Glomerulonephritis

What is it? Glomerulonephritis is an acute inflammation of the glomerulus that can lead to chronic disease. In glomerulonephritis, the glomeruli capillaries become inflamed and impair the kidneys ability to filter urine. Glomerulonephritis is typically preceded by a group A beta-hemolytic streptococcal infection of the throat. Other illnesses that precede glomerulonephritis are impetigo, upper respiratory tract infections, mumps, varicella zoster virus, EpsteinBarr virus, hepatitis B, and HIV. The antigenantibodies deposit in the glomerulus in the presence of these infections. This causes thickening and scarring of the glomerular filtration membrane, which leads to decreased GFR.Medications such as gold used in the treatment of rheumatoid arthritis, may also cause glomerulonephritis due to antigen antibody complexes deposited in the glomeruli.When the glomerulus is damaged, protein and blood cells can leak out into the urine. The bottom line is this: if your glomerulus is not working properly, then everything having to do with kidney function is messed up! OTHER IMPORTANT THINGS TO KNOW Glomerulonephritis is: 1. Mainly seen in boys ages 3 to 7, but can be seen at any age. 2. Treatable with full recovery in 60% of adults. However, there is a great chance of permanent renal damage, which can progress to chronic renal failure, especially in the elderly population. 3. A severe illness, which can vary from client to client depending on how much of the glomerulus is damaged. What causes it and why? Table 15-2 describes the causes and explanations for glomerulonephritis. Causes Why Streptococcal infection Antibodies lodge in the glomerulus due to strep infection of the throat or skin and cause scarring; antibodies attach to an antigen forming an antigen antibody complex, which can damage kidneys. Immune mediated response which is a noninfectious cause Inflammation of blood vessels in the kidney called vasculitis; due to various autoimmune disorders or related to antigenantibody complexes Antigenantibody mediated

Viruses and parasites

Signs and symptoms and why Signs and symptoms usually subside in 10 to 14 days. Table 15-3 describes the signs and symptoms and background for glomerulonephritis. Signs and Symptoms Why Asymptomatic Latent symptoms due to slow progression of disease Hematuria, proteinuria When the glomerular membrane is damaged (inflammation, thickening, scarring), the openings in the glomerulus enlarge, allowing protein and blood to leak out. Glomerular bleeding can occur and make the urine acidic (blood is slightly acidic). When glomerulus is damaged and inflamed, the GFR decreases (not as much blood passing through glomerulus), so sodium and water are retained. Anytime the kidneys are sick, odds are fluid retention will occur as they are unable to excrete properly.

Edema found mainly in hands and face

Malaise, headache, nausea and vomiting Elevated blood pressure and fluid volume overload with weight gain Dark urine that contains blood (smoky, coffeecolored appearance that looks like a colacolored soft drink or tea); possible first sign of glomerulonephritis Anemia Kidney produces erythropoietin under healthy conditions, which is responsible for red blood cell production. With renal failure, erythropoietin production is impaired, which interferes with red blood cell production; blood is excreted in the urine Dyspnea, engorged neck veins cardiomegaly, pulmonary edema, periorbital edema Hypertension (with possible headache) Circulatory overload Confusion, somnolence, seizures Circulatory overload; sodium imbalances can also affect the level of consciousness and cause seizures Oliguria (one of the first symptoms) Kidneys are unable to excrete properly; worsens as GFR decreases Quickie tests and treatments Tests: _ Serum electrolytes: elevated due to decreased excretion. _ Serum protein and albumin: decreased because these substances leak from the blood supply into the urine; albumin can also be decreased as fluid is retained, causing a dilution effect on the blood, which makes albumin even lower. _ Urinalysis: positive for blood, protein, white blood cells. _ 24-hour urine specimen for creatinine clearance and for total protein assay: client may lose up to 3 grams of protein every 24 hours. _ Serum BUN and creatinine: elevated due to decreased excretion. _ Renal ultrasound or x-ray of kidneys, ureter, and bladder (KUB): may show kidney enlargement. _ Renal biopsy: monitor health of kidney tissue. _ GFR: decreased due to inflammation (may be less than 50 mL/min); the older the client, the more decreased the GFR. GFR is measured through a creatinine clearance test. _ Antistreptolysin-O titer: elevated in presence of glomerular damage due to strep. _ Other immune tests may be performed as glomerulonephritis can be due to an immune system problem such as antinuclear antibodies, decreased C3 complement, and IgG present in serum (also known as cryoglobulins). _ Throat culture: positive if glomerular damage is due to strep. Treatments: _ If BUN is increased and oliguria is present, then dietary protein should be limited or restricted. Under normal circumstances, protein breaks down into urea and is excreted by the kidneys. However, if the Circulatory overload Retention of toxins; kidneys are unable to filter and excrete bad substances properly; toxins make you feel bad. Related to decreased urine output with subsequent fluid volume excess Red blood cells and protein that are not normally allowed through the kidney now pass through due to damage.

kidneys are not working correctly, then urea is not excreted and BUN will go up. Limited or restricted intake of dietary protein keeps BUN from increasing. _ Low-sodium diet until kidney function normalizes: sodium causes fluid retention. _ Monitor fluid intake closely due to edema and fluid retention. _ Diuretics help kidneys get rid of excess sodium and water. _ Phosphate-binding drugs (Amphojel): decrease phosphorus in the blood and increase serum calcium. _ H2-blockers and proton pump inhibitors treat stress ulcers. _ Steroids depending on the cause (autoimmune disease): decrease inflammation in the glomerulus so membranes can heal. _ Treat infection (strep) with antibiotics. _ Monitor intake and output. _ Measure weight daily at the same time each day. _ Bed rest: decreases metabolic demands on the body, but also induces diuresis, which is good; supine position perfuses the kidneys which increased urine production. _ Increase carbohydrate intakes to improve energy and to prevent body from breaking down protein for energy. _ Dialysis or kidney transplant: treatment for chronic glomerulonephritis. _ Plasmapheresis: removes antibodies. _ Diuretics and blood pressure medications: decrease extra fluid volume. THINK ABOUT THIS Creatinine is formed from creatine phosphate, which is stored in the muscle and is normally excreted by the kidneys. It is produced constantly and is directly related to muscle mass. Serum creatinine and GFR are inversely related. A rise in serum creatinine suggests renal disease, because the kidneys are unable to excrete it. If creatinine rises by 50% in the blood, then GFR has gone down by 50%in other words, 50% decrease in kidney function.When the GFR is decreased, the glomerulus is not filtering as it should because it is sick. Therefore, you see a rise in the serum creatinine. GRF cannot be measured directly. It has to be calculated. GFR is an estimate of renal function and is calculated by a formula using urine and plasma creatinine (dont worry; the physician will do the calculating). Since urine creatinine is needed to figure GFR, how do we get this value? A creatinine clearance value from the 24-hour urine specimen is used. Creatinine clearance is the amount of creatinine excreted from the kidneys in 24 hours. This is one reason to obtain a 24-hour urine specimen. Creatinine clearance is used to determine the rate of glomerular filtration. There is no way to determine exactly what the GFR is, but creatinine clearance is used to help determine an estimate of GFR. Specifically, the creatinine clearance measures the amount of blood that is cleared of creatinine in 1 minute. This value is plugged into a formula to determine GFR. What can harm my client? _ Too much protein in the diet. _ Renal failure, resulting in dialysis. _ Hypertension. _ Congestive heart failure. _ Hypertrophy of the heart. _ Hypertensive encephalopathy (medical emergency), seizures. _ Pulmonary edema. _ Urinary tract infections. _ Fluid and electrolyte imbalances. _ Sepsis. If I were your teacher, I would test you on . . . _ Definition of glomerulonephritis. _ Signs and symptoms of glomerulonephritis and why. _ Causes of glomerulonephritis and the impact on fluids and electrolytes.

_ Complications and related treatment. _ Nursing interventions such as monitoring intake and output and daily weights. _ Diet modifications. _ Function of albumin and related kidney function tests. _ How age affects GFR. _ Medication side effects; the use of steroids and how this affects client roommate selection (client may be immunosuppressed).