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Nephritic Syndrome

What is Nephritic Syndrome?

Nephritic syndrome is a disease of kidney structure element- glomeruli. Nephritic syndrome is also known as glomerulonephritis and it is characterized by edema, increased blood pressure and haematuria (red blood cells in urine). Nephritic syndrome can develop rapidly- acute glomerulonephritis or progress slowly- chronic glomerulonephritis. In rare cases acute glomerulonephritis can cause serious complications- if acute nephritic syndrome evolves into rapidly progressive glomerulonephritis which can cause kidney failure ^{[1, 5]}.

Causes

Infections

Bacterial
- Streptococcus- after throat or skin infection, most likely in children between 2 and 10 years of age
- Staphylococcus (can also cause toxic-shock syndrome)
- Pneumococcus ^[2]
Viral
- HIV
- Chickenpox
- Hepatitis virus B or C
- Cytomegalovirus
- Epstein-Barr virus
Fungal
- Coccidioides immitis
Parasitic
- Malaria
- Filiriasis
- Trichinosis^[3]

Vasculitis

Churg-Strauss syndrome- eosinophilic granulomatosis with polyangiitis
Wegener granulomatosis
Microscopic polyangiitis
Cryoglobulinemia
Henoch-Schonlein purpura^[3]

Immune disorders

Systemic lupus
Goodpasture syndrome

Other causes

Hereditary nephritic syndrome
Drugs
IgA nephropathy
Membranoproliferative glomerulonephritis
Gullain-Barre syndrome
Serum sickness ^[4]

Chronic glomerulonephritis causes

Chronic glomerulonephritis can be caused by the same conditions as acute glomerulonephritis. Also, acute glomerulonephritis can become chronic. In most cases the exact cause of chronic glomerulonephritis remains unknown. It can also be caused by hereditary nephritis- a genetic disorder ^[3].

Symptoms

In some cases the underlying cause is not known. When patient presents with symptoms of nephritic syndrome, it is worth checking for other symptoms or diseases that are quite rare and patient might not know about them:

Sinusitis, lung infiltrates and symptoms of nephritis is a classic presentation of Wegener granulomatosis
Vomiting, nausea, abdominal pain in young patients can suggest Henoch-Schonlein purpura- symptoms similar to Peutz-Jaegers syndrome
Lupus eritematosus can present with pain in the joints
Coughing of blood- Goodpasture syndrome
Skin rashes can be a symptom of vasculitis, lupus, cryoglobulinemia and Henoch-Schonlein purpura ^[1].

Diagnosis

The diagnosis of nephritic syndrome consists of physical examination, as well as laboratory and imaging studies.

Physical examination

When examining the patient, there are a variety of possible symptoms that are connected with nephritic syndrome and possible underlying cause:

Symptoms of fluid overload
Edema around eyes and/or feet
Edema of the lungs- can present as crackles on auscultation
Elevated pressure in jugular veins
Ascitis
High blood pressure
Rash
Swelling of the joints
Pain in the kidney area
Hematuria
- Microscopic- red blood cells only found when examining urine with microscope
- Macroscopic- visible blood in the urine
Neural examination
State of consciousness can be altered due to high blood pressure
Abdominal pain
Weight gain
Loss of appetite
Ulcers in the mouth
Respiratory tract infection

In many cases patients have normal physical examination and blood pressure ^[3].

Patient history

To diagnose nephritic syndrome, knowing the underlying cause can be helpful. It is important to ask patient the following:

Age
Gender
What are the symptoms and their severity
Onset of symptoms
- Post-infectious nephritic syndrome usually occurs 1-4 weeks after infection
- Onset of nephritis after 1-4 days of being infected with streptococcus suggests existing kidney disease
Recent infections prior to onset of symptoms

Nephritic Syndrome edema

Are there any other systemic diseases the patient knows about
Has the patient traveled recently ^[1]

Clinical symptoms

Hematuria- presence of red blood cells in the urine
Oliguria- small amount of urine
Edema- edema can appear on the face, around the eyes or throughout the body. Edema is usually present in the morning
Headache
Confusion
Shortness of breath
Pain sensation around the kidney area^[1]

Urine analyses

Urine analysis is one of the most important examinations to diagnose nephritic syndrome. In urine analysis there can be abnormalities in the following:

Protein- mildly increased

red cell casts

Red blood cells- either some cells seen in the microscope or visible blood
White blood cells
Cellular casts- red cell casts is a definitive feature that suggests glomerular damage
Fat bodies
Electrolytes
Urine sodium

24-hour urine study can be helpful in making the diagnosis. The urine sample is dark brown. There is increased level of protein. Creatinine clearance can be helpful in detecting level of renal dysfunction^[1].

Blood analyses

In blood samples the following features can be observed:

Dilution anemia- hematocrit levels are decreased due to high fluid volume in blood (also see myelodysplastic syndrome)
Increased serum creatinine
Increased urea
Serum electrolytes-
Low levels of albumin (serum protein)
Glomerular filtration rate is determined and it shows the level of kidney function
Complement levels- usually decreased, but in some cases levels can be normal^[1,3]

Other tests

Antibody to nephritis-associated protease are present in case of streptococcal infection
Antinuclear antibodies can be present in case of lupus and polyarteritis nodosa
Triglyceride levels
Hepatitis B and C virus tests
c-ANCA can be positive in case of Wegener granulomatosis ^[1,3]

Imaging studies

X-Ray imaging is suggested for patients who present with cough. Chest X-ray can show signs of edema, as well as signs for syndromes like Goodpasture syndrome and Wegener granulomatosis
CT imaging can be helpful if abscess is suspected. CT with contrast is used for patients with hypertension and altered consciousness (for other conditions that can alter consciousness read Stevens-Johnsons syndrome).
Ultrasonography is used to assess the size of the kidney and exclude obstruction^[5]

Renal biopsy

In most cases renal biopsy is not performed. When the exact cause of the disease is unknown and the symptoms are severe, biopsy can help in determining the exact cause of nephritic syndrome.

Treatment

There is no specific treatment for nephritic syndrome. The treatment consists of managing symptoms and underlying cause. In severe cases of lung edema (when acute respiratory distress syndrome can occur) and altered mental status patient should be placed in intensive care unit.

Medications

Antibiotics to prevent the spread of underlying infection
Loop diuretics can be used for patients with severe hypertension
Vasodilators are used for patients with hypertension and hypertensive encephalopathy
Glucorticoids are used in severe cases of post-streptococcal glomerulonephritis^[5,6]

Diet

Nephritic syndrome patients have to restrict intake of fluids and sodium in their diet. That can help in reducing and preventing edema. In case the patient presents with abnormally high levels of nitrogen containing compounds in the blood, proteins have to be restricted ^[5].

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References

Treatment and other relative information about nephritic syndrome for patients and specialists: http://emedicine.medscape.com/article/239278-treatment#d10
Patient information about nephritic syndrome (glomerulonephritis): https://www.kidney.org/atoz/content/glomerul
Causes and other features of nephritic syndrome: https://www.msdmanuals.com/home/kidney-and-urinary-tract-disorders/kidney-filtering-disorders/glomerulonephritis-nephritic-syndrome
Diseases associated with nephritic syndrome http://geekymedics.com/nephrotic-vs-nephritic-syndrome/
Overview of Nephritic syndrome: http://www.healthline.com/health/acute-nephritic-syndrome#Overview1
Patient information: http://patient.info/doctor/acute-nephritis