Chronic glomerulonephritis is a progressive diffuse immuno–inflammatory lesion of the glomerular apparatus of the kidneys with an outcome of sclerosis and renal failure. It may be asymptomatic, include an increase in blood pressure, edema, and disorders of the general condition. In diagnostics, urine test, ultrasound of the kidneys, morphological examination of renal tissue (biopsy), intravenous urography, renography are used. Treatment includes nutrition regulation, corticosteroid, immunosuppressive, anticoagulant, diuretic, hypotensive therapy.
ICD 10
N03 Chronic nephritic syndrome
Meaning
Chronic glomerulonephritis in urology and nephrology is understood as primary glomerulopathies of various etiology and pathomorphology, accompanied by inflammatory and destructive changes and leading to nephrosclerosis and chronic renal failure. Among all therapeutic pathology, the disease is about 1-2%, which suggests its relatively high prevalence. Pathology can be diagnosed at any age, but more often the first signs of nephritis develop in 20-40 years. Signs of a chronic process are a long (more than a year) progressive course of glomerulonephritis and bilateral diffuse kidney damage.
Causes
Infectious factors
Chronization and progression of the disease may be a consequence of incurable acute glomerulonephritis. At the same time, there are often cases of the development of primary chronic glomerulonephritis without a previous episode of acute attack. The cause of the disease is not always possible to find out. The leading importance is attached to:
- nephritogenic strains of streptococcus;
- the presence in the body of foci of chronic infection (pharyngitis, tonsillitis, sinusitis, cholecystitis, caries, periodontitis, adnexitis, etc.);
- persistent viruses (influenza, hepatitis B, herpes, chickenpox, infectious mononucleosis, rubella, cytomegalovirus infection).
Non-infectious factors
In some patients, chronic glomerulonephritis is caused by hereditary predisposition (defects in the cellular immunity or complement system) or congenital renal dysplasia. Also, non-infectious factors include:
- allergic reactions to vaccination;
- alcohol and drug intoxication;
- immuno–inflammatory diseases – hemorrhagic vasculitis, rheumatism, systemic lupus erythematosus, septic endocarditis, etc.
The emergence of pathology is facilitated by cooling and weakening of the general resistance of the body.
Pathogenesis
Immune disorders play a leading role in the pathogenesis of chronic glomerulonephritis. Exogenous and endogenous factors cause the formation of specific CIC consisting of antigens, antibodies, complement and its fractions (C3, C4), which are deposited on the basement membrane of the glomeruli and cause damage to it. In chronic glomerulonephritis, the glomerular lesion is intracapillary in nature, disrupting microcirculation processes with the subsequent development of reactive inflammation and dystrophic changes.
The disease is accompanied by a progressive decrease in the weight and size of the kidneys, compaction of renal tissue. Microscopically, the fine-grained surface of the kidneys, hemorrhages in the tubules and glomeruli, loss of clarity of the cerebral and cortical layer are determined.
Classification
In etiopathogenetic terms, infectious-immune and non-infectious-immune variants of chronic glomerulonephritis are distinguished. According to the pathomorphological picture of the detected changes, there are minimal, proliferative, membranous, proliferative-membranous, mesangial-proliferative, sclerosing types of the disease and focal glomerulosclerosis. During the pathology, there is a phase of remission and exacerbation. According to the rate of development, the disease can be rapidly progressing (within 2-5 years) and slowly progressing (more than 10 years).
In accordance with the leading syndrome, several forms of chronic glomerulonephritis are distinguished. Each of the forms proceeds with periods of compensation and decompensation of nitrogen-releasing kidney function:
- latent (with urinary syndrome);
- hypertensive (with hypertensive syndrome);
- hematuric (with predominance of macrohematuria);
- nephrotic (with nephrotic syndrome);
- mixed (with nephrotic-hypertensive syndrome).
Symptoms
The symptoms are due to the clinical form of the disease. The latent form occurs in 45% of patients, occurs with isolated urinary syndrome, without edema and arterial hypertension. It is characterized by moderate hematuria, proteinuria, leiocyturia. The course is slowly progressing (up to 10-20 years), the development of uremia comes late. With the hematuric variant (5%), persistent hematuria, episodes of macrohematuria, anemia are noted. The course of this form is relatively favorable, uremia rarely occurs.
The hypertensive form of chronic glomerulonephritis develops in 20% of cases and proceeds with arterial hypertension with mild urinary syndrome. Blood pressure rises to 180-200 / 100-120 mm Hg, often undergoes significant daily fluctuations. There are changes in the fundus (neuroretinitis), hypertrophy of the left ventricle, cardiac asthma, as a manifestation of left ventricular heart failure. The course of this form is long and steadily progressing with the outcome of renal failure.
The nephrotic variant, occurring in 25% of cases, proceeds with massive proteinuria (over 3 g / day), persistent diffuse edema, hypo- and dysproteinemia, hyperlipidemia, dropsy of serous cavities (ascites, hydropericardium, pleurisy) and associated dyspnea, tachycardia, thirst. Nephrotic and hypertensive syndromes are the essence of the most severe, mixed form of chronic glomerulonephritis (7% of cases), which occurs with hematuria, pronounced proteinuria, edema, arterial hypertension. An unfavorable outcome is determined by the rapid development of renal failure.
Diagnostics
The leading diagnostic criteria are clinical and laboratory data. When collecting anamnesis, the fact of the presence of chronic infections, acute glomerulonephritis, systemic diseases is taken into account.
- Urine test. Typical changes in the general analysis of urine are the appearance of erythrocytes, leukocytes, cylinders, protein, changes in the specific gravity of urine. To assess kidney function, Zimnitsky and Reberg tests are carried out.
- Blood test. Hypoproteinemia and dysproteinemia, hypercholesterolemia are detected in the blood, the titer of antibodies to streptococcus (ASL-O, antihyaluronidase, antistreptokinase) increases, the content of complement components (SZ and C4) decreases, the level of IgM, IgG, IdA increases.
- Ultrasound of the kidneys. With the progressive course of chronic glomerulonephritis, it detects a decrease in the size of organs due to sclerosis of the renal tissue.
- Radiation methods. Excretory urography, pyelography, nephroscintigraphy help to assess the state of the parenchyma, the degree of renal dysfunction.
- Additional methods. To detect changes from other systems, ECG and EchoCG, ultrasound of the pleural cavities, and fundus examination are performed.
- Kidney biopsy. To establish the histological form of chronic glomerulonephritis and its activity, as well as to exclude pathology with similar manifestations, a kidney biopsy is performed with a morphological examination of the obtained sample of renal tissue.
Depending on the clinical variant of the disease, differential diagnosis with chronic pyelonephritis, nephrotic syndrome, polycystic kidney disease, kidney stones, kidney tuberculosis, kidney amyloidosis, arterial hypertension is required.
Treatment
The features of therapy are dictated by the clinical form of the disease, the rate of progression of disorders and the presence of complications. It is recommended to observe a gentle regime with the exception of overwork, hypothermia, and occupational hazards. During periods of remission, treatment of chronic infections that support the course of the process is required. The diet prescribed for chronic glomerulonephritis requires limiting table salt, alcohol, spices, taking into account the liquid consumed, increasing the daily protein allowance.
Drug treatment consists of immunosuppressive therapy with glucocorticosteroids, cytostatics, NSAIDs; prescribing anticoagulants (heparin, fenindione) and antiplatelet agents (dipyridamole). Symptomatic therapy may include taking diuretics for edema, hypotensive agents for hypertension. In addition to full inpatient courses of therapy during periods of exacerbation, supportive outpatient therapy during remission, treatment at climatic resorts is indicated.
Prognosis and prevention
Effective treatment of chronic glomerulonephritis can eliminate the leading symptoms (hypertension, edema), delay the development of renal failure and prolong the patient’s life. All patients are registered at the dispensary with a nephrologist. The most favorable prognosis has a latent form; more serious – hypertensive and hematuric; unfavorable – nephrotic and mixed forms. Complications that worsen the prognosis include pleuropnemnonia, pyelonephritis, thromboembolism, renal eclampsia.
Since the development or progression of irreversible changes in the kidneys is most often initiated by streptococcal and viral infections, wet hypothermia, their prevention is of paramount importance. With concomitant pathology of chronic glomerulonephritis, it is necessary to monitor related specialists – an otolaryngologist, dentist, gastroenterologist, cardiologist, gynecologist, rheumatologist, etc.