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Overview of Glomerular Disorders

By

Frank O'Brien

, MD, Washington University in St. Louis

Last full review/revision Jan 2020| Content last modified Jan 2020
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The hallmark of glomerular disorders is proteinuria, which is often in the nephrotic range (≥ 3 g/day).

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

  • Nephrotic range proteinuria, and nephrotic urine sediment (fatty casts, oval fat bodies, but few cells or cellular casts)

  • Hematuria, usually in combination with proteinuria (which may be in the nephrotic range); the red blood cells (RBCs) are usually dysmorphic and often there are RBC or mixed cellular casts (nephritic urine sediment)

Nephrotic syndrome is nephrotic urine sediment plus edema and hypoalbuminemia (typically with hypercholesterolemia and hypertriglyceridemia).

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, membranoproliferative glomerulonephritis (GN), and 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 Glomerular Disorders by Age and Manifestations) although there is much overlap. The disorders may be

Table
icon

Glomerular Disorders by Age and Manifestations

Age (years)

Nephritic Syndrome

Nephrotic Syndrome

Mixed Nephritic and Nephrotic Syndrome

< 15

Mild PIGN

Lupus nephritis (membranous subtype)

Lupus nephritis

15–40

Lupus nephritis (membranous subtype)

Late PIGN

IgA nephropathy

Lupus nephritis

RPGN

> 40

IgA nephropathy

Light chain deposition disease

Late PIGN

IgA nephropathy

RPGN

* More commonly manifests as nephrotic syndrome.

GN = glomerulonephritis; IgA = immunoglobulin A; PIGN = postinfectious glomerulonephritis; RPGN = rapidly progressive glomerulonephritis.

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

Diagnosis

  • Serum creatinine level and urinalysis

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 Glomerular Disorders by Age and Presentation and 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).

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