuloma
# the upper respiratory tract is involved
# there is a stenosis that is present in larynx, trachea, and the bronchioles
# the pulmonary system is involved
# the presence of anti-neutrophil cytoplasmic antibodies
# the presence of glomerulonephritis
In 1990, the American College of Rheumatology accepted classification criteria for Granulomatosis with polyangiitis. They were not intended for diagnosis, but for inclusion in [[randomized controlled trial]]s. Two or more positive criteria have a sensitivity of 88.2% and a specificity of 92.0% of describing Granulomatosis with polyangiitis.<ref name="Leavitt">Leavitt RY, Fauci AS, Bloch DA, Michel BA, Hunder GG, Arend WP, et al. The American College of Rheumatology 1990 criteria for the classification of Wegener's granulomatosis. ''Arthritis Rheum'' 1990;33:1101-7. PMID 2202308.</ref>
* Nasal or oral inflammation:
** painful or painless oral ulcers ''or''
** purulent or bloody nasal discharge
* Lungs: abnormal chest X-ray with:
** nodules,
** infiltrates ''or''
** cavities
* Kidneys: urinary sediment with:
** microhematuria''or''
** red cell [[urinary casts|casts]]
* Biopsy: granulomatous inflammation
** within the arterial wall ''or''
** in the perivascular area
 
According to the Chapel Hill Consensus Conference (CHCC) on the nomenclature of systemic vasculitis (1992), establishing the diagnosis of Granulomatosis with polyangiitis demands:<ref name="Jenette">Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, Hagen EC, Hoffman GS, Hunder GG, Kallenberg CG,''et al''. Nomenclature of systemic vasculitides. Proposal of an international consensus conference.''Arthritis Rheum'' 1994;37:187-92. PMID 8129773.</ref>
* a granulomatous inflammation involving the respiratory tract, and
* a [[vasculitis]] of small- to medium-sized vessels.


Several investigators have compared the ACR and Chapel Hill criteria.<ref name="Bruce">Bruce IN, Bell AL. A comparison of two nomenclature systems for primary systemic vasculitis. ''Br J Rheumatol''1997;36:453-8. PMID 9159539.</ref>
.


==References==
==References==

Latest revision as of 18:10, 27 July 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Ali Poyan Mehr, M.D. [2] Associate Editor(s)-in-Chief: Krzysztof Wierzbicki M.D. [3], Amandeep Singh M.D.[4],

Ahmed Elsaiey, MBBCH [5], Nazia Fuad M.D.

Overview

Rapid diagnosis of rapidly progressive glomerulonephritis is very crucial to save kidneys function. It includes blood workup and renal biopsy.Renal biopsy will provide the definitive diagnosis about the extent of involvement. Sometimes the result can be delayed ,in such cases the emperative therapy should be started to prevent end stage renal disease.

Diagnostic study of choice

Renal biopsy:

  • Renal biopsy will provide the most accurate reslt.
  • Renal biopsy will give accurate information about the extent of the disease and therapy can be planned accordingly.
Microscopic findings of RPGN Source:By Nephron - Own work[2]
Immunoflourescence
  • In type I RPGN- diffuse and linear deposition of IgG along the GBM.
  • In ttype II RPGN- diffuse and irregular deposition of IgG and C3 in the mesangial matrix.
  • In type III RPGN- no finding.
  • Electron microscopy
  • In type I and type III, no electron dense deposits are seen.
Serologic studies

.

References

  1. ↑ Jennette JC (March 2003). "Rapidly progressive crescentic glomerulonephritis". Kidney Int. 63 (3): 1164–77. doi:10.1046/j.1523-1755.2003.00843.x. PMID 12631105.
  2. ↑ https://commons.wikimedia.org/w/index.php?curid=17591464
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