NCLEX Review Guide: Glomerulonephritis

Definition and Process

• Glomerulonephritis refers to inflammation of the glomeruli, the specialized capillary networks in the kidneys responsible for blood filtration. The condition damages the glomerular basement membrane, resulting in increased permeability to proteins and altered filtration capacity.
• The pathological process involves immune complex deposition in the glomerular membrane, leading to complement activation, inflammatory cell recruitment, and subsequent tissue damage.

Classification

• Acute Glomerulonephritis (AGN): Sudden onset inflammation often following a streptococcal infection (post-streptococcal glomerulonephritis), typically occurring 1-2 weeks after a throat infection or 3-6 weeks after a skin infection.
• Chronic Glomerulonephritis: Progressive form that develops slowly over years, potentially leading to end-stage renal disease requiring dialysis or transplantation.
• Rapidly Progressive Glomerulonephritis (RPGN): Aggressive form characterized by rapid decline in kidney function over days to weeks, often associated with crescent formation in histological examination.

Classic Symptoms

• The classic triad of glomerulonephritis includes hematuria, proteinuria, and edema. Gross hematuria may present as tea-colored or cola-colored urine due to the presence of red blood cells passing through damaged glomeruli.
• Hypertension commonly occurs due to fluid retention and activation of the renin-angiotensin-aldosterone system. Patients may report headaches, visual disturbances, and dizziness as manifestations of elevated blood pressure.

Systemic Manifestations

• Patients may experience fatigue and malaise due to the accumulation of waste products normally filtered by the kidneys. In severe cases, uremic symptoms including nausea, vomiting, and altered mental status may develop.
• Fluid overload can lead to pulmonary edema with dyspnea, orthopnea, and crackles on auscultation. Cardiac manifestations may include heart failure symptoms if hypertension and volume overload become severe.

Laboratory Tests

• Urinalysis typically reveals hematuria (RBCs or RBC casts), proteinuria, and sometimes pyuria. The presence of RBC casts is particularly significant as they indicate glomerular origin of bleeding.
• Blood tests include BUN and creatinine (to assess renal function), electrolytes, complete blood count, and specific immunological markers such as anti-streptolysin O (ASO) titers, complement levels (C3, C4), and autoantibodies (ANA, anti-GBM antibodies, ANCA) depending on the suspected cause.

Imaging and Procedures

• Renal ultrasound may show enlarged, edematous kidneys in acute glomerulonephritis or small, echogenic kidneys in chronic disease. Ultrasound also helps rule out other causes of renal dysfunction such as obstruction.
• Kidney biopsy is the gold standard for definitive diagnosis, providing information about the type, severity, and potential reversibility of glomerular damage. Light microscopy, immunofluorescence, and electron microscopy are used to characterize the pattern of injury.

Assessment

• Perform comprehensive assessment focusing on vital signs (especially blood pressure), fluid status, urine output, and presence of edema. Document the extent and distribution of edema using a consistent measurement technique.
• Assess for signs of complications including hyperkalemia (cardiac arrhythmias, muscle weakness), uremia (nausea, confusion, pruritus), and fluid overload (dyspnea, crackles, S3 heart sound).

Interventions

1. Implement strict fluid and sodium restrictions as prescribed to manage edema and hypertension. Typical restrictions range from 1-2 liters of fluid daily and 2-3 grams of sodium.
2. Administer medications as ordered, which may include antihypertensives, diuretics, immunosuppressants, and antibiotics for underlying infections.
3. Provide protein management based on the degree of proteinuria - high-quality protein diet for nephrotic syndrome or protein restriction for advanced renal insufficiency.
4. Monitor for and prevent complications through regular assessment of vital signs, laboratory values, and symptoms.
5. Provide education on disease process, medication regimen, dietary restrictions, and signs of worsening condition requiring medical attention.

• Glomerulonephritis is inflammation of the kidney's filtering units (glomeruli) that can be acute or chronic, primary or secondary to systemic disease.
• The classic triad includes hematuria, proteinuria, and edema, often accompanied by hypertension.
• Diagnostic evaluation includes urinalysis (RBC casts are diagnostic), blood tests (BUN, creatinine, complement levels), and kidney biopsy for definitive diagnosis.
• Management focuses on treating underlying causes, controlling blood pressure, managing fluid status, and preventing progression to chronic kidney disease.
• Nursing care includes monitoring vital signs, fluid balance, and laboratory values; administering medications; providing dietary guidance; and patient education.