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 Glomerular Disorders: Overview of Nephrotic Syndrome) is nephrotic urine sediment plus edema and hypoalbuminemia (typically with hyperlipidemia).

Nephritic syndrome (see Glomerular Disorders: 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 Glomerular Disorders: Fibrillary and Immunotactoid Glomerulopathies), membranoproliferative glomerulonephritis (GN—see Glomerular Disorders: Membranoproliferative Glomerulonephritis), and lupus nephritis (see Glomerular Disorders: 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 Table 1: Glomerular Disorders: Glomerular Disorders by Age and Manifestations) although there is much overlap. The disorders may be primary (idiopathic) or have secondary causes (see Table 2: Glomerular Disorders: Causes of Glomerulonephritis and Table 4: Glomerular Disorders: 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 Table 1: Glomerular Disorders: Glomerular Disorders by Age and Manifestations and Table 4: Glomerular Disorders: 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).

Table 1
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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.

Last full review/revision March 2013 by Navin Jaipaul, MD, MHS