Question 1 of 10

    Nephritis (Nephritides)

    Hunter enlarged kidney[1]

    Nephritis is a condition, characterized by inflammation of the kidneys, which is majorly caused by infections, autoimmune diseases or exposure to toxins. The kidneys constitute of the glomerulus, interstitial tissue and tubules.

    Presentation

    Some of the common symptoms of nephritis include the following [6]:

    • Feeling of pain and burning sensation during urination
    • Presence of blood and pus in the urine
    • Fever accompanied by vomiting 
    • High blood pressure in individuals who have developed glomerulonephritis
    • Pain in the pelvic region, kidneys and or abdomen
    • Development of edema in the face, legs and hands due to accumulation of fluid
    • Frequency in urge to urinate
    • Urine is cloudy in appearance 

    Entire body system
    Falling
    Recurrent Urinary Tract Infection
    • Recurrent urinary tract infection itself can cause ammonium magnesium phosphate stones, further aggravating tubulointerstitial disease and perpetuating infection.[emedicine.medscape.com]
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  • Face, Head & Neck
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  • Skin
    Erythema
    • Physical examination was remarkable for malar erythema, tender joints and an elevated blood pressure.[consultqd.clevelandclinic.org]
    • Rule Sensitivity Specificity Misclassified cases(number) 1997 ACR criteria 267/310 (86%) 365/392 (93%) 70 SLICC criteria 292/310 (94%) 361/392 (92%) 49 11. 1997 ACR criteria Malar rash Fixed erythema, flat or raised, over the malar eminences Discoid rash[slideshare.net]
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  • gastrointestinal
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  • urogenital
    Macroscopic Hematuria
    • Poor prognosis associated with hypertension, greater than 1.5 grams of protein/day, renal insufficiency or absence of macroscopic hematuria.[clinicaladvisor.com]
    • Features % Proteinuria 100 Miroscopic hematuria 80 Tubular abnormalities 60-80 Reduced renal function 40-80 Nephrotic syndrome 45-65 Granular casts 30 Rapidly declining renal function 30 Hypertension 15-50 Hyperkalemia 15 Macroscopic hematuria 1-2 Acute[slideshare.net]
    Oliguria
    • This can lead to reduced glomerular blood flow, leading to reduced urine output (oliguria) and retention of waste products (uremia).[en.wikipedia.org]
    • Fractional Excretion of Sodium (FENa) may be useful if oliguria 7.[renalandurologynews.com]
    • Patients with AIN can present with features that indicate an immunological reaction (typically fever, rash and raised eosinophils) along with symptoms of acute renal failure, including oliguria, malaise, anorexia, nausea and vomiting.[pharmaceutical-journal.com]
    • Clinical Features Patients with AIN typically present with nonspecific symptoms of acute renal failure, including oliguria, malaise, anorexia, or nausea and vomiting, with acute or subacute onset. 5 The clinical presentation can range from asymptomatic[aafp.org]
    • Patients may be oliguric or nonoliguric; in a retrospective study that included 60 cases of AIN (92 percent of which were drug induced, with the remainder idiopathic), oliguria was present among 51 percent [ 11 ].[uptodate.com]
    Renal Injury
    • The latter type of renal injury is caused by hepatitis B virus (HBV), hepatitis C virus (HCV), a part of HIV and parvovirus B19.[omicsonline.org]
    • In secondary care Investigations are focused on assessing severity of renal injury and looking for the underlying cause - discussed in detail in the separate Glomerulonephritis article.[patient.info]
    • Acute interstitial nephritis (AIN) defines a pattern of renal injury usually associated with an abrupt deterioration in renal function characterized histopathologically by inflammation and edema of the renal interstitium.[aafp.org]
    • Another form of renal injury is secondary amyloidosis.[kidneypathology.com]
    Uremia
    • This can lead to reduced glomerular blood flow, leading to reduced urine output (oliguria) and retention of waste products (uremia).[en.wikipedia.org]
    • It is manifested by polyuria, urine of low specific gravity, and terminal uremia. lupus nephritis glomerulonephritis associated with systemic lupus erythematosus. parenchymatous nephritis nephritis affecting the parenchyma of the kidney. suppurative nephritis[medical-dictionary.thefreedictionary.com]
    • Do not neglect the occurrence of early Uremia symptoms like headache, loss of appetite, nausea and vomiting, decreased urination, etc.[kidneyabc.com]
    • […] such as primary vasculitis; myelitis; peripheral or cranial neuropathy in the absence of other known causes such as primary vasculitis, infection and diabetes mellitus; acute confusional state in the absence of other causes, including toxic-metabolic, uremia[slideshare.net]
    • Progressive renal failure leads to anemia, uremia, and electrolyte and acid-based abnormalities.[emedicine.medscape.com]
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  • Workup

    Various tests would be required for diagnosing the condition of nephritis. These would include the following [7]:

    • Laboratory studies: Several laboratory investigations would be required such as blood urea nitrogen levels, urine culture along with urinalysis and complete blood count. Blood tests to analyze levels of electrolyte and creatinine would be done. In addition to these, other laboratory studies include lupus serologies, antiDNAase B, serum IgA measurement, measurement of components C3 and C4, antistreptolysin and cellular antineutrophil cytoplasmic antibody. These tests would help detect infection in general and also give insights about presence of a bacterial infection [8] [9].
    • Biopsy: Biopsy of the kidney would be required when the patient shows signs of edema, proteinuria, hypertension and hematuria.
    • Imaging: Imaging studies such as CT scan of the abdomen and pelvic region is indicated to check for signs of infection. In addition to this, renal ultrasonography is done to rule out other conditions of tumor, kidney stones, renal artery stenosis and hematuria.

    Treatment

    The primary goal of treatment would be to correct the underlying disease condition that is causing nephritis. For this, medications and certain home care measurement would be required to treat the condition. Medications such as antibiotics are required if bacterial infections are the source of the problem. If autoimmune reactions are the cause, then various immunosupressants would be administered.

    Individuals with nephritis should give special considerations to their diet and their activity profile. Sodium and fluid restriction would be required if the patient is suffering from hypertension as the underlying condition. Along with this, a high carbohydrate diet would also be recommended for a short period in order to prevent breakdown of body protein. Calcium supplementation would also be indicated to maintain the normal serum calcium levels [10]. Individuals are also advised against carrying out strenuous activity; however, they are permitted to undertake daily light activities.

    Prognosis

    Prognosis of the condition is favorable with prompt initiation of treatment. However, failure to do so can cause damage to the organs, causing kidney failure. In such cases, individuals may require dialysis for filtering off the wastes from the body. Mortality due to nephritis in children is found to be higher in cases when there is development of complications. The several complications involved with kidney failure include uremia, anemia, overload of fluids, electrolyte imbalance, anorexia, sexual dysfunction and poor growth [5].

    Complications

    Acute Glomerulonephritis
    • Acute glomerulonephritis: This form of nephritis can develop suddenly after a serious infection, such as strep throat , hepatitis , or HIV .[medicalnewstoday.com]
    • Causes and symptoms Acute glomerulonephritis usually develops a few weeks after a strep infection of the throat or skin.[medical-dictionary.thefreedictionary.com]
    • Nakazawa T, Tomosugi N, Sakamoto K, Asaka M, Yuri T, et al. (2000) Acute glomerulonephritis after human parvovirus B19 infection.[omicsonline.org]
    • The urinalysis, for example, typically shows granular and epithelial cell casts and free epithelial cells in acute tubular necrosis; red cell casts, as well as red and white cells in acute glomerulonephritis; and few, if any, abnormalities in prerenal[uptodate.com]
    Acute Interstitial Nephritis
    • Acute interstitial nephritis (AIN) is rapidly developing inflammation that occurs within the interstitium.[healthcommunities.com]
    • This image shows acute interstitial nephritis.[emedicine.medscape.com]
    • Treatment of Interstitial Nephritis Acute Interstitial Nephritis Withdrawal of the offending agent is the primary treatment for acute interstitial nephritis.[lecturio.com]
    • Praga M, Gonzalez E ; Acute interstitial nephritis.[patient.info]
    Acute Pyelonephritis
    Ascites
    • Nephrotic syndrome may lead to edema, ascites, and hyperlipidemia, adding to the risk of coronary artery disease and the potential for thrombosis.[emedicine.medscape.com]
    Chronic Glomerulonephritis
    • Back to Top Prevention There is no specific prevention for most cases of chronic glomerulonephritis.[nytimes.com]
    • Sometimes, years after an acute episode, individuals develop chronic glomerulonephritis .[medicalnewstoday.com]
    • Interstitial nephritis represents the end result of several different renal diseases including chronic glomerulonephritis and chronic pyelonephritis.[vetbook.org]
    • "Influence of pregnancy on the course of primary chronic glomerulonephritis".[clinicaladvisor.com]
    Chronic Pyelonephritis
    • Interstitial nephritis represents the end result of several different renal diseases including chronic glomerulonephritis and chronic pyelonephritis.[vetbook.org]
    • In the case of chronic pyelonephritis, a sixmonth course of antibiotics may be necessary to rid the infection.[medical-dictionary.thefreedictionary.com]
    Glomerulonephritis
    • Some types of glomerulonephritis may get better on their own.[nytimes.com]
    • Glomerulonephritis is inflammation of the glomeruli.[en.wikipedia.org]
    • Glomerulonephritis is discussed in more detail in the separate Glomerulonephritis article.[patient.info]
    Goodpasture Syndrome
    • Nephrotic syndrome Bright's Disease Goodpasture syndrome[en.wikipedia.org]
    • Immunologic diseases (eg, associated with lupus, Goodpasture syndrome) Acute transplant rejection Infections, including bacterial (must be accompanied by obstruction or reflux), viral (eg, cytomegalovirus [CMV], hantavirus, human immunodeficiency virus[emedicine.medscape.com]
    • It can also be caused by lupus and less common conditions such as Goodpasture syndrome or granulomatosis with polyangiitis (GPA).[medicalnewstoday.com]
    Hemoglobinuria
    • Bloody urine after strenuous exercise may also result from march hemoglobinuria, which is caused by trauma to red blood cells, causing their rupture, which leads to the release of hemoglobin into the urine.[en.wikipedia.org]
    Hemorrhage
    • This bleeding should be regarded not as a sign of nephritis , but rather as a hemorrhagic manifestation. nephritis is an occasional complication, and constipation is very usual.[dictionary.com]
    • If we looked at the papilla we would see large areas of necrosis and hemorrhage.[vet.uga.edu]
    • A child with glomerulonephritis (GN) might die of potential complications of severe hypertension (eg, cerebral hemorrhage) or complications of renal failure (eg, hyperkalemia ).[emedicine.medscape.com]
    • […] state or movement disorder 2–5 Aseptic meningitis, myelopathy 1 Cardiopulmonary 60 Pleurisy, pericarditis, effusions 30–50 Myocarditis, endocarditis 10 Lupus pneumonitis 10 Coronary artery disease 10 Interstitial fibrosis 5 Pulmonary hypertension, ARDS, hemorrhage[slideshare.net]
    Interstitial Nephritis
    • ) , Renal tubulo-interstitial disease (disorder) , Tubulointerstitial nephropathy (disorder) , Interstitial nephritis , Renal tubulo-interstitial disease , IN - Interstitial nephritis , Interstitial nephritis (disorder) , Interstitial nephritis (qualifier[fpnotebook.com]
    • Treatment of Interstitial Nephritis Acute Interstitial Nephritis Withdrawal of the offending agent is the primary treatment for acute interstitial nephritis.[lecturio.com]
    Mood Disorder
    • Manifestation Prevalence, % Neurologic 60 Cognitive disorder 50 Mood disorder 40 Headache 25 Seizures 20 Mono-, polyneuropathy 15 Stroke, TIA 10 Acute confusional state or movement disorder 2–5 Aseptic meningitis, myelopathy 1 Cardiopulmonary 60 Pleurisy[slideshare.net]
    Nephrotic Syndrome
    Pyelonephritis
    • This is an example of pyelonephritis.[vet.uga.edu]
    • , primary/idiopathic Nephritis, tubulo-interstitial, secondary Obstructive pyelonephritis Primary tubulointerstitial nephritis Pyelonephritis Pyelonephritis (kidney infection) Secondary tubulointerstitial nephritis Type 1 Excludes calculous pyelonephritis[icd10data.com]
    • Acute pyelonephritis may require hospitalization for severe illness.[medical-dictionary.thefreedictionary.com]
    • Pyelonephritis Pyelonephritis is an inflammation of the kidney, usually due to a bacterial infection.[healthline.com]
    • Read more on pyelonephritis .[healthhype.com]
    Stroke
    • Loss of these proteins can result in blood clots, causing sudden stroke.[en.wikipedia.org]
    • Complications Primary complications associated with hypertension include: Seizure Encephalopathy Stroke End-organ damage Posterior reversible encephalopathy syndrome [ 4 , 5] Primary complications associated with kidney failure include: Fluid overload[emedicine.medscape.com]
    • Both lupus itself and the drugs taken to manage the disease can put the patient at greater risk of infection, cardiovascular disease, risk of stroke, osteoporosis, and weight gain.[hss.edu]
    • Manifestation Prevalence, % Neurologic 60 Cognitive disorder 50 Mood disorder 40 Headache 25 Seizures 20 Mono-, polyneuropathy 15 Stroke, TIA 10 Acute confusional state or movement disorder 2–5 Aseptic meningitis, myelopathy 1 Cardiopulmonary 60 Pleurisy[slideshare.net]
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  • Etiology

    Autoimmune diseases are the major cause of nephritis. Following this, the condition can also occur due to infections and exposure to toxins. Individuals suffering from systemic lupus erythematosus are at an increased risk of developing nephritis. There have been instances, where nephritis can also be caused by heredity. However, such cases are rare and nephritis is majorly caused either by infections or autoimmune diseases. A kind of nephritis, known as athletic nephritis occurs as a result of excessive strenuous exercises. Such a type of condition gives rise to cylindruria, proteinuria and hematuria [2].

    Epidemiology

    The exact incidence of nephritis across the globe is unknown. Based on the statistics given by Center for Disease Control and Prevention, it was reported that approximately 39,480 people die due to nephritis in US each year. In addition, kidney disease was ranked 9th as the leading cause of mortality amongst the US population [3].

    Sex distribution
    Age distribution

    Pathophysiology

    Kidneys form an important organ of the body, responsible for maintain water and electrolyte balance, regulate acid-base concentration, and filtering off metabolic wastes. These bean-shaped organs process about 200 quarts of blood everyday and remove excess water and waste products from the body. Conditions interfering with the normal functioning of the kidneys are infections and underlying disease conditions.

    These factors promote development of inflammation of the organ which can further lead to kidney damage. In addition to infection and disease conditions, individuals can also develop nephritis if they have undergone surgical procedures of the kidneys or are allergic to certain medications [4].

    Prevention

    Certain practices can help prevent the onset of infections which would in a way avoid the onset of nephritis. Healthy living and appropriate water consumption can help keep the bladder clean and also avoid infections. Alcohol consumption and smoking are known to cause damage to the kidney and should therefore be avoided. Certain fruits and vegetables act as natural diuretics and should be made a part of daily diet. These consist of grapes and coconut water.

    Summary

    There are three types of nephritis, interstitial nephritis, glomerulonephritis and pyelonephritis. In interstitial nephritis, the area between the renal tubules undergoes inflammation. In the condition of glomerulonephritis, the filtering units of the kidneys, the glomeruli, get inflamed. Pyelonephritis occurs as a result of infection of the bladder, favoring development of inflammation of the kidneys. Nephritis, if not treated on time can turn severe, leading to development of several complications such as kidney damage [1].

    Patient Information

    • Definition: Nephritis is a condition, wherein the kidneys undergo inflammation usually either due to infections or autoimmune diseases. Such a type of condition should be promptly treated in order to avoid development of kidney damage.
    • Cause: The various causative factors for nephritis include bacterial infections, autoimmune diseases, and allergic reactions to antibiotics and or surgical procedures of the kidney. All these factors can trigger an inflammatory response, giving rise to nephritis.
    • Symptoms: Individuals with nephritis suffer from pain during urination, frequency in urge to urinate, pain in the abdomen and pelvic region, fever as well as vomiting. Affected individuals also experienced swelling in the arms and legs due to accumulation of fluids and also pass out blood in urine.
    • Diagnosis: The various diagnostic procedures employed include blood tests, blood culture, urinalysis, urine culture, complete blood count and serology tests. In addition, kidney biopsy would be required in individuals who suffer from hematuria, edema, proteinuria and hypertension.
    • Treatment: Antibiotic medications form the basis of treatment regime. Dietary restrictions along with fluid control would also be done in order to correct the condition of nephritis.

    Self-assessment

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    References

    1. Michel DM, Kelly CJ. Acute interstitial nephritis. J Am Soc Nephrol 1998; 9:506.
    2. Cornell LD. IgG4-related kidney disease. Curr Opin Nephrol Hypertens 2012; 21:279.
    3. Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990; 5:94.
    4. Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001; 60:804.
    5. Paueksakon P, Revelo M, Lee SM, et al. Acute renal failure in a 64-year-old white man.Am J Kidney Dis 2000; 36:669.
    6. Goda C, Kotake S, Ichiishi A, et al. Clinical features in tubulointerstitial nephritis and uveitis (TINU) syndrome. Am J Ophthalmol. 2005;140(4):637-41.
    7. Wen YK, Chen ML. IgA-Dominant Postinfectious Glomerulonephritis: Not Peculiar to Staphylococcal Infection and Diabetic Patients. Ren Fail. 2011;33(5):480-5.
    8. Lins RL, Verpooten GA, De Clerck DS, De Broe ME. Urinary indices in acute interstitial nephritis. Clin Nephrol 1986; 26:131.
    9. Cornell LD. IgG4-related kidney disease. Curr Opin Nephrol Hypertens 2012; 21:279.
    10. Flanc RS, Roberts MA, Strippoli GF, et al. Treatment of diffuse proliferative lupus nephritis: a meta-analysis of randomized controlled trials. Am J Kidney Dis. Feb 2004;43(2):197-208.



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    1. Hunter enlarged kidney, Public Domain

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