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The glomerulus is a histologically complex structure consisting of the epithelial cells [podocytes], basement membrane, capillary endothelium, and mesangium. A variety of different insults can occur within these structures causing different patterns of injury. Examples of injuries that can affect any or all of the constituents of the glomerulus are (1) overwork injury, as in CKD; (2) an inflammatory process, such as SLE; (3) a podocyte protein mutation, as in hereditary focal segmental glomerulosclerosis (FSGS); or (4) a deposition disease, as in diabetes or amyloidosis. Different glomerular patterns of injury tend to cause different clinical syndromes or findings, which may help narrow the differential diagnosis; however, when a glomerular disease is suspected, a kidney biopsy may be needed to clarify the etiology.

CLASSIFICATION

Glomerular diseases can be classified in one of two clinical spectra—the nephritic spectrum and the nephrotic spectrum (Figure 22–3). Differentiating between a clinical presentation within the nephritic spectrum versus the nephrotic spectrum is important because it helps narrow the differential diagnosis of the underlying glomerular disease (Tables 22–7 and 22–8).

Figure 22–3.

Glomerular diseases present within one of the clinical spectra shown; the exact presentation is determined by the severity of the underlying disease and the pattern of injury. Nephritic diseases are characterized by the presence of an active urine sediment with glomerular hematuria and often with proteinuria. Nephrotic spectrum diseases are proteinuric with bland urine sediments (no cells or cellular casts). All glomerular diseases may progress to a chronic, scarred state. (Reproduced with permission from Megan Troxell, MD, PhD.)

Table 22–7.Classification and findings in glomerulonephritis: nephritic spectrum presentations.

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