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Glomerular DiseasesEdit

Glomerular diseases are a diverse set of disorders that affect the tiny filtering units of the kidney, the glomeruli. They range from relatively mild conditions to aggressive illnesses that can progress to kidney failure. These diseases can present with protein in the urine, blood in the urine, swelling, and high blood pressure, and they require careful diagnostic workup to identify the underlying cause and guide management. Because the glomerulus is central to filtering waste while preserving essential proteins, the goal of therapy is to slow or stop injury, control blood pressure, and protect kidney function over time. nephrology kidney glomerulus

Overview

Glomerular diseases encompass immune-mediated processes, metabolic disorders, genetic conditions, infectious etiologies, and drug-induced injuries that disrupt the structure and function of the glomerulus. They can present as nephrotic syndromes (heavy proteinuria, hypoalbuminemia, edema, hyperlipidemia) or nephritic syndromes (hematuria, reduced kidney function, and variable degrees of proteinuria and hypertension), and some forms progress rapidly to kidney failure if untreated. The heterogeneity of these diseases means that treatment is often tailored to the specific histology and the patient’s overall health. nephrotic syndrome nephritic syndrome proteinuria

Classification

Etiology and pathophysiology

Glomerular injury can arise from antibodies and immune complexes depositing in the glomerulus, dysregulation of the complement system, podocyte injury, or metabolic stress. Some conditions are primary diseases of the kidney, while others are secondary to systemic illnesses such as autoimmune disorders, infections, or diabetes. The pathophysiology often informs treatment choices, including immunosuppression, modulation of the renin–angiotensin system, or targeted therapies aimed at specific pathways. immune complex complement system podocyte diabetic nephropathy lupus nephritis

Clinical features

Presentations vary by disease but commonly include: - Proteinuria, which may be heavy in nephrotic forms or modest in other diseases. proteinuria - Hematuria, sometimes with red cell casts, indicating glomerular bleeding. hematuria - Edema, especially in nephrotic syndromes, due to loss of albumin and shifts in fluid balance. edema - Hypertension and decreased kidney function, which may progress without treatment. hypertension renal failure - Fluid overload and fatigue in advanced disease. renal failure

Diagnostic approach

Evaluation starts with history, examination, and basic labs, followed by urinalysis, blood tests, and imaging as needed. A kidney biopsy is often essential to distinguish among glomerular diseases when the presentation is not clearly attributable to a single cause. Immunologic testing (including antineutrophil cytoplasmic antibodies, complement levels, and specific autoantibodies) can help identify autoimmune or immune-mediated etiologies. The goal is to identify the precise disease to guide targeted therapy and prognostication. urinalysis renal biopsy autoimmune disease immunofluorescence electron microscopy

Management and treatment

Management centers on protecting kidney function, reducing inflammation when present, and addressing systemic risk factors. Core strategies include: - General measures: blood pressure control, typically with agents that block the renin–angiotensin system (ACE inhibitors or ARBs), management of edema, and dietary salt restriction. ACE inhibitors ARB sodium restriction - Immunosuppressive therapy: corticosteroids and steroid-sparing agents are used in selected immunologic or inflammatory glomerular diseases, balancing potential benefits with infection risk and other adverse effects. The choice of regimen depends on the specific disease and biopsy findings. corticosteroids immunosuppressive therapy rituximab - Disease-specific treatments: in infectious-associated glomerulonephritis or immune-mediated vasculitis, antimicrobial therapy or targeted immunomodulation may be necessary. IgA nephropathy vasculitis post-infectious glomerulonephritis - Antiplatelet/antiproteinuric strategies: beyond BP control, supportive therapies aim to reduce proteinuria and protect kidneys. Statins may be used for cardiovascular risk management in nephrotic syndrome. statin cardiovascular risk - Renal replacement therapy: for patients who progress to end-stage kidney disease (ESKD), dialysis or kidney transplantation becomes necessary. dialysis kidney transplantation

Genetic and hereditary forms

Some glomerular diseases arise from inherited mutations affecting podocytes, basement membrane proteins, or other components of the filtration barrier. Genetic testing and family counseling can be important in selected circumstances, particularly in younger patients or those with a family history of kidney disease. genetic testing podocyte basement membrane kidney transplantation

Prognosis and outcomes

Prognosis depends on the specific disease, severity at presentation, response to therapy, and the patient’s comorbidities. Some glomerular diseases respond well to treatment and stabilize over time, while others may progress to chronic kidney disease or require long-term dialysis. Early recognition and appropriate management improve the chance of better outcomes. prognosis chronic kidney disease ESKD

Controversies and debates

  • Cost, access, and value of therapy: high-cost biologics and immunosuppressive regimens can strain healthcare budgets. From a conservative, results-focused standpoint, the emphasis is on therapies with proven long-term benefit and careful patient selection to maximize value. Critics of expansive use argue for tighter evidence and cost-effectiveness analyses before adopting expensive regimens broadly. cost-effectiveness healthcare access
  • Screening and early detection: debate exists over broad population screening for proteinuria or early glomerular disease. The responsible position emphasizes targeted screening in high-risk groups and patient education, while warnings are raised about false positives and unnecessary interventions. screening proteinuria
  • Immunosuppression versus watchful waiting: while prompt treatment is essential for certain rapidly progressive or severe forms, there is concern about overtreatment in milder forms where long-term benefits are uncertain and infection or malignancy risks accumulate. Advocates for a cautious approach stress rigorous disease stratification and shared decision-making. immunosuppressive therapy rapidly progressive glomerulonephritis
  • Health disparities and biology: disparities in outcomes across racial and socioeconomic groups are real and multifactorial. Proponents of a health-policy stance argue for addressing social determinants and ensuring access to care, while opponents of identity-focused critiques contend that biology and genetics also play a role and that policy should prioritize measurable health gains. From this viewpoint, practical, evidence-based interventions that improve kidney outcomes take precedence over broad demographic narratives. health disparities socioeconomic status
  • Data and risk communication: there is ongoing debate about how best to communicate risk, prognosis, and treatment trade-offs to patients, balancing clarity with respect for patient autonomy and informed consent. risk communication informed consent

See also