Monday, June 27, 2022

Glomerulonephritis Due To Infectious Hepatitis

Chronic And Recovered Thrombotic Microangiopathies

Treatment & prognosis of Acute Glomerulonephritis – Dr. Sharat Honnatti

The following are chronic and recovered thrombotic microangiopathies associated with a membranoproliferative pattern of renal injury :

  • Healing phase of hemolytic uremic syndrome and/or thrombotic thrombocytopenic purpura
  • Syndromes of circulating antiphospholipid antibodies
  • Radiation nephritis
  • Nephropathy associated with bone marrow transplantation
  • Sickle cell anemia and polycythemia
  • Transplant glomerulopathy

What Are The Kidneys And What Do They Do

The two kidneys are bean-shaped organs located just below the rib cage, one on each side of the spine. Every day, the two kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid.

Blood enters the kidneys through arteries that branch inside the kidneys into tiny clusters of looping blood vessels. Each cluster is called a glomerulus, which comes from the Greek word meaning filter. The plural form of the word is glomeruli. There are approximately 1 million glomeruli, or filters, in each kidney. The glomerulus is attached to the opening of a small fluid-collecting tube called a tubule. Blood is filtered in the glomerulus, and extra fluid and wastes pass into the tubule and become urine. Eventually, the urine drains from the kidneys into the bladder through larger tubes called ureters.

Each glomerulus-and-tubule unit is called a nephron. Each kidney is composed of about 1 million nephrons. In healthy nephrons, the glomerular membrane that separates the blood vessel from the tubule allows waste products and extra water to pass into the tubule while keeping blood cells and protein in the bloodstream.

Natural History Of Hcv Infection

Hemodialysis patients are at particular high risk for bloodborne infections because of prolonged vascular access and potential for exposure to contaminated equipment. It has been estimated that, among patients on hemodialysis, the prevalence of HCV infection varies greatly, from less than 5% to nearly 60% according to different areas of the world . Regardless of the geographic location, however, the prevalence is consistently associated with patient age and the number of transfused blood products . Given the introduction of routine screening and heightened attention to prevention of spread, the prevalence of HCV infection has declined in many dialysis centers, and yet it remains unacceptably high, ranging from 8% to 10% even in the most industrialized countries . In European dialysis centers the incidence rate for new-onset HCV infection varies from 0.4% to 16.0% per year . Spontaneous disappearance of HCV RNA has been reported in 1% of untreated dialysis patients .

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Racial Sexual And Age Differences In Incidence

In the United States, MPGN predominantly affects the white population. Type I disease affects women more often than men, whereas a nearly equal sex distribution is seen in MPGN type II.

The idiopathic forms of MPGN are more common in children and young adults . Isolated reports of involvement in patients as young as 2 years and as old as 80 years are noted in the literature. Secondary types of MPGN predominate among adults.

Clinical Course And Prognosis

HPR volume 12 issue 42: news (23 November)

The natural history of HBVMN is incompletely understood. Spontaneous regression of the nephrotic syndrome was reported in 3060% of cases of HBVMN, and these patients had usually remained symptomatic for 12 months or longer . The remaining patients had persistent proteinuria with fluid retention . Seroconversion to anti-HBeAg is associated with remission of proteinuria . There have also been reports of progression to renal insufficiency in those patients who do no clear the virus . The majority of children however have a benign course. A report by Gilbert and Wiggelinkhuizen in 1994 in a study from Cape Town reported 71 children with HBV-associated nephropathy. In this cohort of patients, 37 of patients went into spontaneous remission, this was associated with HBeAg clearance in 33 patients over 90 months the average time of clearance of HBeAg to remission was 5 months. A second report by Bhimma et al. of 93 children with HBV-associated nephropathy in black children in KwaZulu/Natal in South Africa showed 70 of the 93 patients to have MN with a pattern of disease similar to that reported from other regions in South Africa.

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Other Hepatitis C Virusrelated Glomerulopathies

Although MPGN is most commonly associated with HCV infection, other glomerulonephritides are also reportedly associated with HCV, including membranous nephropathy, focal segmental glomerulosclerosis, postinfectious glomerulonephritis, thrombotic micro-angiopathies, IgA nephropathy, and fibrillary or immu-notactoid glomerulopathy. While the long-term effects of HCV-associated glomerulopathies are unclear, studies have shown that patients with HCV infection, irrespective of etiology, are 40% more likely to develop ESRD than the general population., The prognosis of HCV-associated glomerulopathies is poor because of a high incidence of cardiovascular diseases and infections.

Hepatitis C Virus And Renal Manifestations

Chronic HCV infection can potentially cause chronic kidney diseases. Both glomerular and tubulointerstitial diseases associated with HCV have been described. However, the exact mechanism of these diseases is unclear. An association between HCV infection and albuminuria without overt kidney disease has also been described hence, HCV infection may have a greater influence on renal dysfunction than is presently documented., The most common renal manifestations of HCV infection are essential mixed cryoglobulinemia leading to mem-branoproliferative glomerulonephritis , MPGN without cryoglobulinemia, and membranous glomerulonephritis. On the other hand, patients with end-stage kidney disease are at an increased risk of acquiring HCV infection due to their frequent exposure to potentially contaminated devices in dialysis units and their long-term use of vascular access.

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Epidemiology And Transmission Of Hbv Infection

The HBV is globally distributed and estimated to have infected 350 million people worldwide, making it one of the most common human pathogens . The prevalence of HBV infections is highest in developing countries in Africa, Asia, and the Pacific Islands and lowest in developed countries . In Africa and Asia where infection is endemic, it is usually acquired in the first decade of life. The way the disease spreads however may differ in these regions . In areas of high HBV incidence, transmission is usually vertical from infected mother to child, or horizontal within families. In intermediate areas of prevalence, HBV is spread horizontally, with the highest rate of infection occurring among older children, adolescents and adults. In areas of low prevalence, HBV is primarily a disease of adolescents and young adults and is transmitted sexually or parenterally .

Table 1

Worldwide distribution ofhepatitis B virus infection

The prevalence of HBV infections in developing regions is not well documented. In Africa it is estimated that approximately 98% of the 470 million inhabitants are infected with the virus at some time during their lives and about 10% develop chronic infections . In China and Southeast Asia, vertical transmission is responsible for about 50% of the chronic carrier rate, but in other areas of high endemicity such as the Middle East and India, horizontal transmission among children and young adults is more important .

Glomerular Disorders In Diseases Classified Elsewhere

Nephrotic Syndrome – Types and pathology (histology)
    2016201720182019202020212022Billable/Specific CodeManifestation Code
  • N08 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
  • The 2022 edition of ICD-10-CM N08 became effective on October 1, 2021.
  • This is the American ICD-10-CM version of N08 – other international versions of ICD-10 N08 may differ.
  • N08 describes the manifestation of an underlying disease, not the disease itself.

“code first”

  • underlying disease, such as:
  • E85.81 Light chain amyloidosis
  • E85.82 Wild-type transthyretin-related amyloi…

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Worldwide Perspective Of Hbv

The reported prevalence of HBV-associated nephropathy, particularly MN, closely parallels the geographic patterns of prevalence of HBV . In children with HBV-associated nephropathy, it would appear that horizontal transmission of HBV is the predominant mode of transmission in most regions . The rarity of HBV-associated nephropathy in developed countries such as the USA and Europe probably reflects the rarity of HBV infection, particularly in children. In the USA, HBVMN is most frequently seen in African Americans . In developed countries, HBV-associated nephropathy is frequently seen in adults who are high-risk groups such as intravenous drug abusers, dialysis patients, etc.

Following the report by Levy and Chen on the worldwide perspective of HBV-associated glomerulonephritis in the 1980s, further reports of HBV-associated nephropathy have been from the southern African continent . The possible reason for the low reporting of cases of HBV-associated nephropathy is the introduction of HBV immunization in several regions endemic for HBV infection the decline in the incidence of HBV-associated nephropathy accompanying the decline in HBV infection.

What Are The Symptoms Of Glomerulonephritis

Symptoms of glomerulonephritis often come on slowly. You might not notice that anything is wrong. Signs of glomerulonephritis are often found at routine wellness visits with your health care provider. Your health care provider might want you to have more tests to check for glomerulonephritis or another kidney disease if your tests show any of the following problems:

Contact your health care provider if you notice any of the following symptoms, as they may be signs of glomerulonephritis or another kidney problem:

  • Pink or brown-colored urine
  • Swelling in your face, eyes, ankles, feet, legs or belly area
  • Feeling more tired than normal

If you notice any symptoms or if your tests show that your kidneys might not be working as well as they should, your health care provider might ask you to have one or more of the following tests:

  • Urine test: Your health care provider will take a urine sample to check for blood, protein, white blood cells and red blood cells.
  • Blood test: Your health care provider will take a blood sample to check the levels of waste in your blood.
  • Imaging tests: Your health care provider might want you to have an X-ray, ultrasound or CT scan so that he or she can see your kidneys.
  • Kidney biopsy: Your health care provider or a surgeon will use a special needle to take a tiny piece of tissue from inside your kidney. The tissue sample will be looked at under a microscope to check for glomerulonephritis.

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Clinical Features And Laboratory Findings

The mean age was 13 years old in patients with HBV-PIGN, consistent with the fact that PIGN occurs more commonly in children. The mean age was 12 years old in non-HBV associated PIGN . There were 8 males and 2 females in the HBV-PIGN group and 4 males and 6 females in non-HBV associated PIGN group. All10 patients with HBV-PIGN were positive for serum HBsAg and HBeAg and HBcAb at the onset of acute nephritis. Four had high titer of circulating HBV DNA ranging from 4 to 9.5×106 copies/ml. However, only one patient had a mild liver function abnormality, with a small increase in serum aspartate aminotransferase and alanine aminotransferase activities. It was noted that three patients with HBV-PIGN had skin impetigo before PIGN, although the causative bacteria was not identified. None of 10 HBV-PIGN patients had current, or a history of, acute hepatitis B infection. Serological HBV infection markers were negative at birth. In addition, there were no signs of acute flare of chronic hepatitis B, such as jaundice, increased bilirubin, continual and gradual elevation of liver enzyme activity, or severe thrombocytopenia.

Clinical Manifestations And Natural History

Screening for Viral Hepatitis During the Domestic Medical ...

Besides MPGN, other forms of glomerular disease have been associated with HCV infection, which include IgA nephropathy, postinfectious glomerulonephritis, membranous nephropathy, thrombotic microangiopathies, focal and segmental glomerulosclerosis , and fibrillary or immunotactoid glomerulopathy . The course of these HCV-associated nephropathies is characterized by remission and relapsing phases.

The long-term outcome of HCV-associated nephropathies remains ill-defined. In a recent retrospective cohort study involving over 470,000 adult veterans, patients with HCV infection were more likely to develop ESRD than HCV-seronegative patients . Moreover, in patients with an estimated glomerular filtration rate â¤30 ml/min per 1.73 m2, the presence of HCV was associated with a nearly threefold higher risk of ESRD. These findings were confirmed by a subsequent cross-sectional study showing that HCV-positive patients had a 40% higher likelihood for developing renal insufficiencyâdefined as serum creatinine levels â¥1.5 mg/dlâcompared with seronegative subjects . Beside the risk of renal disease progression, the overall prognosis for patients with HCV-related nephritis is poor because of a high incidence of co-infections and cardiovascular disease .

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What Causes Glomerulonephritis

It is not always possible to know what causes glomerulonephritis. Many diseases and conditions can lead to damage of the glomeruli, but someone may also have glomerulonephritis without ever having one of these diseases or conditions. Some of the problems that can lead to glomerulonephritis include:

  • High blood pressure

What Is Glomerulonephritis

Inflammation of the glomeruli of the kidney results in a condition known as glomerulonephritis. A healthy glomerulus allows waste products and extra water to pass in urine while keeping blood cells and protein in the bloodstream. However in glomerulonephritis, proteins and sometimes red blood cells leak out which is not just the loss but also a cause of fluid accumulation and swelling in the body.

The nephron is the smallest filtering unit of the kidney. Each nephron comprises of a renal corpuscle and renal tubule. The renal corpuscle, in turn, is formed by the glomerulus and the Bowmans capsule. The glomerulus is that part of the nephron which removes the waste and excess fluid from the blood. Thus, it has a primary role in filtration. For assessing the functional capacity of kidneys, Glomerular Filtration Rate is determined.

Glomerulonephritis may be acute or chronic and may be caused due to a variety of reasons including underlying diseases such as diabetes. If the condition remains untreated and inflammation lasts for a longer period, risk of kidney damage severely increases.

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What Is Nephrotic Syndrome

Nephrotic syndrome happens when your kidneys start losing large amounts of protein in your urine. As your kidneys get worse, extra fluids and salt build up in your body. This causes you to have swelling , high blood pressure and higher levels of cholesterol. Nephrotic syndrome may come from kidney diseases or from other illnesses such as diabetes and lupus. Some medicines, IV drug abuse and HIV may also cause it. Sometimes, nephrotic syndrome goes away after treatment. Other times, this condition may last for many years and eventually lead to kidney failure.

Deterrence And Patient Education

Hepatitis A Virus (HAV) for USMLE

It is important to cut down salts from the diet during acute disease.

For progressive disease, dietary restrictions help to reduce the build-up of wastes and also prevent states of fluid overload.

Cessation of smoking is also paramount in decreasing the aggravation of the renal disease.

Education in countering diabetes and elevated blood pressures is also important, through adequate lifestyle modifications and standardized therapy. Patients must also be counseled regarding the control of hyperlipidemias.

Problems with respect to sexual health usually can occur in kidney disease, especially in men. Hence, appropriate guidance regarding the same should be provided to the patient.

Patients with nephrotic syndrome and especially those with progression into chronic kidney disease are vulnerable to infections, so a seasonal flu vaccine and pneumococcal vaccines are of help for them.

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Severe Acute Respiratory Syndrome Coronavirus

Six percent of patients suffering from severe acute respiratory distress syndrome had acute renal impairment. Despite detection of viral DNA in the urine, there was no evidence of viral tropism of the kidney. The pathology is exclusively tubulointerstitial nephritis. The mechanism of disease is probably related to multiorgan failure, rhabdomyolysis, and hemodynamic disturbance.

What Are The Types Of Glomerulonephritis

There are various ways of classifying glomerulonephritis.

It may be classified based on the development of glomerulonephritis:

  • Chronic glomerulonephritis: Chronic form of glomerulonephritis develops over several years. If the symptoms are not identified in an early stage, this may lead to complete kidney failure.
  • Acute glomerulonephritis: Acute glomerulonephritis is characterized by the sudden appearance of symptoms. This may be due to infection or due to some other reason. At times, no treatment is required, and the condition becomes normal with time. In some cases, medical intervention is necessary.

Classification may also be done based on the cause of glomerulonephritis:

  • Primary glomerulonephritis: Primary glomerulonephritis occurs on its own and is not developed due to other existing diseases in the body.
  • Secondary glomerulonephritis: Reason for secondary glomerulonephritis is an underlying disease. These diseases may include infection, lupus, or diabetes.

Glomerulonephritis can be classified based on immune reactions:

  • IgA glomerulonephritis: Such type of glomerulonephritis may be due to the accumulation of IgA antibody in the glomeruli, which causes damage.
  • IgM glomerulonephritis: Accumulation of IgM antibody damages the glomeruli.

Glomerulonephritis can be classified based on the location and extent of damage within the glomerulus:

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Viruses And Mechanisms Involved In Viral Nephropathy

Different mechanisms are operative in different viral nephropathies . In acute glomerulonephritis, direct viral infection of the glomerulus induces proliferative changes following release of cytokines. The nephropathy is reversible in most cases if the virus is rapidly cleared. In chronic forms of glomerulonephritis, persistent viral infection provides continuous antigenic stimulation, resulting in antibody production and formation of immune complexes. Studies indicate a role in the disease pathogenesis for these immune complexes, which can be derived from the circulation or formed in situ., Viral proteins cause inflammatory renal diseases via synthesis of various mediators that can cause sclerosis and worsen glomerulopathy., A direct cytopathic effect of viral proteins has also been postulated. In hepatitis C virus -induced mesangiocapillary glomerulonephritis , production of circulating cryoglobulins is induced as an abnormal host response to infection. Cryoglobulins are either type II or type III. At least two classes of immunoglobulins are involved, one of which is polyclonal. In acute renal failure associated with infection by hantavirus or severe acute respiratory syndrome coronavirus, the pathogenetic mechanisms of interstitial nephritis, disseminated intravascular coagulopathy, and multiorgan failurerather than formation of immune complexesare predominant.

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