Diffuse Proliferative Glomerulonephritis

Diffuse proliferative glomerulonephritis (DPGN) is a histopathologic classification of glomerulonephritis (GN) characterized by an increased cellular proliferation affecting > 50% of the glomeruli. Mesangial, endothelial, and epithelial cells are notably increased. The most common causes are lupus nephritis class IV and IgA nephropathy IgA nephropathy IgA nephropathy (Berger's disease) is a renal disease characterized by IgA deposition in the mesangium. It is the most common cause of primary glomerulonephritis in most developed countries. Patients frequently present in the second and third decades of life and, historically, with a preceding upper respiratory or GI infection. IgA Nephropathy. Individuals may present with symptoms related to the renal disease, such as fatigue, nausea, vomiting, hematuria, proteinuria, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema. Other manifestations related to the underlying disease can be present. Diagnosis is made by laboratory tests, renal imaging, and renal biopsy. Microscopic findings show hypercellularity of mesangial and endothelial cells, with capillary loop thickening. Early aggressive therapy is indicated and is based on the specific etiology.

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Overview

Definition

Diffuse proliferative glomerulonephritis (DPGN), a histopathologic classification of glomerulonephritis (GN) commonly associated with autoimmune diseases, is characterized by an increased cellular proliferation affecting > 50% of the glomeruli.

  • Mesangial, epithelial, endothelial, and inflammatory cells are increased in the glomeruli.
  • Can progress to rapidly progressive GN

Etiology

  • Lupus nephritis class IV is the most common cause of DPGN.
  • IgA nephropathy IgA nephropathy IgA nephropathy (Berger's disease) is a renal disease characterized by IgA deposition in the mesangium. It is the most common cause of primary glomerulonephritis in most developed countries. Patients frequently present in the second and third decades of life and, historically, with a preceding upper respiratory or GI infection. IgA Nephropathy
  • Anti–glomerular basement membrane (GBM) disease 
  • Granulomatosis with polyangiitis Granulomatosis with Polyangiitis Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease of unknown etiology. It leads to a necrotizing granulomatous inflammation of small and medium-sized blood vessels of the nose, sinuses, throat, lungs, and kidneys. Granulomatosis with Polyangiitis
  • Microscopic polyangiitis
  • Henoch-Schönlein purpura Henoch-Schönlein Purpura Henoch-Schönlein purpura (HSP), also known as immunoglobulin A vasculitis, is an autoimmune small-vessel vasculitis that typically presents as a tetrad of abdominal pain, arthralgia, hematuria, and purpuric rash. Henoch-Schönlein Purpura
  • Cryoglobulinemia
  • Vasculitis
  • Infectious causes:
    • Infective endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis
    • Hepatitis C Hepatitis C Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). The infection can be transmitted through infectious blood or body fluids and may be transmitted during childbirth or through IV drug use or sexual intercourse. Hepatitis C virus can cause both acute and chronic hepatitis, ranging from a mild to a serious, lifelong illness including liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis C Virus
    • Hepatitis B Hepatitis B Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus

Epidemiology

  • Prevalence of lupus nephritis: around 40% of individuals with lupus in the United States
  • Incidence of end-stage renal disease (ESRD) attributed to lupus nephritis: 4.5 cases per 1 million cases in the general population
  • Women are more likely to develop DPGN.
  • Men are more likely to develop aggressive cases of DPGN.
Diffuse_proliferative_lupus_nephritis

“Flea-bitten” appearance of the cortical surface of a kidney in diffuse proliferative glomerulonephritis.

Image: “Diffuse Proliferative Lupus Nephritis class IV” by Ed Uthman. License: Public Domain

Pathophysiology

Mechanism of injury

  • Depends on the underlying cause of DPGN
  • Typically involves deposition on immune complexes, which in turn activates the complement pathway:
    • Immune complexes are aggregates of antigens and antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins.
    • Deposition occurs in the mesangium, GBM, or subendothelial or subepithelial locations.
    • Results in recruitment of inflammatory cellular infiltrates, proliferation of mesangial and endothelial cells, and necrosis
    • Severe cases may have cellular crescents (epithelial cells, activated macrophages, and fibrin) and fibrin thrombi. 
  • Cytokine release leads to cellular injury.

Effects

  • Immunologic attack on the glomerulus → ↑ GBM permeability to protein, RBCs, and WBCs
  • Capillary loops become obliterated and sclerosis develops → hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension and renal failure
  • Fibrinoid necrosis in the glomerular vasculature → vasculitis → ↓ renal filtration and function

Clinical Presentation

General manifestations

Presentations vary considerably, with most symptoms occurring because of the decrease in GFR caused by DPGN.

  • Nonspecific symptoms:
    • Nausea
    • Fatigue
    • Vomiting
    • Oliguria
  • Nephritic symptoms:
    • Proteinuria
    • Hypertension
    • Edema
    • Hematuria

Presentation in relation to underlying disease

Because DPGN is caused by another condition, the symptoms of the underlying cause are often present, such as in: 

  • Systemic lupus erythematosus Systemic lupus erythematosus Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus ( SLE SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus):
    • Rash
    • Joint pains
    • Photosensitivity
    • Serositis
    • Oral ulcers
  • IgA nephropathy IgA nephropathy IgA nephropathy (Berger's disease) is a renal disease characterized by IgA deposition in the mesangium. It is the most common cause of primary glomerulonephritis in most developed countries. Patients frequently present in the second and third decades of life and, historically, with a preceding upper respiratory or GI infection. IgA Nephropathy:
    • Preceding upper respiratory or GI infection
    • Flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Gross hematuria
  • Anti-GBM disease:
    • Majority with renal disease
    • About 25%–60% with pulmonary manifestations:
      • Hemoptysis Hemoptysis Hemoptysis is defined as the expectoration of blood originating in the lower respiratory tract. Hemoptysis is a consequence of another disease process and can be classified as either life threatening or non-life threatening. Hemoptysis can result in significant morbidity and mortality due to both drowning (reduced gas exchange as the lungs fill with blood) and hemorrhagic shock. Hemoptysis
      • Cough
      • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
  • Granulomatosis with polyangiitis Granulomatosis with Polyangiitis Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease of unknown etiology. It leads to a necrotizing granulomatous inflammation of small and medium-sized blood vessels of the nose, sinuses, throat, lungs, and kidneys. Granulomatosis with Polyangiitis:
    • Pulmonary (hemoptysis, cough)
    • Head and neck (nosebleeds, hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss, nasal cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage deformities)

Diagnosis

Renal biopsy

  • Gold standard for diagnosis 
  • Light microscopy:
    • Marked hypercellularity of endothelial and mesangial cells
    • Capillary loop thickening (wire loops)
    • Inflammatory cell infiltration
    • Severe forms: cellular crescents and necrosis
  • Immunofluorescence microscopy:
    • Absent (or mild) glomerular staining for Ig and/or complement in ANCA-associated GN (pauci-immune disease)
    • Granular deposition of Ig, complement, and fibrin along the GBM in most, except anti-GBM disease
    • Linear deposition in anti-GBM disease
  • Electron microscopy:
    • Electron-dense deposits noted in the mesangial, subendothelial  intramembranous, and subepithelial areas
    • In SLE SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus: wire loop lesions in the mesangial and subendothelial areas
    • In anti-GBM disease: linear and intramembranous deposits 
    • In poststreptococcal GN: subepithelial deposits (humps) 
    • In ANCA-associated GN: few or no deposits
Histology for diffuse proliferative glomerulonephritis

Histology for diffuse proliferative glomerulonephritis with leukocytic infiltration

Image: “Diffuse proliferative glomerulonephritis with leukocytic infiltration” by Cannata-Ortiz P. License: CC BY 4.0

Other diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests

  • CBC findings (depending on underlying disease) can include:
    • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview 
    • Leukopenia
    • Lymphopenia 
    • Thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
  • Renal function tests: 
    • ↑ Serum creatinine due to kidney damage
    • ↑ BUN due to kidney damage
  • Urinalysis may show any of the following:
    • RBCs and casts
    • WBCs 
    • Granular casts
    • Proteinuria
  • Serologic tests to evaluate for the primary etiology of DPGN:
    • Positive ANAs: nonspecific, but positive in majority of cases of SLE SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus
    • Positive anti–double-stranded DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure (anti-dsDNA) and anti-Smith (anti-Sm) antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: SLE SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus
    • Low C3, C4, and CH50: SLE SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus, postinfectious GN, poststreptococcal GN, cryoglobulinemia
    • Positive ANCA: granulomatosis with polyangiitis
    • Positive anti-GBM antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: anti-GBM disease
    • High titers of anti–streptolysin O: poststreptococcal GN
    • Elevated serum IgA levels: IgA nephropathy IgA nephropathy IgA nephropathy (Berger's disease) is a renal disease characterized by IgA deposition in the mesangium. It is the most common cause of primary glomerulonephritis in most developed countries. Patients frequently present in the second and third decades of life and, historically, with a preceding upper respiratory or GI infection. IgA Nephropathy
  • Renal ultrasonography:
    • Confirm that 2 kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys are present and obtain renal size.
    • Evaluate for obstruction or structural lesions that may cause azotemia.

Management

Treatment approach

  • Depends on severity of disease
  • Generally, should be aggressively treated in a timely manner to minimize the risk of ESRD
  • Mild disease:
    • Characteristics:
      • Normal serum creatinine levels
      • Non–nephrotic-range proteinuria
      • Normal estimated GFR (eGFR)
    •  May be managed with an ACEi, a statin (↓ atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis), and regular follow-up
  • Individuals with significant disease (e.g., hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, ↓ GFR, ↑ creatinine): a course of steroids for up to 6 months
  • Additional therapy (including immunosuppressants Immunosuppressants Immunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response. Immunosuppressants) is used depending on response and etiology of DPGN.
  • In ESRD → renal replacement therapy:
    • Dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis 
    • Kidney transplantation

Underlying disease

To reduce progression of renal disease, management will vary depending on the underlying condition. Options are as follows:

  • Lupus nephritis:
    • Pulse methylprednisolone + mycophenolate mofetil (MMF) or cyclophosphamide
    • Other treatments:
      • Biologic therapies (e.g., belimumab)
      • Calcineurin inhibitors (e.g., tacrolimus)
  • IgA nephropathy IgA nephropathy IgA nephropathy (Berger's disease) is a renal disease characterized by IgA deposition in the mesangium. It is the most common cause of primary glomerulonephritis in most developed countries. Patients frequently present in the second and third decades of life and, historically, with a preceding upper respiratory or GI infection. IgA Nephropathy:
    • Glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids
    • For rapidly progressive disease: consider glucocorticoids + cyclophosphamide then azathioprine
  • Anti-GBM disease:
    • Initial treatment with high-dose corticosteroids
    • Cyclophosphamide
    • Plasmapheresis (removal of antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins)
  • Granulomatosis with polyangiitis Granulomatosis with Polyangiitis Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease of unknown etiology. It leads to a necrotizing granulomatous inflammation of small and medium-sized blood vessels of the nose, sinuses, throat, lungs, and kidneys. Granulomatosis with Polyangiitis:
    • Corticosteroids
    • Add other immunosuppressants Immunosuppressants Immunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response. Immunosuppressants (e.g., cyclophosphamide, rituximab, azathioprine)

Differential Diagnosis

  • Rapidly progressive glomerulonephritis Rapidly Progressive Glomerulonephritis Rapidly progressive glomerulonephritis (RPGN) is a syndrome of severe glomerular disease with progressive loss of kidney function within weeks to months. Histologically, crescents (the proliferation of epithelial cells and the infiltration of monocytes/macrophages in the Bowman space) are found in the glomeruli and arise from immunologic injury. Rapidly Progressive Glomerulonephritis ( RPGN RPGN Rapidly progressive glomerulonephritis (RPGN) is a syndrome of severe glomerular disease with progressive loss of kidney function within weeks to months. Histologically, crescents (the proliferation of epithelial cells and the infiltration of monocytes/macrophages in the Bowman space) are found in the glomeruli and arise from immunologic injury. Rapidly Progressive Glomerulonephritis): nephritic syndrome Nephritic syndrome Nephritic syndrome is a broad category of glomerular diseases characterized by glomerular hematuria, variable loss of renal function, and hypertension. These features are in contrast to those of nephrotic syndrome, which includes glomerular diseases characterized by severe proteinuria, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephritic Syndrome accompanied by features of glomerular disease, microscopic glomerular crescent formation and progression to renal failure within weeks to months. Glomerular injury in RPGN RPGN Rapidly progressive glomerulonephritis (RPGN) is a syndrome of severe glomerular disease with progressive loss of kidney function within weeks to months. Histologically, crescents (the proliferation of epithelial cells and the infiltration of monocytes/macrophages in the Bowman space) are found in the glomeruli and arise from immunologic injury. Rapidly Progressive Glomerulonephritis can be from anti-GBM disease, immune complex–mediated injury, pauci-immune necrotizing and crescentic GN, or idiopathic causes. Diagnosis is by history, urinalysis, serology, and renal biopsy. Treatment is with immunosuppressants Immunosuppressants Immunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response. Immunosuppressants, with specific therapy depending on the underlying mechanism of renal disease. 
  • Poststreptococcal glomerulonephritis Poststreptococcal Glomerulonephritis Post-streptococcal glomerulonephritis (PSGN) is a type of nephritis that is caused by a prior infection with group A beta-hemolytic Streptococcus (GAS). The clinical presentation of PSGN can range from asymptomatic, microscopic hematuria to full-blown acute nephritic syndrome, which is characterized by red-to-brown urine, proteinuria, edema, and acute kidney injury. Poststreptococcal Glomerulonephritis ( PSGN PSGN Post-streptococcal glomerulonephritis (PSGN) is a type of nephritis that is caused by a prior infection with group A beta-hemolytic Streptococcus (GAS). The clinical presentation of PSGN can range from asymptomatic, microscopic hematuria to full-blown acute nephritic syndrome, which is characterized by red-to-brown urine, proteinuria, edema, and acute kidney injury. Poststreptococcal Glomerulonephritis): occurs after infection with a group A beta-hemolytic streptococcus. Diagnosis of PSGN PSGN Post-streptococcal glomerulonephritis (PSGN) is a type of nephritis that is caused by a prior infection with group A beta-hemolytic Streptococcus (GAS). The clinical presentation of PSGN can range from asymptomatic, microscopic hematuria to full-blown acute nephritic syndrome, which is characterized by red-to-brown urine, proteinuria, edema, and acute kidney injury. Poststreptococcal Glomerulonephritis is by history, laboratory tests (including urinalysis), and serology testing. Treatment is supportive, and the prognosis is usually excellent, with the majority of individuals recovering without long-term complications.  
  • Membranoproliferative glomerulonephritis Membranoproliferative Glomerulonephritis Membranoproliferative glomerulonephritis (MPGN) is also known as mesangiocapillary glomerulonephritis. Membranoproliferative glomerulonephritis is a pattern of glomerular injury characterized by mesangial hypercellularity, endocapillary proliferation, and thickening of the glomerular basement membrane (double contour formation). Membranoproliferative Glomerulonephritis ( MPGN MPGN Membranoproliferative glomerulonephritis (MPGN) is also known as mesangiocapillary glomerulonephritis. Membranoproliferative glomerulonephritis is a pattern of glomerular injury characterized by mesangial hypercellularity, endocapillary proliferation, and thickening of the glomerular basement membrane (double contour formation). Membranoproliferative Glomerulonephritis): histologic renal lesion characterized by glomerular injury with GBM thickening and mesangial proliferation. The pathogenic process of MPGN MPGN Membranoproliferative glomerulonephritis (MPGN) is also known as mesangiocapillary glomerulonephritis. Membranoproliferative glomerulonephritis is a pattern of glomerular injury characterized by mesangial hypercellularity, endocapillary proliferation, and thickening of the glomerular basement membrane (double contour formation). Membranoproliferative Glomerulonephritis can be either immune complex–mediated or complement-mediated. Individuals can present with nephritic syndrome Nephritic syndrome Nephritic syndrome is a broad category of glomerular diseases characterized by glomerular hematuria, variable loss of renal function, and hypertension. These features are in contrast to those of nephrotic syndrome, which includes glomerular diseases characterized by severe proteinuria, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephritic Syndrome, variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables proteinuria, and renal function. Renal biopsy shows the pathologic renal lesion, and further investigation (e.g., laboratory tests) will point to the underlying cause (infections, autoimmune disease). Treatment is based on the etiologic disease.

References

  1. Bomback A.S., et al. (2021). Lupus nephritis: diagnosis and classification. UpToDate. Retrieved August 13, 2021, from https://www.uptodate.com/contents/lupus-nephritis-diagnosis-and-classification
  2. Falk R.J., et al. (2021). Lupus nephritis: Initial and subsequent therapy for focal or diffuse lupus nephritis. UpToDate. Retrieved August 13, 2021, from https://www.uptodate.com/contents/lupus-nephritis-initial-and-subsequent-therapy-for-focal-or-diffuse-lupus-nephritis
  3. Ikhlas M., Anjum, F. (2021). Diffuse proliferative glomerulonephritis. StatPearls. Retrieved August 13, 2021, from https://pubmed.ncbi.nlm.nih.gov/32644412/
  4. Ikhlas M, Anjum F. (2021). Diffuse proliferative glomerulonephritis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK558986/

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