Analogy of hernia

1. Institute of Health Science
Department of Nursing
Postgraduate Program of Adult Health Nursing
Chronic Glomerulonephritis Seminar Presentation
Set By: Rebira Workineh (AHN Student)
Rebira W. (AHN student)
2/13/2024
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2. Objectives
Rebira W. (AHN student)
At the end of this session, the participants will be able to:
 Define chronic glomerulonephritis
 Identify the development of chronic glomerulonephritis
 Explain etiologies of chronic glomerulonephritis
 Understand how to diagnose chronic glomerulonephritis
 Describe the differential diagnosis of chronic glomerulonephritis
 Identify possible management for patients with chronic glomerulonephritis
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3. Outlines
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 Introduction to CGN
 Epidemiology
 Pathophysiology
 Etiology
 Clinical manifestations
 Investigations
 Differential diagnosis
 Medical mgt.
 Nursing mgt.
 Prevention
 Complications
 References

4. Introduction to CGN
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 Nearly all forms of AGN have a tendency to progress to chronic glomerulonephritis.
 CGN is characterized by irreversible & progressive glomerular & tubulointerstitial
fibrosis, leading to a reduction in the GFR & retention of uremic toxins.
 If disease progression is not halted with therapy, it results in CKD, ESRD, & CVD.
 CGN is the 3rd leading cause of CKD, & accounts for about 10% of all patients on
dialysis.
(Kawasaki Y et al, 2011)

5. Introduction to CGN Cont’d…
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Definition
 CGN is a kidney disorder caused by slow, cumulative damage and scarring, usually
by inflammation, of the tiny blood filters in the kidneys.
 These filters, known as glomeruli, remove waste products from the blood.
 Inflammation typically results in one or both of the nephrotic or nephritic
syndromes.

6. The National Kidney Foundation
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 NKF defines CKD on the basis of either of the following criteria
o Evidence of kidney damage based on abnormal urinalysis results or
structural abnormalities observed on ultrasound images
o A GFR of < 60 mL/min for 3 months or longer
According to this criteria, the NKF developed guidelines that classify the progression
of renal disease into five stages
 This classification includes treatment strategies for each progressive level as follow

7. The NKF Cont’d…
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Stage 1
 This stage is characterized by kidney damage with a normal GFR - ≥ 90 mL/min
 The action plan consists of diagnosis and treatment, treatment of comorbid conditions, slowing of the
progressing of kidney disease, and reduction of CVD risks
Stage 2
 This stage is characterized by kidney damage with a mild decrease in the GFR- 60-90 mL/min
 The action plan is estimation of the progression of kidney disease

8. The NKF Cont’d…
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Stage 3
 This stage is characterized by a moderately decreased GFR- 30-59 mL/min
 The action plan consists of evaluation and treatment of complications
Stage 4
 This stage is characterized by a severe decrease in the GFR - 15-29 mL/min
 The action plan is preparation for renal replacement therapy
Stage 5
 This stage is characterized by kidney failure
 The action plan is kidney replacement if the patient is uremic

9. Epidemiology
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 In the United States, CGN is the 3rd leading cause of ESRD
 It accounts for 10% of patients on dialysis
 In Japan and some Asian countries, CGN has accounted for as many as 40% of
patients on dialysis
 However, subsequent data suggest that in Japan, the rate of CGN in patients on
dialysis is 28%.
 The cause of this decline rate is not known
(Nakai S et al, 2004)

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11. Etiology
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 The progression from AGN to CGN is variable, based on the cause of the condition
 Complete recovery of renal function occurs in patients with poststreptococcal
glomerulonephritis
 Other glomerulonephritis, such as IgA nephropathy, often has a relatively benign
course
 Many do not progress to ESRD
 Progression patterns may be summarized as follows

12. Etiology Cont’d…
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Rapidly progressive glomerulonephritis or crescentic glomerulonephritis
 About 90% of patients progress to ESRD within weeks or months
Focal segmental glomerulosclerosis
 About 80% of patients progress to ESRD in 10 years
 This form may be related to HIV infection
Membranous nephropathy
 About 20-30% of patients with membranous nephropathy progress to CRF &
ESRD in 10 years

13. Etiology Cont’d…
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Membranoproliferative glomerulonephritis
 About 40% of patients with membranoproliferative glomerulonephritis progress to
CRF & ESRD in 10 years
IgA nephropathy
 About 10% of patients with IgA nephropathy progress to CRF & ESRD in 10
years
Poststreptococcal glomerulonephritis
 About 1-2% of patients with poststreptococcal glomerulonephritis progress to CKD
& ESRD

14. Etiology Cont’d…
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Lupus nephritis
 About 20% of patients with lupus nephritis progress to CRF& ESRD in 10 years
 The presence of antineutrophil cytoplasmic antibody is also an independent risk
factor for poor renal outcome.
(Wang Y et al, 2016)

15. Pathophysiology
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Reduction in nephron mass from the initial injury reduces the GFR
This reduction leads to hypertrophy and hyperfiltration of the remaining nephrons
and to the initiation of intraglomerular hypertension
These changes occur in order to increase the GFR of the remaining nephrons, thus
minimizing the functional consequences of nephron loss
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The changes, however, are ultimately detrimental because they lead to
glomerulosclerosis & further nephron loss

16. Pathophysiology Cont’d…
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 In early renal disease, decline in the GFR leads to slight increases in serum
creatinine levels
 Azotemia (i.e., a rise in blood urea nitrogen & serum creatinine levels) is
apparent when the GFR decreases to < 60-70 mL/min
 Reduction in the GFR also results in the following

17. Pathophysiology Cont’d…
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 Decreased production of erythropoietin, thus resulting in anemia
 Decreased production of vitamin D, resulting in hypocalcemia, secondary
hyperparathyroidism, hyperphosphatemia, & renal osteodystrophy
 Reduction in acid, potassium, salt, and water excretion, resulting in acidosis,
hyperkalemia, hypertension, & edema
 Platelet dysfunction, leading to increased bleeding tendencies

18. Clinical Manifestations
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Symptoms
 Weakness and fatigue
 Loss of energy, appetite, and weight
 Pruritus
 Early morning nausea and vomiting
 Change in taste sensation
 Reversal in sleep pattern
 Peripheral neuropathy
 Seizures
 Tremors

19. Clinical Cont’d…
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Signs
 Hypertension
 Jugular venous distention
 Pulmonary rales
 Pericardial friction rubs in pericarditis
 Tenderness in the epigastric region or blood in the stool
 Decreased sensation and asterixis

20. Investigations
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Clinical findings
 History collection
 Physical examination
Urinalysis
 The presence of dysmorphic RBCs, albumin, or RBC casts suggest
glomerulonephritis as the cause of kidney failure
(Edgar V Lerma et al, 2022)

21. Investigations Cont’d…
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Urinary protein excretion
 Estimated by calculating the protein to creatinine ratio on spot morning urine
sample
Complete blood count
 Anemia is a significant finding in patients with some decline in the GFR
 Is the result of marked impairment of erythropoietin production & alterations
in iron absorption that accompany CKD from ferroprotein and FGF23

22. Investigations Cont’d…
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Serum chemistry
 Serum creatinine & BUN levels are elevated
 Impaired excretion of potassium, free water, & acid results in hyperkalemia,
hyponatremia, and low serum bicarbonate levels, respectively
 Impaired vitamin D-3 production results in hypocalcemia, hyperphosphatemia, and
high levels of parathyroid hormone
 Low serum albumin levels may be present if uremia interferes with nutrition or if
the patient is nephrotic

23. Investigations Cont’d…
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Renal biopsy
 Kidney biopsy is usually unnecessary
Imaging Studies
 Ultrasound: Presence of both kidneys, size & exclude structural lesions that
may be responsible for azotemia

24. Differential Diagnosis
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 Azotemia, uremia, chronic kidney disease
 Crescentic glomerulonephritis
 Diffuse proliferative glomerulonephritis
 Glomerulonephritis associated with non-streptococcal infection
 Membranoproliferative glomerulonephritis
 Membranous glomerulonephritis
 Poststreptococcal glomerulonephritis
 Rapidly progressive glomerulonephritis

25. Management- Diet & Activity
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Diet
 Protein restriction (0.4 to 0.6 mg/kg/day)
 Slow the decline in GFR and reduce hyperphosphatemia (serum phosphate > 5.5
mg/dl) in patient with serum creatinine levels > 4 mg/dl
 Should follow low potassium diets (2000-3000 mg/dl)
Activity
 Patient should increase their activity level as tolerated
 This may aid in blood pressure control

26. Pharmacologic Therapy
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BP Management
 Angiotensin converting enzyme inhibitors are the first treatment of choice
 Angiotensin II receptor blockers are used to retard the progression of CKD in
patient with diabetic and nondiabetic nephropathy
 Combination of ACEIs and ARBs- to achieve better pressure control & preservation
of kidney function

27. Pharmacologic…
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Diuretics
 Are used to treat edema & hypertension
 Increase urine excretion by inhibiting sodium and chloride transporters
 Loop and thiazide are among classes of diuretics
 Examples: Furosemide (Lasix), bumetanide, torsemide, ethacrynic acid &
hydrochlorothiazide, metolazone
 Others: Beta blockers, calcium channel blockers, alpha1 antagonists, direct
vasodilators, etc.

28. Pharmacologic…
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Fibrosis inhibition
 Progressive fibrosis is the hallmark of chronic glomerulonephritis
 Inhibitors of fibrosis is intended to slow the progression
 Pirfenidone is the best candidate, inhibits transforming growth factor & collagen
synthesis
 Others: Mineralocorticoid antagonists, nonsteroidal mineralocorticoid antagonists
(better, b/c the former induce hyperkalemia)
(DeFronzo RA et al ,2022)

29. Pharmacologic…
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Sodium bicarbonate
 Reduce tubulointerstitial injury & endothelin production
 Slow progressive kidney damage
 In one study on patients with advanced kidney failure, the administration of sodium
bicarbonate preserved GFR decline
 Even in patients with relatively preserved GFR in stage 2 CKD, the administration of
sodium bicarbonate was shown to preserve kidney function over 5 years
(I de Brito-Ashurst et al, 2009 & Mahajan A et al, 2010)

30. Renal Replacement Therapy
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 These options of renal replacement therapy are used when GFR falls below 20-25
ml/min
 Renal transplantation must explored when GFR falls below 20 ml/min
 Hemodialysis
 Peritoneal dialysis
 Renal transplantation

31. Nursing Management
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Nursing diagnosis
Acute pain R/T inflammation of renal cortex AEB facial expressions & verbalization of patient
Goals
To reduce pain
Intervention
Assess pain characteristics
Provide comfort devices, quite environment and calm activities
Administer the analgesic according to physician order

32. Nursing Management Cont’d…
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Nursing diagnosis
 Excess fluid volume R/T accumulation of fluid in the body AEB edema & weight gain.
Goal
 To maintain the fluid volume
Intervention
 To change the position frequently
 To elevate the edematous extremities
 To administer the diuretics to promote the diuresis
 To administer the albumin helps in shifting the fluid from the ISC to IVC

33. Nursing Management Cont’d…
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Nursing diagnosis
 Ineffective breathing pattern R/T accumulation of fluid in the peritoneal cavity AEB
respiration rate, dyspnea.
Goal
 To improve the breathing pattern
Intervention
 Instruct the patient to perform the deep breathing exercise
 To provide the semi-fowler position
 Encourage the rest between the activities to avoid the overexertion

34. Prevention
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 One should seek medical assistance as soon as possible if they have impetigo or a
sore throat due to a strep infection.
 Follow safe-sex guidelines and abstain from intravenous drug use to prevent
infections like HIV & hepatitis, which can cause some types of glomerulonephritis.
 Control high blood pressure to reduce the risk of kidney damage from
hypertension.
 In order to help avoid diabetic nephropathy, control blood sugar.

35. Complication
 Metabolic acidosis
 Pericarditis, pulmonary edema
 Uremic encephalopathy
 Uremic gastrointestinal bleeding
 Uremic neuropathy
 Severe anemia & hypocalcaemia
 Hyperkalemia
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36. References
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 Kawasaki Y, (2011). Mechanism of onset and exacerbation of chronic
glomerulonephritis and its treatment.
 Nakai S, et al, (2006). An overview of regular dialysis treatment in Japan (as of 31
December 2004).
 de Brito-Ashurst I, et al, (2009). Bicarbonate supplementation slows progression of
CKD and improves nutritional status.
 Mahajan A, et al, (2010). Daily oral sodium bicarbonate preserves glomerular
filtration rate by slowing its decline in early hypertensive nephropathy.
 DeFronzo RA, et al, (2022). Modifying chronic kidney disease progression with the
mineralocorticoid receptor antagonist finer none in patients with type II diabetes.

37. 2/13/2024
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Stay Bless!