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Overview of Glomerular Disorders

by Navin Jaipaul, MD, MHS

The hallmark of glomerular disorders is proteinuria, which is often in the nephrotic range (≥ 3 g/day).

Glomerular disorders are classified based on urine sediment as those that manifest predominantly with

  • High-level proteinuria alone (nephrotic urine sediment)

  • Hematuria, usually in combination with proteinuria (nephritic urine sediment); the RBCs are usually dysmorphic and there may be casts

Nephrotic syndrome (see Overview of Nephrotic Syndrome) is nephrotic urine sediment plus edema and hypoalbuminemia (typically with hyperlipidemia).

Nephritic syndrome (see Overview of Nephritic Syndrome) is nephritic urine sediment with or without hypertension, elevated serum creatinine, and oliguria.

Several glomerular disorders typically manifest with features of both nephritic and nephrotic syndromes. These disorders include but are not limited to, fibrillary and immunotactoid glomerulopathies (see Fibrillary and Immunotactoid Glomerulopathies), membranoproliferative glomerulonephritis (GN—see Membranoproliferative Glomerulonephritis), and lupus nephritis (see Lupus Nephritis).

The pathophysiology of nephritic and nephrotic disorders differs substantially, but their clinical overlap is considerable—eg, several disorders may manifest with the same clinical picture—and the presence of hematuria or proteinuria does not itself predict response to treatment or prognosis.

Disorders tend to manifest at different ages (see Glomerular Disorders by Age and Manifestations) although there is much overlap. The disorders may be primary (idiopathic) or have secondary causes (see Causes of Glomerulonephritis and see Table: Causes of Nephrotic Syndrome).

A glomerular disorder is usually suspected when screening or diagnostic testing reveals an elevated serum creatinine level and abnormal urinalysis (hematuria with or without casts, proteinuria, or both). Approach to the patient involves distinguishing predominant-nephritic from predominant-nephrotic features and identifying likely causes by patient age, accompanying illness (see Glomerular Disorders by Age and Manifestations and see Table: Causes of Nephrotic Syndrome), and other elements of the history (eg, time course, systemic manifestations, family history).

Renal biopsy is indicated when diagnosis is unclear from history or when histology influences choice of treatment and outcomes (eg, lupus nephritis).

Glomerular Disorders by Age and Manifestations

Age (yr)

Nephritic Syndrome

Nephrotic Syndrome

Mixed Nephritic and Nephrotic Syndrome

< 15

Mild PIGN

IgA nephropathy

Thin basement membrane disease

Hereditary nephritis

Henoch-Schönlein purpura

Lupus nephritis

Congenital nephrotic syndromes

Minimal change disease

Focal segmental glomerulosclerosis

Lupus (membranous nephropathy)

Lupus nephritis

Membranoproliferative GN

15–40

IgA nephropathy

Thin basement membrane disease

Lupus nephritis

Hereditary nephritis

RPGN

PIGN

Focal segmental glomerulosclerosis

Lupus nephritis

Minimal change disease

Membranous nephropathy

Diabetic nephropathy

Preeclampsia

Late PIGN

IgA nephropathy

Membranoproliferative GN

Fibrillary and immunotactoid GN*

IgA nephropathy

Lupus nephritis

RPGN

> 40

IgA nephropathy

RPGN

Vasculitides

PIGN

Focal segmental glomerulosclerosis

Membranous nephropathy

Diabetic nephropathy

Minimal change disease

IgA nephropathy

Amyloidosis (primary)

Light chain deposition disease

Benign nephrosclerosis

Late PIGN

IgA nephropathy

Fibrillary and immunotactoid GN*

RPGN

*More commonly manifests as nephrotic syndrome.

GN = glomerulonephritis; PIGN = postinfectious glomerulonephritis; RPGN = rapidly progressive glomerulonephritis.

Adapted from Rose BD: Pathophysiology of Renal Disease, ed. 2. New York, McGraw-Hill, 1987, p. 167.

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